Do you run on time?

In our discussion on achieving ‘Zen’ in general practice, time pressure was identified as one of the most significant factors that decrease our enjoyment at work. It is a chief ‘zen-zapper’.

No one benefits from a waiting room full of people. 

It is certainly not valued by the patients, who have better things to do (well, some of them, sometimes).

The more people, the more space required to accomodate them. And if people are hanging around you need to have up-to-date magazines, and toys for kids, and comfortable chairs, possibly coffee, a TV, and (in extreme cases) beds.

It is uncomfortable to be a receptionist when people are watching you for long periods. There is only so much of ”Are we there yet?” that you can take.

Does every consultation begin with an apology – “Sorry to keep you so long!”

It makes it harder to concentrate on the patient in front of you when you are aware there are a queue of people waiting to step into their seat. This is made worse by the fact that people who have been waiting for  a long time think that they need to make it all worthwhile, so launch into a long list of complaints and problems (fair enough!)

Running late in our appointment schedule is ‘muda’,(waste), and against all the principles of ‘Lean Thinking’.

Perspective

However, we need to keep our quest for running on time in perspective.

Would you prefer that patients complained that you always kept them waiting, or would you prefer that they complained that you don’t appear to listen to their concerns and that you are not thorough?

We strive for patient centred care. It is, as always, a matter of balance – in this case between the needs of the person we are seeing and the inconvenience of those waiting to be seen.

What can we do?

The Twelve Enlightened Paths to becoming a Time Lord

Some doctors (my partner for one) always run on time, and always seem to deal with all their patients’ issues. No matter how quickly they are seen, the patients come out saying ‘He is so thorough!’.

Doctors who can run to time and meet their patients needs are ‘Time Lords‘.

People in control of a situation do not look rushed. Top sportsmen seem to live in a different space / time continuum to the rest of us. ‘Time Lords’ also seem to find this place

Time Lords do not look rushed. They know to make sure that they identify and address the patients’ concerns. Importantly, the patient also perceives that they have done so.

(Did you know that the average patient visiting a physician gets only 22 seconds for his initial statement before the doctor interrupts. However, the ‘mean spontaneous talking time’ when the physician is instructed not to interrupt the patient is only 92 seconds -(did they gag the doc to do this study?).

For many years I’ve been seeking the Enlightened Path so that I too can become a ‘Time Lord’. I’ve spoken to a number of Masters, and though I can’t yet snatch a pebble from their hands, I can now file this report on what I have learned.

1. Fifteen Minutes Late does not mean you are early.

Running to time starts with an attitude.

Even though I turn up for my 9 O’Clock patient only a few(?) minutes after 9.00, there’s always time for a coffee and to have a chat and to check my emails and to tidy my desk before I call in the first patient, isn’t there?

Once you get behind you can *never* make those minutes up!

So take the example of Aesop’s tortoise and get a good start. In fact, jump the gun if you can.  Its not Bejing – noone will recall you for a false start.

At other times during the day we often get so used to running behind time that, when we are only being fifteen minutes late, it feels like we are running early. “Gee, I’m not doing too badly today, think I’ll have a rest and grab a coffee”

Have you noticed that when you absolutely must get away at a certain time – that you manage to do it. (say, to catch a plane, or to go to a Sportsman’s Lunch, or to hit off at 1.30). Robbie Deans says that winning is a habit. Get in the habit of doing all that you need to do (and not doing extraneous stuff) so that ‘running to schedule’ becomes an everyday occurrence. Out the Drive by Half Past Five! That’s the attitude.

2. Work your Appointment Book

Every Monday is really busy because too many people need to see us! 
Its been the same for years. Jeezzz. Bloody patients. Do you think they’ll ever learn?

It is silly to act surprised each Monday about how many people need acute appointments. It is an important principle of Lean Thinking that you don’t blame people – if you want different results, change your system.

Numerous studies have demonstrated that demand for appointments is both finite and predictable.

In our practice, we measured how many patients wanted an appointment on each Monday over a two year period – and the results were astonishing in their consistency!

Have you tried working to this hypothesis - 

The number of  acute appointments I will need to ‘carve out’ from my schedule on any particular day is predictable.

Measure how many acute apppointments are needed each day. Then have your receptionists keep an appropriate number of appointments free. Book routine follow ups on the days that are in least demand – for the 70% of people whose don’t care when they come in (except Wednesday which is Bingo and Friday which is bowls)

You can actually know what the demand is going to be on each day next week – so work your books like a game of Tetris – slot appointments where they fit best.

Use Double and Special Appointments sparingly

Some appointments undoubtably need to be double appointments. Those medicals for Veteran Affairs that require 24 pages to complete, for example. And there are some patients for whom we have to bite the bullet and accept that they are never going to compete a consultation in less than 30 minutes. However, Time Lords do not seem to find it necessary to make lots of double appointments. Like addressing one complaint at a time, double booking blows out the number of days it takes for patients to ‘get in’.

3. Max Pack

“I’m sorry. We are busy today. If you want fries and a coke with that you’ll have to go to the back of the queue”

I know that the GP registrars are often trained to deal with one quick problem at a time and make people come back if they have more than one problem or a more complicated issue. 

Is that a good solution? Maybe – if you are short of patients, or don’t have enough to do to fill your day.

I think it is disatrous. By making another appointment, the queue of people waiting to see us increases. Our backlog grows. The patient has to go to all the trouble of coming back – of not doing something else that they would more profitably be doing, and driving back to our surgery, and finding a park, and waiting again. In the interim their concerns remain unaddressed. 

And on the day that they come back,  we can’t see other patients that want to see us because we are still dealing with the problems that should have been dealt with last week. It is a vicious cycle.

In general, a Time Lord shuns the ‘quick-fix’ of one problem at a time and does all the ’stuff’  that needs to be done in one visit. In America they call this ‘MaxPacking’.

A Time Lord knows to ‘Do Today’s Work Today’. 

To MaxPack you need to control the patient’s list.

4. Control the Patient’s List

You’ve spent 5 minutes checking out three benign naevi, and 5 minutes looking at a sore shoulder. Just when you think you’ll regain some time (you Time Lord, you), the patient says “What I’m really here for doctor is…..”.

If your patient brings in a written list, take it from them early in the consultation. Otherwise, before you spend a long time looking at the seborrhoeic keratosis on their temple so that they think they are getting value for money, check with them if there is anything else they are planning to ask you about today.

This gives you a chance to prioritise the time you need to spend on each of their concerns.

Wherever you can, MaxPack!

Often you’ll find that the last two items on the list will only take a minute or so. Do them, even if it puts you a little late. Do what you can to avoid them having to come back until the time that is clinically indicated. 

If there really are patient concerns that would be better addressed at another consultation, always express this in a patient-centred way. I’ve heard doctors say “Look, I don’t have time to deal with that today. You’ll have to come back”. What message would you take from that if you were the patient?

A Time Lord would frame it more like this. 

“That is a very important question. I think the best thing to do is for us to book a time now when we can deal with it appropiately and thoroughly”. 

Andrew Knight adds

I learnt a key strategy from Michael Greco a couple of years ago. As well as ‘controlling the list’ I now also ask the patient to prioritise…”of all of these issues which ones do you most want us to have dealt with before you leave today?”. This helps me be patient-centred and allows me to meet their pressing needs while having permission to confidently postpone less important issues if necessary.

Often having an established routine in your practice in which each patient has an ‘Annual Check’ gives us an appropriate time to which we can defer some issues.

5. Use the Annual Check

It is often recommended that we should opportunistically address preventative activities when patients come in with unrelated problems. This falls by the wayside when we are pressured by time.

Time Lords manage this differently, and are proactive in ensuring that every patient every year has ‘An Annual Check’. This consultation incorporates a full physical examination and addresses all the ‘red book’  recommended preventative activties. So when a patient comes in with a sore throat, you can address just that one issue, knowing that  everything else has been (or soon will be) taken care off.

This ‘Annual Check’ consultation can be improved by using the practice team to ‘get in the Red Zone’.

6. Get in the Red Zone- Use your practice teams

The value in a consultation is the time the patient spends with their doctor addressing their concerns. In America they call this ‘The Red Zone’.

Time spent finding the next patient and waiting for them to walk down the corridor, time spent looking for equipment, and time spent on interruptions take us out of the Red Zone. Such times are ‘muda’.

An extra three minutes per appointment adds up to 1 and a half hours late at the end of the day!

There are many activtities in a practice that can be done just as well (or better) by other members of our practice teams, rather than by the doctors. These include immunisations, taking observations, arranging appointments, ensuring preventative activities are up to date, and even ‘rooming’ the patient.

Make sure you have all the equipment you will need during the day readilly accessible. Better still, allocate that job to someone else.

Time Lords keep in the Red Zone by optimising their practice teams.

7. Engage the Patients in the Process

It is said that the greatest untapped resource in healthcare is the patients themselves.

Andrew Knight once wrote the ‘12 minute slip’, which is available on the apcc site

This slip is handed to each patient when they arrive at the surgery. It confirms that running behind schedule is a problem that the clinic is trying to fix, and reminds the patient that the average appointment time is 12 minutes.

This engages the patients in the process of running to schedule, and was remarkably effective in changing patient expectations in a positive way.
Patients started looking at their watches and saying

‘Right Doc, that’s my time up. You’d better see the next bloke now”.

8. Breaking Up is Hard To Do

Andrew also writes about the psychology of being late.

“I find I spend more time and try harder with people to compensate them for waiting – net result run later, try harder etc. My unassertiveness prevented me from finishing the consultation because I treated it like a conversation and finishing seemed rude. It helped me to realise that by giving a patient and extra five minutes I was robbing the next person of five minutes. The person in front of me always seems to have more rights than the person in next!”

Running on time makes it easier to end the consultation in a timely way.

Make sure you have strategies to end consultations courteously, while affirming the importance of that patient’s concerns.

Conveyor belts and revolving floors are probably not recommended, nor is Gloria Gaynor’s approach.

“Go on now go, walk out the door
just turn around now
’cause you’re not welcome anymore”

9. Make Waiting Time Productive

When you are in the queue for the ‘Tower of Terror’ at Dreamland, they try and make it feel like part of the ride.  You go up and down in lifts and walk back and forth along corridors. You receive a video briefing about ‘the mission’ ahead. This distracts you from the wait, and builds up anticipation for the ride (which in fact takes less than 30 secs).

Even for Time Lords, variabilty in demand means that there will be many occasions when patients need to wait.

Can you make this time productive? Can it improve the health of your patient? Can it make your subsequent consultation easier?

Perhaps patients could complete a form about their health history to make sure that your records are complete and accurate. Does the medication list in your records have any passing similarity with what they actually take ? Could you do some ‘push polling’ – the form might ask them about the healthiness of their lifestyle? Perhaps they could write down the reasons for their visit today so you can control their list? Perhaps the form could include the 12 minute slip.

Perhaps you could utilise your practice team and have your nurse take the next patient into an empty room and assist the patient prepare for the visit.

10. Group your ‘Care-Families’

It is an important principle of ‘lean’ in healthcare to identify patients with similar values and needs – ‘care-families’.

Some practices use their appointment system to specifically separate ‘Acute’ and ‘Non-Acute’ care-families.

They have a ‘jeopardy’ (or on-call) doctor who starts the day with no bookings, and sees everyone who rings up and needs to be seen because of an acute condition. Because they are triaged to some extent on the basis of acuity, and because there is variability in demand, sometimes there will be a wait for those patients who have requested acute consultations. Patients understand this as they only rang up on that day themselves. They also understand that they will often not be able to see their particular physician.

Use of practice nurses can improve the efficiency of the on-call doctor significantly. Smaller practices can ‘carve out’ a part of the day that they devote to seeing only acute appointments.

The ‘care-family’ of acute patients value being seen by their practice on the same day that they have an acute need.

The other doctors in the practice see all the patients who have booked in specifically to see them. These bookings have often been made many days (or weeks) beforehand. It is easier to keep to time when patients arrive in a regulated way, and you do not always have to be worrying about fit ins and extras – a kid arriving needing stitches, the lady who has had a fall and needs a home visit, and a possible infarct in the sister’s room. Your ‘jeopardy’ colleague will take care of them.

The care-family of non-acute patients ‘value’ being seen by their doctor of choice on a day and time that suits them, when the doctor has time to focus on their problems.

11. You gotta dance with them what brung ya.

There comes a time to face facts. You’ve done what you can, but you find that every day you are well and truely late by the 3 O’Clock appointment. Lynne Davies measured for two weeks to find out what was the earliest time she ever saw the 4 O’Clock appt! There is great power in measuring this, so that you can demonstrate it to your staff.

So, why not book some ‘blockers’? If you find you consistently see the 3pm apptointment at 3:30, why not book the 3:00 and 3:15 appointments every day for ‘Mrs Catchup’, and see an extra two at the end of the day instead.

You will still see the same number of people, and see them at the same time you did anyway, and everyone will still get home at the same time.

The only difference is that you won’t be running late at 3.30.

That should improve your Zen.

12. Pain is inevitable. Suffering is optional.

A new patient told me about his previous doctor in another under-doctored town.

“I never waitied for less than three hours to see him and never saw him for more than three minutes!”

Undoubtably, there will be many circumstances in which there will be unavoidable waits for people to see us. Our patients accept this, and we need to accept this too.

Nonetheless, it remains good clinical practice to reduce our waiting times as much as we can. We should learn what we can from our colleagues who have become Time Lords.

I’d welcome your sugggestions and comments.

For me, that includes the map of dermatomes on the arms and legs.

After 20 years, I still have to look them up each time.

Safe and effective patient care can be improved by timely access to decision
support and communication tools. Our IT systems can have an important role, and
an Intranet operating in your  practice is one way to make information
available. (An Intranet is a mini version of the interent, usually available
only within an
organisation.)

Building an Intranet

There are a number of free services that facilitate the setting up of a practice
intranet.

The easist way for Windows users to share resources is to place documents in a
nominated ‘Shared’ directory on one of the computers. Other computers in the
surgery can navigate to that directory using Windows explorer, and bookmark it
for easier finding later using Tools > Map Network Drive.

For more sophisticated features, you may like to install the apache web server
on your Windows computer.

<http://www.ricocheting.com/server/apache.html>

It comes pre-installed and ready to run on MacOSX.

<http://en.wikibooks.org/wiki/Mac_OS_X_Tiger/Using_your_Mac_as_a_Web_Server>

With Apache installed, you can add a Content Manager System, such as that used
by Wikipedia (‘wikimedia’ – used at Goonellebah Medical Centre) or Mambo, which
allow all users to add and update documents

<http://en.wikipedia.org/wiki/Content_management_system>

If you don’t want to fiddle with your own system, Google now provides a free
service called ‘Google Apps for your Domain’. <http://www.google.com/a/>

This is not strictly an Intranet, as it is stored on the Googleservers, but is
an excellent way to provide email addresses, news services, and a shared
calendar for your staff, which can be accessed from home as well as work. It
also provides the ability to collaborate on documents or spreadsheets. The
’start’ page can be customised with a number of different ‘widgets’, including
ones that point to information stored elsewhere on the web and also to
information stored on your local network. You can use your own domain name, or
order one through Google. We use Google Apps for our Intranet homepage and you
can view it at <http://start.alstonvilleclinic.com.au>

Resources to place in your Intranet

There are many textbooks and guidelines (such as the Australian Medicines
Handbook and Therapeutic Guidlelines) that are available in formats which are
ideal for accessing via an Intranet, once the appropriate licensing fees are
paid. This makes it easy to update – do it once on one computer, and its
immediately available everywhere.

Your Intranet can also point users to resources available elsewhere on the web,
such as NSW Health’s comprehensive Clinical Information Access Program
<http://www.ciap.health.nsw.gov.au>, MSD’s site for GPs
<http://www.msd4gps.com.au>, or eMedicine <http://emedicine.com>,
and the NRDGPN Health Services Directory <http://services.nrdgp.org>

Dale Beatty is the practice manager at the Hawkins Medical Clinic at Mt Gambier.
They have a comprehensive intranet built up over 10 years. He points out that if
you use Excel or Word documents with the auto republish function turned on,
staff just have to update the document with new information and this
automatically updates the html file on the intranet site.
<http://office.microsoft.com/en-us/excel/HA102200031033.aspx>

This is some of the information they keep in this way – Telephone numbers,
Policy and procedure manual for the practice, rosters, clinical guidelines, fee
lists for the practice, staff notices, lists of reports requested by third
parties in alphabetic order, lists of reports completed in alphabetic order (for
me, this would be a much shorter list), OH&S regulation link, details of all
correspondence sent each day from the practice, documented system problems and
action taken, CPR instructions, white pages link, mandatory reporting
guidelines, GP numbers – lists of provider, prescriber, RACGP and ACRRM QA nos,
Indemnity membership no and policy no.

Phew. We’ve got some catching up to do.

Patient education handouts, and commonly used forms, are also useful to keep on
an Intranet. Saves rummaging through desks and wandering around the surgery
saying “have you seen………”

And, of course, a map of the dermatomes.

Regular readers know that it consists of a bulldog clip, a bunch of 5” x 3” index cards, and a pen. (For optimal efficiency, hipster afficiandos recommend the Fischer Space Pen (Bullet model), which packs small, opens large, and can write on any surface, at any angle.

A number of people (not including myself, mind you) might consider the original hipster a trifle unsophisticated to pull out at your next meeting with the Minister for Health. There are, however, some more fashionable solutions that offer (almost) the same functionality.

The Levenger International Pocket Briefcase is my current wallet of choice. It has a special writing service that dispenses fresh cards, with a sleeve to store your used ones. There is plenty of space for your cash, cards, receipts and ID, so you don’t need a separate wallet. It includes a pouch purposely designed to hold your Fischer Space Pen, and comes monogrammed in full grain leather.

The Moleskine Memo Pocket also makes a great companion to a HipsterPDA or Pocket Briefcase. It is a pocket-sized accordion file folder, with six compartments in which you can organise your index cards, and an elastic band on front in which you can store fresh cards. It is great when you need to take your entire card collection on the road.

It is more fun planning to be organised than actually doing the work required, and my bookshelf also reflects this. I thought Steve Covey’s ‘Seven Habits of Highly Effective People’ would help me achieve a tidy desk, but it had far loftier goals. It is highly recommended as a tool to sorting out one’s priorities in life – but there are still unimportant non-urgent things that you ignore at your eventual peril.

The HipsterPDA

The very first LFiles article was a filing solution based on 31 manila folders for each of 31 days, and another 12 folders for each month – the ‘Tickler’ system.

And now, for my current preferred organiser, I have returned to my low tech roots. The HipsterPDA (hipsterpda.com) is a recent innovation that has a number of compelling features.

• An advanced handwriting recognition capability
• Natural, fast, flexible data entry
• Innumerable templates to organise your workflow
• Adaptable and customisable
• Light and unobtrusive, fitting in your pocket
• Stores business cards, photos, and small documents
• Simple data transfer between users
• Lifetime guarantee
• Unlimited RAM
• No batteries
• A great talking point

And you can make your own for less than $3! These instructions for building your very own HipsterPDA are courtesy of http://43folders.com,43folders.com
1. Get a bunch of 3×5” index cards
2. Clip them together with a bulldog clip
3. There is no step 3
Voila!

Getting Things Done by David Allen

The HipsterPDA provides the perfect tool to implement the latest and greatest system for personal efficiency – David Allen’s ‘Getting Things Done’ (shortened to GTD by the many online devotees).

GTD involves getting all the ‘stuff’ out of your head and stored in a system where you can be sure it will be dealt with. Stuff is “anything you have allowed into your psychological or physical world that doesn’t belong where it is, but for which you haven’t yet determined the desired outcome and the next action step.” Stuff includes all the ‘open loops’ in our lives – incomplete projects, reports, meetings, ideas, plans, commitments, tasks etc. We all spend so much time running around with all this ‘stuff’ in our heads that there’s no room for anything else. The answer is to get this stuff into a trusted system.

David Allen recommends that we systematically decide what ‘Next Action’ should be taken on each bit of stuff, and put these ‘Next Actions’ in context based lists. And review the lists regularly.

So, if you need to ring a colleague about a patient when next at the surgery, add that to your ‘@surgery’ list. If the next action regarding a planned holiday is to check accommodation on wotif.com, add that to your ‘@computer’ list. If you need to ask your spouse about a proposed roster change, add that to the ‘@wife’ list. If you are waiting for a report before you can perform the ‘Next Action’ in a project, add that to your ‘@Waiting’ list.

With these context-based lists, you can pull out the right one for wherever you happen to be, and can be sure that the item you choose to work on is the most appropriate at that time.

GTD recommends you use a folder based reference system for material that you may need later and maintain a ‘Tickler’ system to store date-sensitive notes and papers. The book is so detailed that it recommends a particular Brother brand labeller (and the sad thing is, I bought that particular labeller!)

By scheduling a ‘weekly review’, where you systematically revise your various Next Action lists, you can be confident that all your responsibilities and tasks are being dealt with. You can relax and clear your mind for focusing on the task at hand, and being more creative. Hence ‘GTD’ is billed as ‘The Art of Stress-Free Productivity’.

There are many software applications that are based on GTD. However, the HipsterPDA is considered by many to be the tool of excellence. It is easy to maintain the many lists required on different Index Cards.

You can jot down phone numbers, store business cards, keep track of Ward rounds, take agenda’s to meetings. At your weekly review, you can transfer the cards to a more appropriate place – such as your Tickler or reference files, or add contact details to your mobile phone, or enter notes on your computer. The beauty of GTD is that you use ‘Horse for Courses’, so that your email application, when configured correctly, and your pile of bills to be paid, are also ‘Next Action’ lists and part of your GTD system.

The HipsterPDA can be further customised by using any of a number of freely downloadable templates that can be used to print your own index cards. Try diyplanner.com or 43folders.com for many ingenious suggestions and tools to improve your PDA.

Since the promotion of the HipsterPDA, historians have discovered that it was used by none other than the great Thomas Jefferson. Pictured is his small ivory notebook, on which he wrote in pencil. If we see further, it is because we stand on the shoulders of giants!

Sound familiar? It has been estimated that if a more conscientious GP than myself read two journals a week, by the end of 12 months he or she would be eight years behind in their required reading.

It is common to feel overwhelmed by the waves of information flowing over us, and by the incessant demands on our time. This column each month will explore ways to claim back our time. After all, as Jeff Davidson says, money comes and goes, but time just goes, whether you?re having fun or not.

Fear not. There are ways to control the flow. The problem is not new, but is increasing.

Sir Arthur Conan Doyle, the creator of Sherlock Holmes, was himself a GP, and therefore familiar with the problem.

Dr Watson was surprised that Sherlock Holmes did not know that the earth went around the sun. On being told, Holmes decided to immediately forget the fact.

“Now the skilled workman is very careful indeed as to what he takes into his brain attic. He will have nothing but the tools which may help him in doing his work, but of these he has a large assortment and all in the most perfect order…”

“Depend upon it there comes a time when for every addition of knowledge you forgot something that you knew before. It is of the highest importance, therefore, not to have useless facts elbowing out the useful ones…”

A means of classifying the relevance and validity of the medical literature was proposed by Slawson and Shaughnessy and further defined as follows by Dr Mark Ebell.

The information that we need to know as GPs must be patient orientated, evidence based, and to matter – we need POEMS.

The term Poem refers to the kind of article that

• addresses a clinical problem that primary care physicians will encounter in their practice
• measures outcomes that we and our patients care about: symptoms, morbidity, quality of life, and mortality.
• has the potential to change our practice if the results are valid and applicable.

An example of a POEM is a randomized controlled trial that demonstrates that not patching corneal abrasions leads to less pain and faster healing than patching. It is a common problem, an outcome that is important to our patients (they get better quicker with less inconvenience), and is a change from our current practice.

On the other hand, there are DOES – disease orientated evidence, much beloved of pharmaceutical reps. These findings are often premature and incomplete – we need to know whether patients have less fractures, or their nocturia improves, or their quality of life is better – not if they have decreased urinary calcium excretion, or their urinary flow rate is better, or Californian rats show tumour slowing.

The bad news is that a survey of medical literature has shown that 97% of articles are DOES. The good news is therefore that we only have to read those 3% of articles that are scientifically valid, about conditions that we see in primary practice, with worthwhile outcomes, and would lead to a change in our current practice – the POEMS.

Receiving reams of irrelevant information is more than just inconvenient .It wastes our most precious resource (our time). It contributes to a feeling of being overwhelmed. It gives us a sense of guilt about the adequacy of our continuing medical education. It also dangerously distracts us from learning that which we have a duty to know.

So, what steps can we take to improve our information management.

1) whenever you receive a ?pseudo-journal? – pharmaceutical company material disguised as a journal, ask your secretary to fax or write a form letter to the editor requesting you be removed from their mailing list. If they persist, mark the envelope ?Return to Sender? and post it back at their expense.

2) review the journals that you subscribe to or receive – cancel any that haven?t been opened in the last 3 issues, however worthy.

3) consider subscribing to a POEMS clipping service – maybe Infopoems InfoPointer at www.infopoems.com, who review 90 journals monthly and email a summary of any POEMS found ($US 129 annually)

An example InfoPoem -http://www.infopoems.com/InfoPointerSample/Synopses/EB03200001.htm
Are oral antihistamines an effective treatment for atopic dermatitis?

There is no evidence that anti-histamines reduce pruritis in patients with atopic dermatitis. They may have a benefit because of their soporofic effects. If you prescribe an anti-histamine, use an older, sedating agent and recommend it for use at bedtime. Heck, maybe we should have them read some journal articles! There is no evidence to support the use of expensive non-sedating agents for this condition. (ME)

4) schedule some time to skim through any journals that make the cut – if they keep piling up, cancel them.

5) only look at any articles that are relevant to your practice,are scientifically valid and have appropriate outcomes. Reject all DOES.

if the article fulfills 5) and would change your current practice, ie if the article is a POEM

then

6) circle the relevant information in the abstract.

and most importantly

7) share the knowledge – have your secretary copy it for your partners – if they then follow your example you are leveraging your time. Also ask your secretary to fax the clipping to the MedAu POEMS service at 02 66223185 – we will collect and assess all Poems we receive, summarise those that are valid and relevant, and make them available online, via email, and as a regular newsletter – you can then benefit from the efforts of many peers. Membership is free. Continue to contribute.
file the clipping – more on filing in a later column.

9) vigorously discard the left over journal, with its DOES, crappy anecdotes, columns, endless advertisements and other distractions.

Sherlock Holmes went on to tell Watson

“A man should keep his little brain attic stocked with all the furniture that he is likely to use, and the rest he can put away in the lumber-room of his library where he can get it if he wants it.”

We will talk further about maintaining the lumber-room of the library in future columns

Mark Ebell, Department of Family Practice ,Michigan State University,
An Introduction to Information Mastery
http://www.poems.msu.edu/InfoMastery/default.htm

Slawson DC, Shaughnessy AF
Obtaining useful information from expert based sources.
BMJ (England), Mar 29 1997, 314(7085) p947-9

InfoPoems
http://www.infopoems.com

Eye patches for corneal abrasions
http://www.infopoems.com/poems/jc059604.htm

Jeff Davidson,
Idiot’s Guide to Time Management

Key Points

• Time is our most valuable resource.
• Seek out POEMS – patient orientated evidence that matters.
• Reject all other information and cancel unsolicited and irrelevant journals.
• Share the knowledge you gain.