Why is it so difficult for doctors to stay on time?

I’m sorry.”

I said that phrase a lot last night during evening patient hours.

With an overfilled schedule, I mostly said it to patients who waited twenty, thirty, even forty-five minutes for me to see them.  ”I’m sorry for your wait.  I appreciate your patience.”  I say these sentences far more often than I should. Why is it so difficult to stay on time?

I could blame my inadequate supply of nursing staff; our health system thinks that I only need one nurse to room, vaccinate, and phlebotomize my patients.  I could blame a convoluted rooming process and the occasional lack of available rooms.  I could even blame my patients, who somehow seem to show up early or late but rarely within their allotted appointment time.

But, mostly, I have to blame myself.  ”Yes, I’ll freeze your warts” even though there wasn’t enough time for that when we also dealt with this patient’s recent emergency room visit.  But I know that she can barely afford her co-pay and hated to ask her to return.

And I just couldn’t seem to rush telling another patient that his nagging cough and recent “bronchitis” was probably a new asthma diagnosis.  Or telling the patient after him that her wet mount didn’t show yeast, as she predicted, but sheets of white blood cells – which, along with the frank cervical discharge on exam, indicated a likely STD from her new partner.

I believe that these issues deserve time, but I still don’t like inconveniencing the patients who come after.  ”Can I put off that bloodwork until the next visit, doc?  I can’t keep the babysitter waiting much longer.”  What else could I say but “of course”?

The worst “I’m sorry,” though, came with the last visit of the night.  Follow-up high blood pressure with an overweight teen.  While reviewing the labs from our first visit with her and her mother, I realized that the A1C I had ordered (given her weight, family history, and the acanthosis nigricans on her neck) was not there.

Correction: the A1C I thought I had ordered.  The order was not there.  And I would have to stick her again to get it.

“I’m sorry,” I said yet again.  ”Remember the test I ordered to check for diabetes?  Well, it looks like I forgot to enter it into the computer.  I’m very sorry that I made that mistake.  To get that test, we’ll have to draw more blood from you.”

“You mean from the elbow, like before?” she asked calmly.  When I nodded “yes,” she said nonchalantly, “okay.”

I was so grateful for her undeserved graciousness, as I was for my earlier patients who had shrugged off my apologies for my tardiness.

Thank you, my patients.  Thanks for accepting me, mistakes and lateness and all.

Jennifer Middleton is a family physician who blogs at The Singing Pen of Doctor Jen.

Submit a guest post and be heard on social media’s leading physician voice.

email

Comments are moderated before they are published. Please read the comment policy.

  • Anonymous

    Consider your options for staying on time in primary care, with the shortage and all.  First, no emergencies or urgent problems.  Way too problematic for your schedule.  See only healthy patients, but then of course when they ask for something extra (freeze the wart, etc), you can just say no, please reschedule. Then you get unhappy pts(and whom can blame them?)  Oh, and what about all of those abandoned pts who actually could benefit from medical care? Too bad for them, at least you’re on time. 
    Or you could do it old school and extend your hours to give your patients more access to you, but now you’re looking at 70 hours per week and your first heart attack at 50 instead of 60 and a good chance of  divorce. Hard to sell that to the new docs coming down the pike.
    Or you can see pts who are actually sick, but you’ll only be able to see a few of them if you want to stay on time, and emergencies are still out of the question. Just send the overflow to the ER.  But wait, that’s expensive for them and the system.  Suboptimal.  Oh, and you’ll also fail financially and go out of business and end  up working for some evil CorpMed outfit somewhere and contemplating getting out of medicine altogether. But I digress….
    Or you could go concierge and have all the time in the world and make lots of money.  Pity about the 1500 people who used to be your pts but whom you have told to hit the bricks and who now wind up in the ER or urgent care. 
    Primary care: Dipped in manure and then shot for stinkin’.  Fortunately most of our pts understand our predicament and accept it graciously. 

    • Anonymous

      So you think that corporate medicine is the only cost effective way to provide primary care?

  • http://twitter.com/advskinwisdom Advanced Skin Wisdom

    Excellent description of how it feels.  Add to that an elderly person with difficulties obtaining transportation who comes in with several obvious skin cancers that need diagnosis and treatment.  Or a woman who unexpectedly lost her husband several days ago and needs to be comforted.  It’s tough to tell these folks, “Well, you know, I don’t want to keep others waiting.”  My only hope is that my other patients will understand and know that should they find themselves in similar need of my time, I will gladly give it.

  • http://twitter.com/advskinwisdom Advanced Skin Wisdom

    Excellent description of how it feels.  Add to that an elderly person with difficulties obtaining transportation who comes in with several obvious skin cancers that need diagnosis and treatment.  Or a woman who unexpectedly lost her husband several days ago and needs to be comforted.  It’s tough to tell these folks, “Well, you know, I don’t want to keep others waiting.”  My only hope is that my other patients will understand and know that should they find themselves in similar need of my time, I will gladly give it.

    Emily M. Altman, MD, FAAD
    Advanced Skin Wisdom
    Comprehensive Dermatology and Laser Center, LLC
    http://www.advancedskinwisdom.com

  • http://apainedlife.blogspot.com/ Carol Levy

    Don’t double and triple book, as does one of my docs.  I rarely hear the “I’m sorry” after being made to wait for half hour or more.  I have no problem with waiting 15 minutes, after that I would appreciate an explanation or, at the least, an apology (that is sincere).
    I used to have to wait 2 sometimes 3 hours for one of my docs.  I do not recall h im apologizing but because he spent so much time with me I had less problem with it because I knew he was late because he was caring and listening, still if you know you are consistently late then maybe your booking needs to take that into consideration.

  • Anonymous

    I’m a primary care physician.  As a means of trying to stay on time, I function in a near manic state during my workday.  I do listen to my patients, but the conversations are usually sped up versions of what you would hear in the real world.  To do it right, you need cooperative patients who know how to play the game. I usually do run on time and have good patient satisfaction measures, because most of my patients learn my style within 1-2 visits and adapt well to it.  I have developed a focused way of listening early in the interview and use nonverbal cues from the patients as well to hone in on the major issues.  There are about 5% of my patients who will not or cannot cooperate and always take extra time.  They are the ones that give me cold sweats when I see their names on the schedule.  They always seem to have 10 issues and are filled with anxiety or intractable dissatisfaction.  I do my best to accomodate them, but often run behind on those days.  Luckily, because I’m on time 90% of the time, my patients accept my apologies when I am late.  This hypomanic mode of working has its drawbacks.  I am mentally gone by the end of the day, and often don’t have enough mental energy in the tank to be emotionally present for friends and family.  I exercise regularly, and engage in creative hobbies when I have the time, but I fear that career burnout may set in without changes in the way primary care is set up in this country.  I am thankful that I am privileged to be needed in my community and to get paid well for doing a difficult job.  What I feel, though, is that what I am asked to do within my series of 15 minute visits during the day feels like I’m trying to solve difficult logic puzzles, provide psychological counseling, and run a gauntlet of regulatory hurdles 20 or more times a day.  Each time I knock on the exam room door, it’s like a starting gun goes off.  The problem is to sort out which of these mentall processes each patient needs quickly and to do it in a way that satisfies and truly helps them.  It’s not a matter of double and triple booking as some commenters have stated.  Rather, it’s simply a fact that in the USA, doctors are expected to see 4 patients per hour for follow-up visits, and we get no more that 45 minutes for a complete annual history and physical.  I wish I could hold my auto mechanic to the same standard…