Effective Time Management: Surgery, Research, Service, Travel, Fitness, and Family

Abstract

Over 1,500 years ago, the St. Benedictine Monks used planning and strict schedules to increase their productivity. Since then, surgeons have developed several different strategies to manage our time effectively. Finding a balance among career, family, and hobbies is essential for maintaining satisfaction and optimizing productivity. Several recurring themes throughout the medical literature offer potential solutions to help maximize the little time surgeons possess. In this article, we will explore some of the methods and strategies available to help surgeons minimize waste and make the most of the most precious commodity we have—our time.

Objectives: On completion of this article, the reader should be able to summarize the history of time management, the recurring themes in medical literature, and how to apply these concepts to achieve their career goals.

“Lost time is never found again, and what we call time-enough, always proves little enough”——Benjamin Franklin 1758

The History of Time Management

Few resources are as precious and limited as time. Today's world operates at a lightning fast pace where every second counts. To make each moment worthwhile, it has become critical that we develop effective time management strategies. Historically, as our demand for efficiency and productivity have increased, so too have our attempts at controlling our schedules and managing our time.

Be assured, time management is not a new concept. In fact, the history of time management actually predates “time” itself. Before mankind had invented the calendar, sundial, or clock, we had a primitive understanding of seasons, sunsets, and sunrises, and understood how important optimal timing was with regards to successful farming, hunting, and migration.¹ The first peoples to use daily schedules and strict planning were probably the St. Benedictine Monks in the sixth century AD.² Their discipline allowed them to accomplish more in 1 day than anyone thought possible. Due in large part to their unique obedience and planning, they were able to flourish as authors, healers, scholars, and religious leaders.

Similarly, 500 years ago Leonardo Da Vinci, the “Renaissance Man,” accomplished more in the realms of art, science, and literature than anyone could have imagined. Despite his innumerous monumental achievements, he constantly felt plagued by inefficiency and wasted time. In addition to attempting radically new sleep/wake cycles, he also undertook several different methods to increase personal productivity.³ Da Vinci would sleep for very short periods of time (less than 30 minutes) several times a day. This method, known as polyphasic sleeping, allowed him to spend only 2 to 4 hours sleeping each day.⁴ In addition, he even practiced taking notes with one hand while drawing with the other.⁵

However, it was not until the industrial revolution of the 18th century that the philosophy of time management grew exponentially. This large shift toward an emphasis on efficiency is thanks largely in part to contributions from innovators such as Adam Smith and Eli Whitney.^{6 7} In 1776, Adam Smith wrote The Wealth of Nations and brought to light novel concepts such as the division of labor and defined productivity as the production of either goods or services.⁸ Today, this still stands as a fundamental work in economics and nation building. Eli Whitney capitalized on these fundamentals and together with interchangeable parts (a boldly new concept at the time) was able to produce cotton and firearms at record-breaking rates.⁹ At the turn of the 18th century, national productivity was at an all-time high. Instituting assembly lines and the concept of shift work allowed goods to be manufactured at an unprecedented rate.”

Benjamin Franklin, widely considered as the father of modern time management, put it all together and developed many of the common time management strategies we still utilize today. His essay entitled “The Way to Wealth” is a collection of adages and suggestions that were published in the Poor Richards Almanac from 1732 to 1758.¹⁰ His philosophy put an emphasis on being efficient, planning, and working hard to get the job done. “Time is money,” “Don't leave 'till tomorrow what you can do today,” and “Early to bed, early to rise, makes a man healthy, wealthy, and wise” are just a few well-known quotations illustrating his values.¹¹

As the world continued to progress, time management and efficiency became increasingly important. In 1959, James McCay published the first book strictly dedicated to the art of time management, and since then there have been thousands of publications on the subject.¹² An Amazon.com search reveals over 100,000 hits. The World English dictionary has over 60 phrases related to “time.” David Allen, author of “Getting Things Done,” created his own company that specializes in time management, resourcefulness, and personal productivity. With proven success and widespread high demand, his company is now an international, multimillion dollar corporation.¹³

Given the exponential increases in innovation in a global economy, set in the era of “24/7” social media, there is an ever-increasing demand for efficient productivity. Industry requires up-to-the-second information and accountability. In fact, several authors hint at time becoming the currency for the new millennia (a concept exemplified in the 2011 movie “In Time” starring Justin Timberlake).^{3 14} Despite the logical importance of efficiency within business, the health-care industry still lags woefully behind. With the various time demands, doctors are often disorganized, hospitals become inefficient, and national health care winds up increasingly wasteful. Teaching time management and efficiency skills is rarely seen in today's medical school, residency curriculum, or clinical practice, and is largely left to be learned through trial-and-error method or not at all. In addition, there are ever-changing requirements for increased documentation, electronic medical records, billing, coding, etc. Together these can combine to create immense physician frustration, inefficiency, and burnout rates in surgeons that approach 50%.¹⁵

The ultimate goal is to develop a schedule that meets the needs and desires of the individual physician. This agenda may be vastly different from one surgeon to the next, and may even evolve significantly throughout one's career. In general, surgeons live chaotic lives. Our professional lives are filled with clinical duties, greater administrative responsibilities, increasingly less time in the operating room, and even less time spent at home. For academic surgeons, research and training residents/fellows is an additional task. For those who chose a community-based practice, managing a business and devoting time to the local community are commonplace. Military physicians have service obligations to their troops and their command. Already, the time allotted to family, pets, travel, leisure, exercise, etc. can be very limited or even nonexistent. Although the daily goal often starts out to “Dominate!” the road is frequently paved with obstacles. Therefore, it is particularly important that we develop excellent time management strategies as early in our career as possible to maximize efficiency in all areas of our lives.

What Does the Literature Say on Time Management?

Despite an overwhelming amount of literature on corporate level time management strategies and policies to improve efficiency in industry, there is very little published regarding physicians–and lesser still specific to surgeons. The diminutive amount of medical literature that does exist originates almost exclusively from primary care physicians in the outpatient setting. With a wide variety of practices, preferences, and personalities, it is easy to imagine the breadth of proposed solutions. Rather than regurgitating the entire spectrum, we will focus on the recurring themes that are the backbone of numerous publications. It is important to note that we understand many readers will find some aspects of these time management strategies to be extremely helpful and others ineffective. Furthermore, some are so obvious and straightforward that it may appear almost condescending. However, as the author Richard Bach said, “The simplest things are often the truest.” Ultimately, the most important goal is finding which method(s) work well for you and then implementing them.

Prioritize

Our time is incredibly valuable to our patients, our families, and ourselves. It is important not to spend too much time on the unimportant. Parkinson law states that it is human nature to spend inappropriate time and energy on insignificant tasks that are perceived as important, rather than those of true importance.¹⁶ Pareto's Principle, also known as the “80/20 rule” or the “law of the vital few,” states that 80% of our results come from 20% of our time/energy. This does not mean we have to settle for 80% or “B-” outcomes, rather it emphasizes that generally 8% of our goals are completed easily, whereas inordinate amounts of energy can be required for the remaining 20%. The solution to these dilemmas is to prioritize your goals.¹⁷ This can be done with daily tasks as well as career goals such as 1-year, 5-year, and 10-year plans. Yet, before you can start to manage your goals in life, you must first define and prioritize them.

Manageable, Realistic To-Do Lists

One of the most recurring themes in the literature is the emphasis on creating lists and ranking them in priority order.^{3 18 19 20 21} As an analogy in the personal finance arena, you cannot create an effective budget without first identifying where and how you spend your money. Most authors recommend ranking items by priority and urgency. This has the dual benefit of creating a concrete list to help us stay on track as well as helping to guide which tasks get completed first. In general, there are four categories: (1) urgent and important, (2) nonurgent and important, (3) urgent and not important, and (4) nonurgent and not important. Clearly items in number 1 need to be dealt with now, number 4 issues can be delayed, and numbers 2 and 3 can be dealt with as soon as there are no more urgent/important issues.

This concept can be applied to daily activities (talk with the clinic nurse, edit a manuscript, and daily ward rounds) as well as more global aspects of our lives (research, family, church, etc.). Naturally, these lists will be dynamic and items are expected to shift into and out of categories as circumstances change. Factors such as the meaning of the task to others (i.e., your supervisor), or the degree to which you are asked to do new projects commonly cause these fluxes in significance. What is important is that the physician makes a list, works to complete the tasks, and continually updates and reassesses the list so that it accurately reflects his/her goals for the day or for their career.

It is likely more essential that the list is manageable and reflects what is practical and pragmatic. Tasks should be classified objectively and planning should be realistic. The list does more harm than good if it is unrealistic, unruly, or inaccurate. At a minimum, there should be two mandatory time slots. The first should be private time for you.³ What is done during this time period or its duration is not as important. It is up to you—do what you enjoy and make sure it is long enough so that you feel rejuvenated and fulfilled. The second mandatory slot is for unforeseen delay. Unfortunately, delays are a guaranteed part of life and every day seems to bring a new interruption. If you allow a small “fudge factor” you will be more consistently on track, or at least more able to catch up.²²

Saying “No” and Delegating

As physicians we are leaders. As surgeons, most of us feel that the way to ensure a job is done right is to do it ourselves. Although this may be accurate, it is impossible to give all things our undivided attention. We must learn to delegate responsibility and limit our commitments by occasionally saying “no.” Saying no to a colleague, boss, or loved one can be extremely difficult at times. However, this can be an extremely important step toward protecting the limited time we have. Several authors have illustrated that learning professional and considerate methods to decline new responsibilities can significantly improve job fatigue and feelings of being overwhelmed.^{3 21} Some providers have such difficulty saying “no” that they overcommit, overextend, and frequently find themselves exhausted and overwhelmed. This is an extremely common difficulty in every profession and there are entire books, Web sites, videos, conferences, and manuscripts committed to the subject. Some articles even offer physicians very specific methods to say “no.”²³

It goes without saying that you also have to be cognizant of the offers that you decline, especially early in your career. Opportunities may arise, that while they may stretch you, are too good to pass up and not likely to come your way again. Similarly, while refusing once may be understandable (especially with a courteous explanation to those propositioning your help), several “no's” are likely to find you without future tenders. Depending on your workload, future goals, and person requesting, you may want to take this into consideration. In contrast, overextending yourself, not following through, having significant delays in completion, and turning in shoddy work is not acceptable either. In these cases, it is often better to have declined initially.

The concept of protecting our health, sleep, and schedules should not be overlooked. During present day residency, time is somewhat guarded by the Accreditation Council for Graduate Medical Education and the “80-hour work week.” For those who trained before 2003, or when recent graduates transition to practice, there are no regulations to safeguard your time. It falls completely up to the individual provider who, unfortunately, frequently neglects his/her own well-being for the sake of their career, patients, income, etc. While starting on time has more of an implication on daily schedules, saying “no” and delegating responsibility is more pertinent on the larger scale. This may require teaching office staff or junior partners skills that previously have been handled alone. Physicians that are frustrated with the lack of time spent in one arena, or the redundant time spent in another, may need to reconsider their commitments. It is no mistake that protecting our time, saying “no,” and delegating responsibility is one of the more frequently cited solutions to burnout and fatigue.^{3 19 21 24}

Start On Time and Do not Procrastinate

In 2010, Dr. Stillwagon published the “ten time commandments” to help physicians effectively manage their time and complete tasks. Not surprisingly, the number one commandment was to start on time. Falling behind early in the day is frequently cited as a major aspect in faulty time management that can have compounding detrimental effects on productivity and physician satisfaction.^{19 20 22 24} Although punctuality does not have direct implications on the “big picture” items such as balancing the time between work and family, starting on time is the most simple and doable task to maintain daily productivity, optimize efficiency, and minimize frustration.

Dr. Lowes wrote a cover story for Medical Economics in 2007 that exposed the prevalence of procrastination among doctors.²⁵ Here, he clarified the common causes for this behavior and boldly explained how to suffocate this bad habit with the utmost urgency. Frequently, procrastination was a conscience decisions made by the physician because of lack of interest or understanding. If we are confused or uninterested in something, we are more likely to put it off. In addition, procrastination is usually found outside the realm of patient care and is more prevalent in administrative, economic, or managerial aspects. Regardless, the solution is simple: Stop, now! If it is a task that will take less than 2 minutes to complete, do it right away. If not, put it on your more urgent to-do list and get it done soon.²⁵ If it is something that confuses you, either get more information or delegate it to someone with better understanding. The bottom line is we need to be more disciplined and force ourselves to get the job done or assign it to someone who can.

Multitasking

The concept of multitasking can be a little controversial. The true definition of human multitasking is focusing on more than one significant task simultaneously. This method can actually have the opposite effect in many physicians and cause disorganization and inefficiency.²⁶ Realistically, only approximately 10% (or less) of us can truly “multi-task,” regardless of what we believe.³ Today's vernacular usually implies that we are working on more than one project and commonly refers to the art of starting a new assignment before the completion of the previous. The bottom line seems to be that (1) true multitasking is rare, (2) trying to balance several tasks simultaneously can have deleterious consequences, and (3) know what works best for you.

Some of us thrive on the high-speed transition between tasks and juggling as many things at once, while others become gridlocked at the thought of moving on until the first task is completed with a level of attention needed to ensure accuracy. Recently, authors have discovered that younger people seem to be better at multitasking, even apart from texting while doing anything else.²⁷ Whether this is a generational phenomenon or purely a reflection of the aging brain is unclear. Is it because younger physicians are products of the electronic age or is this difference purely because of reduced neurophysiologic conduction? Facebook, Twitter, Wikipedia, 4G, and so on allow us to process information and interact at lightning speeds. Teenagers can read their email, check the football score, and blog about the presidential election with one hand during a commercial break. A meta-analyses review comparing college-aged students to the elderly showed that our ability to “dual-task” tends to drop with age. Elderly participants seemed to have more difficulty maintaining concentration in more than one global arena (i.e., “task switching”) suggesting that multitasking becomes more difficult with age.²⁷ Truthfully, learning and multitasking are complex skills that are influenced by several different factors. Hopefully, further discovery will lead to better understanding and increased efficiency for each individual.

Final Thoughts

You may now be asking, “Okay, so where do we go from here?” The difficulty with this subject is not in understanding complex concepts, but rather in applying the material to everyday life. Time management for surgeons can be broken down into two major phases: the daily schedule and our overall career goals.

Thankfully, being efficient on a daily basis can have profound implications on your overall productivity and satisfaction, even beyond 1 day. Prioritize your daily goals and create a list. Start on time and work your way through a “to-do” list. Do not procrastinate; it is all too easy to get sidetracked or to put things off. We must stay disciplined and maintain our focus. Do not be too rigid, however, as physicians must remain flexible and expect some unanticipated delays. That is just a part of our profession and our lives. Look at the fluidity and uncertainty of medicine as a blessing and not a curse.

When it comes to your overall goals like your career, travel, leisure, and family, the same concepts apply. Prioritize your goals—whether they may be to take your children to school once a week, climb a mountain, or visit a country. Our goals must be realistic and manageable. This is why prioritizing them is so important. How important is publishing? Do you want administrative responsibilities? Have you always wanted to coach little league? The first step is making sure you have optimized your daily schedules and efficiency. However, the unfortunate truth is that there is still only so much time in a day. Although becoming chief of surgery, President of the American College of Surgeons, research guru, operative wizard, and board member of the local Parent Teacher Association would all be remarkable achievements; this may simply not reasonable, or likely.

Surgeons must limit their obligations and protect their time. The best way to do this is by learning effective and professional strategies to say “no.” Yet, decline the “right” things, not necessarily those that will ultimately truly help you achieve your most important goals. Think of each offer or new responsibility as a compliment and blessing rather than a hassle. Never commit to anything instantly, but think it through. Take some time to assess how this new “job” will fit with your goals. If it is seems to be something desirable, where is it going to fit into your priority list? Chances are, time will have to be taken from one of your existing responsibilities or hobbies to make time for the new assignment. Is this acceptable? Does writing a chapter on “Time Management” help you manage your time? Maybe for some, not for others.

There is no set template for the right amount of time spent in the operating room, research laboratory, gym, or clinic. Do not underestimate the value of staying healthy, exercising, and getting sleep. A total of 20 to 30 minutes of exercise in the morning before showering (which you likely do every day anyway) may pay invaluable rewards toward your health, self-esteem, and likely overall energy level. Continually, reassess you current condition and compare it with your ideal situation. Adopt changes, and make the adjustments needed to merge the two into one. As you transition through your career, your ambitions, goals, and attitudes will change. If you find yourself no longer pleased with the status quo, change it.

If you are having difficulties, ask the advice of a respected colleague or mentor. Chances are that they can give excellent insight from an outsider's perspective and offer unbiased guidance. It was surprising that noticeably absent from the recurring themes in literature was simply reaching out and asking for advice. It retrospect, it seems logical because most physicians embrace the “get the job done yourself” mentality. However, seeking the counsel of someone who has likely “been there and done that” can be innumerably beneficial.

The bottom line is that you need to find what works for you. Use bits and pieces from each of the above suggestions to create your own individualized plan. Each of our solutions will all be a little different. Once you have a developed a successful method, stick with it, be disciplined, and give 100% to what you are doing at that time. At the same time, plan in advance to reassess along the way and find out how you can improve, and what needs attention. If you find yourself worrying about the office when you are at home, you need to assign more time and energy into completing the essential tasks at the office before you come home, so that you can be 100% present for your family. Likewise, if at work you are distracted by the guilt of missing your child's soccer game, you need to leverage in more time with your family. Be resilient. Both your day and career can seem completely out of your control at times. Stay positive. A small-calculated adjustment today can result in profound change for the future. One of the joys of medicine is the endless options it offers, its constant challenges, and its consistent changing. Use this flux to your advantage. Explore new aspects of surgery and design your career to involve features that energize and excite you. Although “Dominating the Day!” is a mantra to some, 5 minutes of peace and quiet is priceless to others. Simply put, time is the most valuable commodity we have. It must be fought for, defended, and protected with the utmost priority.

Time stays long enough for anyone who will use It.

—Leonardo Da Vinci