Everything in health care seems to take a long time.
Remember the last time you tried to schedule a routine doctor’s appointment? More than likely, the receptionist told you the doctor couldn’t see you for another week or even another month.
Perhaps you’ve had the experience of a loved one being hospitalized on a Friday night for a major (but not life-threatening) problem, but who waited until Monday to go to the operating room.
Ask physicians about these delays and they’ll likely describe them as “necessary evils,” a consequence of having to reserve time in their daily schedules for patients with urgent problems. Doctors could never provide immediate care to the sickest patients if they tried to accommodate the schedules of all patients, they’d say.
There’s some truth to both claims. But they are far from complete explanations of patient delays. People today expect their services to be performed quickly yet health care is frequently an exception. The thing is, it doesn’t have to be this way.
Is the problem too few physicians?
In some places, namely rural and medically underserved areas, there is a shortage of physicians. This is especially true for specialists and sub-specialist care providers.
In these areas, there is simply not enough supply to meet demand. There, physician shortages commonly lead to unavoidable delays.
Individuals in rural areas understand this reality. Rather than wait, they frequently choose to travel long distances to major cities for their routine medical care. Those in economically challenged and medically underserved communities often find themselves with no choice but to forgo medical care altogether.
This is not the case in most urban areas. If managed efficiently and effectively, there are enough physicians to treat the population’s total needs. In these well-staffed places, every patient should be able to see a provider in a timely manner for routine care, as well as for urgent problems.
But patients in these communities often experience similar delays. In this case, it’s not an issue of too few physicians but rather a failure of health care system design. Queue theory mathematics helps explain the difficulty and offers potential solutions.
The “n of 1″ problem
Mathematicians recognize that even when there is enough supply to match average demand, delays are frequent because of variations in daily and weekly demand.
As we would predict, individual physicians, particularly specialists who work as solo practitioners, receive many more referrals and appointment requests in some weeks than others.
But of course, during weeks when one community physician has more referrals than he or she can see, there likely are other physicians in that same specialty and community who have lower demand.
The result is that patients in one doctor’s practice are waiting to be seen while a second doctor is only partially scheduled. And in this example, the reason that one is busy and one is available has little to do with patient preference. It’s a matter of chance.
And when every physician needs to reserve appointments for last-minute urgent care, people with more routine needs end up waiting even longer.
Queue theory demonstrates that when variation in demand is relatively low at the community level, it is extremely high at the individual physician level. When doctors work together as one, they can manage this variation effectively. But when each physician works independently (N of 1), then queue theory predicts that patients inevitably will wait for care even though specialty expertise is readily available nearby.
Reducing wait times requires collaboration, cooperation
Queue theory points out the consequences of variation in demand within the context of a single health care provider’s practice. To better understand the problem and the solutions, let’s take the example of a grocery store.
In most stores, patrons decide which check-out counter to use. In general, they pick the counter with the shortest line.
But imagine if patrons were assigned a specific check-out stand when they first walked through the door. What they might find is that their pre-assigned lane is long while other clerks have no customers at all.
It sounds absurd to imagine running a grocery store this way. But de facto, this is how most of the health care industry operates. On days when one physician in a town is fully scheduled, there are others in the area whose schedules are wide open.
To address the variation in demand, queue theory offers two solutions. Community doctors could allow all patients to view their schedules so patients can select the physician they wanted to see that day based on availability.
Alternatively, physicians could form a single medical group of highly qualified individuals and schedule each patient to see the first available doctor who was trained to care for his or her problem, usually on the same day. But today, neither of these solutions are offered in most communities. The reason is economics.
Doctors in fee-for-service medicine are paid for each visit. As a result, they’d fear the loss of personal revenue every time a patient saw another doctor.
Therefore, patients with routine problems end up waiting when they don’t have to.
The “five-day mindset” in hospitals
Hospital delays have a different cause.
Hospital administrators and physicians try to maximize care on weekdays and limit care to medical emergencies on weekends. That’s because doctors, nurses, and staff are reluctant to work on weekends for personal reasons, and would rather wait until Monday to provide routine treatment.
In most communities, only one physician from each specialty is assigned to deliver care on weekends while on-call nurses and technicians provide only emergent diagnostic and interventional services on Saturdays and Sundays. When the single, on-call doctor for a particular specialty is in the operating room performing an emergency surgery, all of the patients in the emergency room whose problems are not as severe are forced to wait.
And if a stable patient admitted Sunday morning requires a complex radiology test or a non-emergency surgical procedure, the department manager may decide not to call in the standby team over the weekend, preferring to wait until Monday.
That’s why patients admitted on Friday night or over the weekend end up staying longer than patients admitted for the same problem Monday through Thursday.
But what is considered a medically appropriate delay can have negative consequences for patients. Hospital delays increase the risk of a patient experiencing an avoidable complication, such as a hospital-acquired infection or delirium. And in some cases, the added time may allow the patient’s condition to worsen.
Once again, there is a mathematical solution. Delays could be minimized without increasing costs if hospitals evened out staffing across all seven days.
But doctors, nurses and technical staff prefer the five-day model.
Ask doctors about the weekends, and they assure you they’re always available to provide “emergency care.” But providing routine care sooner – and thereby decreasing the risks to patients while lowering total cost – isn’t their imperative. And the medical culture supports this view.
Patient awareness is the key to change
Many patients accept delays in health care because they don’t realize anything else is possible.
Change is possible but never easy. Doctors would need to implement new systems and technologies that allow patients to see the first available physician. And hospitals would need to confront the five-day model and deal with unhappy physicians, nurses, and staff.
But once patients experienced this level of control over their health care, they’d never accept today’s delays again. We are entering a new era of consumerism. People want the same level of convenience from health care they experience elsewhere in their lives. And the best part is that with a few changes, they can have it.
Robert Pearl is a physician and CEO, The Permanente Medical Group. This article originally appeared on Forbes.com.
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