White Coat Underground

Via Tara Parker-Pope at NYT I learned of a little economics piece in the same paper. It looks into the economics and cost of waitng for health care services.

No one like waiting at the doctor. I’ve heard many people say, “Well, if he is going to use up my valuable time, then I’m sending him a bill.”

While I appreciate the sentiment, it’s not that the doctor thinks her time is more valuable than yours; it’s not a matter of your time vs. the doctor’s. It’s yours vs. the other patients. All of a doctor’s patients compete for the reletively limited resource of her time. There may be a few doctors out there who can limit themselves to only a few patients per day, but in primary care medicine, in order to keep the lights on you have to see lots of patients. But you also have to stop by the hospital, call people back, check on labs and tests, and go to the bathroom. Even if you keep your practice light, your time is finite.

Some doctors run a terrible office, and sometimes people wait inappropriately. But as I always tell my patients, “someone today might have needed a little extra time. Next time it may be you, and you’ll get it, even if someone else has to wait.”

Comments

  1. #1 Joe
    February 9, 2009

    @PalMD, you wrote “Some doctors run a terrible office, and sometimes people wait inappropriately. But as I always tell my patients, “someone today might have needed a little extra time. Next time it may be you, and you’ll get it, even if someone else has to wait.”

    When I am waiting for service in a store, sometimes they say “sorry that took so long” and I reply that I don’t mind waiting since I figure I’ll get that much attention if I need it, as you suggest. I can see that process.

    However, in the 1960s I worked in a doctor’s office and read some of his “office practice” magazines. They were full of articles explaining why the doctor should overbook patients rather than wait for one if there were late or “no-shows.” When a doctor claims an emergency took her time, we cannot see the process and that leaves me suspicious; particularly because being late is so common.

    I trust what you are saying about yourself; but I wonder how representative you are. Waiting is so common (doctors have “waiting rooms” rather than “entrances”), one wonders why it is not built into the system. Surely, there is enough experience to factor it in if one wanted to eliminate “the wait” (outside of real, not falsified, emergencies). Emergencies are too common, and too convenient, to explain so much of the inconvenience to patients.

    Yes, you acknowledged that some offices are poorly run. I continue to wonder if most offices are poorly run; even deliberately, poorly run from the standpoint of the patient-in-waiting.

  2. #2 Scott Belyea
    February 9, 2009

    But you also have to stop by the hospital, call people back, check on labs and tests, and go to the bathroom.

    Surely this is not news. And yet my experience would suggest that this is not really factored into the appointment schedule. I also wonder about “deliberately poorly run” offices.

  3. #3 PalMD
    February 9, 2009

    Yes, doctors often overbook, and yes, it would be nice if we could “factor in” all of the patient care “stuff”, but patient care is very mushy. Patients and their health are unpredictable, and people no-show reasonably often. If I were to leave bigger spaces in my schedule, the wait wouldn’t be in the waiting room, it would be at home waiting to get an appointment in several months.

    Unless we recruit thousands of more primary care docs, or change the compensation model considerably, there won’t be any change.

  4. #4 Scott Belyea
    February 9, 2009

    Unless we recruit thousands of more primary care docs, or change the compensation model considerably, there won’t be any change.

    I don’t buy it. I’ll give one example. I’m fortunate to deal with a clinic with a different attitude. My wife and I have each had calls about an hour before scheduled appointments suggesting that we show up 30 minutes later because things are backed up.

    To be blunt, you sound as though you’re saying, “Look … I’m the doctor and I know best!” I strongly suspect that you don’t intend to come across that way, but …

  5. #5 PalMD
    February 9, 2009

    Doctors hate long patient wait times. It makes for unhappy patients and for doctors falling behind in all the rest of their work/family stuff.

    If you have a suggestion that would allow primary care offices to operate more like McDonald’s, I’m listening.

  6. #6 Joe
    February 9, 2009

    Pal,

    I don’t have a better suggestion, I wish someone who studies the system would. My major complaint is that we cannot tell when our time is being wasted by the doctor. As I said, I trust what you write; I just don’t know how much typical waiting by others is purely inconsiderate. I don’t hold you responsible for answering that.

  7. #7 Art
    February 9, 2009

    It isn’t the waiting per se that gets me. It is the assumption by the doctors, and/or their staffs, that people can afford to be made to wait.

    Case in point is after I tore my ACL. Orthopedic specialist consistently made me wait for one, sometimes two, hours. Nobody else in the waiting room. I got the feeling I was interfering with his golf schedule.

    Here I am making just a buck or two over minimum wage, struggling to make rent and they make it impossible for me to lose any less than half a days wage so this over friendly dunce can spend thirty seconds feeling up my knee before announcing that I should come back in two weeks. For my trouble I hand over sixty bucks, over and above the loss of half a day and the disfavor of my employer for being ‘unavailable’. The boss doesn’t care if I can walk and the doctor doesn’t care if I have to live on the streets.

    Above this the doctor has the unmitigated gall to phrase his treatment recommendations in terms of: ‘If you were my son … ‘. Well, I’m not your son and no I can’t swing the $6000 down it would take to have you darken the doorstep of an operating room on my behalf. Even if I could afford it when I started I can’t now because of the loss of half a day’s wage and $60 every two weeks for four months has bled my wallet white. All that, apparently, based on a complete lack of any actual treatment, to satisfy professional curiosity and desire to fondle as many knees as possible before he dies.

    Overpriced arrogant ponce.

  8. #8 PalMD
    February 9, 2009

    I just don’t know how much typical waiting by others is purely inconsiderate. I don’t hold you responsible for answering that.

    Well, I do hold myself responsible, at least in a way. For example, with Art it might be useful if we strictly follow the evidence when it is available. For example, some of my diabetics complain about coming in every 3 months, for good reasons, but the evidence points toward much better outcomes with close monitoring.

    Yearly physicals, on the other hand, have much less data to back them up, and it’s unclear what we should do about those. They are probably a good idea for most people, but the data is skimpy.

  9. #9 Kairol Rosenthal
    February 9, 2009

    I’m a young adult cancer patient and have racked up weeks worth of time waiting for doctors. I don’t buy that timeliness cannot be done. Some of my doctors are perfectly on time and never a wait; others I pack a lunch, reading material, and plan for three hours. Is it that the lights cannot be paid or is the difference between the profit margins? (I don’t mean that rudely – I think docs should get big bucks – you have the most important jobs I can think of!) I just don’t get the huge difference. You guys need to talk to my GP to see how he gets it done!

  10. #10 PalMD
    February 9, 2009

    I don’t buy that timeliness cannot be done

    I don’t either…but under our current system, it’s damned difficult. (This is written by a doc who is nearly always on time, but i’ve sacrificed quite a bit for that).

  11. #11 nm
    February 9, 2009

    Waiting time is a pretty effective way to transfer costs to patients and into the cash-free economy. It still costs a lot but it doesn’t cost actual money from the point-of-view of healthcare providers or funders.

    It’s not like it’s PAL’s fault. He and everybody else are doing their best in the completely strange economics that surround healthcare. It’s not a market economy so the sorts of things widget makers (or Mcdonalds) can do can’t necessarily be done in healthcare.

  12. #12 ddc
    February 10, 2009

    Here in Britain the doctor sometimes keeps me waiting. But I can’t bill him for my time, because he doesn’t bill me for his.

  13. #13 davidp
    February 10, 2009

    I stopped going to a primary care doctor here (in Australia) when I found out that his office’s policy was that if there were walk-in patients waiting, they would make patients with appointments wait at least 20 minutes before considering sending them in to see a doctor – the cost to the patients with appointments of 30 minutes wait was considered zero.

  14. #14 nm
    February 10, 2009

    ddc

    Yes he does bill you for his time- just indirectly. The NHS pays his salary and you pay for the NHS through taxation.

    This is the root of the problem. The patient doesn’t pay for healthcare directly so customer service tends to go out the window. A third party be it the NHS or an american insurance company who is paid for by your employer quite often pays the bill.

    davidp gives an excellent example of could happen in Australia when you are behaving like a direct consumer in a market economy. I don’t argue it’s right to do it this way of course…

  15. #15 Lora
    February 10, 2009

    I know there are still issues with open access “same day” scheduling–loss of continuity of care, especially. But it seems that some practices at least have managed to keep these issues under control by careful and thoughtful implementation. And at least one study showed some beneficial impacts on ER admissions, because people were able to see their regular doctors in a timely fashion, before illnesses worsened.

    Have you tried open access scheduling already, and it hasn’t worked? I know there is also a sort of cultural barrier to the concept of open access scheduling, where office managers and so forth just cannot quite get the concept–did you find that was a problem?

  16. #16 Nico
    February 10, 2009

    I’ve had some pretty crazy waits, but then, on the flip side, when I needed to get seen, that day, I was in, and probably bumped a couple people, and when the issue ran later in the day, my doc was still there, afterhours, to see to my care.

    I’ll bring a book and wait, it’s ok.

    It can happen so easily, an extra 2 minutes here, an extra 3 there and by midday, you’re running off schedule. So if you want to be the patient who’s seen on time, first thing in the am is better odds, in my experience.

    ( the same applies to busses, dentists and various other forms of “waiting”.)

  17. #17 D. C. Sessions
    February 12, 2009

    The last time I had to wait for more than a few minutes at my PCP’s, he told me “I’m sorry, but one of my patients came in with a nasty case of conjunctivitis and I couldn’t see sending her to ER.”

    Neither could I — and I don’t mind him taking the time to clean up afterward, either.

The site is currently under maintenance and will be back shortly. New comments have been disabled during this time, please check back soon.