Why do doctors run so late? “Overbooking is rarely the cause of the problem.”

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  • Anonymous

    Everybody in society is overscheduled, time stressed and late.

    Today is typical for my anesthesia practice when I work outside the operating room for patients undergoing various procedures throughout the hospital:

    First patient arrives 45 minutes late; a rushed preoperative visit and good luck allows me to finish their care only 15 minutes behind. However…
    Second patient 20 minutes late; we miss our time slot in the MRI scanner causing us to finish 55 minutes late.
    Third patient ate breakfast and needs to fast a few more hours before safe anesthesia; this make them functionally three hours late.
    Fourth patient arrives on schedule, but I’ve been idle for over an hour (becaus #3 was not ready). Patient 5 is 20 minutes late; by now number 3 has met fasting criteria and wants to know when he can go. I take number 5 (who only goofed by 20 minutes) first, then number 3 goes last, only 40 minutes after he was medically elligible but 3:40 after his scheduled time.

    The first three patients, as a ‘punishment’ for their tardiness receive expedited care (my effort to get back on schedule) at the time of their choosing. They are probably noting on a satisfaction survey that I seemed rushed, not grasping why that might be. Number 3 is really anoyed because I didn’t immediatly take care of him earlier; he’s also anoyed about the NPO thing too as it seems to him it was someone elses fault that he ate a donut with his morning coffee against instruction.

    Lateness is a two way street. Patients notice if they have to wait, but never recognize the havoc they play on the health care system when a hospital full of doctors, nurses, and patients wait for them.

  • kateykakes

    I rarely ever complain when I have to wait around to see my PCP. IMO, he’s the best and definitely worth waiting for. Besides, if there’s someone who needs the extra attention, I’d feel better knowing that my doc is taking care of the patient rather than him rushing them out the door. Who needs a doc like that?

  • Anonymous

    It’s always our fault and not the doctors’ fault. I show up 30 minutes early, and I still get seen 1 or 2 hours past my scheduled appontment all the time.

  • Anonymous

    I think there is blame on both sides but any doctor who has to respond to unscheduled hospital emergencies can run late through fault of his own. That said, some doctors offices run chronically late and they need to run a little tighter ship. OTOH, patients often shoe up late late, don’t follow directions, and demand care for conditions that they were not scheduled to be seen for. It’s a wonder that any busy doctor’s office runs on time.

  • Anonymous

    Oops. “through fault of his own” should read “through no fault of his own”.

  • Anonymous

    And when I seen the non-emergency and non-urgent patients in the ER
    after they have waited an hour or 2 hours and complain for the long wait,I want to tell them go see your PCP and wait at their waiting rooms.

  • Anonymous

    I mean non-emergent …

  • Anonymous

    Maybe, doctors should not schedule any patient for 30 minutes in the middle of their schedule in the morning and in the afternoon to allow them to catch up, and just extend their office hour by one hour in the afternoon which they end up doing anyway if they are running behind all the time. Just a suggestion on time management.

  • Anonymous

    To the last poster: scheduling schemes that allow buffer slots for last-minute emergencies and catch-up have been around a long time. Many doctors already use them. There are all sorts of names for these, “rolling wave” and whatnot; the problem is that even those can be defeated.

    Interruptions for phone calls, even when unavoidable, patients who schedule a visit for one problem then add two more once in the room and late arrivals that leave appointment time wasted while forcing everyone after to wait longer all undermine the best-conceived schedules. Lengthening the workday isn’t practical as many doctor’s office employees have family obligations that require a set closing time, and the cost of staying open late, particularly of staff overtime wages, can be cost-prohibitive.

    Only one scheme actually works on time: seeing fewer patients per day in longer appointment slots. The problem is that to make it feasable in the present reimbursement climate would make accepting most insurer schedules including Medicare and Medicaid impossible. You would have to run a cash-only practice and charge what you needed to make a worthwhile living and pay your bills. Some doctors do this, but there are a lot of patients who couldn’t pay what a practice would have to charge to do this.

    The reality is, most patients will not pay anything over their required copayment even to see a doctor they claim to prefer who is outside their list of plan participants. There is always a lot of talk, but that is all it usually is, and there is rarely a willingness to put anything meaningful behind it.

    CH

  • jk

    I’ve been to a lot of doctors in my life and most of them have been late and I have few basic rules I try to follow:

    1. If my doctor doesn’t rush me, I can’t really complain that she didn’t rush the guy before me.

    2. Be on time. Remember when you are late and they still fit you in, it’s not the doctor’s time you are wasting, it’s all her other patients’ time. (And we don’t like it.) Heck, be early. It gives you time to fill out paperwork and, sometimes, will even get you in early.

    3. Relax. Yes, the doctor will probably be running late and you need to plan your time with that in mind. That is just the nature of medical scheduling. Some appointments will take longer than scheduled.

  • The Mommy Blawger

    A couple comments from the patient’s viewpoint:
    1. If the doctor is running 1/2 hour or more off-schedule, for goodness’ sake the staff should call the patient and let them know so they can wait at home or at the office or run an errand instead of sitting in the waiting room. Or have the option of rescheduling the appointment. Most of us have cell phones these days, you know.

    2. Along those lines, perhaps the medical profession could look to other business scheduling models. Restaurants, for example, with their vibrating pagers.

    3. I understand that there are many, many examples of patients who come in for one problem and then during the exam bring up problems #2 and #3. But doctors should ensure that their staff are carying out accurate and thorough intake/scheduling procedures. For instance, I once arrived for an annual/pelvic exam to find out that I was down for a “5 min. appt. to establish me as a patient for insurance purposes”. The staff was quite put out when they had to “work me in” for a longer appointment. Not my fault; I was quite clear on the phone about what I needed. That is not the only time that my discussion with a scheduler about why I needed to see the doctor was not communicated down the line.

    Also, if I am not familiar with the office staff, I don’t know who I am talking to when I call. I don’t want to go into a long and detailed description of my symptoms with a receptionist who is only going to transfer me to the appointment person. As lawyers, we are trained to ask at the end of a client interview, “is there anything else?” Perhaps if medical staff were in the habit of asking the same question, they would get more and better information.

    That being said, I have been known to be annoyed because I didn’t get to finish a magazine article I was reading in the waiting room :)

  • Anonymous

    I’m constantly surprised by the complaints posted by doctors that patients come in for illness #1 and then bring up symptom #2 when the doctor is leaving the room. Why is this such a surprise?
    You are unsure of what’s wrong, why you’re not feeling well, and it takes a little courage to warm up to confessing what you’re worried about. Hey, I get more warm up talk from a waiter and my dry cleaner and mechanic than I do from the doctor who is supposed to be treating my fearful and anxious psyche as much as my painful and miserable body. Do the word ‘foreplay’ mean anything to you?

    The fears and uncertainties that go along with illness and infirmity are as much of the medical condition that needs a doctor’s attention as the corporeal twinges…so why do doctors resent the few minutes it takes for a patient to reveal his concerns? Time is money money money.

  • Anonymous

    “Time is money money money.”

    True. Are you willing to pay for the time you expect? Or is that a surprise?

    “I’m constantly surprised by the complaints posted by doctors that patients come in for illness #1 and then bring up symptom #2 when the doctor is leaving the room. Why is this such a surprise? “

    It isn’t. But efficient scheduling requires assigning patients into different-sized time slots, not identical ones. Discussions once had can’t be shortened in interest of leaving time for some other subject, it ends up robbing someone else’s appointment time.
    The responses from “patients” here–and we all are–illustrate the point well: “I hate to wait, but I want all the time I think I need when I think I need it (and too bad about everyone else.)”

    “If the doctor is running 1/2 hour or more off-schedule, for goodness’ sake the staff should call the patient and let them know so they can wait”

    Great idea in theory, much more difficult in practice.
    I don’t have a spare person whose job it can be to follow my timing hour by hour to see how behind I’m getting and to see when, by accident of a no-show, when I can catch up. And if I am in the office
    and the ER calls and says I must come now, what about the people checking in at the front desk? Too late to tell them to take another thirty minutes window-shopping.

    Most doctors I know work at keeping on schedule,
    trying to make patients feel as if they have had an opportunity to address their problems without feeling rushed, actually doing the examination, then discussing the treatment plan. All the while, another patient or two are being readied, who expect me to be doing my best to stay on time. Unlike the lawyer-poster above, we are much more tightly scheduled and we cannot bill by the six-minute block against a retainer. Would I like a lighter schedule with longer times and be able to make more people happy? You bet. But there is absolutely no way I could stay in business doing that without dumping all insurance and charging cash–and more than I collect now for an average visit. That may be my fate whether I like it or not, but running a subspecialty referral practice like mine that way might not work at all in my community.

    Lots of my patients are handicapped and can’t manage to get “done” in their allowed time. They have good days and bad ones. They forget why they came, and I have to go through the “twenty-questions” to find out. They are nursing home residents who come with a minder who doesn’t know anything about them and the patient is demented or otherwise unable to relate a meaningful complaint. They bring up very serious complaints at the last minute that can’t be deferred to another visit–and they haven’t a clue that what they mentioned should have been the reason for the visit, not an afterthought. Do I forsee these problems? Always. The problem is, I don’t know when they are coming.

    Another poster brought up a good point, we “reward” tardiness by working harder to fit people in who show up late. Should I punish them instead?
    I need to work to get paid and to pay my practice expenses. Who is being punished if I turn them away? So as things are, I do the best I can.

    I posted above that there is a solution: lighter schedules and longer appointments. I don’t see any volunteers here that would be willing to pay for what that would cost.

    CH

  • Anonymous

    “Hey, I get more warm up talk from a waiter and my dry cleaner and mechanic than I do from the doctor who is supposed to be treating my fearful and anxious psyche as much as my painful and miserable body.”

    Okay then, how much are you willing to pay out of your own pocket for this? Insurance doesn’t reimburse for verbal “foreplay”.

  • SarahW

    Too many appointments in too little time = overbooking. Overbooking may be a necessity in today’s medical business climate, but that’s still what it is. Let’s call a spade a spade.

  • Anonymous

    “Let’s call a spade a spade.”

    You are defining “overbooking” as any schedule that doesn’t give you the time you want whenever you want it. Very convenient thinking. How about paying for the privilege? You can leave the insurance card at home, that will be cash, please. Oh, and figure on paying about double what your insurer and you presently are paying for that slice of time that you want.

    Pretty soon, you will get to schedule an appointment like an airline flight, cash in advance, at your convenience, non-refundable, of course.

  • Anonymous

    Isn’t the solution simply to allow variable fee schedules: if you want to be seen immediately, pay a surcharge; if you can wait, pay the normal fee.

    If a doctor has a bunch a patients willing to pay a surcharge, he would underbook–but would be made whole financially with the surcharge payments.

  • Anonymous

    “Isn’t the solution simply to allow variable fee schedules: if you want to be seen immediately, pay a surcharge; if you can wait, pay the normal fee.”

    Probably. But to do this, a doctor would have to be willing to forgo participation with Medicare for every patient for two years if he even saw one patient on one occasion under these terms. That “surcharge” would be seen as private contracting. Medicare sets limits on how much can be charged their benenficiaries even when the doctor does not accept assignment. So you are talking about a purely cash-basis practice.

  • Anonymous

    OK–then the question is whether given the payments Medicare provides who will derive more utility from the doctor-consumer transaction.

    Doctors essentially derive more money from patients–on top of their Medicare payments– by expropriating the value of their patient’s time.

    This is rational for doctors to do–but they should be honest about their motivations.

  • Anonymous

    “he question is whether given the payments Medicare provides who will derive more utility from the doctor-consumer transaction. “

    Tha is pretty much up to the patient. If the net benefit doesn’t accrue to them, I figure they don’t make appointments.

    “Doctors essentially derive more money from patients–on top of their Medicare payments– by expropriating the value of their patient’s time. “

    Again, patients make that decision. Attendance is elective.

    “This is rational for doctors to do–but they should be honest about their motivations.”

    Pretty obvious, I think. I figure people come to see me for a reason.

  • Anonymous

    “Pretty obvious, I think”

    Well, not obvious to the article or poster–which all babbled about the fault of patients, unforeseeable circumstance, the need to accomodate people as the “cause” of long waits

    It all comes down to money (mostly)–and doctors with a typically preening self-image–and as this comment chain shows–often don’t like to admit that.

  • Anonymous

    “and doctors with a typically preening self-image-”

    Uh, no. Where does that figure in to this, unless you think yourself entitled to what you are unwilling to pay for?

    I could just as easily say it all comes down to unreasonable and self-important patients who have a undeserved sense of entitlement, so much so that they have no sense of responsibility to pay for what they want.

  • Anonymous

    “Doctors essentially derive more money from patients–on top of their Medicare payments– by expropriating the value of their patient’s time.”

    Not really. This is another version of the parable of the broken window. Besides, how exactly do I realize the “value” of this time you think is being “expropriated”? It isn’t mine to have or sell.

    Explain, if you can, how this isn’t the case.

  • Anonymous

    You doctors are spending too much time on this weblog. Go out there and see those patients.

  • Anonymous

    That being said, I have been known to be annoyed because I didn’t get to finish a magazine article I was reading in the waiting room :)
    I usually take the reading materials with me to the examining room. The nurse often takes your temperature and blood pressure and then you have to wait for the doctor – much better to have some reading there.
    I don’t get upset if I have to wait when I am healthy and came for a routine visit. I’d probably be a bit upset if I had been feeling miserable (with the degree of ‘how upset’ directly proportional to my degree of discomfort) – a friend of mine was made to wait for 3 hours in ER when she had terrible stomache pains (she had appendicitus). It is difficult to be understanding if you are in pain.
    I think I’d be willing to give up my turn to someone with higher need. Last year when I was waiting for a pelvic ultrasound and they were running late, a woman gave up her turn for me. I would be more than willing to do the same, but I think that doctors/technicians should consider these things as well even if it makes some people mad.
    When I have a choice I try to schedule my doctor appointments in the morning and allow plenty of time on my work calendar in case I have to wait. But I guess for people who are paid by the hour and who find it difficult to get time off work, it is more of a pain. Not sure what the solution is beyond just accepting having to wait in doctor’s offices as a fact of life. The only possibility I see would be for the doctor’s office to call people scheduled to come in 2 hours time and to tell them the office is running late.

  • gasman

    I had the first comment in this thread. Every day is unfortunately the same.

    My first patient, booked for three hours, failed to show. Having learned over the years that patients sometimes ‘cancel’ their procedures without letting anyone know I called her last night at home. Not my staff or some automated appointment reminder system, I actually called her. We spoke about the planned procedure, time to arrive, when to stop eating, what medications to take and which to not take in the morning. I answered her questions and made certain she had my number.

    This morning no patient. My secretary finally got alhold of the patient. Seems she had some second thoughts and wanted to wait. Half my productivity for the day blown on a whim.

    My preop personal phone calls have reduced this no-show rate because I find people out of town, cold feet, hospitalized across town for something else, out of town guests, etc. But there are still patients who insist on screwing the system.

  • gasman

    My last patient has failed to show up; didn’t bother to call us at all.

    At least the no show is the last patient of the day and I can pack up and go home.

    Nothing ruins a day, and ruins the day of all subsequent patients, when the first patient is late. Damn I wish patients would show up in the morning.

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