Saturday, March 11, 2006

Office Scheduling

Over on Mad About Medicine, Dr. Kirschenbaum responds to writer complaints about office scheduling:
The reality is that dependent upon the day I can schedule an office day with all intentions of being on time and the first patient comes to me with cancer in the pelvis and I have to discuss complete removal of half of the pelvis. This is not a 15 minute visit and can even be a 1 hour discussion.

The issue of waiting is symptomatic of what is wrong with the prevailing culture in medicine. Like most doctors, I was trained with the same attitude: the beginning and end of my obligation to the patient was to intend to be on time. Therefore, a patient should not be angry if I wasn't on time.

Intention, though, is not enough. No doctor doubt thats simply intending to cure a patient is acceptable. We recognize that it is our responsibility as physicians to be knowledgeable enough to apply the appropriate techniques, medications, etc. to actually treat and hopefully cure the patient.

Similarly, it is not enough to intend to be on time, if we are not knowledgeable about whether our intentions are realistic. If, in actual practice, a doctor is never on time, he or she is scheduling patient appointments inappropriately.

There is a tendency among doctors to believe that "the system" is the way it is because it has to be that way. However, scheduling is not some sort of willy-nilly process that cannot take into account the realities of a doctor's life. It is possible to look at a practice and figure out just how often each day or week a particular doctor has patients that require more time than originally scheduled and build that time into the appointment schedule.

Just by way of example: if examining a doctor's practice reveals that on average he sees a patient a day with an unanticipated complication that eats up an extra hour, then he can build an extra hour into the schedule when there are no appointments.

Yes, yes, yes, I am aware that this lowers income. However, if a doctor is finishing each and every day 1-2 hours behind, the reality is that he is overscheduling for his benefit and to the detriment of the patients.

The unfortunate fact is that most doctors don't know how long the average patient waits, and if you don't know, you can't fix it.


Blogger asdfasdf said...

Great blog, I like the angle you're taking on a lot of the issues arising in healthcare.

11:37 PM  
Blogger Shazam! said...

How can you be so angry at the state of our emergency rooms when they clearly cannot abide by the suggestions in this post? We cannot tell patients or ambulances to go away and come back later, or to call or make an appointment. We are required to see every patient that presents to evlauate for the possiblity of an "Emergency Medical Condition". As much as I'd like to be in control of the patient schedule in the ER, we have absolutely no control except by patient education for their next visit.

If 10 patients come in simultaneously, even if the waiting room is empty, all 10 need to be seen. If I am single coverage and spend 10 minutes talking/examing each patient, let alone reviewing lab work & x-rays, that's 2 hours of work not including the waiting times for 1) triage 2) nursing care 3) radiology films 4) lab running test results 5) Documentation 6) consultation with PCP, and finally, you're major point of contention...7) Reviewing this information with the patient and explaining everything to their satisfaction. It's clear that in this situation, which is not unusual at all, someone walking into an "empty" ER at 8AM may be waiting for several hours, even if their problem is percieved as being minor (and therefore the visit should be quick)

Picking on ERs is pretty easy...there are a lot of things that one could be angry about. But confusing bad medical care and inexperienced residents (7 hour wait for IV antibiotics) with the overwhelming problem of overcrowded ERs doesn't really shed much light on the problem.

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1:29 PM  
Anonymous the blogthat ate manhattan said...

I have found that no matter how I schedule my office hours, and how much time I allot (and it is much more than 7 minutes), the patient who has a serious problem requires more time than I have alloted, and the patients behind her on the schedule end up waiting. I have lots of tricks I use to finess this, though - I get their visit started, then while they are dressing, see another patient, then stop back while they are getting their blood drawn so they know I haven't forgotten them, then see them back in the office after I've seen another patient.

But do you know what makes my office hourse run the worst? PAtients who show up late. Most days it's only 1 or 2, but some days it's practically everyone!

10:49 AM  

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