Why Can’t Doctors Be On Time?
I have just, again, walked out of a doctor's office after being kept waiting too long for an appointment.
I have just, again, walked out of a doctor’s office after being kept waiting too long for an appointment. While my threshold is probably lower than most–I’ll inquire as to why I haven’t been seen 15 or 20 minutes after my scheduled time and bail if not given an adequate explanation for the delay*–I’m befuddled that most people seem willing to be treated poorly by service providers who happen to have some sort of medical degree.
In some cases, legitimate emergencies arise. Mostly, though, it seems to be a function of overbooking for the convenience and/or financial benefit of the business. One doc I quit seeing after being kept waiting on three consecutive early morning appointments liked to book two or three customers for the same time slot.
It’s rare, indeed, for a health care provider to appear on time for their appointments, a practice that’s simply not tolerated in other professions. I don’t know whether physicians, dentists, opthamologists, and the like don’t know how to run a business or really think their time is more valuable than that of their paying customers.
Apparently, they’ve trained most of their customers (or “patients” in the odd parlance of the industry) into accepting the fact that they’ll have to waste a lot of time sitting around waiting for the services for which they’re going to be handsomely billed. People wouldn’t put up with it from an attorney or an accountant, though, and shouldn’t put up with it for an office visit with a doc.
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*In today’s case, I was told that they were waiting for a room to be available. This was for an eye appointment which was already 20 minutes overdue. They don’t have a room for each doctor?
I’ve known people who work on the administrative side in medical offices and there’s a number of factors that create this phenomenon.
One is simple overbooking. Given the way insurance works, physicians make more by seeing more patients so there’s an incentive to book as many appointments during a day as possible. Absurdly, this usually means that patients get scheduled as little as 15 minutes apart even though it’s clear that it will take the doctor more than 15 minutes to deal with each individual patient.
Another factor that contributes to this is if the office lets people book “emergency” appointments during the day, which creates an even longer backlog.
It really depends on the habits of the physician and whether or not he or she has an office manager who keeps these issues in mind when scheduling appointments.
It reminds me of a story I’ve heard several times about a lawyer who was made to wait at his doctor’s office for 90 minutes for an appointment that had been scheduled months in advance. When the lawyer got back to his office, he had his secretary prepare a bill for the time he had to wait, and mailed to the doctor. I don’t know if the story is true, but I hope that it is.
@Doug Mataconis: I’m pretty sure I read about people charging their doctors for waiting on CNN.
Almost definitely due to insurance. If you go to a doctor where you pay everything in cash, there’s no wait, basically.
How many doctors are there that want for patients? The problem is there aren’t enough doctors. If James switches to another doctor there will be someone to take his place. What incentive do doctors have to provide prompt service when they know patients/customers are easily replaced?
@Doug Mataconis: I’ve heard that lawyer story as well; I’m thinking it must be an urban legend.
@Modulo Myself:
Really? James’s experience today deal with an eye doctor. I’ve had similar experiences with dentists. Those are two fields of medicine where (1) many people who do have medical insurance don’t have insurance that covers these services (2) even if they do, it’s not complete coverage so there is cash payment at the time of service.
Modulo myself gets it right: you *aren’t* the customer (contrary to your post), the insurance company is. If you were the customer, they would wait for you.
I would imagine that doctors “fully schedule” and then just accept that daily emergencies (and they probably are daily) will shift that a bit. How else could they do it? They don’t know where to schedule the emergencies.
Perhaps they put in 15 min padding at noon to take up part of the slack.
@Andy:
To provide on-time service doctors would need to set aside excess capacity every day for emergencies. That would cost them, and therefore us all.
How many of us want to pay for an idle doctor as well as our own?
(The reason places like Kaiser can keep down rates is that we don’t see our own doctor for minor emergencies. They only need size the “urgent care center” to match local demand.)
@john personna:
This is where practices that have an LPN on staff can be helpful
This is a pet peeve of mine as well, James, even though I try really hard to cut slack (due to, as JP notes, the inevitable emergencies).
I strongly suspect it boils down to this: more patients = more money. The patient needs to be seen. The patient will wait. Patiently! đ Oh, that was awful, but I’m leaving it. Mock as needed.
@Sam Penrose:
I am not so sure: as even then, more customers squeezed into an hour means more $$$.
And @Doug has a point: eye doctors very frequently do not receive insurance payments from any given customer (and dentists only get partial payments) and yet the phenomenon in the same.
Further: if one is sick one is willing to wait because one need relief–demand becomes rather inelastic at that point and hence the willingness to wait regardless of the method of payment.
I have witnessed two type of medical appointment that actually does go more or less like, well, clockwork: therapy and physical therapy. In both cases the appointment has a delineated and clear time parameter: an hour. Therefore, scheduling is easy. (And, I would note, the payment is still by insurance, so that variable is taken out of the equation).
Oh, and I’m all for more urgent care centers/clinics. This seems to be happening, which is all to the good. There’s a fairly new one by us and it came in handy one Sunday.
@Rob in CT: Indeed. They seem to have managed to figure out the waiting issue.
@Steven L. Taylor:
In my experience, private practice therapists (in NYC, at least) are dropping taking insurance because what the insurance pays makes an actual schedule that is kept no longer feasible. Or maybe this is what my therapist is telling me…
Isn’t also the case that for most therapists, psychologists, etc. an “hour long” appointment is typically actually 50 minutes? When you schedule appointments an hour apart, that ten minutes provides a nice scheduling buffer.
I’d say people put up with it in the short-term at least, because they need the services that day, wait or no-wait.
I will say, in my experience at least, this has gotten better in recent years. Service for my personal doctor and for our childrens’ pediatrician is pretty quick, they even have signs in the waiting room that ask you to inform someone if you’ve been waiting for more than 15 minutes. Granted, once put into a room it can sometimes be a bit, but it hasn’t been typically.
I’ve had mixed results with urgent care centers.
@Doug Mataconis:
I think Freud was strict about 45 minutes being the limit, but 50 or so seems to be the norm.
My doctor is pretty good with this. I suspect that it is because he’s got a good scheduler, because every time I come out, she goes “man, I can’t believe he wants to see you on Thursday for a followup: there is no way that’ll work. How about Friday?” Amazing how having someone good at handling this
It drives me nuts too. The worst is the annual medical screening I need to do through work is through one of the occupational health centers, you’re there a minimum of 4 hours for what amounts to maybe 30 minutes of exam time.
The Urgent Care Centers are hit or miss, but they do move you through as quick as they can.
I hold no brief for doctors, but I think some countervailing points should be made.
Patients think nothing of last second cancellations or delays. How does one schedule around that?
The doctor never knows what the appointment will present. If you are the patient, and it’s not a routine vist, and you really want or discover you need the extra time and attention of your physician, do you really want to be shuttled off in a huff? This isn’t an assembly line making plastic injection molded bottles, it’s health care.
My father was an internist. My mother was the office nurse. She was always trying to keep the patients moving; my father didn’t give a damn. I spoke with him about it. His response was terse. “I went to medical school to practice medicine, not make money. I give every patient who walks through that door every bit of attention and time deserved to address their needs before I move on.”
It’s not fun being the patient down the line. But if your blood tests come back with issues, do you want that extra 20 minutes to discuss it with the doctor, or are you more concerned about the patients in the waiting room…………and who should the doctor be concerned with?
@Doug Mataconis: I don’t think the 50 minute appointments are key for therapists; its the fact that if the therapist is fully booked for a day, 90% of the time there will be at least one no-show. The ten minutes are necessary to complete paperwork. If all my wife’s clients show up in an eight hour day, she will be home about an hour later than usual (though some of that will be deferred paperwork).
She would also argue I believe that double-booking is professionaly unethical.
Seems that all the reasons cited so far are valid and contribute to the problem, without any one of them being *the* predominant cause in all cases. I’d add one more to the mix which is the pervasive myth that “health care is different.” I work in the heatlh care payor field, and I hear this one on the order of several times a day.
Some time ago we suggested developing a functionality on our health plan’s website that would let patients rate their providers on a couple of different customer service points. We thought this would be useful for members searching for a provider – – some members want punctuality even if it means seeing a PA instead of a physician; other members want a physician who will spend as much time with them as necessary and are willing to wait for it. The criteria we wanted to use would have been adapted from nationally recognized and industry-accepted surveys on customer experience. (Typically such results are not publicized at the provider level but rather are aggregated, or are used only behind-the-scenes.)
The project was eventually given a no-go because the physicians were uncomfortable with the information being out there, and our upper management (or at least a portion of them) were uncomfortable with the physicians being uncomfortable. The actual cited reasons were many. When pointed out that the reasons were similar to those that could be cited in any given industry (plumbing, for example), the response was, “well, health care is different.”
I say pervasive because the myth underlies everything from arguments about whether to put a physician rating tool on a website right on up to the Solicitor General’s argument to the Supreme Court in support of PPACA, which essentially amounted to: “sure, but health care is different.”
I used to have this problem all the time in Mass and CT. However, in Texas, I rarely wait more than 5 minutes. Perhaps there is something to that tort reform thing after all.
This is all good and wise, thread, but we haven’t solved the real conundrum here: why the hell would an eye doctor take twenty minutes or more to be ready to see a patient?
I think this is mostly just because dealing with people is unpredictable. Emergencies are squeezed in and what was scheduled as a simple appointment turns out to be complex.
Steve
Perhaps it’s because Florida is overstocked with doctors (perhaps because Florida is slack on certification, but that’s another issue), but I never have to wait, as a rule. My appointments start on time, sometimes even a bit early as I’m always early to the waiting room. I’ve had one wait of 15-minutes because the doctor was at a hospital with another patient and couldn’t get loose. Other than that, I waste more time waiting to get a haircut.
@Drew:
You raise valid points. And I’ve been particularly guilty in the cancellation department lately myself. Because of business commitments, I’ve had to reschedule the same doctor’s appointment three times now. I do call as far in advance as I can but it’s been quite unavoidable these past three weeks.
As someone who often gets pissed at no-shows, though, I do kind of feel guilty about it.
I don’t expect precision. After all, my appointment might be slotted after my doctor has seen many other patients that morning. It’s not unreasonable to expect that some appointments might exceed the expected duration for any number of good reasons. I consider a delay of 15 minutes to be within an expected “margin of error”. Now, if my appointment was regularly pushed out by 30 to 60 minutes, then I’d say that my clinic has a management problem.
The American Medical Association, gatekeepers to the doctor’s cartel, keeps the supply of doctors artificially low, creating shortages in the provision of healthcare by doctors. We need to either (a) produce more doctors, or (b) allow basic functions of doctors to be done by nurses instead. Basically, we need to break the cartel.
Overbooking is a big part of it. Above, Doug cites 15 minutes per visit. It’s actually not uncommon for it to be less than that. The doctors go around room to room and instead of giving any particular patient 15 minutes, they’ll see 6 an hour. Or more. My wife gets 20 minute appointments, which is considered a luxury. But she also gets double-booked.
@llama: The AMA is not the gatekeeper to medical education or licensure.
As a current practicing physician, I schedule patients every 15 minutes, with new patients getting 30 minutes. I usually run on time, but as previous posters have mentioned emergencies or complicated cases arise, needing further attention than the allotted time.
Other factors that I encounter throughout the day that need my attention, include calling patients back that have left messages, filling out disability forms, charting patients encounters, sending consultation reports out, and talking on the phone with other doctors can contribute to this sort of back log seen in many offices.
Ironically, in patient cases where it’s a slam dunk diagnosis(needing only 5 minutes of my time to address and treat), patients tend to leave upset that I didn’t spend “enough time” with them, especially if there copay is over $30. So in order to feel like they get “their money worth”, I usually will spend an extra 5 minutes (where i could be catching up from more complicated cases) so the patient doesn’t leave unhappy
@Gromitt Gunn: Tort reform has nothing to do with it you’re just lucky with your choice. My family hasn’t been so lucky down here.
My mother works in the industry and she can give you paragraphs of reasons as to why you end up waiting at a doctor’s office. Most of the reasons stated here are true but that’s only scratching the tip of the iceburg.
Oh man that is so true.
Image how bad it will be when the U.S. gets single-payer, reinbursement rates go down, and care givers have even less time. The future of healthcare is concierge care for the top few percent and the DMV of medicine for everyone else.
I “fired” one doctor after two years, when the extreme delay mark was 90 minutes.
That is, that was the minimal delay. It was usually closer to 3 hours. I would book the appointment for either first thing in the morning or right after lunch, and then arrange to have the entire half a day off from work because I knew I’d spend a minimum of 2 hours (usually more than 3) to see her.
As stated above, if you want doctors to be on time, they would have to build in excess time. So we either get punctual docs or we get productive docs. Cant have both. Also, patients don’t always realize how much work can go into preparing an appointment. Doctors do much of their work outside the exam room.
Distribution of Doctors/population – especially primary care has quite a bit to do with it:
http://storymaps.esri.com/stories/doctors/
A lawyer bills by time, and clients know this, so they come right to the point. Physicians bill by appointment, so patients feel comfortable coming in and telling a long story about their summer vacation, what they saw on TV last night etc. There is also no disincentive for a patient to get one health complaint dealt and then when the doc is leaving the room say “Oh by the way, I vomited blood this morning — should I be worried about that?”. The doctor goes back in to take care of the next patient problem, and the patient pays the same amount.
@superdestroyer: It’s funny you should mention the DMV since in Illinois a trip to the DMV took very little time. Where as down here in Texas if you go to the DMV you can end up waiting in line for four or more hours. One of the first things I noticed when I moved down here was that it seemed like the politicians intentionally designed the government to be as ineffective and inefficient as possible. I was like “no wonder people down here hate government”…
@Gromitt Gunn: Odd. I have friend in the Brownsville area that routinely waits 60-90 minutes past her scheduled time. I’ve repeatedly asked her why she puts up with it, and she replies, “That’s just the way it is here.”
In the Cincinnati area the only times I’ve had to wait a long time past my appointment is when it’s obvious by who’s in the waiting room that the flu or some other such ill is going around. The doc is trying to help as many people as she can.
@Doug Mataconis: At least one person has billed their doctor for waiting time.
As someone who has seen how things work from the other side of the divide, let me assure you that doctors have every desire to be on time. The problem is usually one of the following:
1. A patient comes in late. This throws the entire assembly line out of alignment, so to speak.
2. Registration or nursing is slow to room the patient. This can be due to a variety of factors, the most common I’ve seen is an elderly gentleman who needs extra time for weighing, blood pressure, and wheelchair management.
3. The presenting problem is more complex than originally anticipated. 15 minutes for a visit and the patient comes in with multiple complaints or a more serious complaint than you expected.
4. The patient needs extra reassurance or asks many questions.
5. The patient starts by talking about his summer vacation. It takes some time to politely guide him to the subject matter at hand.
Ultimately, one can plan for 15 minute visits, but they often turn into 30-45 minute ones instead. And the expectation in health care is not to shoo the patient out of the door as fast as possible to meet schedule demands. Thus, we have delays.
And this is for doctors who spend their full day at clinic. We still have ones who shuttle between the hospital and clinic, making matters worse. It’s no wonder with low reimbursements, patient backlash, and increasing paperwork, primary care doctors are abandoning the clinics to become hospitalists or specialists.
An addendum.
I don’t know how law practices work, but I can retort sarcastically that they probably overbill for what actually took less time to complete. Doctors on the other hand underbill for what actually took more time than stated.
Physical therapy has the advantage of longer appointment times with less variance in the amount of workup/work needed. Medicine has short appointment times with high variance in time actually needed.
Imagine that the average time for an appointment at a clinic is 15 minutes with a st dev of 7 minutes. Management decides to set appointment time at 15 minutes. You luck out initially in the morning and get 3 5 minute appointments in a row. Great, but you can’t accelerate your schedule because the next few patients haven’t shown up yet. Later in the afternoon you get unlucky and have 2 30 minute appointments for what were 15 minute blocks, and maybe the first one showed up 15 minutes late. The result is the entire afternoon becomes a scramble to catch up.