Waiting on the Doctor...Is There a Better Solution?

     My wife had an appointment with her doctor today.  Her doctor is one of my partners.  She texted me when it was 35 minutes after her scheduled appointment.  She had been roomed, but still hadn't been seen.  She was frustrated.  She has a job.  She has meetings.  She didn't like the fact that her doctor was running over 35 minutes behind.  I think she was ultimately seen by the doctor 40-45 minutes after her scheduled appointment time.
     "You've got to expect at least 30 minutes after the scheduled appointment time until you are seen by the doctor," I explained.  "Anything before that, and you're lucky.  If it's been 35 minutes, that means she is running only 5 minutes late."
     "I can hear her in her office.  It sounds like she's dictating," my wife texted to me.  I said she's probably doing that now, so she doesn't have 2 hours more of work when she gets home at night creating her office notes.  "At least she isn't wasting your time playing on the Internet," I said.  This didn't make her feel any better.
     My wife contends that in her industry, if a client had to wait 15 or 30 minutes for a conference call, that client would drop her and her company.  She wants to know why can't a primary care office always be punctual.  So let me answer that question:  because the practice of medicine isn't able to accurately be distilled into an exact time slot.  This doesn't mean that we can't be more mindful of peoples' time, nor does it mean that there isn't room for improvement.  But let me explain just a few things of what office-based primary care doctors do when you're waiting to be seen:

• Create office notes, the legal medical documentation of the patients' encounters with the doctor
• Review xrays and labs, and place new orders (instructions) based on them
• Refill prescriptions
• Answer the questions of nurses and medical assistants regarding other patient care issues
• Receive phone calls from pharmacists and other medical professionals
• Wait on hold with insurance companies for prior authorizations and peer to peer consultations to approve patient imaging and non-formulary medication requests
• Sign orders and review monthly medication lists for nursing home patients
• Sign orders and plans of care for patients sent to physical therapy, occupational therapy, and speech therapy
• Read the patient consultations from medical specialists
• Read hospital admission and discharge notes, and follow-up any remaining issues needed
• Update patient charts based on medical correspondence
• Place lab orders for patients who want to have their results prior to upcoming visits
• Review mountains of mail with recommendations and reminders from insurance companies regarding the medications patients are taking but maybe shouldn't be taking; the medications the patients are supposed to be taking, but haven't refilled; the lab tests that are recommended but haven't been drawn (but were probably drawn a month ago but the company doesn't have that information yet)
• Review EKG and spirometry results
• Discuss staffing and performance issues with the office managers

     "What is the solution?" you may ask.  Well, there are currently solutions if you want to be seen punctually, nearly every time.  It is called concierge medicine.  The way it works, is that you pay a retainer (fee) yearly (usually to a third party company, but sometimes directly to the practice), which allows the doctor to see less patients daily, spend more time with each patient, and should therefor allow him to be punctual with your appointment time.  The retainer allows the doctor to bring in approximately the same amount of revenue with less patients to manage.  In terms of societal good, it is concentrating the doctor's skills across a smaller population of people who need care.

     For the super-rich, there are personal doctors, who are on retainer for either one or a handful of clients, and who may accompany them on trips or whatever their needs may be.  There will usually be a legal contract outlining the expectations of care.  This service is quite expensive (likely from $20,000 to $200,000 a year, depending on the medical specialty or other services required).  It is also risky from the doctor's perspective.  While you may not have much overhead to pay for, if you lose even a few of your handful of patients, you suddenly have income problems.

     I'm a free market guy, and I am all for concierge medicine.  It isn't right for all doctors.  Imagine a doctor with no personality offering this premium service.  If you pay nearly $2500 a year simply for the opportunity to get into the doctor quickly and on time, plus you pay the office charges on top of that, and you meet the doctor who is gruff or has a milquetoast personality, do you think his practice will stay open long?  No way.  But I think if that is the kind of practice a physician wants to try to establish, let him.  (Currently there are laws that prevent doctors who take Medicare from directly up-selling potential services such as same day care, as these are thought to be standard care.  To skirt these regulations, third party companies offer the concierge service, then pay the doctor to act as a consultant to take care of their patients.)

     My practice consists mostly of very kind, and appreciative working class people.  I have physicians and bank presidents as patients.  I also serve ex-felons and garbage collectors.  Patients will come in with one problem, but you may discover many others.  Unfortunately, sometimes what you discover may need to be urgently addressed.  Example:  a patient schedules an appointment due to decreased hearing.   The workup shows cerumen (ear wax) impactions.  You try to remove them, but they are too hard.  So then you have the nurse soak the ears with a solution, then flush them out 10 minutes later.  It is now nearly 20 minutes since first being seen.  The patient's ears are clean as a whistle.  The hearing is restored.  And as you are trying to escort the patient out of the room, you get the dreaded, "Oh!  I forgot to mention.  I've been having this chest pain for the past 3 days every time I walk up a flight of stairs.  I feel tightness, and must rest for 5 minutes before it goes away.  Do you think this is something I need to worry about?"

     And that, my friends, is the issue, right there.  To stay on time, I could say, "That is a very serious issue.  You need to make another appointment regarding that ASAP."  The patient would be upset, thinking that he is here with me now, why don't I address the problem?  Or, he says "Okay," but has a heart attack later that day, and his family sues me for not working up the problem when he brought it to my attention.  Or, I say go straight to the ER, which in most cases will be a waste of time if the patient isn't symptomatic, or the ER visit could have been worked up ten times cheaper as an outpatient.

     So, I need to take another 5 minutes to get the story regarding the chest pain, what makes it better or worse, order an EKG and chest x-ray, interpret them, order labs, and if needed, refer to a cardiologist.  As you can see, this additional information leads to another 20 minutes of time spent.

     My patients are more than time slots.  They are people, with problems and needs.  Granted, if I know somebody has a million active problems that I am addressing, I'll place a note that they always need a 30 minute slot, in hopes of not running too behind.  But if there are urgent issues, they're going to be addressed.  And this makes all the patients next in line late.  I can't tell you how many times patients will break down crying in the office, unloading the emotional baggage of family and personal traumas that they have been carrying for years, if asked the right question.  When a patient is hurting, crying, exposed and vulnerable, I am not going to say "Wrap it up.  Your 20 minute slot is over."  Instead, you just listen.  When a patient is crying because her son was murdered, sometimes you just need to be there for her.  And it is going to make everyone downstream late.  It's just the way it is. 

     What I ask of my patients is understanding and patience when I am running behind.  Sometimes I may be early.  But this isn't so common, unfortunately.  When I am behind, my office and medical assistants should have the courtesy to inform you of the fact, and to let you know how many patients are in front of you to be seen, or what the expected wait may be.  If this doesn't work for you, I understand, and I'll let you reschedule without any penalties for missing today's time slot.

     Perhaps you have a good solution to help me, or other doctor's stay punctual?  Please let me know!  And follow me on Twitter at https://twitter.com/OldFashionedDr.  Thanks for reading!