Long waits at the doctor’s office disrespect patients

I wasted time, and now doth time waste me.
-William Shakespeare, Richard II

A friend recently asked me a simple question: Why do we have to wait so long for doctors and not for other professionals, like lawyers, accountants, or dentists? And what can we do about it?

A study by Press Ganey showed that the average time patients spend waiting to see their health provider is 24 minutes. The research was done back in 2009 and I think new data would show people are typically waiting much longer these days. As you might guess, overall satisfaction drops the longer a person has to wait.

Waiting to see a physician is much, much different from waiting for an airplane or a bus.

You’re often anxious about the appointment, uncomfortable, in pain, or worried. I have a friend who had to wait three hours for her first chemotherapy appointment, which seems cruel. Another friend had to wait almost an hour to get oral surgery: sitting in a cold office, having had no food or water since dinner time the night before, and very nervous.

Why are you kept waiting? 

There are, of course, many different reasons why you may be kept waiting a long time by your health care providers. While there is always the possibility of an emergency having caused an unusual delay, most practices seem pretty consistent; they either always keep you waiting or rarely make you wait. That’s due to the healthcare providers’ basic philosophies about their time and money; how much they value their patients’ time; and their ability to run a smooth and efficient practice.

A practice that doesn’t make you wait has undoubtedly made a philosophical and financial decision that it’s not right to make patients sit very long in the waiting room. They respect your time as much as they respect their own. So they are careful to reserve a few slots every day in their schedule in case a patient’s visit takes longer than expected or there’s an emergency. They also create some “breathing time” in the schedule to help ensure the ebb and flow of people in and out won’t create a frustrating and tiring delay for their patients.

A practice that always makes you wait has a different perspective. They are typically maximizing revenue, over-booking multiple appointments to allow for some “no-shows,” and even encouraging extended patient visits and un-planned procedures because they increase the day’s revenue. Basically:

More Patients + More Procedures = More Practice and Personal Revenue

Sometimes, the practice is just lax. I had the first appointment of the day to see my general practitioner and waited a very long hour. When I asked the office staff how that could possibly be, and was there an emergency, they said, “Oh, no, she comes in when she comes in.”

Some of us mind all this more than others. A good friend of ours told me he has come to expect long waits when he or his wife sees a specialist. (He’s right. Average waiting times of specialists are longer than generalists). So he brings a big stack of back issues of the Financial Times and starts plowing through them.

What could they do about it?

There are lots of things patient-centered healthcare practices could do to improve things if they wanted to, in addition to avoiding over-scheduling. They could routinely call or email you if they’re running late. They could give you a device (like restaurants do) that will buzz when you’re called (when your “table’s ready,” so to speak), allowing you to step out in the fresh air or grab some coffee in the building’s lobby if you like.  They could sincerely apologize. They could come out into the waiting room and inform folks about the situation. (Of course, when they routinely run late they wouldn’t even think to do this).

What can you do?

Here are a few approaches you can take to deal with this issue:

  • Book the first appointment of the day or the first appointment after the office’s lunch period. This doesn’t always work because some practices book several people for every slot, but it’s worth a try and it’s likely to minimize your wait at least a bit.
  • Call ahead and ask how the day is going in terms of appointment delays and see if you should come in a little later. I’ve tried this with various results. Sometimes they just warn you that they’ll take you based on when you come through the door.
  • If you’re seeing a doctor who is prone to being called out of the office — a specialist such as an obstetrician/gynecologist or a surgeon — be sure to call ahead to see how the day is going. If you can reschedule on a bad day, you may save yourself a lot of time and aggravation.
  • After you’ve waited for 15 minutes or so (or whatever amount of time you’re personally comfortable with), ask the office staff  how much longer they think the waiting time will be. If their answer doesn’t please you and if your problem doesn’t require immediate attention, ask to reschedule your appointment. Somehow that often gets you seen more quickly.
  • Consider talking frankly with your doctor or writing a letter explaining your frustration about the long waits and ask that the practice institute measures to improve the situation. See what happens.
  • Complain about the waiting times on social media sites like Facebook or Twitter, or websites like Yelp or Angie’s List.
  •  Send your doctor a bill for what you consider to be your excess waiting time. Don’t laugh. People have received checks.
  • If you don’t want to keep seeing your doctor, you can sue your doctor in small claims court for your time. People have succeeded at this. It certainly makes a point.
  • Be a super patient patient. Bring fun things to do, read or listen to and hunker down for the afternoon with an amazing attitude. (This would be very hard for me).
  • Find a new doctor. Ask the new practice’s staff what their philosophy of waiting times is before you book. Listen to what they say.

The bottom line: Expecting me to wait a long time in a doctor’s office tells me two things. First, I don’t feel respected. The physician is, after all, my consultant. And secondly, I wonder how committed the practice is to my comfort and to reducing my anxiety when they seem to be putting more emphasis on their needs than on mine.

Barbara Bronson Gray is a nurse who blogs at BodBoss.

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  • http://twitter.com/_connectedcare Dr Irwin Lim

    I would agree. I hate waiting so I decided when I set up my own practice (I’m a rheumatologist) that I would not keep patients waiting. We schedule appointment times more generously and do not double-book. We also leave some breaks to allow catch-up for the inevitable problems that demand more time and attention. Being busy & having medical “emergencies” is relatively predictable or at least, can be anticipated.

    • http://twitter.com/bbgrayrn bbgrayrn

       I agree! Thank you for your comment.

  • http://www.facebook.com/profile.php?id=529170324 Anna Lauriente

    if I have to wait longer than 20 minutes, I reschedule and leave. My time is just as valuable as theirs.

  • http://www.facebook.com/people/Jackie-Swenson/100000046998781 Jackie Swenson

    As a patient with multiple health issues, I’m fortunate to be living just 10 minutes away from a big teaching hospital.  There are ‘weekend clinics’ available for non-emergency care on Saturdays and Sundays. For non-emergency problems, I could get same day appointment using ‘urgent care’ which is part of the Internal Medicine Clinic where my family doctor is located. 

    There’s a 24-hour on-call nurse line for us to get advices. Because of my medical history, the on-call nurses almost always recommend me going to the ER.  But I’ve learned ER is not the place to go if it’s not a true emergency situation.

    As for the wait time before my regular appointment, I’ve learned to be ‘patient’ because I know my doctors are trying their best to provided the best care for their patients.  I would read magzines and watch the cable TV programs – after finishing filling out the 4-page patient information survey… [Come to think of it, that might be one stratege to keep the patients occupied.  Plus it’s a good opportunity for the patient to thinik through the ‘reasons’ why they are seeing the doctor. 

  • http://www.successfulworkplace.com/ Chris Taylor

    Great story about something that everyone has experienced too many times. If we think about the doctor’s office in traditional ways, this is a scheduling problem (queueing theory and over-scheduling) or a revenue maximization at our expense. What if it is something entirely different?

    I was at Wisconsin’s Thedacare last week and saw first-hand how they manage schedules at their Encircle facility. They track when patients arrive, when they’re put in a room, when the staff comes and goes, and the overall scores for satisfaction. They’ve standardized much of the work, including how to resupply the room so that they’ve cut the time down without hurting quality. By tracking and improving process, they know when they’re ahead or behind and can add to the schedule or ask someone to come later (better the one than the many) and keep satisfaction high.

    By incrementally measuring everything, they know how long things really take. They even know the time tendencies of each physician, which is an important part of the equation!

    • http://twitter.com/bbgrayrn bbgrayrn

       Great points.

  • Matthew Mintz

    Ms. Gray’s resume is quite impressive, but I am guessing she has not worked in a primary care office.  I can not speak for other specialities, but the reason that primary care doctors run behind is that reimbursement from insurance companies are so low that they only way they can make ends meet is to see more patients. The equation “More Patients + More Procedures = More Practice and Personal Revenue” is not correct for primary care.  It’s more like (More patients x low reimbursement) - increased staff for dealing with insurance companies – No high paying procedures like the specialists have = too many patients in too little time. 

    This is not about profit and greed.  It’s about survival. In fact, some physicians are actually going broke! http://video.foxnews.com/v/1370749684001/doctors-going-broke/

    Let’s say a family physician sees 25 Medicare patients a day, 5 days a week for 50 weeks out of the year*. At the current rate of $68.97 per visit, this generates $431,062 in revenue. At 60% overhead (conservative estimate for traditional PCP practice) of $258,637, this family physician’s income would be $172,425 per year, which is close to the average salarly of a family physician.  Now one could argue that this salary is pretty darn good (and compared to most Americans it is); however, you need to factor in the at least seven several years of training after college when the physician was making nothing or minimum wage as well as the high cost of student loans, which average around $170,000 after graduation.  It is no wonder why are medical students are not choosing primary care as a specialty.

    Because of the low reimburse rate, primary care physicians operate on the margins.  They can not afford to reserve a few slots for emergencies or for some “breathing time.”  In fact, practice have to book to account for “no shows” because not to maximize profit, but to make ends meet. They must see too many patients in too little time, which means long waits for everyone.  This is also why many patients (especially in urban areas can’t find a primary care doctor. They have so many patients, they can’t accept any more and have closed their panels.

    Some primary care physicians have become tired of trying to practice complex medicine in too short of a time, apologizing to patients for making them wait so long, and stressing over keeping a practice afloat. These physicians have choosen several alternatives which include not taking insurance altogether, retainer practices or direct primary care practices which utilize a monthly fee structure.

    Hopefully Obamacare will solve this problem and truly value the work that primary care physician provide. Investment in primary care is truly wise as data supports it saves money in the long run.  However, until then, many patients are going to have to make a choice: wait to see a primary care doctor or pay a little extra. Is this fair? No, of course not. Doctors fleeing insurance based practices are not a solution but a response to a broken system.  However, despite the high premiums that both patients and their employers pay, this does not result in enough payment for primary care physicians to sustain a practice.

    *though many insurances pay higher than Medicare, some (especially Medicaid) pay lower. Because of this and the fact that Medicare payments are public knowledge, I chose this as an example.  Also, most primary docs will tell you that you can’t see 25 Medicare patients a day because they are all too complex, making the reason why patients have to wait even clearer.

    • http://twitter.com/bbgrayrn bbgrayrn

      The problem, however, is that making patients wait isn’t increasing your revenue. It’s just making them wait. If the scheduling system were improved, if patients were called to be told to come a little later because the schedule has gotten backed up, if the practice planned for the inevitable longer appointments and built in some flexibility, all would benefit. See Chris Taylor’s excellent comment below.

      • hh1111

        I see that you have repeatedly suggested calling patients to let them know you are running late.  Who do you propose do that?  The nurse who is calling in prior authorizations?  Or the secretary who is calling insurance companies?  Or the doctor who is running late?  And then when 4 people show up late in the afternoon – 2 on time and 2 who came later because they were called – who do you see first and who has to wait? 

  • http://www.facebook.com/profile.php?id=698811753 Linda Krencik

    I hope your doctor never has to take the time to explain a medical condition, it’s impact on your health, the health of your loved ones, potential treatments and their outcomes to you and then run out of the room because another patient is waiting.  Have some compassion, will you?? 

    Oh wait, here’s an idea…maybe you can bill the patient that made the doctor late in the first place…how does that sound?

    • http://twitter.com/bbgrayrn bbgrayrn

       Of course there are times when, despite every effort, patients end up waiting. But that begs the question: why do some offices have minimal waiting times and others almost always have long waiting times? It’s most likely due to trying to fit too many patients into the hour or the day. I think it’s compassionate to figure out what is causing long waiting times and work to solve it.

      • http://twitter.com/RichmondDoc Mark Ryan

        Many offices could keep a waiting time to a minimum by limiting the number of problems physicians will address in one visit.  That would work to keep us on schedule, but would require more return visits and would not be satisfactory for most/any patients.

        • Anne Frates

          That’s WHY there are always 5 or 6 ‘by the way’s -I have to sit for an hour to get in  to the doctor…I’m not going to call for every symptom or difficulty; I wait until something is necessary and try to get the other stuff dealt with at the same time. It’s not the co pays, it’s the huge mess it makes of my days to have to wait and wait and wait for the specialist to get to me. He’s always nice, and apologizes, but I still feel that since he knows that his patients all have multiple issues that he should schedule more time for each, rather than run late every single day, and be frantically running from pillar to post all the time.

          • southerndoc1

            Wow!

            You admit you’re scheduled for one problem, and you demand that the doc address six others, and you complain that the doc isn’t on time. Hello, Ms. Center of the Universe!

            Until the payment system changes dramatically, patients will get scheduled for appointments that are 15 minutes or less. Deal with it.

        • katseye1969

          I respectfully disagree Mark. Sometimes, it’s not until dialogue is open, that a patient realizes what he or she is experiancing is relevant. Sometimes, a visit can open a can of worms, and it’s not until we talk to our docs that we realize things are connected, therefore, requiring more time. I travel to see my docs, so a follow up visit to address other issues, is not possible. We need to cover a lot of ground with each visit to get the maximun benefit.

    • katseye1969

      LOL Linda! You sooo remind me of me! :) One time I was in the hospital with chronic pancreatits. (I had a bad birth defect) I had a whipple, a gastric pacer, a CP/ICT, and a roux-en-y for bile reflux. Everyone wanted to see the girl without a pancreas. One doc came in and talked to me for hours about my condition. He asked me if he could be my advocate. A few weeks went by, and I got a bill in the mail from him. I kindly wrote him a note and explained to him that he learrned from me, he didnt help me, he was there to learn from me, so I sent HIM a bill for my time.

  • http://twitter.com/RDBowman R Bowman

    I am a primary care physician.  The reason I “get behind” is that patients, once they have the doctor’s  attention, want to keep his or her attention.  Patients often have an “oh by the way…”  comment after I think we’re done.  They might be scheduled for a quick visit for a sore throat, but at the end of the visit, out jumps the 3 months of burning in the feet, or the pain in the chest last month that can’t be ignored.
     It seems that there’s always something more to be asked of the doctor.  Sometimes patients come in with a list of 4 or 5 topics to cover.  Even if I’m not double booked, it can take 30- 45 minutes to address everything that should be addressed in a chronic care visit for diabetes, high blood pressure or COPD, or more often, all three together.  If I allowed 30- 45 minute slots for every patient, I would not be able to keep the doors open.  Perhaps a specialist can do this, but a PCP cannot.  If everyone’s problems could be taken care of in about 7-8 minutes, then no one would ever have to wait.  It’s just not feasible with the baby boomers getting older.  Please do not misunderstand me, I do not mind taking care of all those problems, I’m glad to check on your heart or do that documentation of a foot exam so medicare will pay for your diabetic shoes when you just came in for a sore throat.  That’s my job.  But it can’t be done in 15 minutes….  Unfortunately, the hospitals and universities who own PCP practices like mine still give me a 15 minute per patient schedule to work with… and that’s not up to me.

    and my salary is 30K below that average for a family doc… and I had over $170k of loans when I started practice, that’s more than my mortgage!

    So please, understand that I value your time, and I will work as quickly as possible.  When I am sitting in front of you, you have my full and undivided attention, and most likely you’ll keep it for more than 15 minutes. :-)

    • http://twitter.com/bbgrayrn bbgrayrn

       Understandable. but it sounds like Chris Taylor (comment below) has some good suggestions. In my experience, most healthcare providers and most practices develop patterns that can be studied and applied to improving scheduling and reducing patient waiting times.

      • Matthew Mintz

        One needs to understand that Chris Taylor’s example is Thedacare which is an integrated system.  They have several clinics with multiple specialists that feed 5 hospitals.  The are a large employer in the state of Wisconsin and provide health care for many.  The reason this fact is important, is that in an integrated system, primary care physicians don’t have to make money.  They don’t have to see as many patients as a private practice doctor.  They are generally salaried doctors and don’t have to worry about the bottom line.  This is because they feed a larger system that have hospitals and specialists where the real money is made. Because of this big systems care run more efficiently.  Often though, the downside is lack of personalized attention. 

        • southerndoc1

          Good post, but strongly disagree with your statement that “big systems can run more efficiently.” What they can do is negociate contracts so that they get paid 3-4x what smaller practices get paid for the same services. They may run more smoothly and have nicer fountains in the lobby, but efficiency drops dramatically as size increases.  
           

          • buzzkillersmith

            Southerndoc1 has it right, as usual.  Big systems are not more efficient, at least in family medicine; their increased revenue from what the economists call rent-seeking just hides the fact that they are more expensive overall  and less efficient.  Many of us have worked in systems where we administered to by 25-year-old business school graduates who had no   knowledge of medical care (or much else) and who were shown the door in a year or two by their equally incompetent ueberadministrator, only to be replaced by the next in line. These folks, many of them nice folks, provided no value whatsoever. I generally tried to be nice to them when we “dialogued.” They don’t exist in small doctor-owned practices.

    • katseye1969

      My GI doc and endo, etc, all schedule me as their last appt of the day because they know I require a lot of time and I travel extensively to see them, so when I am there, I get their undivided atention.

  • buzzkillersmith

    In primary care you have two options:  One, you can see loads of patients, some of whom have emergencies and cause you go get behind, or, two, you can go out of business. 
    If you want Cadillac service, pay for it by joining a concierge practice Those of us in family medicine who, through the goodness of our hearts,  take all comers are given a VW budget, a budget not of our choosing, I assure you. Mark my words, in a few years you’ll be lucky to get to see a doc at all. So sit down, open the magazine and count your blessings.  Or leave, your choice. You won’t be missed. There are plenty more patients who would love to take your place in my waiting room. 

    • estelac72

      There’s a third option: see loads of patients, realize the system in your waiting room needs improvement, and then try to improve it. Or at least acknowledge there’s a problem. Or at the very least, try not to tell patients they won’t be missed… Because how else would we patients enjoy the overflowing goodness of your heart?

    • http://twitter.com/bbgrayrn bbgrayrn

      Wow.

      Could you at least alert patients to call ahead to see how the schedule is running? For many sick patients, a long wait is debilitating. You can also try leaving a few slots open for potential emergencies to improve the scheduling flow and avoid backing up.

      • buzzkillersmith

        I live and work  in a rural area.  I have patients coming into my office with big, big lacerations.  I have patients coming in with heart attacks and with gastrointestinal bleeding and with pulmonary emboli. This is not a well-check practice where we discuss vitamins.  It’s the front lines, baby, and I love it.  My patients don’t complain because they know I might save their life someday.  Funny how you urban types are trapped in your own little mindsets. 

        • katseye1969

          This is sooooo true! I used to have chronic pancreatitis and many times my GI doc would drop everything to “rescue” me from my misery. Now, when I see my GI doc, I expect to wait and know he is caring for another pt who was as sick as I was.  My heart always goes out to the pt that I am waiting on, knowing that person is gravely ill and thanking God my doc dropped everything to help me when he did. He needed to. I beleive you must extend common courtesy and respect to other pt in this “I want it now’ world we live in. I’m wih you Buzz, I totally get what you are saying

    • EmilyAnon

      “So sit down, open the magazine and count your blessings. Or leave, your choice.
      You won’t be missed. There are plenty more patients who would love to take your
      place in my waiting room.”

      Wow, have you ever really said that to a sick patient who questioned the long wait?  Just reading it was like being punched in the stomach.

      • buzzkillersmith

        Of course not.  I say, “How can I help you?”  And then I spend the time needed to help the person.  And then the next person has to wait. 

        • http://twitter.com/palmd PalMD

          Medical care is not a commodity like any other. It is inherently unpredictable. it has a set of ethics (which is good) not required by most professions.  Time is not, and cannot, be the primary value.  Care is care, not time.  Patients don’t pay for being on time (sorry), they pay for good care.  If we could afford to have a PCP for every thousand patients, problem solved.  Never gonna happen.

  • http://makethislookawesome.blogspot.in/ PamC

    One of the main problem I see is not in emergencies, but in the lack of time allotted for patient to tell their story. 
    http://www.kevinmd.com/blog/2012/03/medical-exam-designed-engage-patients.html Doctors are *going* to run overtime if they stick by this model, especially when dealing with complicated cases. 

  • http://www.fancyscrubs.com/ Ken and Lisa Buben

    24 minutes is not bad. I’ve been waiting for an hour or more to get into my elderly parents doctors appointment. I now CALL FIRST and see if they are running late as I have to take time out of my workday. 

  • http://twitter.com/RichmondDoc Mark Ryan

    As a physician who rarely runs on time, I think it is worth noting a different set of concerns than the author proposes.

    Many primary care physicians work with complicated patients: folks who have multiple chronic medical illnesses, co-morbid mental health issues, and the like.  Often times, patients have multiple problems that require attention at the same time: I cannot help you control your diabetes if you are depressed.  You would like me to address your chronic pain before I focus on your blood pressure.  Add on the need to follow evidence-based guidelines and preventive care and you can see how quickly the situation can get out of control: if physicians provided all evidence based care for all their patients with diabetes at one time, studies have shown that it would take 17 hours a day.  In the context of pay-for-performance initiatives and the expectation that all problems will be addressed at one time in one visit, the time pressures are enormous.

    I am bothered by the fact that the author gives so little consideration to why physicians might be running behind.  It is not often as simple as “they don’t care” or “they haven’t prioritized your time”.  It is a complicated combination of complexity of care, patient expectations to have care provided at one time (without a second visit/co-pay), primary care offices running at high capacity because of a workforce shortage, etc.

    I do not like being behind schedule at all…but I usually am.  In our office, we have 20 minute appointments, I arrive early to prepare for the patient care session, and do what I can to facilitate care.  I usually end the day about 40-60 minutes behind schedule.  Office workflow evaluations in our office show that we provide an average or 24 minutes of in-room care for each 20 minute slot; with 13 patients on the schedule, those extra 4 minutes add up to 50 minutes of delay.  If an earlier patient arrives late, then their peers often pay the price because we are obligate to see patients so long as they arrive within 30 minutes of their scheduled time.

    I agree with the author that practices/physicians that run late can find ways to reduce the inconvenience.  At the heart of the issue, though, is the way that primary care and office-based care is valued: if the time that physicians spent with patients was actually reimbursed at a level that accounted for overhead costs, office salaries, etc, then physicians could schedule fewer patients, reduce the total number of appointments, and have the necessary time to handle that 24 minutes of work without issue.  Until this changes, though, patients and physicians will continue to face time pressures.

    • http://twitter.com/bbgrayrn bbgrayrn

       You also might consider ways to alert patients that you’re running late. Or suggest to them that they call ahead to see if you’re running on schedule.
       If, as you say, you’re getting backed up on a daily basis, then you might as well allocate more time per visit from the beginning, or add in some “blank” visits to help you catch up. Otherwise, you’re just chronically stressed, trying to catch up, and it will never end. You also may be losing good patients who just don’t have the time to spend in your waiting room any more.

  • http://twitter.com/RichmondDoc Mark Ryan

    Another aside: to answer the rhetorical question about why we don’t wait for lawyers or accountants?  They often bill by the hour, so no customer wants to spend any more time than they must.  In healthcare, the copay gets you in the door, but every time you get in the door, there’s a copay.  Therefore, there is an incentive to maximize your (the patient’s) value by addressing as many issues as you can once there…especially if transportation is an issue.

    We don’t wait much for dentists because much of what happens in the dental office is 1) routine care mostly handled by a dental hygienist or 2) complicated procedures that the dentist schedules separately.  There is not comparison to a dental hygienist in primary care because (unlike medical care) what the dental hygienist does is relatively consistent and predictable.  Any detected problems: come back to see the dentist on their separate schedule.  Medical care can not be easily divided in the same way.

    • http://twitter.com/bbgrayrn bbgrayrn

       Yet, if you’re finding your patients are trying to maximize their time with you, and you’re committed to giving them that time, then you may want to plan for it and cut the time people will be waiting. As for dentists, they would probably argue that crowns, extractions and related procedures can easily present the unexpected and  take longer than planned.

      • MaMD

        Again, good idea in theory, but in practice, few doctors work in environments where they can control this.  Instead of urging patients to bill their doctors for lateness, why not ask them instead to write a letter to the practice administration and to their insurance company asking for longer scheduled visit times?  I wonder if insurance companies would be forced to pay attention if enough people wrote them letters?  Maybe that is naive, but wouldn’t it be worth a try?

  • mata_o_diabo

    “a study by press-gainey showed…”

    …i’ve seen enough.

    • http://twitter.com/bbgrayrn bbgrayrn

       Common experience, of course, goes way beyond the study to confirm long waiting times are becoming the norm.

      • mata_o_diabo

        i see from your website that you also like to quote the IOM study.

  • Matthew Mintz

    Ms. Gray,
    As you can see from the comments below you have stimulated a great discussion.  I also appreciate how you have responded to many of your commentors.  Rather than reply to your many comments below, I will just submit a new comment.
    The point that I think you are missing is that though there is no question that process improvement/appropriate planning/scheduling systems, etc. can make incremental improvements in patient wait times, the core problem has to do with that fact that physicians (primary care in particular) need to see too many patients.  You can’t schedule extra time to account for this, or you would be in the office until 10pm. The only way to make a substantial improvement in patient wait times is to either 1) decrease the number of patients you see or 2) limit that patient’s time, i.e. Mrs. Jones your 15 minutes are up, we will need to discuss your diabetes at another scheduled visit. Since no physician (that I know at least) would even consider option #2, and since insurance based practices can not decrease the number of patients they see, they run behind.
    Could some practices improve their processes? Absolutely. Do some busy, insurance based practices run more smoothly than others? Sure.  However, the core issue is the low value our broken health care system places on primary care.

    • sFord48

      “Since no physician (that I know at least) would even consider option #2 ”
      I had a doctor tell me during an office visit that my time was up and she needed to see other patients.  I was in tears, discussing the debilitating symptoms I was having when she told me my time was up.

      The next time I saw this doctor, she was 45 minutes late for my appointment.  She told me she had an “emergency.”

      Primary care is only for the ordinary.  If it is too difficult to diagnose and treat in a 10 minute session, it’s better to go to a specialist…who will spend the time.

      • voitokas

        I have sometimes found the opposite – I think the difference is between physicians, not between specialists and PCP’s.  That said, I agree with Matthew Mintz’ assessment above, that PCP’s are subject to vastly more pressure by the undervaluing of their services by our twisted system.

      • http://twitter.com/palmd PalMD

        I admit that i do from time to time cut off a patient and tell them that other issues will have to wait. This is not inherently cruel, but good medicine.  A patient who schedules a diabetes appointment but also wants to discuss a host of non-urgent issues, and has scheduled a short visit, will be asked to come back.  A patient who says, :”oh by the way, im horridly depressed and my life sucks and i may want to kill myself” will stay as long as is needed, and the next patients will simply run late, because that’s good doctoring.
        In our practice we are certainly driven by the bottom line, but not exclusively. We have a popular practice, with long waiting times for a new patient appointment.  If we try to schedule compulsively we would have to turn away patients.

    • http://twitter.com/bbgrayrn bbgrayrn

       Thank you for your comments! Help me out, though: it seems like everyone in the waiting room is going to get seen? No one is sent home without seeing you.

      So the problem isn’t the number of patients being seen. It’s the scheduling and the allocation of time. You may not be allocating enough time per visit, given the time you spend with each patient. Or you may be slipping “urgent care” visits into the schedule, causing delays.  Granted, it’s an amazingly unpredictable business but when patients are waiting more than 30 minutes in many practices appointment after appointment, day after day, something is wrong.

      When you’re backed up, do your staff ever call or email patients and suggest they arrive a little later to avoid a wait?

      I bet you, too, would have a far better day and enjoy the practice of medicine more if you found a few ways to try to solve these scheduling problems.

      • Matthew Mintz

        No, the problem is the number of patients that needs to be seen.  Assume that a doctor needs to see 24 patients a day (4 physicals and 20 regular visits) to maintain his salary, pay his staff, pay the office rent, etc.  Assume also that the physician would like to be home for dinner at a reasonable time. Assume the doctor would like to eat lunch. Clinic would go from 8-noon and 1-5pm, or two 4 hour sessions, with each session having ten 15 minute regular visits and two 30 minute physicals.  This is the typical schedule for a primary care physician. There is no room for error. There is no room for a patient showing up even one minute late.  There is no room for a follow up visit (say diabetes, hypertension and high cholesterol) to take longer than 15 minutes.  There is no room for a patient who shows up on time to be delayed because there is problems confirming the patient’s insurance status. Even on a day when no emergencies occur, with this tight of a schedule, there is no room for any deviation in this schedule for the doctor to run on time. Thus, what ends up happening is that as each session progresses, the doctor runs more and more behind.  That one hour lunch quickly disappears because the morning session isn’t done until 12:45.  Leaving at 5pm, forget about it. By the way, when do you think the doctor returns all the phone calls from patients, call backs from the pharmacy regarding prior authorization, or reviewing lab results?   During that 15 minute lunch. How in the world is the doctor or their staff (who is busy checking in the patients to keep the doctor on time or arguing with the insurance companies to get paid for services rendered) going to have any time to notify patients if the doctor is running late?  The doctor will always be running late. 

        The problem is that to maintain his salary, the doctor has to see too many patients.  The only way the doctor could stay close to on time would be to start clinic much earlier and/or end clinic much later. Though certainly possible,  one of the assumptions above is that the doctor would like to be home for dinner at a reasonable time. You might be able to fix things a little bit with more flexible scheduling/process improvement, etc. but only by a tiny bit. 

        The problem is too many patients. The reason why there are of too many patients is that primary care physicians are not adequately reimbursed for the services rendered.  Most hairdressers get reimbursed better than primary care physicians.  And hairdressers have lower overhead (don’t need to hire an extra employee simply to do billing) and don’t have to pay malpractice insurance.

        No amount of scheduling techniques, built in breaks in the schedule, or improvements in process will solve the problem of too many patients, unless reimbursements to primary care are increased. 

        There are several solutions to this problem:
        1. Health care reform which (through either ACO’s, PCMH’s and/or different reimbursement models) pay more for primary care services.
        2. Patients pay more, i.e cash only, retainer practices, direct primary care
        3. Patients recognize that if they don’t want to pay more and can’t wait for health care reform that they are going to simply have to wait. 

        • katseye1969

          I think it would good to have docs on salary like they do at the Cleveland Clinic. They can properly care for pts without having to concern hemselves with the bottom line

  • southerndoc1

    Not mentioned so far is the fact that EMRs have been shown, over and over again, to slow docs down, and the requirements of  “Meaningful Use” that docs do multiple secretarial chores during the visit are  making the problem much worse.

  • MaMD

    With primary care doctors leaving the field at an alarming rate, I feel it is harmful to point fingers at each other and cast blame.  Few doctors want to keep patients waiting, but they usually work in practices that give them no control over this. I was only allowed to schedule in breaks in my schedule, in order to give “wiggle” room, when I first started fresh out of residency. Some of your suggestions were excellent, but others like billing your doctor for lateness or complaining about your doctor or doctor’s office on social media is simply hurtful.  Granted , there are doctors who are careless about making patients wait, but most are honestly trying to get through their day and take care of each patient the best they can.  Most of my colleagues scarfed down their lunches in front of the computer, while following up on patient tests and calling back patients.  They barely had time to run to the bathroom before seeing their first afternoon patient. 

    If we are to get through this and solve the problem together, we all need to show some compassion, including to the doctors and nurses, many of whom are in similarly pressed schedules.  It may be easy and convenient to bash late doctors, but please remember that we are only human and working under a severely constrained environment.  I made a habit of apologizing for patient’s wait time and also, when possible, asked the medical assistant to give my patient a heads up when I was running more than fifteen minutes late. Your anger would be better channeled into grassroots efforts to break the hold of the insurance companies that control most physician practices.  

    • http://twitter.com/bbgrayrn bbgrayrn

       I appreciate your comments. I’m not trying to “bash” anyone, but would like the system to work better for everyone involved. There is a science to effective scheduling. I think a lot of physicians could do better if they put more thought into what is driving the problem and what the alternatives might be. From some of the comments to the piece, it seems many physicians are not troubled by the long waits many of their patients must endure.

  • nightingale260

    Is it an oversight that no one has considered the possibility that a patient may not be able to reschedule? When I make an appointment, I arrange the rest of my responsibilities around that and sometimes it’s a real challenge to do so. I may have had to put in some paperwork at the job to get the time off or arranged a babysitter to care for my children while I’m at the doc’s office or scheduled other appointments in the same geographical area because it was convenient to do so.  Calling ahead (or getting a call from the office) to find out how the doc’s day is going will only add to my frustration and stress.

  • http://www.facebook.com/juli1004 Juli Oh

    I had to wait over 3 hours to see a neurologist in the past and i didn’t like it and next time i went there, I brought my origami to fold and something to do. I was amazed that I didn’t have to wait it certainly changed. I always ask my neurologist why i have to wait so long and he said he started seeing the first patient late so he was way behind. When I went there few months later, everything changed. I was able to see the doctor and not have to wait for 3 hours. 

  • http://www.facebook.com/juli1004 Juli Oh

    The dentist is I’m worry about. I had to have wisdom teeth out so i went in and wait 6 hour or so. although i did have the procedure and i do understand that my dentist was busy with patients. if that happens again, i’m going to ask them to reschedule so that i don’t have to wait like that anymore.  

  • katseye1969

    There are times I don’t mind waiting for my docs. I see highly specialized doctors and knowing he probably has a pt with pancreatis, is ok with me. God knkows when I had pancreatitis, I needed my doc to see me immediatly. I do HTAE when docs double book to meet their expenses and it’s “mass medicine”. I refuse to participate in it. Many times I have waited hours at my hemetoligist for an infussion. That was totally unacceptable, but knowing he is also an oncolisgist and has cancer pts, it’s ok.

  • MarcGarfield_DPM

    I generally run on time (80-90%)  But I am very sympathetic and have more than my share of times where I fall behind.  I would simply agree with what has been said as the reason.  1. You cannot make a living on 10 patients per day with 40 min appointments. 2.  Three patients 5 minutes late can disrupt your workflow so that a patient might wait 45 minutes, because your exam room are full and you cannot move the next patient back until everything is done.  3.  The oh just one more thing syndrome is probably going to end and is the most subject to physician control if one can develop the tact and persuasion to have a patient return and pay new copays for additional complaints.  But it has to be done! 4.  Urgencies, emergencies and  benign areas of high concern demand additional time beyond what you scheduled. 5. Indecision, patients are given options which require lengthy explanations and cannot be moved from the exam room until a decision on further care is established 5b. even if the patient is not indecisive the planned prescription or procedure requires full disclosure of potential adverse effects and alternatives.
    Contrary to the authors assertion that making patients wait is a financial decision, the contrary may be true.  We often want to make sure the patient has everything addressed that is of high importance, this generally yields less money and more aggravation.
    I have seen practices where patients are scheduled every 5 minutes and run on time.  These doctors have generally decided what your diagnosis and treatment is before they walk in the door and are out before you can say, “Just one more thing”.  These practices often have high patient satisfaction rates.  These practices have often decided to take the risks of minimizing disclosures and other bewildering discussion provoking information, for the sake of efficiency.  But not all of us want a practice of templates and cookie cutter approaches offering little discussion on treatment options. But I suppose we will all get there eventually. 
    No one wants to hear this but, it is the nature of health care to have such high variability between patients that you should expect to wait, if you want to ensure that you and every other patient gets full consideration. 

    • http://twitter.com/bbgrayrn bbgrayrn

       I completely understand the variability. But I think physicians need to build their scheduling system around the assumption of variability.

      I also have a question. You say, in #1 above, that “You cannot make a living on 10 patients per day with 40 minute appointments.”  But it sounds by how you describe your practice like you are regularly spending more than 10 – 15 minutes per patient. I don’t understand how having longer patient waiting times raises your revenue?

      • MarcGarfield_DPM

        Longer patient waiting times does not raise your revenue, it hurts your bottom line because you are not getting your patient out the door and billing the next 9921X.  I simply stated that your business model assumptions may have more variability than you have addressed in your post.  Today is a good example, I have a bunch of short visits on the  schedule and nobody is waiting.  But one of the patients I saw today, I had scheduled a few months ago for a similar uncomplicated visit and she presented with a deep draining diabetic infection at the same time as 2 other patients with similar but unexpected issues.  Yesterday, I had a child scheduled for follow up on an ingrown nail procedure done 1 month ago (99% of the time this is literally a 1 minute everything is fine visit). 
        As I am evaluating his toe, his dad relays that he broke his foot went to urgent care and is still in alot of pain.  Then, I noticed the procedure site has become reinfected.  That was the start of my day.  These are all things I love to treat, but take more time than a typical 1 month post op visit on a minor procedure. I do leave gaps in my schedule for emergencies so I generally recover
        from these mornings.  But for the 3 or 4 patients scheduled after wards I
        have fallen behind.  Not because I did not respect there time, but
        because there is only so much I can control or put off.
        As I am writing this, I am reminded of the other factor beyond my control that cannot be ignored, and that is: calls on hospitalized patients, usually things that could wait or in this case a patient that bumped his foot after surgery and is bleeding through his dressing and onto the floor. My last scheduled patient has just no showed (One more thing we cannot control). And on that note I guess I’ll conclude my bloviating for today…off to the hospital.

  • http://twitter.com/sbrhealth SBR Health

    Maybe I am extremely lucky, but all the doctors I have had care for me are incredibly dedicated and very much in demand. Let’s get real – how can a physician control their time when they are courteous to some patient or patients a head of you and spend the time they actually need with them to care for them, have to deal with emergencies and running over on their surgeries or rounds in the AM, have to schedule tightly to deal with a high number of missed appointments, etc. The reality if you go to any medical appointment, you will probably need to wait some indeterminate amount of time, so just plan for it. Technology allows us to have an officer, books, email, games, etc. at our fingertips in the waiting room.

    Think the receptionists or physician assistants should be better at keeping patients informed on the wait times? Most of the time my experience has shown me that they are just as frustrated as we are about not knowing when the physician will make it to clinic, how long the physician will be with each patient, etc. And, I’ve been in the OR when an operation has gone wrong, and the physician starts fretting about being late for clinic. Let me tell you, if I was on the table, I’d rather have him/her be concerned about me and not someone who is ambulatory and is not at immediate risk.

    Yes, physicians can better leverage technology to keep patients informed of the wait times, changes in schedules, offer reschedules, etc. Don’t hold your breath waiting for them to adopt and deploy these technologies. Even with these, you still have to do last minute planning around them.

    There is one technology I wish my physicians would adopt however, and that is televideo. I’ve been told by some of my colleagues that about 80% of their in clinic appointments are consults and could just as effectively be done by video. This would allow us the flexibility to continue to be productive while waiting, not require us to take long amounts of time off from work to get to and from the appointments, and give us more flexibility to deal with schedule changes.

    So, let’s not get upset at the doctors, let’s get upset with the lawmakers and insurance companies at not adopting policies for paying for tele-vists as fast as they should!

  • Lindaag

      I see a Thedacare doctor at a different facility than Encircle and
    usually wait about 20 min. for an early morn appointment (I try to be 5-10 min early so am there about 30 min before being ushered back to the exam room). The longest wait was 35 min in the waiting room and another 20 in the exam room but that only happened once. When I go
    for a routine physical every two years, I always warn my boss that I’ll may be late for work that day. I’m not taking any medications nor
    do I have any medical problems when I go (at least not so far) and don’t
    bring up any additional issues. My doctor is caring and competent so I
    bring a book, magazine or some work to catch up with and  assume she’s
    taking care of someone who needs the attention. My dentist has about the same waiting time.

  • Sam23345

    I would disagree.  Long waits can indicate a doctor spends time addressing all the needs of a patient, especially if it’s a complex case, rather than rushing the patient out the door.

    I’m a patient with complex multi-system symptoms/disorders and I’ve been to doctors with long waits and doctors with short waits.  The doctors with short waits limit 1-2 symptoms per visit and it doesn’t matter if I’ve had 5-6 new problems since I’ve seen them.  It doesn’t matter that all these new problems may be related to one thing.  They cut me off at 1-2 symptoms.

    I’ve been to doctors with long waits.  And I’m fine with that.  It’s because, in my experience, these doctors are taking the time to get the full picture from all their patients.  I end up waiting, but I know it’s because those patients, and myself are going to get the care we need without the doctor cutting us off because “time’s up”.

  • http://www.facebook.com/profile.php?id=1041948409 Susan Hone D’Agostino

    Most common reason a doctor is late for an appointment?  Patients who are late…please keep that in mind before placing full blame on the physician.   Many docs will see a patient up to 15 minutes late for their appointment.  

  • Sophie Zhou

    I went to see an orthopedic surgeon yesterday and I was kept waiting 15 minutes, which is not all that bad. But when I went into the room to see the doctor, you could tell he was rushed. He took all of 10 seconds to look at my x-ray. He spoke so fast that I could barely understand the diagnosis (actually, I’m not really sure at all because I couldn’t read his handwriting either). If doctors scheduled better, they’d be able to give their patients more care and the wait issue would be a non-issue. The only problem with this course of action of course is doctor’s earnings. With so many costs, doctors are forced to keep hectic schedules in order to keep their practice solvent. What solution is possible? 

    - alittlehappi.blogspot.com

  • http://twitter.com/palmd PalMD

    Exactly. Complaining about waiting is really a complaint about the care the previous patients received. If a patient wants to “help the system”, they could limit the visit time themselves. But this would be idiotic.

  • http://twitter.com/palmd PalMD

    It’s not a zero sum game of time value. This isn’t a train station.  If you want a good doctor, chances are you are going to wait. If you want an ontime doctor, chances are you’re at a patient mill.