Today, we’re speaking to Andrew McClarey, who works as a GP and Education co-ordinator Lead for General Practice in the Scottish Centre for Simulation and Clinical Human Factors.

Title of paper: “Quick wins” vs “eating the frog”: Exploring general practitioners’ prioritisation dilemmas

Available at: https://doi.org/10.3399/BJGP.2025.0628

Link to tactical decision making games: https://archive.johs.org.uk/article/doi/10.54531/svvw4195

This is the first study to look at the factors which experienced GPs consider when prioritising their acute workload. Several themes have emerged which highlight the importance of prioritisation training in General Practice. These themes could be used to teach prioritisation decision making to GP registrars or in the creation of continuing professional development resources for experienced GPs.

Transcript

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A

00:00:00.400 - 00:00:56.560

Hi and welcome to BJ GP Interviews. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for listening to this podcast today.

In today's episode, we're speaking to Dr. Andrew McClary.

Andrew is a GP partner and he also works as Education Coordinator, Lead for General Practice in the Scottish Centre for Simulation and Clinical Human Factors. We're here today to discuss the paper that he's recently published in the bjjp.

And the paper is titled Quick Wins versus Eating the Frog, Exploring general practitioners Prioritization dilemmas. So, hi, Andrew, it's really nice to meet you.

And this paper really stood out to us, I think, because prioritisation is something that gps do every day, but it's not really something that we discuss explicitly. I'm just interested in what made you do this work and made you interested in studying it.

Speaker B

00:00:57.200 - 00:02:00.600

It's interesting, I think, that for me, I finished my GP training just after the pandemic and therefore I did a lot of my training during the COVID pandemic. And around then the face of general practice, like most things in life, changed completely overnight.

We moved on to telephone consulting and being encouraged to have empty waiting rooms.

And I think around the same time we realized that we probably couldn't continue doing what we had been doing, which was being everything to everyone, which brought us on to prioritizing our workload. We have to decide who needs seen, who does not, and when are they seen. And that was a real gap for me in the training that I was provided.

And I found myself going into working as a fully qualified GP without really an awareness of how to prioritise in a, in a sensible way. And I think that's where this interest was born out of.

Speaker A

00:02:00.760 - 00:02:42.050

And before we get into what you found, it's probably worth saying a little bit about how you approach the study. So this was a qualitative interview study involving gps from a range of practices and career stages.

And what you did was you really explored how they prioritized work during the course of a typical surgery.

And then I guess through those interviews you looked at sort of the strategies and influences and trade offs that shaped those decisions in everyday general practice. But one of the things I found really interesting was that prioritization wasn't just about clinical urgency.

And I wonder if you could talk through some of the other factors that GPs are weighing up quickly, I suppose, when they're deciding what to tackle first.

Speaker B

00:02:42.690 - 00:06:17.800

Absolutely.

It was very interesting, the themes that emerged from the data and also actually how much agreement There was amongst the gps in the focus groups, as we're not traditionally a group of people who agree about very much. So one thing that GP is particularly interested in, there's five main themes. One is about the system awareness.

So we're aware about our own surgeries and where the pressure points are.

For example, we're low on particular acute slots today, or there's a certain type of patient that is coming in more frequently at the moment, so we're aware of that. But it's not just having that awareness, it's also being able to adjust how we consult based on the pressures that the system are under.

For example, if there are a lot of children or fevers coming in, we want to see them all face to face. We ask the admin team, just bring them all in face to face and we'll see them that way, rather than setting everything up over the phone.

So it's not just an awareness of the system, but actually adjusting ourselves to that demand. Another one is the time management. What's the most efficient use of my time?

How am I going to get out on time this evening for nursery pickup or whatever else I have to do in the evening? But it's not just our time, it's also the system's time.

So what I mean by that is, I know if I try and refer to a hospital service in the afternoon, they'll probably be at capacity. If I do that in the morning, I am much more or first thing, except an afternoon surgery.

I'm much more likely to have my patient accepted and managed in a way that I think is most appropriate for them. Also, third theme, familiarity with our patients.

We are more familiar with our patients and therefore we don't have to go trawl through their histories. We know, right? I know that patient, I know what that's about. I spoke to them about it last week. Let's just phone them first and move on.

That's an easy thing for me to do. Then relationships.

Fourth theme, relationships with patients, in that we develop a trusting relationship, particularly if you've been working in a practice for a long period of time.

For example, we might be able to have a conversation on the phone saying, well, are you as bad as you were the last time, for example, when you went to hospital with your copd? Is it as bad as that? Well, no, no, Doctor, not as bad as that. And you know these patients and you trust them to tell you the story like it is.

But we also not only prioritise relationships with our patients, but also with other staff members.

For example, if you're interrupted during a duty doctor session and it's the practice nurse who is needing help with something, that person is there in front of you. They're a valued member of your team and you want to be able to provide input for them in a timely way.

And I guess that takes us back to system awareness. We know that that nurse has also got lots of patients to see, and if there's a delay in that, then the whole system is suffering from it.

And then lastly, fifth is this idea of personal preferences. Some of us like doing hard things first, so that's eating the frog.

Some of us like the quick wins and the endorphin release, of actually seeing all of the columns or all of the slots in the IT system changing a different color, we get a bit of a rush from that. There's no right or wrong answer with this, but actually a lot of it does come down to that.

But it's also about looking after ourselves, but also balancing that against good patient care and what needs to be done first from a clinical urgency perspective.

Speaker A

00:06:18.360 - 00:06:45.170

And the title of the paper is Quick Wins versus Eating the Frog.

And I find that really interesting because from my own clinical practice, sometimes I feel like I'm telling myself off if I'm only taking off the easy tasks, because I know then at the end of the day I'm going to have all the long referral letters, the things that I've really been putting off. And I think, gosh, why did I leave it to this point, really?

But I wonder if you can explain what that means a bit more generally, and why it captured something important about GP decision making.

Speaker B

00:06:45.570 - 00:08:12.210

I think ultimately, for me, it's about when we are at the trainee stage. We are actually honest about how we approach prioritizing our workload. And I think ultimately that comes down to personality.

Some of us like doing the more difficult things first, and then we feel that we've got the wind at our back and we're able to go on about our afternoon knowing that the most difficult thing in that list is done. In fact, the quote goes, eat a live frog first thing in the morning and nothing worse will happen you for the rest of the day.

And I think that's probably paraphrasing a little bit, but I think that's the thing. If the worst thing is out of the way, the afternoon suddenly seems much better versus actually some of us need that endorphin release.

And the highs, I guess, of actually seeing, feeling that we're going through our afternoon at a Good rate. And we are managing things well and some of us like that.

But I think ultimately, if we can have that conversation at the trainee stage to say, look, you're either a frog eater or you're a quick winner and you have to decide which you are. And maybe actually you're at the point in your career where you have the opportunity to actually try these out.

Say, right, we'll do the hardest thing first, how does that feel? Versus, you know, take off a few easy things, how does that feel? And you'll get an idea of what you're like as a person.

So I think that's where that comes.

Speaker A

00:08:12.210 - 00:08:35.850

In for me and I just wanted to go back to unpick some of the themes that you're talking about and I wonder what your thoughts are about sort of this role of familiarity with patients. How do you think that knowing your patients really influences prioritization decisions?

You took an example of knowing whether you can trust a patient, for instance. And for me that also links in a bit with continuity of care, I think.

Speaker B

00:08:37.420 - 00:10:02.500

Yeah, absolutely.

I think working in the same place for a more prolonged period of time allows us to develop this familiarity with patients that's impossible to have even if you're just as a trainee in a practice or new there. There's probably a few avenues we could explore here.

So one is about I see your name on the list, I see what the problem is, I know what that's about and I can tick that off very easily. I can see that as a quick win almost because I'm so familiar with your story and your situation. Perhaps only me, perhaps only I can sort that out.

Let's do that because I'm the best person to do that and let's do that now because I'll feel that I've achieved something, but it's a double edged sword because actually seeing the same person over and over with shortness of breath, who is copd, your bias will push you towards yes, this is copd, and you're missing something else that's perhaps serious because you're so keen to make the presentation fit into the last five times that you've saw that person. So you have to be aware of your own biases.

Even though the familiarity allows you to be very quick, perhaps in your decision making, you also have to have a little bit of having the brakes on to ensure that you're not missing things.

Speaker A

00:10:03.060 - 00:10:13.060

And there definitely is that tension, as you say, about experience helping GPs make rapid decisions, but also that experience can introduce bias. So I think that's a really interesting tension.

Speaker B

00:10:13.540 - 00:10:14.260

Absolutely.

Speaker A

00:10:15.540 - 00:10:23.300

How much of prioritisation do you think is about managing risk? And do you think some of it is just about managing workload as well?

Speaker B

00:10:23.970 - 00:10:47.570

I remember actually during one of the focus groups, one of the participants said, well, yeah, if this was to be a game, it would be called risk, because actually when we are dealing with our duty, doctor There is risk everywhere. And I think that it would be impossible to actually tease apart managing risk, because it's all risk versus anything else that might come up.

Speaker A

00:10:47.730 - 00:11:04.830

You've touched on this and I think that one of the most striking points in the paper is that prioritisation is a core skill that we're all doing all the time, but it often isn't formally taught. Do you have any ideas about why that is and how do you think we should teach this to our GP registrars?

Speaker B

00:11:04.910 - 00:12:01.130

I think perhaps it hasn't been traditionally taught because it wasn't necessarily part of our roles. And now as time has gone on, we have to. In fact, it's one of the biggest parts of the day.

And it was interesting because There was about 39 participants in the focus groups and there was a tremendous amount of agreement on how we did it, but no one had particularly received any prioritization training and it was all left on the job. And if they had done any, it was ad hoc. It was never a fixed part of the curriculum for us. We have developed a tool called a tactical decision game.

A tactical decision game is a tabletop simulation exercise whereby the participants are forced to make prioritization decisions on imperfect information.

Speaker A

00:12:02.250 - 00:12:03.930

Sounds like life in general practice.

Speaker B

00:12:04.090 - 00:13:11.410

Absolutely. It's a duty doctor session and it lends itself beautifully to training prioritization skills to registrars.

It works best as a group of seven, eight registrars with one facilitator.

The participants initially prioritize as individuals the list of 12 or 13 presentations, and then actually what happens is they move into the group and ultimately it's a group decision as to which presentation is being dealt with first versus last. And it means that it's all about learning from each other and learning where their own tolerances of risk are.

And it can be a really rewarding and useful session to deliver. And it's something that the registrars in particular have found useful.

But actually, in my now role as the education coordinator lead, I'm now running this to fully qualified GPs in general practices. And it's amazing the amount of conversation that can be generated by playing this game together.

Speaker A

00:13:11.570 - 00:13:17.360

Yeah, I'll definitely be taking that back to my Own practice. Is there a link available for that or is it widely available?

Speaker B

00:13:18.160 - 00:13:26.720

Yes, it's. The game is. Yes, it's available in ijos. It was published in IJOS a few years ago.

Speaker A

00:13:27.200 - 00:13:39.840

Great. We'll link to that in the show notes. That's perfect. Great.

And I guess just having done this work, was there anything in the findings that changed the way that you think about your own prioritization decisions when you're at work?

Speaker B

00:13:40.140 - 00:15:27.870

I think that I came at this research as a relatively junior GP who had only begun to develop my own prioritization strategies. And it was incredibly interesting to learn from those who had been doing this for years.

I think a key one for me was about time management and the recognition that everything that we do in that four hour session will chip away at the time that we have available to carry out the work.

So, for example, you see a set of notes and you see a slot or so you see a patient's name and a slot note and you think, oh, I wonder what that's about. And you click into a set of notes, there's a minute gone.

And I know a minute is a small amount of time, but actually over an entire session, that can really add up.

Hi and welcome to BJ GP Interviews.

I'm Nada Khan and I'm one of the Associate editors of the Journal.

Thanks for listening to this podcast today.

In today's episode, we're speaking to Dr. Andrew McClary.

Andrew is a GP partner and he also works as Education Coordinator, Lead for General Practice in the Scottish Centre for Simulation and Clinical Human Factors.

We're here today to discuss the paper that he's recently published in the bjjp.

And the paper is titled Quick Wins versus Eating the Frog, Exploring general practitioners Prioritization dilemmas.

So, hi, Andrew, it's really nice to meet you.

And this paper really stood out to us, I think, because prioritisation is something that gps do every day, but it's not really something that we discuss explicitly.

I'm just interested in what made you do this work and made you interested in studying it.

It's interesting, I think, that for me, I finished my GP training just after the pandemic and therefore I did a lot of my training during the COVID pandemic.

And around then the face of general practice, like most things in life, changed completely overnight.

We moved on to telephone consulting and being encouraged to have empty waiting rooms.

And I think around the same time we realized that we probably couldn't continue doing what we had been doing, which was being everything to everyone, which brought us on to prioritizing our workload.

We have to decide who needs seen, who does not, and when are they seen.

And that was a real gap for me in the training that I was provided.

And I found myself going into working as a fully qualified GP without really an awareness of how to prioritise in a, in a sensible way.

And I think that's where this interest was born out of.

And before we get into what you found, it's probably worth saying a little bit about how you approach the study.

So this was a qualitative interview study involving gps from a range of practices and career stages.

And what you did was you really explored how they prioritized work during the course of a typical surgery.

And then I guess through those interviews you looked at sort of the strategies and influences and trade offs that shaped those decisions in everyday general practice.

But one of the things I found really interesting was that prioritization wasn't just about clinical urgency.

And I wonder if you could talk through some of the other factors that GPs are weighing up quickly, I suppose, when they're deciding what to tackle first.

Absolutely.

It was very interesting, the themes that emerged from the data and also actually how much agreement There was amongst the gps in the focus groups, as we're not traditionally a group of people who agree about very much.

So one thing that GP is particularly interested in, there's five main themes.

One is about the system awareness.

So we're aware about our own surgeries and where the pressure points are.

For example, we're low on particular acute slots today, or there's a certain type of patient that is coming in more frequently at the moment, so we're aware of that.

But it's not just having that awareness, it's also being able to adjust how we consult based on the pressures that the system are under.

For example, if there are a lot of children or fevers coming in, we want to see them all face to face.

We ask the admin team, just bring them all in face to face and we'll see them that way, rather than setting everything up over the phone.

So it's not just an awareness of the system, but actually adjusting ourselves to that demand.

Another one is the time management.

What's the most efficient use of my time?

How am I going to get out on time this evening for nursery pickup or whatever else I have to do in the evening?

But it's not just our time, it's also the system's time.

So what I mean by that is, I know if I try and refer to a hospital service in the afternoon, they'll probably be at capacity.

If I do that in the morning, I am much more or first thing, except an afternoon surgery.

I'm much more likely to have my patient accepted and managed in a way that I think is most appropriate for them.

Also, third theme, familiarity with our patients.

We are more familiar with our patients and therefore we don't have to go trawl through their histories.

We know, right?

I know that patient, I know what that's about.

I spoke to them about it last week.

Let's just phone them first and move on.

That's an easy thing for me to do.

Then relationships.

Fourth theme, relationships with patients, in that we develop a trusting relationship, particularly if you've been working in a practice for a long period of time.

For example, we might be able to have a conversation on the phone saying, well, are you as bad as you were the last time, for example, when you went to hospital with your copd?

Is it as bad as that?

Well, no, no, Doctor, not as bad as that.

And you know these patients and you trust them to tell you the story like it is.

But we also not only prioritise relationships with our patients, but also with other staff members.

For example, if you're interrupted during a duty doctor session and it's the practice nurse who is needing help with something, that person is there in front of you.

They're a valued member of your team and you want to be able to provide input for them in a timely way.

And I guess that takes us back to system awareness.

We know that that nurse has also got lots of patients to see, and if there's a delay in that, then the whole system is suffering from it.

And then lastly, fifth is this idea of personal preferences.

Some of us like doing hard things first, so that's eating the frog.

Some of us like the quick wins and the endorphin release, of actually seeing all of the columns or all of the slots in the IT system changing a different color, we get a bit of a rush from that.

There's no right or wrong answer with this, but actually a lot of it does come down to that.

But it's also about looking after ourselves, but also balancing that against good patient care and what needs to be done first from a clinical urgency perspective.

And the title of the paper is Quick Wins versus Eating the Frog.

And I find that really interesting because from my own clinical practice, sometimes I feel like I'm telling myself off if I'm only taking off the easy tasks, because I know then at the end of the day I'm going to have all the long referral letters, the things that I've really been putting off.

And I think, gosh, why did I leave it to this point, really?

But I wonder if you can explain what that means a bit more generally, and why it captured something important about GP decision making.

I think ultimately, for me, it's about when we are at the trainee stage.

We are actually honest about how we approach prioritizing our workload.

And I think ultimately that comes down to personality.

Some of us like doing the more difficult things first, and then we feel that we've got the wind at our back and we're able to go on about our afternoon knowing that the most difficult thing in that list is done.

In fact, the quote goes, eat a live frog first thing in the morning and nothing worse will happen you for the rest of the day.

And I think that's probably paraphrasing a little bit, but I think that's the thing.

If the worst thing is out of the way, the afternoon suddenly seems much better versus actually some of us need that endorphin release.

And the highs, I guess, of actually seeing, feeling that we're going through our afternoon at a Good rate.

And we are managing things well and some of us like that.

But I think ultimately, if we can have that conversation at the trainee stage to say, look, you're either a frog eater or you're a quick winner and you have to decide which you are.

And maybe actually you're at the point in your career where you have the opportunity to actually try these out.

Say, right, we'll do the hardest thing first, how does that feel?

Versus, you know, take off a few easy things, how does that feel?

And you'll get an idea of what you're like as a person.

So I think that's where that comes.

In for me and I just wanted to go back to unpick some of the themes that you're talking about and I wonder what your thoughts are about sort of this role of familiarity with patients.

How do you think that knowing your patients really influences prioritization decisions?

You took an example of knowing whether you can trust a patient, for instance.

And for me that also links in a bit with continuity of care, I think.

Yeah, absolutely.

I think working in the same place for a more prolonged period of time allows us to develop this familiarity with patients that's impossible to have even if you're just as a trainee in a practice or new there.

There's probably a few avenues we could explore here.

So one is about I see your name on the list, I see what the problem is, I know what that's about and I can tick that off very easily.

I can see that as a quick win almost because I'm so familiar with your story and your situation.

Perhaps only me, perhaps only I can sort that out.

Let's do that because I'm the best person to do that and let's do that now because I'll feel that I've achieved something, but it's a double edged sword because actually seeing the same person over and over with shortness of breath, who is copd, your bias will push you towards yes, this is copd, and you're missing something else that's perhaps serious because you're so keen to make the presentation fit into the last five times that you've saw that person.

So you have to be aware of your own biases.

Even though the familiarity allows you to be very quick, perhaps in your decision making, you also have to have a little bit of having the brakes on to ensure that you're not missing things.

And there definitely is that tension, as you say, about experience helping GPs make rapid decisions, but also that experience can introduce bias.

So I think that's a really interesting tension.

Absolutely.

How much of prioritisation do you think is about managing risk?

And do you think some of it is just about managing workload as well?

I remember actually during one of the focus groups, one of the participants said, well, yeah, if this was to be a game, it would be called risk, because actually when we are dealing with our duty, doctor There is risk everywhere.

And I think that it would be impossible to actually tease apart managing risk, because it's all risk versus anything else that might come up.

You've touched on this and I think that one of the most striking points in the paper is that prioritisation is a core skill that we're all doing all the time, but it often isn't formally taught.

Do you have any ideas about why that is and how do you think we should teach this to our GP registrars?

I think perhaps it hasn't been traditionally taught because it wasn't necessarily part of our roles.

And now as time has gone on, we have to.

In fact, it's one of the biggest parts of the day.

And it was interesting because There was about 39 participants in the focus groups and there was a tremendous amount of agreement on how we did it, but no one had particularly received any prioritization training and it was all left on the job.

And if they had done any, it was ad hoc.

It was never a fixed part of the curriculum for us.

We have developed a tool called a tactical decision game.

A tactical decision game is a tabletop simulation exercise whereby the participants are forced to make prioritization decisions on imperfect information.

Sounds like life in general practice.

Absolutely.

It's a duty doctor session and it lends itself beautifully to training prioritization skills to registrars.

It works best as a group of seven, eight registrars with one facilitator.

The participants initially prioritize as individuals the list of 12 or 13 presentations, and then actually what happens is they move into the group and ultimately it's a group decision as to which presentation is being dealt with first versus last.

And it means that it's all about learning from each other and learning where their own tolerances of risk are.

And it can be a really rewarding and useful session to deliver.

And it's something that the registrars in particular have found useful.

But actually, in my now role as the education coordinator lead, I'm now running this to fully qualified GPs in general practices.

And it's amazing the amount of conversation that can be generated by playing this game together.

Yeah, I'll definitely be taking that back to my Own practice.

Is there a link available for that or is it widely available?

Yes, it's.

The game is.

Yes, it's available in ijos.

It was published in IJOS a few years ago.

Great.

We'll link to that in the show notes.

That's perfect.

Great.

And I guess just having done this work, was there anything in the findings that changed the way that you think about your own prioritization decisions when you're at work?

I think that I came at this research as a relatively junior GP who had only begun to develop my own prioritization strategies.

And it was incredibly interesting to learn from those who had been doing this for years.

I think a key one for me was about time management and the recognition that everything that we do in that four hour session will chip away at the time that we have available to carry out the work.

So, for example, you see a set of notes and you see a slot or so you see a patient's name and a slot note and you think, oh, I wonder what that's about.

And you click into a set of notes, there's a minute gone.

And I know a minute is a small amount of time, but actually over an entire session, that can really add up.

And when I'm teaching this now to registrars, I encourage them to think about how they manage their time in that way, because actually that's very important.

Another one is you look at a presentation, you think, that patient's going to need a home visit.

I think they're going to need a home visit.

And perhaps I would have been guilty previously of thinking, yeah, they probably will need a home visit, but I don't lift the phone and find out more information.

And that's just eating away at you over the course of the afternoon, thinking, that patient's going to need a visit.

I bet they are, and perhaps they don't.

Or perhaps, actually you've squandered an opportunity to get more information.

So I think it's about time management, but also part of that is about scanning through your list and seeing, right, these are the patients that I'm going to need to focus on to make decisions, and then the rest of them I can fit around that.

And I guess, finally, if there's one message you'd like the listeners to take away from this paper, what do you think it would be?

I think it's interesting to think about how GPs make these decisions in the real world, because ultimately we are taught a very specific consultation model.

And therefore that is the idea of what is perfect and how general practice should be carried out and that is what we still aspire to.

However, it was the admission amongst a group of gps that actually when things are very difficult, we consult in different ways because we want to be safe.

And I think it's having that open and honest conversation with ourselves, but also with our trainees to say, look, there are bad days.

There are.

And we have to recognize that these are bad days and consult differently.

And I think that's part of normal general practice.

It's perhaps not this gold standard that we aspire to, but actually is still safe.

My GP trainer was a firm believer in Stockton Davis, for instance, and there are still times where I can hear her voice in my head when I know I haven't done all the housekeeping type stuff that I should be doing.

And I kind of kick myself.

But that's just life, isn't it?

Like you're saying, I think in terms of how we.

How we need to practice and when we're under pressure and our mind is in five places at the same time.

Exactly.

Yeah.

Any final thoughts?

Anything else you want to add just to our chat today?

No, no.

Thank you.

Thank you for having me and thank you for.

Thank you to BJGP for publishing our work.

Great.

Well, it's been lovely to speak to you today, Andrew.

So, yeah, thanks again for, for joining us today.

Thank you and thank you all very much for your time here and for listening to this BJGP podcast.

Andrew's original research article can be found on bjgp.org and the show notes and podcast audio can be [email protected] I will try and find the link for the tactical decision game that Andrew discussed and add that to the show notes as well, in case anyone's interested.

Thanks again for your time and bye.