Strictly speaking this isn’t about participatory medicine, but it is about being an empowered consumer of care. There are several dimensions to empowerment, including (but not limited to):
- Knowing what you want
- Recognizing whether you’re getting it
- When you’re not, speaking up about it – courteously, when you can.
You know real change is happening when the world becomes ready to hear it, and respond. So I’m thrilled about today’s Empowered Patient column by CNN Senior Medical Correspondent Elizabeth Cohen, Would Your Doctor Pay for Wasted Time?
She writes about doctors who are now paying patients if they have to wait too long! It’s a glimpse of a world that’s almost unimaginable: healthcare delivery that works smoothly for everyone – the providers and the patients and families they serve.
Boeing employee Elaine Farstad spent two extra hours waiting, and sent the doctor a bill for her time – and they paid it! (I can hear the screeches of alarm across the country as I write this…) Several doctors offer gifts or cash.
The column has several what-to-do’s, including a link to the doctor list at the Ideal Medical Practices Organization, which encourages its doctors to be on time.
(By the way, this isn’t just a “be nicer to patients” issue – I think a root cause of our problems in healthcare is that it’s the only industry I know where the definition of quality doesn’t start with “What does the customer value?” I’m not saying that being on time will cure cancer, or anything like that – I’m saying, my gut says good and valuable things will happen if we make customer service a priority in healthcare. Cohen links to an episode in my own life two years ago, and in that case the hospital actually listened and changed their practices, because they “got” that they were inadvertently not valuing patients’ time. Hooray!)
Really enjoyed the article; this is timely. Many practitioners keep patients waiting an excorbitant amount of time. They believe their time is more valuable than that of their patients. This is grossly disrespectful, if if happens for other than a good reason, such as a surgery, or other emergency truely causing a backup. On the other hand, many are backed up, due to overbooking; many attempt to compensate their schedules for patients who blow off their scheduled appointments, without notice. Despite what lay people believe, the medical people get nothing when a patient is supposed to show up, and does not. Both parties, the patient if the doctor is late, or the doctor should be compensated (insurance companies will not) for a “no-show”. I am “old school”, and do not over book.
Oh, how I wished I had the cojones to invoice my doctor. I have to admit there are some Drs I will suck it up to wait for, but those that I find are not helpful I just don’t go back (ok, not always). As Dave’s age old post notes http://patientdave.blogspot.com/2009/07/customer-service-in-healthcare-not-all.html this doesn’t always end with the doctor’s office…Xrays, or Physical Therapists.
I think we must balance the need to always run on time with the needs of our patients. The practice of medicine — at least in primary care, but also in many other specialties — is not a one-size-fits-all, predictable enterprise. If it were then I could offer service guarantees around running on time. But it is not.
For one thing, as Dave and I have pointed out many times, we don’t often negotiate an agenda ahead of time. This means that both the patient and the clinician may have different agendas in mind when the patient arrives. If the patient has many things on her (hidden) agenda but running on time was of tantamount importance, then I’d have to tell the patient that we won’t be able to address their concerns and they need to reschedule.
In addition, sometimes events occur that we could not anticipate at the time of scheduling, which can be medical or psychosocial. For example, the patient with upper back pain is actually having angina. Or the patient, not previously known to be depressed, breaks down in tears during a discussion. Or the patient has questions/concerns that need to be addressed related to a new diagnosis. Or the patient collapses during a visit. If you were the patient in these circumstances, would you want your physician to look at the clock and tell you that your time is up? I realize that some physicians practice this way, but is that really patient-centered?
Since there is an unpredictability to medical practice, an ideal system would have additional capacity baked in. For example, scheduling patients for more time than they need or having extra clinicians available to help out in these scenarios. Unfortunately, this is not a financially sustainable model outside of concierge medicine practices.
I have dealt with all of these scenarios (and more) and it is often challenging to balance the pressing needs of the patient before me and the needs of the patients waiting to see me. It is particularly hard to ask patients to make another appointment to address their needs when their doctor’s office is hard to get to (as is my urban practice) or their doctor’s schedule is full (as many of ours are).
My (imperfect) solution is to focus on the pressing needs of the patient with me. My waiting patients know that they may have to wait, but they know that when their turn arrives that they will be heard and their needs will be met. They accommodate by bringing a book or work to occupy their time. I also encourage patients to negotiate agendas with me ahead of time through PatientSite, but only the minority take the time to do that.
Great comment, Danny. As I’ve said, I’ve come to expect that you’ll be late, so I bring computer (because your practice has wifi) or reading. And I block out time – far more than the nominal appointment – in my calendar.
The challenge here is, whose responsibility is that broken commitment? I’ve learned to deal with it but I know first-hand that your desk staff doesn’t communicate “He’s often late – plan on it and don’t be surprised.” And the one time I called ahead about whether you were running late, they lied – I later learned you were already an hour late. Or they simply didn’t know, and assured me anyway. That’s just inconsiderate of them, and can be corrected without altering your practice, right?
That’s what I mean by customer service practices, as distinct from the medical service. Hm, would HCA be amenable to improving that? (Thinking out loud….)
Finally, I look forward to when doctors’ offices, like airlines, have “flight status updates” (online or even SMS) so we can manage our time accordingly. Clearly that technology exists. :–)
Waddaya think?? I know you don’t run the show there, but I’m a believer that all team members can speak up and suggest improvements. :–)
I agree. Those would be tremendous services, and I wish my practice could implement them. They would be difficult to manage, in practice, however, since at any given time I might be working on two different patients, both of whom finish simultaneously. So it may appear like I’m x minutes behind, but all of a sudden that estimate is incorrect.
Yeah, but we’re not talking precision – we’re talking “We’re running 45 minutes to an hour late.”
Okay, enough – one of us should suggest it to the practice manager.
And, btw, so this doesn’t seem like it’s “all about me,” I recall a visit a year or so back when an elder man and his son were waiting, scheduled for the slot after me. They were VERY upset that they were already well past the appointed time, and the son was anxious about getting back to work. And I hadn’t even been seen yet, before them.
I explained that I’d learned to plan on being late.
Again I don’t want to suggest de-prioritizing good medicine but I do bet the staff could communicate about it. And now that I think of it, your HCA colleague Jerome Groopman writes in How Doctors Think about a doc he knows who has simply decided to block out some of the hospital’s imposed time slots, because she knows she’ll always be late.
Again, just thinking out loud. Far be it from me to know what’s possible in your working environment, where you don’t set the policies…
Interesting conversation. I would like to point another viewpoint. Most people have to take PTO to go to the doctor during work hours. I do. Paid Time Off is for any time I use, not just medically. So, if I’m not sure how long I’ll be, I have to mark off half a day “just in case”. For those folks who have no PTO, and must lose money when off, it gets tremendously more burdensome. In this economy, that’s a large number of folks. I would speculate the majority.
In my own experience, because of my own illness, I’ve had to use a lot of time for these visits which I wished I could save for my surgeries and recuperation. I lost a lot of money because of the wasted time (my perspective).
I love the texting/SMS/airline analogy, Dave!!
Just to be clear, Robin, the texting/SMS thing ain’t just an analogy – it’s a clear vision I have, with certainty, about how things WILL work, in the predictable future.
Look at the super-modern “Book Online Now” thing Howard has, if you haven’t seen it already: http://www.howardluksmd.com/. Not the same, but a hint of how things are starting to shift.
As word gets around about good docs who also have great customer service, AND as we become more able to “change shops” with our portable medical records, a whole lot will change faster than it has before. (Not instantly, but still…)
I believe it, Dave. “Analogy” was the wrong word. I stand corrected. “Example” would have been better.
P.S. I’ve been booking online for years with my endocrinologist, and we speak via email and phone (have for years). He does this with all his patients. I guess he’s ahead of his time. I suspect he’d do text if I asked, but he hasn’t, yet. Now, my PCP is another story, but she’s working on it. She and I have had a lot of talks.
The video that started the CNN piece:
Excluding emergencies, reasons why doçtors are late
for scheduled appointments:
Not advising receptionist of real reason for appointment
(wrong time allotted)
Add-on complaints & “oh by the ways”
Add-on family members “mom brings sick siblings to one child’s visit”
Not having insurance card/appropriate ID/copay ready etc. . .
On cell phone
Socializing with staff
Personal phone calls
Drug rep conversations
Arrive late for work (poor time management)
Consulting with other doctors
Third party B.S. (prior auths, insurance hoop jumping etc. . ) **
EMR Issues/IT breakdown
** Since PHYSICIAN signed contract with abusive third party
and PATIENT pays monthly premiums then this
is a PHYSICIAN & PATIENT-CAUSED delay.
My Take: http://www.idealmedicalcare.org/blog/should-physicians-pay-patients-for-waiting/
Pamela Wible MD
I don’t overbook, I don’t socialize with staff, I don’t take personal phone calls unless one of my kids is literally on fire or they discovered the cure for cancer. I stopped seeing drug reps 7 years ago. I don’t overbook and try to keep a realistic schedule.
As a traditional internist I do rounds at the hospital in the morning and respond to medical emergencies during office hours. This means there is the rare occasion that I run late in the office. My patients know that when I’m with them, they are the most important person who is getting my undivided attention. If there’s a serious problem going on I would never tell them to schedule another appointment. I’m not flirting with nurses, checking my stocks online, sleeping in, or playing solitaire on my computer.
The other part of my time is spent in seeing patients, consulting other doctors, answering many patient phone calls (and emails) and paperwork, paperwork, paperwork.
A primary care office is not like a movie theater where the movie always starts on time, nor is it like a lawyer’s office that bills people by the minute just for a phone call. My office staff lets patients know if I’m running late and that I respect their time. If a patient ever sent me bill for lost time they would definitely get something in the mail in return – a dismissal letter.
Hi, Doc R – I don’t know you except by this comment, and I just want to say, I love the sound of your approach, I honor the work that I imagine goes into it, and THANKS.
Then Docs should be paid for patients wasting their time. I get calls on Christmas day asking about band-aids. If I was a lawyer I could charge for these calls. How about that?
ABP, speaking only for myself, I agree! Wasting resources is dumb and there ought to be responsibility.
I long for the day when we’ll have a truly functional market for health services, so both providers (clinicians) and customers (patients) can find models that work. Perhaps it would be a bundled flat-rate plan, with levels (Basic, Silver, Gold, Platinum); perhaps something else. The only thing that’s sure today is that for whatever reason, too often neither the professional nor the “customer” gets what they want.
I read Danny Sands’s note above with first-hand experience, being a patient of his myself.
Somehow we have to get to where we can all operate the way we want, and leave for somewhere else if we don’t like it. My impression is that right now both consumers and providers are inhibited from doing that by … the money people. Your thoughts?
p.s. Why on earth would a call like that reach you after hours? I’m guessing there aren’t tiers of service, e.g. nurses or aides for “tier 1 support,” as it’s called in high tech?