Margaret McCartney: Why GPs are always running late
BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3955 (Published 29 August 2017) Cite this as: BMJ 2017;358:j3955
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This is a very important essay. As we know, in outpatient primary care, many visits are not required. Patients are told to "follow up" for tests that may not need to have been done. And at the visit, we are asked to serve the agenda of regulatory bodies and the body in front of us. By using computer tools that further slow the ultimate goal of comforting and caring for the patient, we are all taxed. "Less is More" in so many of these situations.
Competing interests: No competing interests
GPs are always running late because they cling to the belief that patientscan have their problems dealt with in the ten minute slot allocated to them. They stick with this belief despite years and even decades of experience telling them otherwise. I struggled to not run late and knew GPs who always finished their surgeries 1-2 hours late. Even if the GP was comfortable with this it is unlikely his GP partners and the later patients felt the same. It may be that some loyal patients put up with this by rationalising that the GP is late because he/she is willing to give them all the time they need. But, at least for me, running late was only stressful.
I once did a quick survey of 100 consecutive patients and found the average number of problems presented was 2.4. As the years went by I became more and more concerned that practising medicine this way was increasingly risky, not just to the patient presenting, but to the patient who may be more seriously ill but could not get an appointment.
GPs are caught in a dilemma. Increased consulting times are needed for modern complex care but will mean less availability.
Perhaps a rushed consultation is better than none.
How many times did I start a surgery late because of some urgent matter or prolonged visit only to have a serious or complex first patient? I would then see my carefully scheduled day fall off a cliff.
But for those GPs who persistently run late I suggest you recognise this and do what I did. Start your surgeries 20-30 minutes early and book a 20-30 minute break in the middle of the surgery. If running late you can catch up if not, have a cup of tea and sign some prescriptions!
Competing interests: No competing interests
Well done Margaret McCartney for saying what we all know to be true. I am not sure how doctors have painted themselves into this corner and I have no idea how they will ever escape from this crazy situation, but it is a scandal.
I was a hospital doctor for 40 years and was very fortunate that my specialty (clinical chemistry) did not set any objectives as to how many patients I had to see. I was, in effect, supernumerary in the endocrine clinic and deliberately kept a low profile. This meant that if I needed to take thirty minutes with a new patient I could. Over and over again patients would say that I was the first person to ever have given them time to "tell their whole story". This led to high levels of both doctor and patient satisfaction. Another side effect of his care was that followup appointments were of short duration. There were no unexpected new symptoms that had been missed the first time and both the patient and I had a clear idea of intended management and expected outcomes. Surprises were few and far between.
In the private medical sector doctors generally do give an adequate amount of time to their patients - for the obvious reason that patients will not accept anything less. This may not need to be very long. I recently saw a doctor because of an inguinal hernia and because I am otherwise pretty healthy the consultation was short and to the point. All the important ground was covered and I felt I was given all the time I needed.
General practice is not getting any easier, patients expectations are rising, so are the numbers of older patients with multiple pathologies. Recruitment is problematic. I wish the new generation of doctors a long and rewarding professional life but I doubt they will get the same levels of satisfaction that those of us now about to retire have been privileged to enjoy.
Competing interests: No competing interests
Margaret McCartney recognises a real problem but proposes the wrong solution
Margaret McCartney is right when she says that "general practice is based on a lie—a lie that we can do this safely and well in 10 minutes." But she misses the root cause of the problem and therefore one effective solution.
The problem is the assumption that a 10min appointment is a good way to deal with the majority of demand placed on GPs. Trying to fit the widely varied nature of specific patient requests into a 10min slot is a little like trying to fit all children into a single size of shoe.
GPs who take the time to assess what it is that patients actually need often find that as much as 2/3 of patient requests can be dealt with in a lot less than 10mins on a phone call or online. This leaves them with much more flexibility to use their face to face time for those that need a longer session (and gives them the flexibility to vary the consultation time without overloading their working day).
This requires a radical change in the way practices respond to patient requests. Instead of allowing patients to book appointments, they should first route all requests to a GP who can assess whether they need an appointment (this can be done on the phone or online). This enables the GP to either respond rapidly or to bring the patients who need it in for a face to face appointment. In our experience the majority of patient requests can be handled without a face to face appointment and in less time that it takes for a 10min face to face slot. This leaves the GP with a lower overall workload and one that is more focussed on, and can allocate more time for, the patients who really need it.
The primary problem isn't that GPs are under resourced or overwhelmed by demand (though they may be): it is that they are often inflexible is how they organise themselves to meet that demand. More flexibility would give them more headroom to do a good job, would lower the stress of overwork and would keep their patients happier as well. Their resistance to trying new approaches to how they organise their work is the biggest barrier.
Obviously, I'm biased as I compile the analysis for askmyGP (one of the firms that helps GPs do this). But don't take my word for it: watch this video (published by NHS England) from a GP describing how redesigning his work solved the problem: https://www.youtube.com/watch?v=7Py8GcPvCaQ
Competing interests: I provide analysis for askmyGP, a company that helps GPs organise their work more effectively by changing the way they work using online and telephone consultations.