By Sanaz Majd
FEBRUARY 9, 2015 – Waiting at the doctor’s office
has got to be one of the most frustrating things we all deal with.
You are imprisoned in a cold, mundane room, bored out of your mind, listening to the ticking of the clock, feeling like every minute is a minute wasted. I know how you feel, because I’ve been there. I once waited for 4 hours to see my perinatologist (yep, 4 hours!) when I was pregnant with my twins. It’s frustrating.
Yet, as we saw in my previous episode Why Is My Doctor Always Late?, Im often guilty of being late for my patients. If you haven’t had a chance to check out last week’s episode, I urge you to do so right away. In it I describe a typical day in the life of a primary care physician and highlight some of the underlying problems of the profession.
The episode drew a huge response and I thank those of you who posted your insightful thoughts about this problematic situation.
One of the most frequently asked questions was “Why can’t the doctors’ appointment slots just be longer?” That way the time pressure would be alleviated and no one would be late and in a hurry.
That’s what we’re going to look at today.
Why Can’t Appointment Slots Be Longer?
I’ve practiced medicine in several different settings, including public health, an HMO system, and a large non-profit medical group. Amazingly, the time issue is the same everywhere.
There are 5 main reasons why appointment slots cannot be longer at your primary care doctor’s office:
Reason 1: Most primary care physicians are employees
This means they don’t have the ability to make organizational decisions about the practice. They receive a mandate to see a patient every 15-20 minutes and they must stick to that.
How is this tiny timeframe decided? I’m getting to that.
Reason 2: Healthcare is a business
Even if your PCP does have decision-making opportunities (as in those in private practice), the fact is that healthcare is a business in the United States. That means medical groups and private practices need to make a profit in order to survive. Medicare and health insurance companies do not reimburse primary care services well, so in order to make a profit, physicians are required to see more patients and more quickly, whether they like it or not.
Let me be clear: This is not about greed (despite what some of you have suggested). It’s about survival. It’s sink or swim for primary care clinics.
Have you noticed that many smaller, private doctors’ offices are closing their doors? This is why. They cannot financially make it work. The overhead cost to run a primary care clinic is immense. It’s much more than just the doctors’ and nurses’ salaries. As many of you mentioned in your comments to last week’s episode, it’s also rent or mortgage, gas, electricity, the photocopier, the ultrasound machine, various test paraphernalia, vaccines, syringes, exam beds, EKG machine, and EKG paper. Not to mention the costly malpractice insurance for both the office and the provider, the licensing fees, IT support, the cleaning crew, benefits for the staff, fees for biohazardous waste disposal, fees for the electronic charting system, building maintenance…I could go on and on.
This sink or swim phenomenon is another reason why medical students are choosing specialties, rather than primary care. They realize that not only would they be spending the next few decades having to work under stressful time constraints, but they would be doing so while simultaneously sinking in school loan debt.
Medical school tuition is on average between $30,000 and $40,000 per year (and that doesn’t even take living costs into consideration). Multiply that by 4 years, then add the school debt from 4 years of college prior, and the minimum of 3 years of residency where you make only enough to slide by while the loan interest accrues. That’s a minimum of 11 years of school loan debt that reaches anywhere between $150,000 and $200,000.
Who could blame medical students for passing on primary care? It’s exactly why we’re experiencing a primary care doctor shortage in this country.
Some primary care doctors are leaving their jobs in pursuit of something you may have heard of called “concierge medicine.” In this kind of practice, the doctor doesn’t accept health insurance of any kind and cares for fewer patients. Each patient pays a flat monthly fee (determined by the doctor or clinic) in exchange for unlimited access to their doctor.
In this type of practice, you may have to pay out of pocket for any tests, imaging, or medications (which may be quite costly), but you will have a much longer appointment slot, shorter wait times, and unprecedented access to your doctor (even via phone and text).
I think it’s a brilliant idea – it works for some patients and some doctors really well. But it’s not for everyone. Some patients simply cannot afford this and some areas of the country don’t yet have these types of clinics. But it is an alternative.
Reason 3: Access of care
How fast do you want to see your doctor? Do you want to be able to see them the same day if you all of a sudden feel sick, or are you OK with waiting 6 weeks?
The average primary care doctor manages between 1,500 and 2,300 patients, depending on the practice. So the access to your doctor is often one reason appointment slots must be shorter. The more patients a doctor is responsible for, the fewer time he or she can spend with each individual patient.
This is why doctor tardiness is not improved in an HMO system in the U.S. because appointment durations must still be 20 minutes long in order to allow for this “access.
If we increase interest in primary care amongst medical students, and there an increase in U.S. primary care residency programs to match that interest, it may be a different story one day.
Reason 4: Scheduler limitations
For those rare, lucky doctors who have the opportunity to vary the time templates for their patients, it may still not be enough. Why? Because the person scheduling the appointment on the phone often does not have medical training. This means he or she will likely not be able to accurately gauge the complexity of the reasons for the patient’s visit and thus, not allocate the appropriate amount of time for the appointment.
I gave an example of just such a case in my previous episode, Why Is My Doctor Always Late? Check out Ms. Sadness, one of the last patients of the morning.
Reason #5: Unpredictability
Medicine, like people, isn’t always predictable. Sometimes a patient may be scheduled for a simple pap smear, but you discover that their blood pressure is incidentally 186/95 on the day of their appointment.
Or a patient comes in with flu symptoms, but their last blood test for diabetes was over a year ago (and off the charts uncontrolled). Or just as the doctor is completing the visit, the patient says, “By the way, I’ve been feeling chest pain for the past few weeks. Why do you think this is, doc?”
What can you do as a physician? Ignore the elevated blood pressure, blood sugars, and chest pain just because the patient came in for something entirely different? No, that would be unethical.
So now you see how complex and interconnected this issue is. The fact is that doctors don’t like running late just as much as the patients don’t like waiting, but there are numerous forces acting beyond our control…or are they?
Tune in next week when I provide suggestions for what both doctors and patients can do to improve the situation.
Incidentally, I want to say that even given everything I know about the primary care profession, I would still choose it if I had to do it all over again. There’s absolutely nothing like building a relationship with my patients and helping them to live a healthier life.