Inbox Strategies

What are the best ways to manage an inbox?  There are a lot of productivity experts in the world – one I like particularly is David Allen of ‘Getting Things Done’ fame.  His five minute rule plus project/situation allocation works well for a variety of different contexts.  I will write very specifically about the family physician’s inbox as it is something I know most intimately.

Inbox Rules

1. Do NOT check your results more than once a week when you are not in the office.
2. Be honest about whether you can review your inbox in between patients.  Most people do much better with dedicated inbox review time.  Before clinic and at lunch are great times because if there is an urgent result, you have a good chance of acting on it that same day.
3. Acknowledge that managing your inbox is part of the work and you were paid for it when you initiated the work, either by ordering investigations or referring the patient.
4. Trust the system for communicating emergent results to patients.
5. Trust your consultant colleagues to follow up on their own results unless they are urgent or emergent.  If you see pathology results of cancer, let the patient know.  If you are not sure, create a 1-2 week followup on the result and check back at that time to see if the consultant has dealt with it.
6. When you review a result, decide which category of action it belongs in – see Inbox Actions – and create that task within your electronic medical record.  IMPORTANT: if you are calling a patient in and know what general investigations you will be ordering, do your future self a favour and write a few notes in the followup so you don’t have to think about it again.  ALSO IMPORTANT: if you know you want to recall the patient but don’t have a clear sense of what you are going to do, book the patient for a longer appointment than usual and do NOT think about it again until you have them in front of you.
7. If you do NOT know what to do with a result more or less instantly, go on to the next result.
8. Read to the END of imaging reports and consultant reports – there is often a section with “action for the family physician/ordering provider”
9. Delegate to team members – it takes MUCH less time to message staff – “lytes, Cr, u/s, UPCR, renal/bladder u/s and book f/u to review results” than it would to fill out the reqs and call the patient.  Have your staff reach out to consultant offices to clarify points in letters, inquire about appointments etc.  You are responsible for care, but it is hero mentality creeping in when you do it all.  Trust but verify with your staff – communicate these tasks using the EMR so you can see what has been done.
10. Default to having patients book appointments.  Be very choosy with which phone messages you return same day.  Be very choosy with fax refills – when in doubt, give 30 days of refills and recall the patient for assessment; consider changing your default prescription length if you are getting a lot of fax refill requests; maybe your patients with stable hypertension would do better wth six months of refills.

When you are done with this, you inbox will contain a handful of more complicated results which require some thought.  Recognize that these results are by definition neither urgent nor emergent (because you did not get a call from the lab and you did not decide to call the patient immediately).  It will do these results and the patient no harm at all to let them sit for a few days and percolate.  Likely you will want to recall the patient but it is possible you will want to order further investigations or make a referral to a consultant.  Practice sitting with uncertainty.   You are not a hero and you do not have to immediately know how to deal with every result.  You might consider calling a consultant and getting some phone advice.  You might chat with a colleague.  You might read around this case during your regularly scheduled continuing medical education time*.

*Yes, you should have regularly scheduled CME time.

Useful Affirmations

The important things to tell yourself at this time are:

1. This patient is lucky to have a physician like me, who is thinking carefully about these results and what they mean in the context of the patient’s clinical presentation.
2. I do not have to solve this problem alone – I have colleagues and consultants to ask for help if I am not sure how to interpret these results.
3. This is not an emergency – I have assessed the patient and found them clinically stable (or I would have sent them to the emergency department) and the results did not trigger either a phone call from the lab or identify a clear urgent course of action.  There is time to think about the next steps.
4. I can recall the patient and retake the history, review the physical exam, and (re)consider my differential diagnosis before deciding on my next actions.

TL;DR

Set boundaries with your interaction with the inbox and remind yourself how luck patients are to have you as their physician looking out for them.