In the waiting room

Talking about long waits for patients to see the doctor is like touching the proverbial third rail: sure to spark frustration and anger from patients and defensiveness from the medical community.

They were at it again this week at Kevin, MD, where guest blogger Barbara Bronson Gray wrote about long waits and and delivered the ultimate judgment on this aspect of the patient experience: “Expecting me to wait a long time in the doctor’s office tells me two things. First, I don’t feel respected. The physician is, after all, my consultant. And secondly, I wonder how committed the practice is to my comfort and reducing my anxiety when they seem to be putting more emphasis on their needs than on mine.”

Touché.

As you might guess, it provoked a storm of reaction. “If you want Cadillac service, pay for it by joining a concierge practice,” one person snarked.

Other commenters, most of them apparently doctors, pointed out how hard it is to stay on schedule when patients have multiple and sometimes unpredictable issues that need to be addressed. “It often is not as simple as ‘they don’t care’ or ‘they haven’t prioritized your time,” one physician wrote. “It is a complicated combination of complexity of care, patient expectations to have care provided at one time (without a second visit/co-pay), primary care offices running at high capacity because of a workforce shortage, etc.”

I’m not sure doctors and patients are ever going to see eye to eye on this issue. But there’s no denying that wait times are a major source of frustration for many patients, which begs the question: Is reducing the wait time truly an impossible task, or is it simply not a priority for most medical practices?

And a corollary question: How long should patients reasonably be expected to wait? Is 20 minutes acceptable? What about an hour? What about two hours?

There’s been a considerable amount of study on wait times, what contributes to them and how to reduce them. To be sure, the problem sometimes rests with patients who don’t show up on time, aren’t organized during the visit or wait until the final moments of the encounter to bring up an important issue. But medical practices are kidding themselves if they don’t think they’re contributing to the problem as well.

A few years ago the American Academy of Family Practice hosted a national demonstration project on the patient-centered medical home model that included intensive evaluation of patients’ experiences. Among the issues studied were wait times, which resulted in the uncovering of some interesting data.

Patients were given a clipboard and pen when they arrived at the doctor’s office and asked to record the time at each point during the visit: when they arrived at the office, when they were ushered into the exam room, when the doctor arrived in the exam room, and so forth. There turned out to be multiple bottlenecks, ranging from cumbersome paperwork that patients had to fill out to staff inefficiencies in patient flow and setting up exam rooms between appointments. At some offices the first appointment of the day was scheduled for the same time the staff showed up to work, inevitably resulting in delays. In other cases, the practice didn’t have an appointment schedule that was flexible enough to allow for emergencies or for the patient who needed a longer visit. Sometimes doctors simply weren’t very punctual.

The best time that a practice in the national demonstration project was able to achieve? Thirty minutes, from start to finish (although this practice did not have any ancillary services, such as lab or X-ray, on site).

Dr. Melissa Gerdes describes how it was done:

They were able to achieve a 30-minute cycle time by working closely in teams. They even designed their office space to put all team members, from front-office staff to physicians, in close proximity, which encouraged ongoing communication throughout the day. They started on time. They staffed appropriately and scheduled realistically for the work capacity of the day. And they made being on time a priority.

Consider the example of several health systems that have adopted so-called lean processes that, among other things, cut down on the amount of time patients spend waiting. At a children’s hospital in Wisconsin, the time in the exam room between when the patient arrived and when the doctor came in was reduced from 38 minutes to 11 minutes.

If there’s a common thread here, it’s that the organizations that reduced their wait times were successful because they made it a priority.

What’s a reasonable amount of time for patients to wait? The national average, according to a recent report by Vitals, a physician review site, is 21 minutes. It varies regionally, from a low of 19 minutes in the Midwest to a high of 22 minutes in the South.

What’s unreasonable, then? Here’s a frustrating story from someone in the Boston area who brought a family member to an appointment, struggled with heavy traffic, couldn’t find a place to park, dropped off his relative so she could arrive at her appointment on time – then got lost trying to find the right clinic.

He recounts:

On finally reaching the right clinic, I found my family member patient still in the waiting room. She had not been told by the front desk the doctor was running behind. However, we learned from other patients who had been waiting for up to an hour and a half that she was running behind and that it is possible to give the front desk staff a cell phone number and to leave to get some lunch. We were not offered this option, but when we went to the front desk to ask, we were allowed to do this. On coming back, we still had to wait, and were finally called in at 1 p.m. (for an appointment time that was for 11 a.m.!).

Is this disrespectful of the patient’s time? It would be hard to disagree that at some point, lengthy wait times cross the line from minor inconvenience into major headache – more so if the wait time is poorly managed by organizations that come across as tone-deaf to how patients feel about long waits. Zero wait time may not be a realistic goal but many wait times clearly could be shorter and better handled than they are.