Blog | Wednesday, January 18, 2012

The doctor will see you later ...


Like most doctors, especially us subspecialists, I see my patients by appointment. For many reasons, some sensible and some foolish, our patients' satisfaction seems greatly influenced by how long after the appointed hour they actually get to see the doctor. Many people think that we doctors care little for how long they have to spend in our waiting room. Nothing could be farther from the truth. Actually, I spend a great deal of my day thinking about just that. So I decided that the topic was worth a bit of contemplation and frank discussion.

Of course, there are other ways of allotting a physician's time to achieve the greatest efficiency. Many primary care practices have taken to abolishing appointments altogether, relying on the "law of averages" that a large enough patient panel will generate a relatively stable volume of patient visits from day to day. In fact, this is not a new concept; many old time "GPs" scheduling regimens consisted only of the rule of "first come, first served."

My late father-in-law, whose presence remains in my conscience years after his departure, had a busy general practice in Brooklyn. His office opened promptly at 8 a.m. when he would return from his morning hospital rounds. His secretary/receptionist/medical assistant/office Czar would open the door at the strike of 8 to admit a queue of patients who were literally "presenting" themselves with their complaints. The beauty of the system was that the places toward the front of the line were usually occupied by those most deserving immediate attention, since those in the greatest distress usually had the greatest incentive to arrive earliest.

Priorities were assigned by the sign-in sheet and the waiting room would immediately fill to capacity. Everyone got seen eventually, sometimes after waiting two or three hours, without a grumble and with gratitude for the doctor's seemingly inexhaustible capacity for the application of his healing art and his labor to their problems. I was not there to witness this, but my wife, who served as an office assistant during summers when she was in high school, tells me that there would often be 40 people crowded into the waiting room with half as many chairs. No one resented the wait, because they knew that there was no better doctor to be found in all of Brooklyn, N.Y. than he. And I myself believe that to be true.

Fast forward to 2012. I have a morning full of procedures and some time to grab a bit of lunch, then start seeing office patients shortly after 1 p.m. I allot 15 minutes for a follow-up visit for a gastroenterology patient, 20 minutes for my few remaining internal medicine patients, and half an hour for a new consultation. I rarely see more than 12 people in an afternoon.

My encounters are punctuated by telephone calls from other doctors who I have left messages for to call me about patients we both care for. I am interrupted by calls from radiologists, pathologists, laboratory staff, nurses on the hospital floors, patients whose problems cannot wait until after office hours, and my own staff, who need decisions made about day-to-day matters that can't wait until I finish the patient encounters because some of the staff leave before that time.

Even my wife, who tries not to bother me, sometimes calls on matters that can't wait. Sometimes I am called to the hospital or the emergency room to rescue patients who appear to be trying their level best to bleed to death from one orifice or another. My ever-sympathetic and saintly receptionist spends time mollifying the waiting crowd and offering my best estimated time of arrival.

Meanwhile, during their time with me, the patients I see offer complaints that they failed to mention to staff when they made their appointment, or forgot about until they got in the exam room, or thought they would bring up only when they saw me. The classic schedule-killer is known as the hand-on-the-doorknob remark: "Oh, by the way, Doctor, I've been getting these funny pains in my chest when I go out walking in the cold." So the 15-minute visit becomes 20. The 20-minute visit becomes 40. And the half hour consult becomes an hour. By the end of an afternoon, I am running an hour behind.

So why not just schedule fewer patients? For one thing, I am already having to defer or turn away people anxious to see me and me alone. I would have to delegate them all to my junior partner, who is himself harried, or ask my primary care patients to find a new primary care doctor. Existing patients with urgent problems end up being "squeezed in" to the schedule at times. And yet not infrequently, patients fail to show up without the courtesy of even a phone call, leaving me unexpectedly idle, knowing that I will still be pressed to accommodate the people scheduled later in the session.

Of course, I can use the "down time" to catch up on phone calls and paperwork, but every 15 minute slot that lies idle means some other patient has been made to wait longer than needed and I am bearing the cost of keeping an office open with a staff of 10 people and a large rent with no revenue to support that.

And if I am fortunate, I might find the time to make a few calls to attend to my own personal needs, such as my own care and maintenance and that of my family.

Many people seem to think that doctors have no regard or respect for their time. They write in smug tones in chat rooms about how they presented their doctor with a bill for the time they spent in the waiting room. Some take their delay to mean that I think I am more important than them. Some schedule other engagements an hour after their appointment time and expect to be seen by me in time to travel half an hour by car to get to them. Accustomed to getting a Big Mac and fries within 5 minutes of driving up to the order window, our patients sometimes fail to comprehend that my office is not on par with a McDonald's restaurant. (No disrespect; I envy their efficiency.)

I see Medicare beneficiaries in their 80s who are indignant that I am keeping them from their important pursuit of watching their favorite television show. Some older patients retain a great respect for the healing profession and make no complaint but others, perhaps disinhibited by their age, are downright rude. My wife has a theory that some older patients, even though they have no pressing tasks that I am keeping them from, are annoyed that I have wasted the dwindling time they have remaining on this earth.

Not everyone is put out by waiting to see me. Occasionally, I do encounter patients who conclude from their long wait that I am very busy and thus I must be a very good doctor. Many of my patients have learned to bring a book. The e-reader has been a boon to quite a few. Others relish the chance to read trash magazines and celebrity weeklies they would otherwise not feel a legitimate use of their time. I find some patients happily doing crosswords, Sudoku or checking email on their smart phones when I enter the room.

I assure you, I am mindful of my patients' concerns and their own oftentimes equally busy schedules. There is no satisfaction in entering an exam room an hour after the patient's appointment time to find him or her tapping her feet, looking immediately at her watch, and then at me with a sullen stare or daggers in the eyes. The bolder folks verbalize their frustration or annoyance immediately; others say nothing but are clearly resentful enough to be distracted from getting down to business for the first few minutes.

A colleague described the feeling as "fighting the clock" all day long. Another tells his patients, "I'm pedaling as fast as I can!" I usually tell people immediately that I recognize that they have been waiting a long time or I apologize and explain the reason. Sometimes, though, when the patient remains unforgiving and I am running way behind and feeling overly harassed by demands from all sides, I am tempted to say, "I can do it fast or I can do it right! Which do you want?!" I never say it but I often think it.

But I will be honest. I could arrange it so that no one would ever have to wait more than five minutes to see me. I would schedule an hour visit for each patient and allow half an hour between visits for miscellaneous eventualities. I would see six patients in a day. I would dismiss 90% of my existing patients and see only consultations. I could see people only at their initial consultation and hire a physician's assistant to see every one for their follow-up. I could take a huge pay cut.

Or I would charge each patient four times as much and not accept insurance. Don't think it hasn't been tried! Some primary care doctors have formed "concierge" practices. They offer their services on retainer for a sum of several thousand dollars yearly and limit their panel to no more than 250 well-off people. But clearly this would not work for the vast majority of Americans occupying the "99%" status in the economy.

I could see my six patients a day for the same fees that I now receive. I would still be working an 80-hour week including nights and weekends and simply content myself with the income of the average starting mail carrier, only without pension or health benefits provided to me by my employer, instead having to fund these entirely on my own.

Even then, at the end of the day, if all of us doctors decided to practice that way, we would find that the supply of doctors is grossly mismatched to the demand, and people would not have access to care without waiting months, except for the few who could afford to pay large sums out of pocket.

Which is why my discussion, like many discussions of health care in the U.S., ends up leading to one fundamentally about money. What kind of healthcare delivery workforce can we afford? How do we balance quality and quantity? Do we ramp up our medical schools to turn out four times the number of trainees we do now? We might be able to do this in a decade or two with a crash program, but unless the government is prepared to make medical education free, most will graduate with over a quarter million dollars of indebtedness, and how many of us would make a bargain to start our career at age 33 on the salary of the average postman only without the benefits.

OK, so do we make the training free and pay every doctor a good salary commensurate with the many years of hard work and study and deferment of life's pleasures? Get ready to ante up, folks, because there are some 600,000 of us last time I counted, and if we had 2.5 million doctors earning $200,000 yearly, that's $500 billion yearly in salary. $5 trillion in a decade? So much for balancing the federal budget.

OK, so we train a whole bunch of what are sometimes called "health care extenders" or "providers." You don't get to see the doctor unless someone realizes you might just have an out-of-the-ordinary disease or you are clearly dying. Otherwise, an APRN or PA will be your provider. They seem to be content with salaries in the $100,000 range, knowing that they can work 9 to 5 or if not strictly a day job, at least a guaranteed 40-hour work week, maybe a few 12-hour shifts sometimes overnight. Mark that cost down from $500 billion to only $250 billion yearly, assuming we retire most of the doctors.

Oh, but by the way, a lot of us doctors are going to retire in the next decade. To begin with, we have a disproportionate number of "baby-boomers" in our ranks who are now approaching a retirement age of 70 or so. (Used to be 65 but the recession did a number on a lot of people's pension plans, so they will still be working a while longer, but not forever.)

And the latest news is that Congress is planning to cut our reimbursement for seeing Medicare patients by about 25% as of January 1. They usually rescind the cut by March but this time they supposedly mean business. A lot of doctors will decide they can no longer make a decent living practicing with a quarter of their revenue lost coming from the patients who lay claim to the greatest amount of their time. Some will just stop caring for Medicare patients. Some will only allow time to address one problem per visit and have you return every other week if you have multiple problems. I may be able to continue subsidizing my office practice with reimbursement for procedures, which is only being whittled away more slowly.

So if you think you are waiting too long to see the doctor, don't worry. Soon you will be waiting just as long to see the APRN. But if you can't stand waiting, I hear there are now some websites where for a fee, you can chat with a real doctor. Maybe I'll try my hand at that next.

There has got to be a better way to allocate doctors' time. I plan to reflect on solutions in another post.

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.