Overcoming the resistance to same day appointments

This past weekend I spent time relearning some life lessons.

On Saturday, I picked up a couple screens from the hardware store to reinstall them after they were nearly destroyed by our neighborhood bear. The bear seems to think she will find the birdfeeder that used to hang nearby, so she stands on our deck and leans on whatever is nearby (our screened porch) while she looks for it. Then she heads into our small orchard, stands on her hind feet, and paws the branches for apples (wrong season!)

What does this have to do with acceptance? Well, it’s all about how I react to this unwelcome change in my life. I wasted a good hour searching Amazon.com and other websites for bear repellent devices. I quickly discovered there is quite an arsenal available: strobe lights, sirens, electric fences, and even the advice to introduce neighborhood hunters to your backyard bear!

So the life lesson and how I came to it. I recently read an article in the New York Times about physicians in Kentucky who don’t accept the new “customer service” approach to office scheduling, offering same-day service. As an advocate for open access scheduling, I found myself thinking “what’s the matter with these guys, why can’t they accept change? To be successful in health care we need to accept what our patients want!”

And then I broke out into a big smile and internally laughed at myself. Why can’t I accept that there is a bear in my neighborhood that I can’t control unless I turn my yard into a fortress? Maybe I could breathe and even enjoy the occasional glimpse of this big animal.

Our neighbor has a tire swing and told my wife and I this weekend that the bear has 2 cubs and they actually figured out how to get on the swing! Maybe I should enjoy my new neighbor instead of trying to electrify and fence my border. I bemoan the building of fences between Israel and Palestine or the US and Mexico, but I’d consider doing the same thing in my yard? My doctor colleagues resist changing their schedules just like I resist the bear enjoying my yard.

So what can we do to be better at accepting change?  Zen Master Leo Babauta offers a few suggestions:

  • We cannot keep things the way we want them to be, it’s better to accept them the way they are.
  • Be self aware; you can’t change things in your head if you are not aware of them. Asking for feedback, or listening, can improve awareness. That’s not so easy, but it helps. My wife looked at me surfing electric fence designs (battery, solar, or should I run power out there underground?) and gave me that “Really?” look. I hate to admit it, but that helped me realize the absurdity of what I was contemplating.
  • Realize I cannot control others.  As someone who takes on leadership roles at work, this one is hard. People will only do stuff when they decide it’s in their interest to do so. Yeah, we can change incentives, but carrots and sticks only work for a limited time. Engaging something more fundamental, like passion for the doctor-patient relationship, brings true change.
  • Breathe — this one is so easy and it’s physiologic — it does relax us.

So how do I help my colleagues see the absurdity of their resistance to customer satisfaction with access, just as I realized the absurdity of resisting the bear in my yard?

In my last job, open access scheduling by primary care doctors came only after one early adopter family doc tried it. He had a friend in another state who said he liked it. After shifting his schedule he became the poster boy for open access scheduling: a very busy primary care doc who told all his friends, “you won’t believe how much better this is. I go home on time, and it’s really fun working in an office where everybody is happy!”

It’s time to stop resisting change that is inevitable. Make peace with the bear.

Mark Novotny is chief medical officer, Cooley Dickinson Hospital, Northampton, MA.

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  • buzzkillerjsmith

    So the post up from this one, by Dr. Campbell, tells us how we should all be doing more preventive care, and this post tells us how we should all be doing more acute care. Does anyone else find this comical?

    The local PCP group tried open access for about 6 months and then gave it up. The docs were exhausted. The staff were all looking for new jobs.

    You can’t stuff 15 lbs of sugar into a 10 lb sack but you can bust the sack trying to.

    • http://www.twitter.com/alicearobertson Alice Robertson

      I am waaay behind in my reading and only this weekend was able to read the Wall Street Journal from a few weeks ago. Were you able to read it? It ties in perfectly with what your writings reflect about medicine. Did you see the debates from their panels? If not…not to worry…I will sum it up quickly (off the top of my head so beware).

      I thought it was really interesting, but they addressed several issues that seemed to be discussed a lot here. They hit on same day appointments and why we are so tied up with crap (I can explain that one, but figure you already know). One was, obviously, the use of NP’s and whether they need doctor oversight or not (which apparently in 1/3 of the states they are already doing so w/o physician oversight). It seems some believe if we use NP’s more broadly, and some think if we start using teams and more specialists the GP’s won’t be so overwhelmed (or expected to be a jack-of-all-trades type of doctor). They covered pay-per-performance (if you lack time basically they shared that it offers no benefits and does some harm). Using Cochrane Collaborative notes to show the financial incentives did not help health outcomes. They covered residencies (sharing that smarter care is better than more physical bodies on the field…I am guessing that ties in with teachers who in Asia get better results with huge classrooms than coddled American kids:) Anyhoo….the gist was that 20-30% of care in America is unnecessary (Dartmouth data) referring to team based physicians and leading patients into caring for themselves. Then the dreaded ACO’s and how every physician hired is costly.

      You get the gist. I just figured I would save others an hour of reading, although, I wish I had time to go through the comments section but comments at the WSJ site can take hours of mucking through (but omgoodness when you get that one cheeky one that wraps it up succinctly:)

      • buzzkillerjsmith

        I actually did not see it but it sounds interesting. Thanks a lot for the summary.

      • Guest

        There is a great blog about this very topic on this site regarding what does team based care mean for patients authored by Jesse Gruman (I think I got the name right). Check it out.

  • southerndoc1

    “you won’t believe how much better this is. I go home on time”
    If the OP can give a logical explanation of how a full schedule of appointments scheduled the same day allows the doctor to finish sooner than a full day of appointments scheduled in advance, then I’ll pay attention to what he has to say.
    If not, he’s just another over-paid administrator passing gas in the direction of practicing physicians.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      It’s convoluted, but here is the explanation: if you have a fully booked and double booked schedule for say a month in advance, AND you also accept urgent same day requests to be seen, effectively triple booking you schedule, chances are that both you and the patients will be spending some extra time in the office, particularly on those crazy days when everybody seems to have an urgent matter.
      On the other hand, if you purposely leave a little flexibility in the schedule, chances are that you will be able to accommodate the demand for urgent care without having to stay later, or pick up the pace beyond what you are comfortable with.
      The assumption is that you can estimate fairly well what the demand for urgent (or just convenience) care is and not leave more room than that. It takes a bit of planning.
      If you rarely find yourself in a crunch, than your schedule is fine.

      • buzzkillerjsmith

        Sure, enough same-day appts. Everybody does that, at least everywhere I have worked. But that’s quite different from a complete same-day schedule where some days you go home at 5 pm with some open slots and some days where you go home at 9 pm after being hammered. This is what was going on with the local group.

        If open scheduling works for some groups, that’s great. But Mark N’s wording is telling: “customer satisfaction with access.” Having us available to “customers” 24/7/52 is not humanly possible. We don’t have the medical labor force.

        • Mark Novotny

          so why does the access have to be with your office alone? here in Massachusetts a patient can access a Mass licensed doctor on line from 7 AM to 11PM. what if that visit were part of your on call system. Until we think about different models, we will continue to leave our customers dissatisfied, and let others who are more creative take them away from us.

          • buzzkillerjsmith

            11 pm to 7 am would be better, wouldn’t it? Oh, but we already cover those hours ourselves. Way ahead of ya, man.

          • Mark Novotny

            I think there is a difference between an actual on line office visit, complete with charge, and e-prescribing, and the old ‘on – call’ stuff I did for 20 years taking phone calls from patients.

          • Suzi Q 38

            I agree.
            At times, it is just better to answer that patient’s emails. Most patients would not write to a physician unless it were important. Moreover, if it were really important, they would call or go to the emergency room.

            I am forever jealous of my sister whose surgeon is more than understanding of her fears about surgery on her colon/rectum. She has cancer, and a lot of questions.

            This doctor is just emails her back, even on the weekends! She is a very busy and well-known surgeon at a rather famous cancer teaching hospital. I now know why she is so well-regarded, and patients like my sister feel fortunate. I feel her surgeon is extraordinary, not only in the operating room, but in the office and other times.

            My gyn/surgeon would not even return my emails after 3 weeks had passed. I had escalating symptoms during that time. I sent another note to his nurse, because I gave him the benefit of the doubt, and thought perhaps that he never received the first letter. The nurse responded that “he received it.”

            When my crisis was over, my neurosurgeons (2) were livid when I told them about it. They called my gyn surgeon to say that my body was “paralyzing” and I needed care. You can bet I finally got my phone call from the gyn/surgeon.

            I finally “dumped” him unceremoniously.

            I have complained to patient advocacy, as I really don’t think that doctors should be this callous and uncaring. I got a letter from the
            Chief Medical Officer, who did not answer all of my questions, but at least did acknowledge that my physicians actions were wrong.

            The result so far is that doctors have to not only answer emails from patients, but they have set up some kind of a portal.

            I told the patient advocate that these changes are nice, but why were they “behind the times” in the first place?

          • Mark Novotny

            So all my skeptical colleagues out there: Suzy Q is the informed patient/consumer we all need to hear. We can complain, wonder how in the world we could ever work harder, or we can really listen and begin to think about how care could be redesigned so that providers reconfigure their work and interact with patients with completely novel methods and using broader teams of capable professionals who can meet many of the needs of primary care patients. Primary care teams that include care managers, behaviorists, pharmacists allow direct access from patients to those professionals, and do so using email, text, telephone, and conventional office visits. Online office visits have been studied (http://content.healthaffairs.org/content/32/2/385.full.html)
            and shown to provide better outcomes, lower cost, and high patient satisfaction. We can bemoan the changes- but we physicians need to understand that we are not making the decisions- the consumers are: http://www.cooley-dickinson.org/main/cmoblog/designing_care_with_the_customer_in_mind_263.aspx

          • Suzi Q 38

            Yes, the consumers do vote a bit.
            I know that some physicians that work in rural or less populated areas have more control with respect to doing what they want, rather than what the consumer needs and wants.

            If you work in a more populated city, we have more choices of doctors and hospitals.
            The marketing departments of these hospitals are “listening.”

            We are constantly being bombarded with requests for feedback about our care and providers.

            Communicating via email is going to be a given soon, if it isn’t a standard practice already.

            My MS doctor is 80+ and is still working, seeing patients one day a week. He gave me his email address on the first visit. He said he prefers email because the phone calls tend to come when he is eating lunch or dinner with his wife.
            He would rather get caught up with any new and troubling symptoms when he is ready.
            He said that he checks his email every night.

            I started to think that several of you were just older and more reticent to change.

            I just wanted to point out that my doctor is well known in his field, about to retire and told me that he hopes that he is alive to see me at my next visit, which is in May of 2014, LOL.

            If he can utilize the computer and email, and get his fellows to do so, plus teach the 3 medical students to do so….”Bravo.”

            I was watching a You Tube presentation about the spinal cord injuries and neuropathies by a neuroradiologist at Standford. She was speaking to residents about how to diagnose and treat patients like me.
            She was so interesting that I wrote to her via email.
            My son said that I was nuts. He said that NO One, let alone a well known physician would answer me.

            To my son’s surprise, she did.
            She did more that my own doctor did for me by ignoring me. She sympathized what I had gone through, and clearly stated that she could not give me any medical advice, suffice to say that I needed help ASAP.
            She also invited me to call Standford to get a full evaluation.

            I liked her “style.” She understood that I was a patient needing medical help, and she also wanted my “business.”

            Sometimes doctors are just good.
            Not only are they good doctors, but they are just good people.

            We the “consumers” have to weed out the “lazy,” jaded, and apathetic from our medical care. We have to find and choose the “good.”

          • Mark Novotny

            Susie Q, thanks for your persistence, and raising the bar on expectations. I’m glad you can see that age is not necessarily a reason for resisting change. I am a practicing hospitalist and health system administrator in my 60s. I have been a primary care physician, developed and initiated a hospitalist program, served as a chief operating officer for an employed physician network, developed and led a quality and safety program, introduced lean and six Sigma to 2 different organizations, with measurable improvements in mortality and other clinical measures, served as interim CEO of a health system. My point is that, despite the natural resistance to change, we can take it on if we see more benefit to the change than the current circumstance. Meeting consumer needs 24 7 365 is daunting to most physicians, I think largely because we look at the world as individuals and are still getting used to how to behave as teams and deploy others on our behalf.

            At IHI, one method for breaking down this resistance to change is to put patients on the care teams directly. see http://app.ihi.org/imap/tool/#Process=13ffd8f7-9e9b-4ad0-b2af-dfe192ec66c9

      • southerndoc1

        Of course, in your first scenario, the doc is seeing more patients and will take an income cut if she goes to a more reasonable schedule.
        And the second scenario is the way every well run practice always has and always will operate. But the PCMH apostles crow about it like they’ve reinvented the wheel.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Funny how both you and buzz started your response with “sure” and “of course”… :-)
          I have yet to meet someone who is surprised by the need to see patients that need to be seen at short notice.
          The PCMH is specifically asking for more though. It’s not just urgent care that needs to be accommodated the same day, but also convenience care (e.g. I want my physical today). It’s not asking for a 100% compliance with such requests, only that some time is set aside for this. Hence the customer satisfaction aspect that buzz mentioned.
          In addition, some practices, particularly in underserved areas, suffer greatly from no-shows for appointments scheduled too long in advance. A shorter time from call to visit can improve cash flow significantly.

          There really is nothing new here, but as I keep saying (to no avail), PCMH is (should be?) nothing more than a well run practice, and having a well run practice could be the difference between staying open and being forced to sell out.

          • ninguem

            So…..the PCMH is asking for what any well-run INDEPENDENT practice has done since forever.

            But now in a corporate-run practice where the doctor has no say in day-to-day operations, we need to invent the concept that the independent docs do every day.

            A patient wants a same-day appointment in my office, patient usually gets it.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Exactly. You take a good thing, you break it, and then “innovate” on repairs….

          • buzzkillerjsmith

            Acutely ill pts should be seen in a timely fashion, but as you know, there’s a shortage on and we’re only human. Some pts, a lot of pts, will need to go to the QuickCare. Moreover, it is more important to see pts with HF, CAD, HTN, dyslipidemia and depression even if scheduled in advance, than it is to see sore throats. And as you know, some practices are completely socked in with those types of pts. Much of the public has no idea the complexity and the volume of old sickies we see daily. We have a right to triage, indeed a responsibility.

            It is also reasonable that some convenience care pts be seen right away if that is possible. But It is not reasonable that we should take all comers by working from 9 am until 9 pm. Waiting a few days won’t kill them. If they think it will, there’s QuickCare or the ED.

            Your no-show comment is right on. My neurology buddy in rural northern CA is on the verge of going under and a significant factor is no-shows among Medicaid pts.

          • http://www.twitter.com/alicearobertson Alice Robertson

            CATO did a whole issue devoted to this. They blamed the government for the mess you describe, but many doctors blame patients who demand care that isn’t urgent. If patients were more accountable we may not have a shortage of doctors?? I really didn’t realize so many doctors want to retire or get out. Dr. Jeffrey Singer did three very good articles with loads of stats summed up very well at the CATO Institute site. I know Cleveland Clinic lets you have two no shows then you lose your doctor (not sure for how long). If you are more than ten minutes late you are turned away (unless the doctor takes mercy on you and if they do you will probably wait two hours to teach you a lesson).

            We need patient accountability on more than just wait time or no-shows. There is a progressive program in New Jersey that was featured on Frontline that got astounding results using data from the ER. They brought in teams of medical troubleshooters to go to the root of the problem (i.e. why a guy ran up about a million in fees in the ER. He lived in a mold infested apartment and simply moving him out could stop the ER visits for his asthma). Then the team of nurses stayed on top of the problem. The cost savings were fabulous and the patients get better without bogging down the system. This is just one pragmatic solution but often the government and patients are resistant to helping people help themselves.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Tell him to try and experiment for a few weeks with telling people to come right in… The worse that can happen is that he will be swamped for a while. If he wants to chat a little bit, I’ll be happy to…

          • buzzkillerjsmith

            Thanks for the advice. I’ll talk to him about it.

          • Suzi Q 38

            “My neurology buddy in rural northern CA is on the verge of going under and a significant factor is no-shows among Medicaid pts.”

            Do they call their patients a couple of days before
            to remind them? At the teaching hospital, I get a computer reminder linked to my cellphone.

            Old or young, many patients are forgetful.

  • azmd

    On the one hand, it is clear that physicians need to take proactive steps to address long wait times for appointments.

    Not only is it the right thing to do, but in my community, the fact that it can take an insured patient months to get in to see a psychiatrist on their panel (psychiatrists who have direct-pay practices typically have much shorter wait times) is being used with good effect by the state psychological association to make the case to our legislators that prescribing privileges should be granted to psychologists in order to improve access to care. (Never mind about the fact that the majority of psychologists who appear to be interested in prescribing typically are already in direct-pay-only practices and do not appear to have a strong interest in joining insurance panels.)

    On the other hand, this piece would probably be more effective if the author were in full-time clinical practice and in a position to explain the specific ways in which open access scheduling has made his work day more manageable. Offering platitudes about how others should accept a change that is not going to affect one personally is rarely that persuasive.

  • azmd

    This is definitely a less platitudinous communication than the first one. Perhaps it would have been more effective to lead with the specific examples provided in your links, particularly the one from Colorado. The information provided there is intriguing, and far more convincing than a communication which assumes no need to use facts or specifics to persuade other educated professionals of the advantages of an alternate approach.
    It is paternalistic to offer a communication that effectively reads “open access scheduling is the way to go, and you just need to adjust your attitude and be open to change and let me tell you how you can have a better attitude which I am qualified to do because I recently improved my attitude about a bear in my back yard.”
    P.S. I am not in private practice, so none of this is germane to my actual work. On the other hand, I am keenly interested in seeing all of us work well together to drive needed change in our profession. It frustrates me to see a pattern of administrators communicating in a condescending way that engenders resistance to change and innovation among my colleagues.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      By my calculations, the guy in Colorado “sees” approximately 45 patients per day (22% more visits; 8 more patients per day). I appreciate his new happiness and good fortune, but I am not exactly sure what it is that he is providing open access to.

  • jwalexandermd@gmail.com

    Dr Novotny is correct in saying that the technology and knowledge exists to help primary care practices provide same day access. We’ve done so for over 10 years, although it’s not easy. There are two points that need to be mentioned in addition to the “embrace the bear” message. First, incentives need to be aligned with the proposed change and second, organizational resources need to be available to both make the change and sustain it.

    This touches on a bigger, but related point. Modern primary care is not a “physician” practice but rather a complicated and sophisticated organized approach to caring for these patients that requires the right team, appropriate resources, and organizational knowledge and learning.

    Primary care systems are rapidly evolving and advanced access is an early step – and as Dr N suggests, one that is “inevitable”. I agree it’s time to embrace the bear, but do it with all the right stuff to succeed.

  • southerndoc1

    I’m trying to keep an open mind here, but when you claim that it wasn’t until they studied queuing theory and lean principles that doctors realized there’s more demand for appointments on Mondays and Fridays . . .

    • Mark Novotny

      what I am saying is that queuing theory and lean principles give practices tools to make more precise and workable a response to the awareness that it is busier on those days. Getting rid of waste and rework sounds easy, as does improving scheduling- but other industries have been using these tools for decades to improve flow of other services to people that are messy and complex like health care and not as predictable as an assembly line.

  • Tisburygirl

    As patient I have witnessed/experienced a problem with the same day appointment trend. I (or my child) need to be seen but it’s not same day urgent & my job makes it difficult to leave mid-day, I am unable to make an appointment for the next day or even that week. I tried to make an appointment for the next day when my kid came home from school @2pm with pink eye. Nope, call back when the phones open at 8:30am for a same day. Same Day appointments only