“Time is an ocean, but it ends at the shore”, sang Bob Dylan. I think this is a good metaphor of how time seems to a freewheeling young person, who both feels that their youth will last forever and knows the truth of their mortality.

However, for many clinicians, especially GPs, time is more like a series of small, leaky buckets in a bathhouse. We are the robed attendants whose job it is to clean each patient as best we can before the bucket runs out. They come anticipating a luxurious sunken bath, while we wonder if we can get away with a quick sponge to the armpits and crotch.

Managing time effectively is one of the biggest challenges in clinical practice. Like water, it is becoming increasingly precious — our stress levels rise dramatically when we feel we’re spending too much of it. But sometimes we have no choice.

Take Gary, a middle-aged man I’ve been seeing for a few months. He’s a health professional and seems a fairly typical bloke. Overweight and a bit grumpy, he’d had a few headaches and just wanted a blood pressure check. Not surprisingly, his blood pressure was elevated, and he had mild dyslipidaemia to go with it. He doesn’t smoke and admitted to only two or three schooners every now and then, but denied any other significant history — he just wanted his blood pressure controlled. There was nothing to suggest a neurological cause for his headaches, so I duly trotted out the lifestyle advice (which he already knew) and started him on an antihypertensive.

Over the next 3 months his blood pressure improved a little and he said the headaches had lessened. Then he didn’t show again until it was time for a repeat script. His blood pressure was still suboptimal, and I began talking about adding in another drug. He told me he was thinking of changing jobs. At this point, I finally noted his bleary eyes, haggard face and dull expressionless voice, and realised that this would not be a one-bucket consult.

John was deeply depressed and self-medicating with 10 schooners of full-strength beer daily. He was highly anxious at work, to the point of having panic attacks. He was subject to a range of post-traumatic stress symptoms from his recent close involvement with a variety of distressing incidents including violent suicides, horrific burn injuries and serious child abuse. After such events he had been the one organising care for traumatised staff, but had not himself been debriefed. In addition, he had major personal stress from conflicts in his own family. His overall distress was augmented by a deep shame at his inability to cope with situations.

If this were an inspirational example for general practice trainees, this three-bucket consultation would result in Gary receiving successful treatment for his post-traumatic stress symptoms, leading to more moderate alcohol use and better control of his hypertension and other vascular risk factors. His workplace would retain an experienced staff member it can ill afford to lose. But reality is somewhat less committed to happy endings and, although I’ll do my best with this new information, I don’t yet know how Gary’s future will pan out. Only time will tell.

Some patients do require us to spend time if we’re to have even a small chance of success but, much as we’ve come to disparage “6-minute medicine”, good practice isn’t always about giving more time either. Just as health expenditure if unchecked could expand to swallow the whole state and federal budgets, we all know patients who would gladly guzzle entire sessions for very little benefit. In the end, time management is a zero-sum game. You can try and cheat a bit by drawing on a bucket you’d put aside for yourself or your family, but in the end Gary’s extra buckets mean wet-wipes only for others in the waiting room.

You can tell a lot about our professional values from the way we manage this precious resource. As clinicians we tend to be highly focused on our relationship with individuals rather than populations. Our highest loyalty at any particular moment is to the patient in front of us, followed by those in the waiting room, followed by the rest of our regular patients, with the general populace a distant fourth. We all know that tackling Australia’s undiagnosed mental health problems, for instance, would take far more GP hours than are available. Yet, we would strenuously resist any attempt to force a compromise between patient load and quality of care.

Einstein may have shown us that time is relative, but our commitment to giving individual patients the highest quality of care remains absolute.