An appointment ... to wait?
Patients have long griped about delays at the doctor's office. But solutions do exist.
By Daniel Costello, Times Staff Writer
Before leaving for a checkup with her doctor last month, Suzi Finer called ahead to ask if the doctor was on schedule; the nurse assured that he was. A stickler for time, Finer arrived 10 minutes early for her 10:20 a.m. appointment.
The preparation didn't help. After checking in, Finer sat in the waiting room for 40 minutes. She then spent 20 more minutes "staring at four blank walls" in an exam room, twice poking her head into the hall hoping to grab someone's attention.
"When the doctor showed up, he was nice and very helpful," says Finer, 41, of Beverly Hills. But "no one even apologized." Making matters worse, she says: "They don't validate for parking. I had to pay $9. Cash."
Each day, countless patients like Finer, many of whom are sick, visit their doctors and confront seemingly endless waits. Most view the ritual as a fact of life they can do little about, such as rush hour traffic or holiday shopping. But in an age when a microchip from China can be shipped to Kansas overnight, it's hard not to wonder why people still need to wait so long to see their doctor.
In recent years, the fast-food and retail industries and even time-honored dawdlers such as post offices and departments of motor vehicles have reduced wait times by spending considerable time, money and energy to speed customers along. Most are seeing the fruits of their labor in higher customer satisfaction, lower costs and often a rise in profits.
Waits in doctors' offices, meanwhile, are getting longer. According to the Agency for Healthcare Research and Quality, the proportion of patients who wait more than 30 minutes in their doctor's office rose slightly from 16% in 1999 to 17% in 2001, the last year that information was available.
To be fair, some doctors are trying to alleviate the problem. An estimated 5% of physicians have switched to an increasingly popular scheduling system known as "same day access" that minimizes scheduled appointments and leaves most of their day open for walk-in patients. Some are doing group appointments for up to a dozen people with similar chronic conditions or are allowing patients to set up appointments and view their medical records online, hoping it can reduce phone calls and unplanned office visits. Others are taking the "make them think of something else" approach by adding comfortable chairs, relaxing music and lighting, even coffee and juice bars in their lobbies.
Still, many doctors pay little attention to punctuality. "The issue in medicine is that most people have always believed they can't do anything about things like waiting times, so they never tried," says Mark Murray, a Sacramento healthcare consultant who works with medical practices and hospitals to improve office efficiency.
Long waits aren't just a temporary annoyance. They're a primary factor in how satisfied patients are with their visit. And they are one of the main reasons up to 40% of all patients skip their appointments, making scheduling and staffing levels unpredictable and raising costs across the industry.
What is more, purgatory-like office waits can determine how often some patients seek care. According to a study released last year in the American Journal of Public Health, waiting times of 30 minutes or longer sharply reduced the likelihood that men would visit a doctor again. A woman's decision to return to a doctor is much more affected by the cost of the visit, the study also found. Only 5% of women left waiting stay away.
So what's keeping doctors from being on time year after year? Some simply expect patients to wait for them. But experts say the larger problem is that healthcare has mostly ignored lessons other industries have used to make customer service improvements, partially because few doctors have tried but also because many believe wait-inducing factors can't be changed.
For starters, they say, too few physicians have embraced technology, such as electronic medical records or computer systems to automate and track patient visits. Instead, many offices still use paper forms to record patient visits and insurance information, rely on outdated filing systems, and have inefficient procedures to track patients once they leave the office. Supporters of the new technology say that by standardizing, doctors could considerably speed up appointments.
Eugene Litvak, director of Boston University's Program for Management of Variability in Health Care Delivery, says doctors also put too much faith in the idea that they can't predict surprises. That, Litvak says, isn't true. If doctors looked for natural patterns how many patients arrive before noon on Monday, how many show up with back problems in December they could readjust their staff accordingly and better deal with patients' ebbs and flows.
"Doctors shouldn't assume patients demand is given by God," he says. "No one else does."
Testing their patience
Few researchers track patient attitudes about specific grievances like wait times. But stories of patients pushed to the waiting brink abound. Last summer, a Las Vegas man forced to wait more than three hours in an exam room sued his doctor in small claims court for his lost time. He won the case, but later settled for an apology letter and a promise that the $250 award would be donated to a children's charity.
Tony Epley, of Dandridge, Tenn., says he recently hit his limit with a constantly delayed family doctor. He arrived on time, he said, but after 15 minutes informed a nurse he was leaving. When she told him he would have to pay for a missed appointment, he told her that he had called to ask if the doctor was running late and was refused an answer. He then left and two other patients followed him out the door. "I told them they could bill me all they wanted but they weren't going to get a cent out of me," says Epley, who never received a bill.
Doctors, of course, aren't entirely to blame for lags in waiting rooms. As many physicians point out, healthcare isn't like most industries in which the goal is to sell as many burgers or cars in the shortest time. One major reason why doctors sometimes run late is that it's impossible to predict how long each patient needs to be seen. A schedule that is too rigid could cause some health problems to go undiagnosed.
"You have to spend the time to talk to people. A patient may come in with a cold, but there are other things like anxiety or a problem with their weight you might have to address," says Roxanne Thompson, a pediatrician in New Orleans.
Few doctors and patients would suggest that actual visits with doctors be shortened. Many, in fact, are spending more time with patients during exams. A 2001 study in the New England Journal of Medicine found that physicians are spending longer with patients once they get in the exam room, up two minutes from 16.3 to 18.3 minutes between 1989 and 1998.
But the need to be flexible doesn't mean doctors do a better job scheduling each appointment or dealing with surprises such as walk-in patients, who doctors say are often a main reason they fall behind.
The budding effort to see most patients the same day they call has been shown to relieve some of the problems. Mark Murray, a family doctor who stopped practicing to begin his healthcare consulting company, helped create the same-day-access concept several years ago while working at a family practice in California.
His office had become overrun by delays patients waited as long as three months to get an appointment and then often found a bottleneck of patients in the lobby once they arrived in the office. Even then, most saw their own doctor only about half the time.
So Murray came up with a solution as simple, he says, as what's taught in an Economics 101 class: Make supply equal demand. To do that, he and other doctors in the practice worked overtime to reduce a backlog of appointments and then evaluated their daily patient logs for patterns.
He found that more people showed up on Mondays and Tuesday and that appointments were often longer during flu season and at the start of the school year. So he left a small number of scheduled visits for those who demanded them and began seeing the rest of his patients for appointments often limited to 15 minutes the same day they called.
The outcome surprised everyone. In less than one year, waits to get an appointment were reduced to just one day and delays in the waiting room fell to an average of three minutes. Both patients and doctors reported significantly higher satisfaction.
"There is a domino effect," says Murray. "When one thing is corrected, other things fall into place." The Institute for Healthcare Improvement, a Boston-based nonprofit, estimates that 5% of physicians are using the same-day scheduling approach and expect the number could rise to 10% in the next few years.
Other doctors are trying separate efforts, or a combination of them, to speed patients along.
Two years ago, Fairview Health Services in Minneapolis started using electronic medical records and offering patients same-day appointments in its 24 family clinics; this year it added online scheduling. Dr. Loie Lenarz, a family medicine doctor who oversees the clinics, says waits at Fairview for routine appointments dropped from 15 to 20 days to one in just eight months and patients' cycle time through the office fell from more than an hour to 40 minutes. "It's hard to change something that's essentially been the same for 50 years," says Lenarz. But "look at the results."
Charles Kilo, a St. Louis endocrinologist, is using group appointments. They are generally two-hour appointments, led by him and a nurse, for up to a dozen people with a similar chronic condition such as obesity or diabetes.
The benefits may go beyond just clearing patient logs. Kilo says patients in the groups have time to ask more in-depth questions and also interact with one another and trade experiences. A small number of studies have shown that patients attending group visits had fewer repeat visits, fewer emergency room visits and fewer phone calls to physicians.
The patients "reinforce each other to be healthier," says Kilo, who adds that some insurers balk at paying for group sessions because they consider them prevention rather than treatment.
Significant roadblocks remain before more doctors are likely to wrangle with patient delays. This month, Massachusetts announced plans to substantially expand electronic medical records throughout the state by 2009, but only a handful of other states have expressed interest in similar plans.
A cultural change
A graying population could mean waits to see doctors may get worse. And reduced physician compensation from insurers in recent years has increased the practice of doctors double- and sometimes triple-booking time slots to ensure that they see as many patients as possible.
Making office visits more efficient is "a significant shift in culture for the medical community. It's going to take a long time and focused energy," says Lenarz of Minneapolis.
In the meantime, some physicians may want to stick with the age-old remedy when patients have waited too long: an apology.
Epley, of Tennessee, says he was thrilled when his psychiatrist stepped into the waiting room recently to let him know she was running late. She even asked him if he wanted to come back another day. He stayed and later thanked her.
"The main thing is that she had the courtesy to tell me about the delay, and about how long it could be," he says. "It's when they keep people guessing that makes them crazy."