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.

The doctor is late? Here’s my bill

After waiting two hours to see her doctor for a scheduled appointment, Elaine Farstad got angry. She went home, calculated her hourly pay and sent a bill to the doctor for her time.

“It’s ludicrous – why would I wait for free?” Farstad told CNN in a recent story for its Empowered Patient series. Over the years she has billed six doctors who were more than 30 minutes late; half of them paid her.

Few things rile up patients more than long waits at the doctor’s office. For years, most people simply complained and put up with it. But when patients like Farstad start sending invoices for their time, it seems the balance of power decidedly is changing. Especially if the physician actually agrees to pay the bill.

It’s not clear what to make of this trend, if it indeed is a trend. CNN talked to a doctor in New York who gives patients $5 in cash if they have to wait longer than 15 minutes for their appointment. Another physician in Oregon gives gifts of handmade soap or lotion whenever patients have more than a 10-minute wait to see her. Is this the norm? I doubt it (although it sounds nice).

Judging from the 1,200-plus comments, the CNN article obviously hit a nerve. A similar discussion has been raging at Kevin, MD, here and here.

The debate might seem simple. Beleaguered patients vs. greedy doctors. Hard-working doctors vs. demanding, self-entitled patients. If one thing emerges from the discussion, though, it’s that both patients and doctors are frustrated by the wait-time issue.

Do doctors often keep patients waiting? Of course they do, for a variety of reasons they can’t necessarily control. Dr. Emily Gibson writes:

The patient who is angry about waiting for me to arrive in the exam room can’t know that three patients before them I saw a woman who found out that her upset stomach was caused by an unplanned and unwanted pregnancy. Perhaps they might be more understanding if they knew that an earlier patient came in with severe self-injury so deep it required repair. Or the woman with a week of cough and new rib pain with a deep breath that could be a simple viral infection, but is showing signs of a pulmonary embolism caused by oral contraceptives.

Patients themselves can contribute to the doctor’s lateness by showing up tardy for the appointment, rambling instead of answering the doctor’s questions directly, raising too many issues to address in a single appointment, and waiting until the doctor’s hand is on the doorknob to bring up their most important concern.

The other side of the story? Some practices are disorganized and inefficient, resulting in a physician who’s consistently behind schedule. Sometimes appointment slots are double- or even triple-booked. Some organizations seem tone-deaf to patients’ frustrations with long waits – for instance, clinics like this one, who don’t book appointments for X-rays and thus force patients to literally stand in line waiting their turn. And what about practices who charge patients a late fee if they don’t show up on time, yet don’t hold themselves to the same standard?

Some of the research on patient satisfaction suggests it isn’t the lengthy waiting time that upsets patients; it’s lengthy waiting times with no information. Studies on this issue have found that when patients know the doctor is behind schedule, they want to be told – and they also want to be given the option of coming in later or rescheduling the appointment.

In another study, researchers analyzed patient satisfaction data that included wait times and the amount of time spent with the doctor. Their conclusion: Although long wait times are associated with lower patient satisfaction, what seems to matter most is the quality of time spent with the doctor. Patients who spent a long time in the waiting room and then were hurried through their appointment reported the lowest satisfaction. But when patients felt they had adequate face time with the doctor, they were more likely to view a longer wait as an acceptable tradeoff

What do readers think? At what point does the wait become too long – 20 minutes? Half an hour? Do you think it’s acceptable to bill the doctor for your time? (For what it’s worth, I think this is a bad idea – sure to tarnish the relationship and put the physician on the defensive, as well as being a poor use of health care dollars.) Share your thoughts in the comment section. If there are any clinicians out there, I’d be interested in your reaction as well.

Photo: Wikimedia Commons

In the waiting room

If you want to get patients riled up, make them sit for a long time in the waiting room. (Or have them wait in the exam room, a practice that’s supposed to make it look as if the doctor will see you soon but, let’s face it, has very few of us fooled.)

Depending on their mood, some people will fume at the wait. Others are quietly resigned to sitting there and maybe paging through a magazine that has been gathering dust since the Eisenhower administration.

Why is it often so hard for doctors to stay on schedule? The answers, as it turns out, are myriad and not necessarily obvious. This article, which appeared last week in American Medical News, was illuminating for how it dissects the many points at which the schedule can go off the rails – and for its behind-the-scenes look at time-management dynamics that patients don’t often glimpse and that most laypeople are probably totally unaware of.

Of course there are the usual suspects: the emergencies, the appointments that take longer than planned, the patients who show up late for a scheduled appointment. Often, however, problems with punctuality have more to do with poor work flow, inefficient staffing and other issues directly related to how the clinic is managed.

Is the issue that physicians are taking longer than expected with patients? That clinical assistants are slow? That exam rooms aren’t turned around quickly? That patients run late?

Before considering those questions, experts recommend answering this one: Is the physician on time for the first appointment?

When you have a physician “who comes in a half hour late every single time, you’re backed up from the get-go,” said Cheryl Gregg Fahrenholz, president of Preferred Healthcare Solutions, a Bellbrook, Ohio-based practice management consultant.

There are many reasons a physician might be late, and not all of them will be the doctor’s fault. But experts said everybody – physicians included – need to be in place and ready to go when the day’s first appointment begins.

Even if everyone in the practice is on time, other matters can put you behind before the first patient enters. Are the exam rooms ready? Have the sharps containers been emptied? Are charts ready? Is everyone aware of who is doing what today? Has there been a huddle to discuss the varieties of appointments that are scheduled?

Most of this isn’t obvious to patients. They might figure the staff is busy chatting or drinking coffee instead of taking care of business. It may not even cross their minds that they might be waiting because of inefficiencies in retrieving charts or setting up the exam room for the next appointment.

These are only a few of the reasons for lengthy wait times. There might also be bottlenecks at the check-in desk, or perhaps the clinic uses block-scheduling that doesn’t allow enough time for certain types of appointments. An ineffective system for walk-in or urgent visits also can upset the schedule and leave the practice running late for the rest of the day.

Many of these issues, the article points out, can be addressed and fixed - more efficient turnover of exam rooms between appointments, for instance, or adequate staffing at the check-in desk. In other words, long waits aren’t necessarily something that everyone just needs to learn to tolerate. It’s all in how you manage the schedule and plan for the inevitable surprises.

When you think about it, similar lessons could apply to patients who can’t seem to get to appointments on time. Do they actually leave the house (or workplace) on time? Do they plan for busy traffic? Have they accounted for the amount of time it takes to find a parking place, get into the clinic and go through the check-in process? Even a seemingly minor delay can end up making them late.

In the ideal world, everyone would always be on time. We wouldn’t need waiting rooms and we’d all be happier. In the meantime, maybe we can settle for being somewhat more aware of what it really takes to stay on schedule.

There’s a tendency to assume that when patients aren’t on time, it means they don’t value the physician’s time or don’t care about the clinic’s schedule. There’s a tendency to assume that when physicians fail the punctuality test, it means they don’t respect the patient’s time. And maybe it’s true there’s a little bit of mutual disrespect sometimes – but when doctor and/or patient are behind schedule, they’re not usually doing it on purpose. Like a finely tuned clock, multiple things have to mesh in order for a clinic to run smoothly and on time. Making this happen, and making it happen consistently, takes effort and it’s a lot harder than it looks.

Photo: Wikimedia Commons