Waiting is the bane of the medical system

“By the time you see the doctor, you’re either dead or you’re better,” my mother-in-law told me. She had to have multiple tests, all with long waits to get the appointments and the results, before her health insurer would allow her to make an appointment with a specialist.

“Waiting is the bane of the medical system,” a former student, an R.N., concurred. Advances in medicine and technology have improved medical outcomes, but have often resulted in more waiting at a time when every other aspect of life is speeding up. Waiting is a systemic problem exacerbated by advances in medicine and by health care reform.

Some of the ways we wait:

  1. Wait to see if the symptoms go away or get worse. We all struggle with these decisions: do we need to be seen about the fever, back pain, or rash? Sometimes we wait because of denial or hopelessness; sometimes because of the cost or availability of medical care. I make decisions about when I need to see the doctor by asking myself if, under the same circumstances, I would take one of my children to the doctor.
  2. Wait to get an appointment scheduled. I’ve made appointments for a sick child by channeling an old friend who could be relentless: “That is not acceptable. I need an appointment today.” Obnoxious but it sometimes worked. The rest of the time, though, the period between making and having an appointment can feel very long.
  3. Wait to get to the appointment. Doctors and hospitals are more abundant in Greater Boston, where I live, than in other places, although traffic and parking can be problematic. Melody Smith Jones described a man’s six hour commute to see a doctor.
  4. Wait to be seen by the doctor. It isn’t called the waiting room for nothing. Dr. Atul Gawande wrote in The Checklist Manifesto about people in the waiting room getting irate when he was running two hours behind on a hectic day. Being irate – or anxious or bored – is unlikely to increase the quality of physician-patient communication.
  5. Wait in the examining room. At least in a waiting room you are dressed. If it is cold and you are wearing a paper or cloth johnny, distractions don’t work as well and examining rooms have fewer than waiting rooms.
  6. See the doctor. Nowadays, as my mother-in-law recounted, you have to wait for the doctor to review your records before even looking at you. I find it surprising that physician rating systems give equal weight to wait times as they do to “communicates” and “listens”, when the latter are so much more important.
  7. Wait in the lab. The selection of magazines is skimpier. You may be reviewing what you were told not to eat or drink: will that cup of black coffee skew the results?
  8. Wait for lab results. If there are any non-routine reasons for testing, this can be interminable. I leave a lab asking when results will be ready and then I call. A former student told me about using Harvard Vanguard’s MyHealth Online. She said, “I love getting the lab results immediately online but I can see how those without clinical training could be overwhelmed or confused by the data and how to interpret them.”
  9. Wait for the doctor’s interpretation of lab results. Lab results can be hard to decipher without clinical training, as my student said above. Even when I know results are available and the doctor has seen them, it can take many phone calls to obtain the doctor’s message via the secretary. Asking the doctor follow-up questions takes even longer. These are waits with a cell phone never turned off so you don’t miss the call.
  10. Loop. You think you’re done but you may need to see a specialist, get a second opinion, or have more tests. As my mother-in-law pointed out, this process can be controlled more by insurance companies than by doctors’ availability. Another type of waiting also takes place now: waiting to get better. A friend bemoaned how she “couldn’t wait” for her black eye resulting from a fall to clear up because she was tired of people staring at her.

Waiting reduction

We all have to wait. Waiting is an inherent part of being ill. But here are some ways to reduce wait time or lessen the impact:

  1. Schedule tests and doctor’s appointments together. My exercise teacher told me about her husband’s hospital visit that started with a CT scan and ended with a doctor’s appointment to discuss the results. With no problems detected and a year until they next visit, they both said what a relief it was to get it over with quickly. Scheduling appointments together reduced both waiting time and anxiety, although not all tests results can be interpreted this quickly. Personally I find it is much easier to deal with a diagnosis than fear of what a symptom could mean.
  2. Avoid unnecessary appointments through email or phone. A Dutch friend, whose sister and aunt are doctors, recounted instances when she was able to get quick answers by email or phone to questions, be reassured, and save a lot of time and effort. One instance: “Once I was on holiday in Greece and sent my sister a picture when my eye was infected. She told me to buy drops and that it would go away.” Since most people do not have convenient relatives with medical degrees to talk to, being able to easily reach a doctor or nurse by email could provide a way to get a quick answer. Dr. Danny Sands has long been a proponent of physician-patient email, but most practices do not support it. I can easily see the benefits because email forces you to describe a situation concisely and images can be attached as appropriate.
  3. Meet Dr. Skype. Melody Smith Jones posed the question, “Can telehealth be used to end this man’s 6 hour commute by providing him access to the specialists he requires? What barriers and challenges still lay before us to make this a reality?” Dr. Joseph Kvedar answers this, saying “We have to move beyond the antiquated notion that you must visit a physical space and talk real-time with your health care provider to fulfill the process of care.  Seamless communication between you the patient and the system (including your provider but also your health information) will allow us to cut through what is a falsely complex and inefficient system to achieve more efficiency, less waiting and less anxiety.”
  4. Ask the expert. Self-proclaimed experts and community-verified experts provide advice in many sites like Yahoo! Answers. Recently there has been a proliferation of sites supporting health Q&A. A new entry, HealthTap, promotes that it has “Answers from 5,000 U.S. licensed physicians. No waiting room.” I tried it and questioned why I needed to answer so many personal questions during the registration process. Once registered, I started to ask a question but was stumped by how much context to provide. In general one of the things I like about Ask the Expert is the ability to browse other people’s questions – sometimes you learn more from questions you never would have thought to ask – and answers.
  5. Use clinics for non-urgent care. I had a friend who believed that it was important to see the same doctor because he or she could notice changes that might not otherwise be detected. While I agree, the Minute Clinic (note the name) model can potentially reduce some of the use of doctors for non-urgent care.
  6. Enhance health literacy skills. With 80% of US internet users looking online for health information, better health literacy skills are needed to guide the strategies used to seek, select, and use online health information. This is rarely taught in schools or by doctors, and is increasingly necessary because of the lower barriers with social media: it is easier than ever to promote herbal supplements and bad advice.
  7. Make waiting fun – or at least less stressful. Deirdre Walsh, a health coach and a former student, said, “The pain and frustration of endless waiting seems needlessly cruel. But it’s often the emotional toll of fear and uncertainty that does the most damage from the negative effects of stress chemicals on energy, sleep and mood.  If waiting is inevitable, there are self-awareness exercises that restore calm, power, and the sense of control. ” Games and gamification have potential as well: a version of “Wait, wait… don’t tell me!” for the waiting room?
  8. Is there an app for that? Not that I know of, but social media is being used by public health departments to post flu clinic waits and by emergency rooms to post wait times. What about for doctor’s visits? Dr. Richard Besser said, “You shouldn’t have to wait more than 15 minutes unless there’s an emergency.  Social media might be a great place for people to share waiting times.” Along those lines, I read about, but have not tried, WaitChecker, a web-based service to alert patients to appointment delays.
  9. Set expectations. Signs provide estimated arrival times for trains and busses in the public transportation systems in many cities. It is easier to be patient with expectations set, not just for the length of a wait but the course of a disease.
  10. Use waiting time on task. A student once told me that she had a rash when pregnant and assumed it was unrelated to her pregnancy. She searched for information on her iPhone while in the waiting room, decided it might be related after all, and asked her doctor, who treated it. She saved another doctor’s appointment. What if all waiting rooms provided mobile devices? Or promoted prevention with education, exercises, and healthy snacks. Talk about captive audiences.

Quality of health care is paramount

It is important to maintain perspective: quality of health care is paramount. Everyone wants the best care possible and sometimes waiting is unavoidable. With no health advantages to waiting, there is no reason to accept that it’s part of our health system, but, instead to work to reduce waiting, and to reduce the impact of waiting.

Lisa Gualtieri is Assistant Professor in the Health Communication Program in the Department of Public Health and Community Medicine at Tufts University School of Medicine. She blogs at her self-titled site, Lisa Neal Gualtieri and can be reached on Twitter @lisagualtieri.

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  • Paul Levy

    As always, thoughtful comments from Lisa.  The concept of waste, or muda, in a Lean organization covers a lot of these examples.  If health care systems adopted this approach to management, much of this kind of problem could be reduced.  Here is an example, as applied to an orthopaedic clinic: http://runningahospital.blogspot.com/2007/03/lean-machine.html

  • http://www.facebook.com/people/Craig-Koniver/100001463176810 Craig Koniver

    Great advice! For some reason in this day and age, medicine is still practiced the way it was 40 years ago with the same looking offices and same office systems. It is time doctors start moderninzing their own approach to patient care. For my patients, I routinely text, email, video chat and keep myself accessible as much as possible. 

  • http://pulse.yahoo.com/_U4ZSBHBLLXUIFOB6WQIFWB3GE4 Jack

    Please tell me this is modern Swiftian satire. If so, then a hearty golf clap for Lisa.

    If not, then $deity help us.

  • http://twitter.com/lisagualtieri Lisa Gualtieri

    Thanks for the comments. I just read part of the Commonwealth Report http://bit.ly/rIOwwL:
     
    “Patient-centered, timely, coordinated care. In 2008, only 43 percent of U.S. adults with health problems were able to rapidly secure an appointment with a physician when they were sick—about half the rate in the best country. U.S. adults also were among the most likely of those in eight countries surveyed to report difficulty obtaining health care after regular office hours without going to the emergency department.”

  • http://twitter.com/LizKeyser Liz Keyser

    Really interesting post Lisa! I agree with you that all this time waiting is a great opportunity for some edutainment in health.

    “See the doctor” brings up another good point; you have to wait while the doctor reviews your information while the only information you can review on your doctor are from rating/review sites that just don’t get it. Additionally, I don’t know why these sites hop right to quality ratings when they can’t even get the basics down. One doctor I spoke to tried to update his profile on HealthGrades and they didn’t even have his license number right so he couldn’t log in to fix all the other information they got wrong!

  • sudhir ketkar

    Hi all,
    nice to see the article and I agree, waiting has become an integral part of getting treated for a disease or disorder. This is prevalent in US/UK due to the system of practice of medicine. Commuting to a clinic is inescapable part unless clinics open widely to accommodate all parts of the town. Doctors have to take time to mentally put events chronologically. One has to visit a laboratory for giving samples. Reports are released only after the lab. director releases it by signature ( a requirement of ISO 15189). The insurance is paying for all this and it is not that they have never been duped, so they take care that they do not. And yet for an ill patient it is important that things are made as convenient to his/his relatives as possible. 
    From the point of view of health care providers it appears to be inevitable. And YET there has got to be a solution. I am from India and work as a consultant in preparing the hospitals/laboratories for accreditation. I shall quote an instance. When my daughter visited from US, in one hours of landing I had got her checked from an ENT surgeon, a Dermatologist and an Orthopedic surgeon. The laboratory results are available within six hours. This is because the patient is paying for it. BUT BUT the system prevailing over ur place is good and solutions must be found to address this. I dont suppose that a simple problem solving approach, a simple process improvement methods shall not address the problem. 
    I visualize this problem as my relatives in UK, US too have to wait and each element for waiting seems logical. 
    BUT THE PROBLEM CAN BE SOLVED.  Amen……

  • ShelleyWebb

    While I agree that the waiting game is very frustrating and can often be very stressful especially during that time period between testing and the next physician’s appointment, I am going to remind everyone that we have it much better here in the U.S. Than in other countries.
    My sister, who lives in Canada, has been waiting over 6 months now for surgery for 3 kidney stones. In the meantime, she is on PO morphine ( Which will cause it’s own problems), has lost over 10 pounds, and now has pitting edema in her lower extremities. Supposedly she is “next on the list” for surgery.
    So I won’t complain about the waiting periods here.
    But I did write an article about things that can be done while waiting in a doctor’s office. You can find that here: http://tinyurl.com/13gs5z

    Shelley Webb
    http://Www.IntentionalCaregiver.com

  • Anonymous

    Case in point: On Friday, at 2 PM, I noticed the beginnings of a urinary infection, but was not sure. By 4 PM, I was certain — frequency, urgency, burning urination, post-urination pain, cloudy urine, very small quantity. So I called my doc’s office to see if he would call in an order for an antibiotic, and they said he wouldn’t do it unless I was seen but that there were no appointments available until Monday, and could I come in at 10?. I said there was NO way I could wait that long, because I was in excruciating pain, and as a diabetic, I couldn’t take the risk that it would go up to my kidneys.Then they said that they would leave him a message.I asked them to let me know by 6 because the pharmacy closes at 8, and I couldn’t wait until Saturday morning, because I was in so much pain. Well, they never called me back at all, so I went to one urgent care place, and it was closed (business hours only), and ended up in another at the other end of the city. I did get treatment, and had to hustle to the pharmacy across the street for my prescription (of course I had a UTI — my urine was bright with blood at this point).I got my first pill at 9 o’clock, after much pain, unnecessary waiting, and running around. Finally, on Monday, my doc’s nurse called me back to tell me that he doesn’t give prescriptions without a patient being seen. I know full well that he has appointments, but isn’t a doctor’s first obligation to take care of the sick? I have waited in other doctors’ offices patiently because they have handled a sick person’s needs first — that’s OK with me. Why couldn’t MY urgent need be taken care of?

  • http://pulse.yahoo.com/_PR62YR26TZZYHJAGYQJHC5LC4Q Nancy

    I chose my physician for many reasons but one of them is that I can get in to see him within 24 hours almost always if I need to. That’s to see him personally. If I want to see one of his PA’s or another physician I could probably get in that same day. Now seeing specialists is another thing but at least he covers emergencies and can bridge my care until I can be seen by the specialist.

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