Patients in the waiting room do not know why doctors are running late

I hate running late.  I prefer to arrive five minutes early for any meeting.  I was that compulsive student who always turned in papers before they were due.  Now I turn in conference abstracts, grant applications, and even poetry contest submissions, well before their deadlines.  Unfortunately, timing is not always in my control.

I particularly hate running late in clinic.  I want to see all my patients on time.  It is never my intention to keep people waiting.  But all it takes is one patient with more complexity than can fit into their scheduled appointment, and the entire day is thrown off.  It is impossible to catch up again if I am fully booked.

People often complain about having to wait at the doctor’s office and say things like, “The doctor must think his time is more valuable than mine.”  Do they assume that the doctor wants to keep them waiting?  Or that the doctor is wasting time?  Or trying to assert dominance by insisting that the patient be on time and not reciprocating?

No, the doctor is late to see them because he or she was delayed by another patient.  Another patient who needed extra attention to deal with a cancer diagnosis, a spouse’s infidelity, a challenging mental illness, a mysterious pain with no clear answer, an important decision between treatment options, an unexpected procedure, five different serious chronic conditions that all need to be addressed, or any number of other issues that come up.  Many problems do not fit neatly into a 15 minute appointment slot and are going to spill over.

If I had my way, I would have longer appointments.  I would be less rushed and less likely to run behind.  But then I would have fewer appointments available, and patients would have to wait longer to be scheduled.  People already have trouble getting access to primary care.

A family medicine doctor in private practice once told me: “My first twenty patients of the day are overhead.”  He had to see at least twenty patients every day just to break even on the expenses of the practice.  He usually saw about thirty and was always under pressure to do more work in less time.  Every day, he worked through lunch and stayed at the office long after the last patient had left, doing the paperwork and follow-up.

The patients in the waiting room do not see what is going on behind the scenes.  They are not reflecting that our system is designed for acute care and not well suited to managing multiple chronic illnesses or social disasters or the ever increasing demands of preventive care or the burden of unreimbursed work.  They do not see my good intentions to provide excellent care and also run on time.  All they know is that the doctor is late.

Tabor Flickinger is an internal medicine physician who blogs at Tea with Dr. Tabor.

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  • http://www.facebook.com/people/Ardella-Eagle/840440226 Ardella Eagle

    There is late and then there is obnoxious.  I’ve dealt with both.
     
    Late is the doctor whose staff schedules the patients with care and concern; extra time for the consults, doubling up on post-ops, proper mix of consults to established patients.  However, there’s the post-op with the unforseen infection, the need for hand-holding for the unexpected surgery, the emergency fit-in.  These are the nature of the practice, the art of medicine.  A caring staff would explain these situations to the patients in the waiting room and hopefully the patients understand and will remember that the same care and attention will be afforded to them in their turn.
     
    Obnoxious is the doctor who consistantly (I’ve been seeing this doctor for 4 years now.  This happens EVERY TIME) walks into the office one hour AFTER the first scheduled patient.  Through the front door, no less, so that the backlogged patients can see that it is the doctor who is late and not back logged.  Obnoxious is when it is brought to the doctor’s attention, there are poor excuses of rounds being backed up, traffic, and parking issues.  Obnoxious is when staff (or doctor) won’t listen to suggestions for improvement.
     
    Lament all you want, Dr. Tabor, but know you that you’re honestly tardy and not obnoxious.

  • Cathy Blount

    I get why doctors are late.  It’s understandable, and as a patient, I want to know that you’re going to take the time needed with me regardless of your schedule.  This is where the office staff should come in.  If the schedule is off track when I come in for my appointment, that should be communicated.  Personally, that’s my biggest complaint – not that a doctor gets off schedule, but that it isn’t communicated to me.  The lack of communication reflects a lack of respect for my time.

  • Anonymous

    Seems that the doctors are ALWAYS running late.  Based on your explanation, the day is too tightly packed with appointments. If the Dr allowed 30 minutes instead of 15 for an appointment, then even if he did get behind on one, the others would have some slack time built into them and he’d get caught up.  Of course, he would have to take a revenue hit in order by having fewer appointments in a day.

    Maybe it’s the Dr’s greed that keeps him from doing that….

    • Anonymous

      Guess you didn’t read the entire article.  It takes 2/3 of the day to just cover expenses.  30 minutes per visit, unless it’s a retainer style practice, would mean the end of primary care.

    • Anonymous

      If the patient wants 30 minute appointments, she should be willing to pay for that service in a retainer type practice.

      Maybe it’s the patient’s greed that keeps her from doing that . . .

      • Anonymous

        How about making better contracts with your third party payers for higher fee schedule reimbursement? 
        Established Patients CPT – 99211 usually a nurses visit, 5 min
        99212 pretty straight forward, problem focused visit, 10 min
        99213 little more iNn depth, expanded problem focused visit, 15 min
        99214 more indepth and more complex MDM visit, 25 min
        99215 highest level established patient office visit, 40 min

        New patients are 99201-99205, anywhere from 10-60 min visits

        If you don’t like what you are being reimbursed, then re-evaluate what you are accepting as payment in full from insurance companies! If you wish to go to an all cash practice, by all means go ahead! But, it is more common for the doc to be late than the patients. 

        If you streamline your practice, train your receptionists or schedulers well, there is NO reason why you can’t have a profitable ON TIME practice.  Schedule appropriately.  Would ya?  And open a line of communication between your front desk and those in your waiting area, to inform those who have been waiting for 30 minutes why the doctor is running behind and give those patients the opportunity to reschedule. 

        Seriously?  Blame it on the patients????  Give me a break.

        • Anonymous

          Are you serious?
          Are you in practice?  Can’t be by your tone.

          Sorry, but in New Mexico, the insurer TELLS you what you are going to be paid.  No exceptions. I’m part of a very large independent physician group and we can’t even get the insurers to budge, so how can the independent practices even try.   And that includes Medicare, which has increased it’s rates about 5.5% over the last 12 years.  That’s not annually–that’s over 12 years.  Inflation has been about 37-40% over that same time period.

          In my office, it is MUCH more common for the patient’s to be late than for me to be late. I strive very hard to stay on time.  We also let patients know if I get behind by more than 15 minutes.

          Give ME a break.

        • Anonymous

          If you’re replying to me, you’ve set up a whole army of straw men. 

          I never said that I don’t like what I’m being reimbursed, that I don’t have a profitable practice that runs on time, or that I blame “it” (whatever “it” is) on the patients.

          What I will say is that I have no intention of scheduling 30 minute appointments and taking a revenue hit because dennisvolz wants me to. If he doesn’t like what he’s getting in the insurer-run system, it’s his responsibility to look for something more satisfactory outside of it.

  • Anonymous

    My biggest cause of getting behind?

    Patients who show up late to their appointment.

    Seriously.

  • http://www.bryantsstatisticalconsulting.com Donald Tex Bryant

    I understand that PCP are driven by getting the right number of people through the door everyday.  There are ways other than abbreviating patient face-to-doctor time to 15 minutes and running chronically late to insure sufficient income for the practice.  For instance, many practices lose a significant amount of money to poor billing practices, some up to 25%.  Imagine cutting that down to between 1% and 4% and see how much more money flows into the practice, allowing more time to be spent with patients.  Also, if a practice is organized so that information flows seamlessly between staff and physicians, then a considerable amount of wasted time could be recovered.  There is much more wasted effort and lost revenue in most practices than staff and physicians realize.  However, with good problem solving approaches many of these can be identified, tackled and significantly reduced or eliminated.  Training a staff to use Plan-Do-Check-Act or Lean Healthcare, as most of the large hospitals are doing, would go a long way towards helping the physician-patient encounter.

  • http://profile.yahoo.com/2ZCARSYSNRRAUFQLTJFJLC2O5I Deborah

    I showed up 10 minutes early for my last appointment.  After waiting 40 minutes, I inquired.  I was told my appointment was really at 4:00, but they told me 3:30 so I would be on time.  And, because the doctor was a little behind, it would be another 15 to 20 minutes before he could see me.

    • Anonymous

      Obviously, the patients scheduled before you didn’t pay any attention to their appointment times.

  • http://twitter.com/JasonBoies Jason Boies

     I’ve never felt that my doctor was asserting authority or deliberately wasting my time, I’m stunned to hear many people actually think like this.  Some people really seem to think the entire world is out to get them.
    Doctors are busy people, and MY doc is a great guy, fortunately.  I would, however, second Cathy’s point below and say that the only time I’ve encountered any
    frustration at my doc’s office relates to the lack of proper
    communication from the front desk staff. Seems to me that may be the main area to focus on.

    Thanks for this thoughtful post, Dr. Flickinger.  :)

  • Anonymous

    There is annoying late when the patient is in the wi-filess waiting room an hour past their appointment time.  And then there is teeth gnashing late when you’ve been taken to the exam room, instructed to get undressed, freezing in your paper gown, and then an hour goes by with no one having the courtesy to at least poke their head in to re-acknowledge your presence with an update.

  • Anonymous

    Several years ago my OB/GYN was running late due to a delivery and his staff  announced to the waiting room that he was running late because a new person had just been welcomed into the world. We all smiled and went back to reading our books and magazines.

  • Anonymous

    Hey Tabor, sounds to me like it might be time for you to do like my primary care doctor has already done and sell out to a large hospital group in your area. Face it Tabor, the future is ACOs. By selling your patient base, you could become a salaried employee and let the group take care of the details of running an office. You could dump the heating and electric bills, the cleaning bills, the paid staff, the telephone and internet bills, the rent or the mortgage, the maintenance. In an ACO group, you’d have the same patients. You’d have regular hours. You have all of your malpractice insurance paid by a group policy. You’d have paid vacations. You’d have weekends and holidays completely off. You’d have a pension plan. You’d have a 401k plan. You’d have a medical plan for yourself and family. You’d have dental care for you and your family. No more “running late”!

    • Gil Holmes

      Absolutely. Because when you add layers of management, the light/electric/water bill all magically become cheaper.
      Money comes in one way. Patients are seen and stuff(vists, labs, x-rays, etc) are done. Management doesn’t do any of those things. They just add cost. Management needs to be kept to absolute minimum. And yes, I have worked in big conglomerate as an employee and in a private practice. Private practice had much lower overhead.

      • Anonymous

        Yeah, Much lower overhead means much more profit for doctors, right? Darn those pesky patients! If we could only figure out a way for them to just mail in the check or maybe tap into their checking account, then we’d have it made in the shade, right doc? Wouldn’t it be great if we could dump those Medicare patients and cherry-pick more healthy patients? Wow! Profits would skyrocket and you could simply call into the office from the country club from time to time, huh?

  • Sapphire Storm

    I think the point you are making reflects the need for a transformation in health care and health care practice.
    The doctor’s clients should be understanding of the difficulties in modern practice (although this is an age-old
    complaint); and doctors should study ways to alleviate these problems of running a practice in an old fashioned
    way. I’m sure grad schools are researching options as we speak…

  • Anonymous

    Darn those pesky patients! 

  • Anonymous

    I think what is most discouraging as a physician is that patients do not see that we are trying.  We are trying to provide every patient the attention they deserve, which often takes over 15 minutes.  I realize the patient likely does not know there are ever greater demands to DOCUMENT and document every detail of the visit, or the MD’s reimbursement is cut severely.  This requirement takes a significant investment of time which ultimately, is time taken away from the patient.  I am an MD. I do not have a big house or fancy car.   I do, however, have a med school loan. I am not trying to fool the patient, not trying to trick them to get their money.   I am trying to figure out how much discouragement I can take.  

  • Anonymous

    Yes patients become impatient waiting for us. But they seem to lose track of time when you’re with them in the room listening to them veer off from their issues. The human nature of selfishness at its best.

    • Catharine Zivkovic

      You call it selfish to go to your doctor for the very purpose of talking about your issues and taking the time needed to talk about all of your concerns? That’s beyond insane… bordering on the criminal.

  • Catharine Zivkovic

    Exactly who’s idea was it for appointments to last 15 minutes? It is more than a little unsettling that insurance companies, law enforcement, drug companies, and fear of litigation determine the way that medicine is practiced. As an ICU nurse, I’ve experienced similar impossible situations such as family members being outraged that their intubated mother is *drooling* and I haven’t bothered to wipe it (you can be sure that family members are not going to be caught dead doing ‘the nurse’s work’) when, in the room next door, I’ve been trying to keep my second patient from bleeding to death. (Hanging blood products is fairly time intensive, not to mention titraiting pressors.) I suggest that MDs should be the ones determining how long various kinds of office visits should last. For a regular, annual appointment I would say that anything less than one hour is insufficient. Patients who get upset when they have to wait should schedule their appointments first thing in the morning. Otherwise, when I go to the MD, I plan on spending the whole afternoon waiting and being seen in an unrushed, thorough, and comprehensive manner. (But I choose my doctors very, very carefully. It is not unusual for my Gyn to spend an hour with me for my annual visit.) My favorite MD (pain specialist) spent over THREE HOURS with me on my first visit. He doesn’t take insurance and it cost me $350, which I consider a bargain. He is also the best, most respected MD in town — but he was trained in the UK. 

    As it is, patients are paying far too much and getting far too little. But who will stand for change? MDs won’t. They need to squeeze as many bodies into a day as possible. Insurance companies aren’t about to actually pay the bill for adequate care. Patients are generally powerless and lucky if they are able to afford to go to the doctor (not to mention dentist!) at all. Nurse practitioners are excellent choices for annual visits. They are usually far more willing to take the time that is needed for a qualitative assessment, more likely to actually listen to the patient, and can refer problems or potential problems to one of those 15 minute MD appointments.  

    Health care in the US is a total disaster but voters shoot themselves in the foot by having absolutely no clue about the problems and voting in such a way that the disaster will continue — and get worse.

    • http://twitter.com/DarrellWhite Darrell White

      Powerful post. What’s your thought on primary care practices that achieve what you propose by severely limiting the number of patients they see, perhaps by charging an annual fee? 

  • http://twitter.com/DarrellWhite Darrell White

    Good timing. This AM in the clinic we were front-loaded with post-op patients (who usually fly through) and a couple of quick follow-ups from ER visits early in the week (ditto). Ooops…2 technical staff members called in sick. All of a sudden we are in “too many patients, not enough us” mode. Docs take patients back, everyone hustles, front office staff keeps up a running dialogue with patients in the lobby, and we struggle to stay only 15-30:00 behind. One patient storms out (the old “the doctor thinks his time is more valuable mine” thing), and several patients scold anyone in view about “over-booking”. 

    Sigh.

    No pats on the back (“thanks for hustling doc”; “man, I’ve never seen a doctor take a patient back”…nope…not a one), a few sarcastic “nice to see you’re so busy” cracks. We did everything “right”. 

    Our response? “Oh well…this is the cruise we signed up for.” We run on time so routinely that when the wheels come off (more ER’s than planned, disasters, increased complexity, staff illness) we’ve conditioned ourselves to taking this all as a backhanded compliment. 

    It’s a two-way conversation, no? A little slack on each side (patient runs a little late, schedule goes off the rails for an understandable reason) ought to be the rule. Docs, especially primary care docs, are truly squeezed for timespace, and they don’t like it any more than any patients do. 

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