Wednesday, February 6, 2013

The long wait

I remember when I was an intern, I came in to see some patient in some clinic (I like to be really specific in these details). Anyway, we were pretty behind, and the patient had been waiting a long time to see a doctor. And of course, when I got into the room, he didn't want to talk about his medical problems at all, only the fact that he'd been waiting for like an hour.

There was nothing I could say to this guy to calm him down. It was like, he'd wasted all this time waiting for us, then decided he just wanted to waste his entire appointment. And him wasting more time wasn't doing the other waiting patients any favors.

The thing is, we doctors get it. We don't like running behind. And we are patients too and have experienced it from the other end. When I was pregnant, I used to wait an hour sometimes for five minute OB checks, and it got to the point where I decided that if I had another baby (I won't), I would never use that practice again.

These are some of the many reasons why falling behind is not the doctor's fault:

1) Patients who do not show up on time throw off the entire schedule. Or a patient may show up on time and then there's some issue when they're checking in that ends in them being roomed late.

2) It can be hard to predict how long you will spend with a patient. It's not like baking a cake where you put it in the oven for X amount of time. You can't say to a patient that their 20 minutes are up, so seeya. You must address their issues and that can again throw off the whole schedule.

3) Patient don't show up or cancel at the last minute. Seems like that should make the schedule run faster, right? Not really. If you know that a certain number of patients will cancel or no-show, then in order to be able to pay your huge overhead and not starve, you have to book patients with that in mind. Then if they all show up, you may be screwed.

4) Emergencies come up frequently. In my OB practice, I know things got backed up when doctors would get called out for deliveries. Or even if it's not an emergency per se, it's some phone call regarding a patient that you absolutely must take at that moment, or something else that must be done at that moment.

5) Sometimes you are forced to overbook because a patient really needs to be seen.

I'm sure there are tons more reasons that aren't coming to mind right now.

But here's the thing that I don't quite understand:

I mentioned how long I had to wait for appointments with my OB during my last pregnancy. During my first pregnancy, I used a different practice (in a different state), and I never had to wait more than like ten minutes to get in for appointments. Ditto with pediatric practices I've used--some consistently had a very long wait, others would always take us in right away.

So what's the difference between these practices?


  1. For OB - now that I am in a bigger praactice, I am on call a particular day of the week. If you see me that day, you run the risk of me running late or seeing another doc because I got called out. Other office days, I'm not. If due to your schedule you can only see me on say Monday, I will 95% of the time be on time because I'm not on call. Another factor - every group practice that I know of tries to put OB patients on the on-call doc's schedule. They're usually quick appointments and if need be, it's easier to have another doc see them.

    When I was solo - people knew that they would get me, but they ran the risk of me being solo. I tried to be good about updating my office as to ETA.

  2. in my experience (peds), larger practices tend to be more efficient and can absorb that scheduling unpredictability better than smaller practices. if one doc is getting slammed because all of their overbooks show up, another one can grab a patient or two and keep things moving. also, some docs really think they should be able to see 6 patients per hour and set up their schedule that way; others are more realistic. that probably accounts for at least some of the difference.

  3. My best Doc had a simple rules if you missed your appointment, you paid the fee he would have collected as a 'fine'. if you were late and say scheduled for 10:00 and arrived at 10:15 you would get 5 minutes instead of 20 (arrive at 10:21 and you missed your appointment), If you were on time and say had a 20 minute appointment booked, you would get 20 minutes and a well we can;'t cover this this ti,e but it doesn't appear urgent, so tell the reception to book you another appointment and we will get into why you have an itchy toe. The only time I had to wait, i saw them taking out the previous patient by ambulance.

    Some would say it's rough but on your first visit you were told this is how the practice works and just as it's not fair to make you wait because someone was inconsiderate, it's not fair for you to make someone else wait. They also suggested strongly having a list of what you wanted to discuss so the doctor could look it over and prioritize things.


  4. I think it has to do with an ability to organize priorities. I recently quit my children's pediatrician for their terrible wait times and inability to bill by insurance properly.
    To be fair, they accepted any drop-in patient, which is helpful when dealing with children's illnesses, because they often come on suddenly (like ear infections). However, it is not fair to patients who are there for a follow-up, or allergy injection, or who had an appointment scheduled for a routine check-up to have to wait upwards of 2 hours before seeing the doctor. There should be two queues: one for people with appointments, and one for drop-ins. This office makes no distinction.
    It is no surprise that the office manager is the same person who continued to submit my claims under an incorrect group number after I provided the correct one, and repeatedly called to remind her of the change. It went on for over 8 months until she finally billed the correct group number, at which time the claim was considered "too old" and my insurance refused payment. Unfortunately, the office manager is the pediatrician's wife, so it's not as if I could complain to him. Since I work in a pharmacy, I know many other people who use that Doctor, and many of them have the exact same cmplaints- so it's not just me.

  5. I am a psychiatrist and do 15 minute med checks- I schedule 3 an hour which gives me catchup time. I run on time or early- patients are told if they are more than 5 minutes late they'll have to reschedule. I use my catchup time to return phone calls, usually within the hour, so that alleviates crises. I don't see crisis patients because it's too difficult to admit from the office. I haven't been more than 2 minutes late with a patient in months. Patients respond well to the boundaries and know what to expect.

    1. well it's kind of easy to stay on schedule when you are just doing a med check and not actually taking the time to talk to the patient about the underlying issue(s) that is necessitating the meds in the first place.

    2. I know what's going on with my patients- usually more than the therapists who see them biweekly for hour appointments...I have many patients who consider me their therapist even though I am allotted less time to spend with them. I take pride in my efficiency.

  6. I agree with anonymous. If you want a doctor that runs on time, see a private practice psychiatrist. It may be hard to get a new patient appointment, but that is because your time is your time. No double or triple booking.

  7. Not really related, but I always wonder: what kind of especialty do you work in?

    The thing with punctuality, yes, you are absolutely right: how do some people manage to always be on time, while others don't? Mystery...

  8. Sometimes the doctors are just incredibly efficient or see many of their patients frequently enough to know exactly what was going on with them (my family med attending could do many appointments easily in 10 minutes because she saw every member of the family, knows their entire pmh and social history and could get an interim very quickly). Other times, how far behind a doctor is can unfortunately be a reflection of how much they care. I had one attending who never ran behind, but he also hardly touched a stethoscope to a patient's chest, wouldn't let me give him a proper HPI on the patient, and frequently wrote (improper) prescriptions for patients before we even entered the room (and if they objected to that medication for some reason, he'd say it was too late since he already sent it to the pharmacy).

  9. It's all about the style of practice. I've worked with multiple private practice docs, in both solo practice and small group practice, as well as outpatient university.

    The doc I worked with in solo practice had his practice set up so that he saw follow-ups or well checks in the morning, and sick or urgent visits in the afternoon (or in the hour between when the office opened and when he 'officially' started seeing patients). He saw patients every 15 minutes, and kept it that long (and expected me, as a third year student, to do the same). His patients almost always arrived to an empty waiting room and he was very, very rarely more than a couple minutes late. He was internal medicine.

    The small group practice I worked in, one of my preceptors saw patients every 20 minutes, and was pretty good about keeping on that schedule. Every so often, he'd run a little behind, but he'd almost always make it up by the end of the day, so no patient had to wait 5 minutes past their appointment time. One of his partners had a similar schedule, but would take much more time to address all the patient's concerns. She was a lot less efficient, but patients liked her because she was very personable and tried to address all their concerns. She, however, often worked through lunch trying to make up the time she took with patients in the morning, and stayed late seeing patients until 5:30 or 6 in the evening(whereas the first was always done at 4:30). Both attracted a certain kind of patient... the first, more men who were used to bluntness, and the second, more women who were much more talkative. Both were family medicine.

  10. The NP treating one of my clients (developmental disabilities) was always 1 hr late. One day I overheard another patient complain about it....I could tell that the head RN had had it. Her response, "talk to the NP, she cames in late every day". I wanted to clap, I felt so bad for the front staff & nurses who got to hear all the complaints. And not sure what happened but the clinic has new NP's. Yippy

  11. A lot of it can depend on the patient population - if you work in an inner-city centre with patients who have a lot of psychosocial issues (which is the case for a lot of the teaching centres), the appointment times will just take longer because those patients just take longer to deal with. If you're working in a middle-class, suburban practice, things can run much more smoothly. Also, some clinics are just more efficiently run -- like having techs put patients in rooms, do the BPs and urines or whatever before you walk in. And this overall structure has to do with budget and resources, and resource allocation to best serve the patient population (for instance, in the more inner-city clinics (which likely don't have a tremendous budget to begin with), it may be better to spend the money on social workers or NPs who can take some of the load of the physicians vis-a-vis the patients with heavy psychosocial needs, rather than on techs). Some of it also luck -- some days run really smoothly, and other days you get nothing but complicated and unpredictable patients.

    One thing I can say is that it usually has little to do with the skill or "efficiency" of particular physicians. I've done family practice in various settings, and in some places I've been known as a "fast doc" and in others, I feel like I'm always running behind. It's just one of those things that's out of your hands - it just is what it is.

    ER MD

  12. My doctor is almost always late, and we have learned to live around it. We bring books. She is an amazing doctor and gives each patient the time they need. We have booked in what we thought was a quick visit, and ended up being in with her an hour, and showed up with no appointment on her step with bleeding kids. Her personal attention takes time. We have been to other doctors where they have said 'Im sorry, you will need to come back because this will take longer than your appointment is scheduled for'. From my perspective, having her dedicated attention rather than looking at the clock is well worth the wait.

  13. I have one doctor whose office staff can tell me how late he's running (he's always running late, it's just a matter of degree). I used to wait an hour or two, but now I call first and just head to the appointment later. It's fantastic.

    My pet peeve is when I'm taken into the examination room quickly and the majority of the wait is in there. Waiting rooms are filled with things to help you to pass the time, but the exam rooms are sparse.

  14. I am an NP and work in Peds with one MD. In the four years we have been together we RARELY run late. Reasons are we don't double book. Pts who miss or are late too many times are fired. We don't allow Pts to throw the wild card "by the way" at us. If we have the time for a by the way we give it, if not we explain that that is a separate visit. And our receptionist rocks. She knows who runs late or early on our Pts and schedules accordingly. 99.9% of the time there is zero wait.