Monday May 26, 2008
Interminable Waits in the Doctors' Waiting Room
Well, they don't call it the "waiting room" for nothing. You arrive for a 10 am appointment in the doctor's office and fume as 10 am becomes 11 am, 12 pm and sometimes even 1 pm. This week, White Coat Black Art dissects the wait and the reasons for it.
In preparing this show, what astonished me is how often doctors blame patients for the wait. As you'll hear, some doctors complain about patients who bring a list of up to 17 items to discuss with the doctor. Some clinics have fought back by posting signs giving a limit of 2 complaints discussed per visit. Other doctors we talked to mentioned the "oh, by the way" syndrome. That's when the patient spends 15 minutes talking about hangnails, tips on losing 10 pounds and what to do about a rash that's been there for 10 years. Then, just when the doctor gets up and puts her hand on the door knob to signal the end of the appointment, the patient says he has chest pain. That kind of problem is potentially so serious it forces the doctor to sit down and retake the entire history!
On our show, we never let doctors off the hook. There's no question some doctors are the cause of much of the delay...double and even triple booking patients...and never budgeting time appropriately. I'm convinced that flaws in the fee for service system are a big part of the problem. Doctors bill patients what's known as an intermediate assessment per patient for most visits (the name or type of visit varies with the province). The fee is paltry...believe me, you wouldn't expect to get much from a plumber for the fee we pay doctors. I know a lot of MDs who say they have to see 6 or even 8 patients an hour to pay their overhead and have enough left over to make a decent living. It's as if the government figures it won't get into too much financial hock if it lets MDs bill an infinite number of intermediate assessments.
To me, that's just insane. Provincial governments are far too focused on saving money and not enough on delivering appropriate care.
Here's my advice. The government should hire more nurse practioners and pay them a salary to manage the easy family medicine types of problems. That would free up more money and leave doctors to handle the more complex patients. With the money saved, the government could let doctors bill higher fees for more complex patients. They'd take more time with the complex patients and they'd stop cramming 8 intermediate assessments into an hour.
And you wouldn't have to wait so long.
That's my fantasy, anyway. The provinces will never go for it. It's too logical.
Previous Comments (15)
Something has to be done. But I have a feeling that part of the problem is that no one takes women very seriously. My husband once took our child to a specialist. He waited a half hour and left. The office called and apologized and we never waited for more than 15 minutes again. I had often waited for long periods- but I was just a "mom" with "nothing important to do." Ask yourself how long most busy male professionals wait at doctor's offices- I would bet that they don't!Linda Thompson, May 26, 2008 11:04 AM
> That's my fantasy, anyway. The provinces will never go for it. It's too logical.
Great idea that I fully support. However the real fantasy is that you seem to think that your FP colleagues would ever "go for it."Bylo Selhi, May 26, 2008 12:02 PM
I love my doctor, I'm not sure the scheduling philosophy that the office has started using but in the last two years I have always gotten in with in two days of phoning for an appointment even a physical, in fact they won't let me book a physical more than 3 days before the appointment. The doctors in the office are always on time (or close to it)even at the end of the day and they never make me feel that they have more important things to do except for me and my health (or that of my family) I'm very happy with my doctor's (GP)office and the care that my family receives, if only all doctors' offices can be the same way. Love the show.Stacy Stanley Young, May 26, 2008 12:07 PM
I listened to the tail end of your programme this morning with great interest and have a story to tell about wait times.
I have lived with fair health aside from a nasty condition called fibromyalgia and a bout of breast cancer, four years ago.
My G.P. quit his practice and I have been searching for a new doctor for at least two years. Last year I found one close by who had just re-located to Toronto and was still taking new patients. As I had been quietly noticing chronic pain in my neck,(I put it down to arthritis, but it was bad enough to require attention), I made an appointment in May(07) for the earliest available time... Aug. (07) which was a three minute "meet and greet". I left the office with a fee schedule and a referral for an x-ray.
The doctor left me an e-mail to say that she thought I should have an m.r.i. and from that point on I was never able to connect with her, her nurse or her receptionist. It seems that my lovely young Doctor had "made a life style choice" to install an answering service that would not take messages, thus it was impossible to make new appointments, change dates of appointments, cancel appointments, or even follow up on the Doctor's call.
The outcome of this sorry tale is that when I had my regular oncology appointment on Dec.17,(07) and voiced my frustration to my oncologist, she got me an m.r.i by Dec.19 and I was diagnosed with metastasized breast cancer in c2 and c3 vertebrae on Dec.24 and began radiation treatment on Dec.28.
Still unable to connect with my G.P. by mid Jan.(08) I stormed into her office and demanded of her receptionist (shooting the messenger?) that the Doctor help me find someone who was at least accessible. Thank you
When your doctor has prescribed you a lightly tested but highly marketed drug that millions have been given to treat disease they don't have, including you, the doctor (who is already negligent because she/he hasn't read the literarure, just the pharma handout) had better ask *all* the questions and listen to *all* the complaints.
They might add up to something.
Pain in your joints? Pain and weakness in your muscles? Can't get out of the chair? Acid Reflux? Gall bladder acting up? Pancreatitis? Rectal bleeding? Tingling in your fingers and legs? Forgot where you live? Aphasia? Rotator cuff injury, knee injury? Something wrong with your vision?
That's way more than 2 complaints.
And only about 1/10 of the most common documented adverse effects (side effects) of statins: crestor, lipitor, zocor, mevacor and zetia aka ezetimibe or ezetrol.
There's probably only enough time to write prescriptions to deal with the unrecognized side effects, because sitting down and listening and doing some connect the dots would take time.
The patient is now into a prescription cascade, perhaps needs a surgery or two. Hmm. You might need to have that gall bladder out.
Lots of paper flashing across the desk, very little time, certainly not enough time to practice
And that's why physicians are so overworked.riv, May 26, 2008 1:48 PM
My doctor will not do more than "one" item per visit. The last time I saw him , about 5 years a go , he could be heard cursing on the other side of the door , and was visibly shaking and upset as he explained the "one visit" , "one thing" scenario. I was also advised that I cannot come for an appointment without having "something wrong" or pressing. This basically means "zero" preventive medicine. My doctor has basically given me a death sentence if I follow his advice.
I am now relegated to what I would call third world grade walk in clinics.
From what I now understand , preventative medicine is now not covered by BC Medical Services.
I listened to the comments made by a couple of the doctors interviewed for this program, and my first thought was "well EXCUSE ME for getting sick!". WHAT are these egomaniacs doing in a profession that's based entirely on customer service? They seemed to have nothing short of contempt for their patients. They'd be better off in a research lab where they wouldn't have to bother with such trivial annoyances as, say, treating people. Thank goodness my doctor doesn't behave with such smug superiority.Terri Owen, May 26, 2008 6:14 PM
"The government should hire more nurse practioners and pay them a salary to manage the easy family medicine types of problems. That would free up more money and leave doctors to handle the more complex patients.....The provinces will never go for it. It's too logical."
My understanding is that is is the PHYSICIANS who won't go for it. Tell me I'm wrong and I'll be happy. Fancy using physicians' time for routine renewal of prescriptions, for example.C. Ashley, May 26, 2008 8:43 PM
I am a medical assistant and work in the obstetrics/gynecology field. Walk into any of these particular waiting rooms and you will often see patients jammed in like sardines, all waiting for their 5 minute appointment with the doctor. On a routine maternity patient day, it's not uncommon for some physicians to see upwards of 60 or even 70 patients. Then, factor in having the physician being called out of the office a number of times throughout the day to deliver the babies, or do emergency c/sections, etc. and you probably get an idea then just how long some of these poor patients are forced to wait. If the patient doesn't want to wait for the physician because of the delays and asks to rebook her appointment, finding another available appointment can be difficult. This is because some of these physicians only work part-time and consequently the number of office booking days are limited. As a result, available appointment spots are very few and far between. What generally happens then is that these additional appointments are added on to an already fully booked upcoming day. And the cycle continues...
Why do some obstetricians/gynecologist see so many patients? In this part of the country, one of the main reasons has to do with the fact that we are in the midst of a "baby boom". Then there's the fact that there aren't enough specialists in the field for the numbers of patients needing to be cared for. It could also be argued that the "fee for service" method of payment is a factor and that some physicians do not feel they are adequately compensated unless they see a large volume of patients throughout the working day. Do the physicians enjoy working like this? Overall I don't think so. Do the patients enjoy this type of medical care and the inevitable wait times involved? I think we can all draw our own conclusions on that question.Barbara, May 28, 2008 10:36 PM
My previous doctor not only overbooked appointments but nothing was ever resolved in one visit. It always required at least one follow up and sometimes two or three.
For example I get wax buildup in my ears, I know nobody really want to hear about ear wax, but it proves my point, I'd go to the doctor to have them clean out.
Initial Visit: I get a schpeil that I need to go home put in olive or mineral oil for a week because the wax is too hard.
Follow Up Visit: A week later I go back and he'd do what needed to be done
Six Month Later
I think I'm a fairly smart guy so I put the mineral oil in for a week before the appointment as recommended from my last visit.
Initial Visit: Again he suggests I put oil in my ears. I tell him I've been proactive and that I have been for the last week or so. He responds by saying the wax is still too hard and to go put oil in for another week and come back.
Follow Up Visit: Suggests again that he can not clean the ears out and that more oil is required before he can do his thing.
Second Follow Up Visit: Finally cleans out my ears
Another 6 Months Later:
Now again not dumb here so the "Double Bill" flag has gone up since the last rounds debacle. This time I don't add any oil to my ears before the visit.
Initial Visit: I get the oil schpeil, lie and say I've already been using oil, he send me away to put more oil in my ears. I don't bother with any oil.
Follow Up Visit: Looks in my ears and says the wax is still to hard, another week more oil. I again don't bother with the oil.
Second Follow Up Visit: Doctor tells me that the oil has done a great job, syringes out my ears. The wax comes out as easy as always and I go home not having put a single drop of oil in my ears through the entire process.
No wonder our doctors office and emergency rooms are so full. If we are are booking everyone in for two and three appointments to resolve a one visit issue.Greg G, May 30, 2008 11:38 AM
I fully believe in the need for nurse practitioners and would welcome one in my doctors office. Frequently the things I visit my doctor for are routine concerns for me and my children, RX refills and the like.
Why not have NP's assisting doctors, and of course letting them know when there are concerns out of their range throughout the province. They are paid less and can deal with the common illnesses and health issues.
Makes sense to me and my family, bring it on.amyinbc, May 30, 2008 11:43 PM
I do appreciate the your program for pointing out the doctor's side of the story of why patients wait so long in waiting rooms. I work at a job that requires scheduling customers and it's true that things happen and the next appointment gets pushed back but if it is happening ALL the time then it's my job to re-assess the bookings. What the doctors in this program should realize is that those people in thier waiting rooms have lives too. If I wait in a waiting room for three hours I have lost a half day of work that I will have to make up for on the weekend.Diana Nutt, May 31, 2008 9:04 AM
My doctor requires 24 hours notice of cancellation of an appointment, otherwise there is a $10.00 fee. Fair enough, I understand the frustration of booking appointments for people who don't show up.
However, it does beg the question of what sort of compensation a patient can expect for the hours spent in the waiting room?
Overall, I don't mind waiting a reasonable length of time because I have a chronic condition and I know that there have been times when the shoe is on the other foot: in other words, to be the patient that needs that extra time. That being the case, I do not begrudge that time to another patient. However, when the waits become consistently upwards of two hours, there is something very wrong.Leslie, June 2, 2008 11:26 AM
The problem with inserting nurse practitioners to look after the "easy medical concerns" so MDs could look after more complex (expensive) issues is many fold.
First, most MDs are unwilling to give up on their domain or scope of practise. Second, they will be very hesitant to give up on the "easy money" of multiple visits. Adding the nurse practitioner to the medical model will only result in additional layer of billing professionals and ultimatley cost the sytem more.
A real solution will have to involve better education of the patient base and an increased profile for the true "preventionist" healthcare provider: Fully funding fitness consultants or personal trainers and nutritionists rather than medical doctors would be a novel, cost effective solution. Universal healthcare could still be provided within institutions but the cost of visits for the "easy medical concerns" would be borne by the patientdave anderson, June 4, 2008 4:09 PM
A couple of thoughts, from a rural family doctor (14+ years) who still tries to practice 'Marcus Welby' (who's he?) style.
1) I believe that everyone's time has value. I try not to waste my patient's time by being tardy, and (s)he knows that they should treat my time the same. Mutual respect makes it all work better that way.
2) Booking - I do not double book. However urgent issues will have to be accommodated in an office once in a while and that can impact the timeliness of an appointment. My secretary/mistress of all will let patients know we are running late - perhaps better to reschedule? Something to ask your doc about?
3) The 'time' thing - physicians are very uncomfortable confronting patients who are taking up another patient's time inappropriately. I got over that years ago. To be fair, most of my patients did too - the vast majority are respectful of their time (and are aware BTW of how long their appointments are).
4) Emergencies - I practice obstetrics including Cesarean sections, emergency medicine, surgery .. oh and I am the local medical examiner too. Physicians are sometimes called out of office because a patient is really sick. That impacts the office, and if patients know that something bigger then them has come up, most are pretty understanding. Years ago a mother brought her son in who clearly was about to obstruct his airway completely - we ran through the (full) waiting room to drive to the hospital and I remember thinking how upset the other patients would be at the (then) new doc in town.
The patients quietly lined up and re booked their appointments - no problem.
Sometimes I think it is easier to practice in a rural locale - patients see you in the community and know what you do (and at what hours you do it). The mutual respect that is reflected in being timely is matched by understanding on both sides of doctor-patient relationship.
By the way, most docs would love to have help in their offices with staff who could deal with the 'fluff' (of which there is little these days) while they concentrate on the weightier manners. The trouble is finding these people. Nurses are needed elsewhere (read 'hospital' care), nurse practitioners are few and far between (and frankly are like a lot of docs - want to specialize in specialty areas not in general practice) and I have not seen yet a provincial government that seriously wants to put the required dollars in supporting this mythical help. But stay tuned on this last point, with most of us getting older and fewer younger practitioners willing to do the 'heavy lifting', this will come to some resolution sooner or later (even though it may be catastrophic).Michael Caffaro MD, June 10, 2008 10:59 PM