Achieving the holy grail of wait-free medical care

We’ve all come to expect our doctors to run late for appointments. I’m a doctor, and when I go to see my doctor, I expect the same. I bring my laptop or something to read to bide the time. Waiting makes us feel like we or our time isn’t valued, and doctors know this. So why is it so hard for doctors, including myself, to stay on time?

 

Most doctors have tightly packed schedules with appointments spaced ten to twenty minutes apart. While some patients are too complicated to be seen in such brief visits, it’s hard to predict how long each patient will need. We aren’t given more time, so we run over, let some things slide, or bring our patients back more often.

The time you have to wait in a doctor’s office is also a downstream consequence of how long you’ve had to wait for an appointment in the first place. Patients often cancel at the last minute or no-show because their visits are booked so far in advance. The average wait time for a doctor’s appointment across the country is nineteen days, and this is likely to get even longer with more people getting health insurance and wanting to see a doctor. Most patients don’t know their schedules that far out, and conflicts arise. In the meantime, while waiting for their appointment, their problem may have resolved. As the risk of last minute cancellations and no-shows increases, so too does the rate of double-booked appointments.

Under our current fee-for-service model, time is money. Doctors are paid based on how many patients they see. It’s hard to predict how many patients will miss their appointments on any one day — the average is about a quarter — but it’s better to have too many patients come in than too few.

Companies like ZocDoc, DocASAP, HealthPost and DrDoctor are making cancelled appointment slots more available for last minute rebooking. Such systems help keep doctor’s appointment schedules solidly booked, but it isn’t clear this does much to reduce rates of double-booking or to reduce patient time in the waiting room.

We could better manage double-booking to reduce the likelihood that one patient will be forced to wait. A small Cambridge-based startup, SmartScheduling, is using information about patients’ prior appointments to identify those who are most likely to cancel at the last minute or no-show. If these patients don’t confirm their appointments, SmartScheduling opens their time slots for double-booking forty-eight hours ahead. Doctors are less likely to have two patients show up for the same time slot and can more easily fit in patients with an urgent issue.

Some doctors’ offices are changing the way they manage their schedules to provide more same-day appointments, whether for urgent or routine visits; you might call it “just-in-time” patient care. It might seem counterintuitive, but same-day booking makes our schedules more predictable. Our patients are more likely to show up and be on time. They are available and have an issue they want addressed that day. In turn, this all means that we doctors don’t have to overbook patients and are more likely to run on time.

It makes sense for us to make room in our schedules for more same-day appointments. Our patients want to see their regular doctor, who knows them best, when they are sick. When we can’t fit them in, they go elsewhere — an emergency room or an urgent care clinic — resulting in discontinuous, fragmented care. No one has the whole picture. Plus, the opportunity to deliver other important preventive or chronic care services is lost.

Dr. Mark Murray, former assistant chief of medicine for Kaiser Permanente in north Sacramento Valley, CA, advises physician practices on how to implement the advanced access model, which allows for a large proportion of same-day booking, what Murray calls “doing today’s work today.”

A number of steps are necessary to make this work. The supply of appointments should match the demand from patients. Each doctor should be responsible for a manageable number of patients. Administrators can measure when patients are most likely to want appointments and ensure clinics are adequately staffed to meet patients’ needs. Patients should be scheduled to see their own physician, who can see them most efficiently. Much of the work doctors do — checking vital signs, reviewing medication lists, tracking down lab and radiology results, offering preventive screening and counseling – could be delegated to others, freeing doctors to focus on more complex diagnostic and treatment decision-making.

By increasing the availability of same-day appointments, the Henry J. Austin Health Center in Trenton, NJ cut their no-show rate in half and no longer has to double-book. According to Dr. Kemi Alli, Henry J. Austin’s chief medical officer, teamwork is key. The workload needs to be better spread across a team, not just the doctor, each with specific defined roles for which they are held accountable. When only the doctor is held responsible for patient outcomes, whatever work hasn’t been done ends up back on the doctor’s shoulders. That slows us down and makes it harder to fit in same-day appointments.

Clinica Family Health Services in Denver, CO implemented the advanced access model several years ago. Clinica cares for over forty thousand patients, most of whom are Hispanic and poor. Since the new system was rolled out, average waiting room times for patients have dropped to ten minutes, and the no-show rate dropped from about 25% to 10%.

According to Dr. Justin Wheeler, Vice President of Clinical Services at Clinica, “Our systems build resistance and fear because we’re denying patients something they need or want.” We make patients schedule days, weeks or months ahead for an appointment, and then keep them waiting in our offices before we see them. But we could re-engineer our systems for wait-free care.

Celine Gounder is a physician and medical journalist.  She can be reached at her self-titled site, CelineGounder.com. All views expressed in this article are hers and should not be attributed to any of her employers.

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

    Excellent discussion on booking. Your discussion of alternative models that work well with fee for service care are excellent.

  • Dr. Drake Ramoray

    I find it much easier to just run on time. When patients arrive late we let them know that our office runs on time, and they should try and make it to their appointments on time. If they become chronically late and have had several warnings they are dismissed. Tardiness has never actualy been a reason for dismissal from my practice (after a few visits people figure out we actually run on time).

    Same for no shows. It’s in the initial patient paperwork. Two no shows in 1 year and we have the option to dismiss.

    Patients wants to discuss additional non-urgent issues outside the time alotted allow them to schedule a sooner appointment with extra time if necessary to meet their needs.

    Granted, I admit this is easier from the speicalists perspective (and those with 10 min corp med appointments need not apply), but I believe you are putting the cart before the horse. Be on time, let your patients know you run on time. Those patients who don’t respect my time in the same way I respect theirs can find another doctor.

    The best part, I don’t have to pay some company to have access to my patient’s scheduling habits.

    • querywoman

      My own endo runs on time. It really hacks me that one of his few net reviews stated he was running late at a first appointment. Never happened to me.
      Are endocrinology needs usually that urgent to demand unexpected time? Aren’t most endocrinology problems chronic, long term diseases to be managed?
      In our 10 or 15 minutes, I never feel rushed. He reviews my A1C, my general health, etc.
      He looks at my skin, really looks, though I have a competent dermatologist. He understands it as an autoimmune disease and has helped raise my Vitamin D levels.

      • Dr. Drake Ramoray

        It’s not so much urgent to demand unexpected time as it is sometimes a request to address an additional problem. It is not uncommon for thyroid patients to want me to address their diabetes or pre-diabetes as they develop even though that is not something I have been caring for in the past. I’m happy to do so but with the time to provide appropriate care.

        As for the primary care guys, I’m cuttin them slack in that they may be managing all 16 problems on the problem list while I may only deal with a handful, and they are far more likey to admit someone to the hospital from the office. They have far more potential for emergencies that may cause them to run behind.

        • querywoman

          You should be addressing pre-diabetes levels, of course, it may just show up on the lab work. In the late 1980s and early 1990s, I had sugar approaching 140. The standard was higher back then. I saw two endos who obviously weren’t trailblazers about lowering standards, and didn’t pick up on it.
          The could have at least told me to eat small meals regularly. I used to be infamous for eating most of my calories at one food. When I eventually got metformin, it really helped my menstrual problems.
          Does a large goiter require more time? Do you do thyroid surgery? If a surgeon does the surgery or someone else does radiation, what kind of followup do you do?
          I consider my own endo my main doctor, even though I do have an internist. His reviews of my general health are stellar. Sometimes he puts his stethoscope on me. Sometimes he checks my feet. I also have a derm and a podiatrist who look at my feet.

  • Kaya5255

    I’ve seen the same PCP for years and yet EVERY TIME I go in for an appointment, I’m handed a ream of paperwork to complete!!! Don’t you folks have EMR’s?? Can’t you just ask if anything’s changed since the last visit? And they generally don’t give me the ream until the exact time of the appointment, even though I come in early!! Talk about ineffiency!!!!
    Maybe if your staff didn’t book 3 people for the same time slot, there wouldn’t be a backlog.
    Don’t waste my time having students/assistants ask me questions and then you show up and ask the same one’s all over again? That’s why I don’t let student/assistants near me.
    Stop thinking only your time is valuable. Your customers usually have to take off time from work…..most times without pay…keep that in the back of your mind.

  • Karen Ronk

    I always think it is a little nutty that people will wait an hour for a table in a restaurant and will camp out over night for the next greatest tech product, but complain about waiting to see a doctor. As a patient, I want a doc who takes extra time if there are multiple concerns or complications and I would grant no less to other patients. Of course, I also base that on the quality of the doc – I won’t wait again for someone who turns out be not worth the wait. Naturally, there are limits and there has to be some attempt at time management, but expecting anything to do with this type of interaction to be manageable to the nano second is just dumb.

  • Dr. Drake Ramoray

    I believe I included rather vigorously that it may not apply to primary care especially in my follow up) Given that caveat I felt it was worth sharing my experience.

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