A word of warning: this article is much longer than usual.
Recently my nephew, Tim, who is a senior in high school, asked me for help on one of his school projects. He was asked to select a frustrating situation he has encountered in his own life and explore the reasons for the frustrations. Tim has some severe back problems, so he has had a lot of doctor visits and chose the topic of patients’ frustrations with long wait times in medical offices. He provided me with a list of very high quality questions that explore this situation. (What do you expect an admiring uncle to say, right?) After I finished my answers, it occurred to me that others may be interested in what I am sharing with him in my answers. Too long a wait time one of the biggest complaints physicians hear, and one of the most difficult to eliminate.
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I will be drawing from three different sources in answering your questions. You might say each of the three provides a specific perspective from which to view the questions. The first is from my own personal attitudes and habits. The second is from the way our office tends to run that also includes the input of my three partners as well as the rest of the office staff. The third is from my observation of what happens in other offices, mostly from reports and complaints my patients provide to me when they first become my patient or after a referral to a specialist.
It seems to me that my answers to your questions has more to do with the way healthcare is evolving in modern society than it has to do with the individual people that happen to go into medicine. My consistent observation over the years is that the people that tend to choose medicine as a career tend to be some of the most selfless, caring people you find anywhere. However, many get very frustrated by the realities of medical care as it is currently practiced (and financed) and some tend to get jaded and can seem to lose this caring attitude with time. The truth is that physicians are like everyone else and respond to the sometimes harsh realities they face in their work.
What underlies all this and tends to distort the attitudes of caregivers over time is the fact that healthcare insurance and financing is a very broken non-system, at present, in the US. Every year for the past twenty years or so, most physicians have been getting paid less by insurers for the same services they provided in earlier years. Every year we also pay more for office space and supplies and salaries for our staff. What this means for someone in private practice is that to just hold the line and try to make what you did in earlier times, you must see more and more patients. In reality, you do often end up seeing more and more patients, spending less time with them and still making less for your efforts than you did in the past. I hear the argument that this is not a problem and physicians are over paid anyway. Given the number of years of training and the sacrifices that medicine often requires, I do not think this is a valid argument. The result of all this is that more and more physicians are leaving private practice and joining large healthcare systems as employees. In some ways this further aggravates the kind of problems we are discussing. As an employee, when your employer directs that you must see more patients and spend less time with them or that you must provide your services in a way you find to be less than optimum, you often have little say in the matter if you want to stay employed.
To answer your very penetrating and complex questions for your project, I am going to focus on answering these questions from my own personal perspective (the perspective I am most sure of and comfortable with). I am sure that what I say applies to many other physicians. I am also sure that what I say will not apply to some others. I know there are specialists here in Albany (particularly a few of those who do not have any competing specialists near by) who routinely allow their patients wait for hours. If I were that inconsiderate in my primary care practice I would quickly go broke.
1. How far apart do you typically book patients?
I typically schedule my first hour at the start of a morning or an afternoon session with an appointment every ten minutes. After the first hour, the rest of the session is booked every fifteen minutes. This type of scheduling helps to compensate for the no shows that almost always occur but are not very predictable. Believe it or not, it is very common for people to make an appointment, not show up and not call. This type of irresponsibility hurts everyone involved, particularly those who would never be a now show.
2. How long, if any, do you think the average waiting room delay at your office is?
The people scheduled for the first slots of a session are almost always on time. As the session proceeds, the chances of having a delay go up higher and higher. At the very end of the session, it is not uncommon to have waits that can approach an hour or more. Not always, of course, but it does happen. Keep in mind that when my patients are late, so am I. This can mean that not only are they inconvenienced, I might miss lunch or end up coming home much later at night than I would otherwise. In addition, when I know my patients are waiting, I tend to get stressed and tense. This is not the way I like to work. I do everything I can to avoid having my patients wait as long as it is still consistent with good quality care (that is, does not involve rushing people who require extra time).
3. In the event of a delay, how long is it into the average day before the delay becomes noticeable?
As is implied by what I say above, delays have immediate impact and accumulate during a given office session.
4. Do you inform patients of delays?
As a practical matter, I cannot personally inform patients of delays, this would only make the problem worse by delaying me further. I rely on my staff to do this. We always try to hire only compassionate, caring people and we physicians must rely on them to use their judgment to keep people informed about delays. My staff knows that I want people to know when we are getting behind, but they are only human and have a lot on their mind. Oversights happen, but we try to minimize them.
5. How often do you remain right on schedule for the entire day?
Rarely. If I were to arrange my schedule so that I was almost never delayed, that would mean I would frequently be waiting around for the next patient after someone no-showed. My productivity would go way down and my office would likely fail financially due to the very high fixed costs that must be paid before any salary can be taken home.
6. If a delay occurs, are you bothered by it?
As I said above, yes, always. For me this is one of the major work stresses in medical practice. I do not feel comfortable when I know people are waiting. I should be more used to delays, I guess, since it is virtually impossible to avoid in modern medicine and I have had plenty of years to adjust.
7. Have you ever made any attempt to reduce waiting room delays? If so, what did you do and how did it work?
I have systematically studied the flow of patients through the office on several occasions. This is difficult to do, but I am sure that if I could just find a way to eliminate most waits, everyone would be happier. Here is what I have found in these studies. It takes about fifteen to twenty minutes between when a patient signs in at their appointment time until the staff can do all they need to do to get them into my exam room and have everything ready for me to visit with them. This is about how long it requires even if everything runs perfectly and smoothly. This is not a delay, but it means patients are usually seen about twenty minutes after their scheduled time. There are many things that can interrupt this ideal and cause delays before I even have a chance to see patients. We study these occurrences and have gotten pretty good at avoiding them. Our success in avoiding these kinds of delays is mostly due to an excellent office manager who hires excellent staff. As I said above, the longer a session goes on, the higher the likelihood of additional delays from responding to what my patients need. This is because when people have unusual problems and are hurting or in danger, I never ignore this or rush them through the office visit. This is why they come to someone they trust. If it takes an hour, it takes an hour. Patient comfort and safety are always the number one priority and are an unavoidable source of unpredictable delays. My patient wait time surveys confirm these observations and have not turned up any clever answers to this problem (much as I wish they would).
8. Have you ever had to wait on a delayed medical appointment? If so, how did it make you feel?
Of course I have. I did not start medical school until I was in my late twenties. I do remember my experiences from back then; I was easily frustrated by waiting. From what I know now, though, I bring a good book with me to read and plan on spending whatever time it takes. Because of what I know about the realities of medicine, I am very understanding about waiting my turn. However, if I had to wait for hours, I would be ticked off, as you can imagine.
9. Are work-ins ever seen before scheduled patients?
Only when a gap develops that does not delay scheduled patients. Our office runs by appointment only (not all medical offices do). If someone just shows up in the office without an appointment, and is not sick enough to be sent immediately to an emergency room, and is in pain or distress, I will see them first and others just have to wait. This is very rare.
10. If a patient has an unforeseen problem that you know will cause the appointment to take longer than the time allotted and therefore delay other patients, what do you do?
I take care of the problem. Think of it this way. If someone has a significant problem, what do you think they want me to do? What would you want done if it were you? Sometimes, non-emergent problems can be referred out to others, when appropriate, or another visit can be arranged if the problem is particularly difficult and time consuming. Usually, it just causes delays. This is a part of medical practice that cannot be reasonably avoided.
11. How severe would a patient’s condition need to be for you to consider seeing him/her after hours?
Once our office closes, there is no staff to help me care for people. Therefore, seeing someone after hours in the office is not an option. I will occasionally begin treating someone and have them rest while the medications or treatments take effect and get back to them later, but this is rarely needed. Generally, severe problems are admitted directly to the hospital or sent to an emergency room. I rarely see “house call patients.” If I do, I do not charge them.
12. How willing are you to admit to a patient that you made the wrong diagnosis and/or prescribed an incorrect treatment?
It may be tempting to cover up a error that a patient is not aware of, but a cover-up is always a mistake, in my opinion. I know I am only human. I am comfortable with the concept I do sometimes make mistakes. When it happens, I inform the patient or the caregiver (unless the mistake has had absolutely no consequences nor foreseeable consequences, in which case bringing it up serves no useful purpose). If I make a mistake that causes harm, even if the harm is minor, the best thing for all concerned is to explain it right away. When I go to sleep at night, I do not want such things disturbing my peace of mind. People respond to honesty quite well, even when they have inadvertently been harmed. A much bigger and a much more common problem is how to handle people who believe you have made a mistake when you haven’t. (You didn’t ask about that. I won’t go into that since this is already long enough.)
13. How long would you continue to attempt to treat a patient if every treatment you prescribed kept failing?
There is always more I can do. I never give up when a patient wants me to keep trying. I am not talking about me trying to treat a problem, though, that I am not the most qualified to treat. It is important to know when this is the case and to get them to someone more qualified if it is the case. That’s why I spent seven years in training – to know this thoroughly. If I limit your question to those situations in which I clearly am the most qualified to treat, it is usually the patient’s attitudes or non-compliance that gets in the way of potential success. Also, effective treatment can result from just listening carefully and educating the person about the treatment options, often using some of the many symptomatic treatments that are always available. The relationship and trust a patient has in their physician are powerful therapeutic tools. (Unfortunately, this is something many “managed care” insurance plans have no concept of.)
14. Before offering a diagnosis, do you ever ask for a consult or second opinion?
When I have taken a good history, examined my patient, and done appropriate tests (usually designed to confirm what the history and physical have indicated), I then usually know what the problem is to a very high degree of confidence. In this situation, a second opinion or referral is a waste of time and money. If, on the other hand, after I have done the diagnostic work thoroughly, I still feel that there may be a potential medical problem I haven’t uncovered, I refer the patient to someone more highly trained in the area of concern. Also, if a patient fails to respond to what should be effective therapy based on my diagnosis, this brings the accuracy of the diagnosis into question and referral out to a specialist is often best. In these situations, it is usually an error of judgment to do otherwise and a common source for justifiable medical malpractice claims.
15. Do you ever compensate patients who have had a delay and/or incorrect diagnosis?
No. I never provide anyone with any guarantees of any kind. My responsibility is to do my best with my training and my experience and this is what I do. I have a simple approach. I treat every patient as if they were a close family member. If a mistake happens, this is part of life. If I were to someday be negligent or make a mistake that violates the usual standard of care and if someone is injured as a result, I would have no problem with making this clear to the patient or family and encouraging my medical malpractice company to provide reasonable compensation on my behalf.
Well Tim, if I can help further, just let me know. Like I said above, I just speak for myself here. I think I tend to hold pretty high standards and I know that there are a few others who don’t. Like any profession, there is a wide range of quality available, but there are very few physicians I have known who are irresponsible and uncaring.
Love and best wishes,
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I had Tim’s permission to publish this. As always, I will be happy to explain anything that is unclear and I warmly invite questions or comments.