Tom Nolan: Freeing up some cognitive bandwidth in general practice

How many tabs have you got open on your web browser? I’ve got 27: six Airbnb properties in Cornwall, five Google maps with journey times to Cornish towns, six recipes for toad in the hole, three attempts to login to BMJ Learning, and the Guardian homepage at various points during the past three weeks. It’s no mystery then, why my computer is grinding to a halt, suffering petit mal absences every time I click.

This is how I feel after a morning surgery. Although I start the day with good intentions to do my referrals and jobs as I go along, things never go to plan. As I run later and later, rather than completing the task straight away, I add it to my list—my brain’s equivalent of opening up a new tab.

The later I run, the more frazzled I get, and the more opening up a new tab becomes the answer to people’s problems. Mrs Jones’s headache becomes a neurology referral instead of finding out what’s really going on in her life. Mr Jones’s headache also becomes a neurology referral. With a few more questions and a bit more headspace, I might have realised that the Jones’s have left their gas on.

The more tabs I open, the greater my sense of impending administrative doom. My system runs slower and slower.

At the end of a clinic my tabs are still all open: do the physio referral, email the diabetes nurse, write a stroppy response to a discharge letter, those neurology referrals, a quality alert, a significant event analysis about that medication error (it wasn’t me, it was the system). The longer they’re open, the less important they seem. That’s when it becomes a real problem and the errors and complaints start piling up.

Is this what the doctor ordered?

As soon as a waiter delivers orders to the kitchen they immediately forget them. Until that point they remember them perfectly. This is called the Zeigarnik effect. So if you want to remember something, leave it incomplete. If you don’t, finish it. I don’t want to remember. I don’t like missing half an episode of Game of Thrones because I’m thinking about Mrs Jones’s neurology referral.

So why do we design our workload to leave things unfinished? Ten minute appointments crammed together for a whole morning is a recipe for full and frazzled brains. If you wanted to create a system that produced unfinished jobs this would be it. Our cognitive bandwidth is limited and gets quickly used up if we leave ourselves dozens of unfinished tasks and unresolved problems.

If we can close our tabs—or not open them in the first place—we can free up some bandwidth and focus more on the patient in front of us. This doesn’t take more money or government intervention, just a change in how we work.

The famous time management method “Getting Things Done” (GTD) says any task that takes under two minutes should be done at once. Fifteen minute appointments enable this and help me enormously. Having a reliable, trusted system for sorting and storing our tasks also helps. GPs are fortunate to have sophisticated systems for task management within Docman, EMIS, FrontDesk, Outlook, and others. Grouping similar tasks to do together can help too: phone calls, referrals, incoming letters, pathology results.

When planning time, some use the 60:20:20 rule: allocate 60% of time for planned work and 20% for unplanned work. The last 20% is for socialising, which might include a clinical meeting, talking about headaches over coffee, or booking your holiday to Cornwall—all of which free up bandwidth.

Note: Mrs Jones’s name was changed to protect her identity, and her referral has been sent.

Tom Nolan is a GP partner in South London.

Competing interests: None declared.