Running Behind

I walk into the exam room and the patient looks up at me with a surprised expression.  \”Wow!  I didn\’t expect to see you so quickly!\”

I smile and turn around to walk out of the door, saying: \”Sorry!  I\’ll leave then and come back later.\”

\”No, no!\”  They respond, smiling.  \”I\’m happy to see you so soon.  It\’s just a surprise.\”

I walk back into the room with a smirk.  \”I just don\’t want to offend you by being on time.  I\’ll try to do better next time.\”

I am not sure if I should be happy or sad with such an interchange.  On one hand, it feels good to stay on time with my appointments, holding up my end of the bargain of the schedule.  On the other hand, the patient\’s surprise betrays the fact that this is not the usual state of affairs.  And it isn\’t.  I generally don\’t run on time and don\’t expect to run on time.

When I first started practice, the stated objective was to get the person out of the office within an hour of their scheduled appointment.  This seemed a blend of realism and responsibility.  At first it was easy to stay up on things.  My schedule was sparsely filled, so I could make up time.  After sixteen years of practice, however, my schedule almost never has open slots; when it does have openings, they are quickly filled.  I still try to get them out within an hour.

I have patients scheduled, with a few notable exceptions, every fifteen minutes regardless of the appointment reason.  I don\’t expect to spend exactly fifteen minutes with people; some will be quick visits lasting 5 minutes and some will take 30.  Usually this averages out to keep me within 30 minutes of the scheduled appointment – something I\’ve grown accustomed to.  Some days, however, conspire against my best attempts to stay within a reasonable timeframe.  Everyone is complicated or needy on those days, and I can get 60 minutes or more behind.  I absolutely hate it when that happens.

But as guilty as I feel admitting this fact, I don\’t think I will ever change things.  Some docs are obsessed with not falling behind.  I can respect that, but for me it is far more important to give every patient the time that they need.  If I have to spend 45 minutes talking to someone, I do.  My patients have learned this: they will always get my full attention and won\’t be rushed.  I do respect the fact that others have their own schedules, but the purpose of the visit is to handle their medical problems.  I don\’t want to hurry through a visit so I can stay on time, missing important things that take some focus or detailed questioning.

This is very hard when I am running behind.  It\’s hard not to feel rushed when you are already apologetic about being behind, but that is when I am most vulnerable to missing things, and I don\’t think people should be short-changed because folks earlier on the schedule took longer.  It all ends up making it hit-or-miss when people come to see me.  Sometimes I am right on time, and sometimes – especially at the end of the afternoon – I am significantly behind.

My long-term patients understand this.  They know they always get as much time as they need, even if it puts me more behind.  They understand that I get behind because of the time I spend.  They know I will chat with them and won\’t get rushed.

New patients are usually surprised they get as much time as they do.  This makes me wonder what other docs do, as I am just trying to do what needs to be done.  I suspect it is because I value the personal interaction and rapport as much as I do the medical knowledge.  I am building relationships, so I will always chat, find out what\’s going on in people\’s lives, and learn about them personally.  Primary care is for the long-haul, and it helps to know as much as possible.

I do write blog posts between patients (like this one), because much of my best stuff comes out of the raw emotion of the office setting.  I try to do it in small chunks, mostly when I\’m waiting for people to be brought to the back, or when I\’m waiting on some test results.

The bottom line?  I won\’t sacrifice being thorough for being on time, and I think one of the biggest parts of being thorough is to talk – even if that talk is about their grandchildren, vacation plans, or job situation.

Gotta go.  Got a patient waiting….

24 thoughts on “Running Behind”

  1. I have seen providers (doctors and PAs) where I felt like speed was more important than answering any of my health questions. I guess it works, since when they were my most reasonable option (e.g., when our family had Tricare) I put up with it, but it wasn’t good for maintaining or improving my overall health.
    I chose my last family doctor based on good reviews about spending time with and listening to patients. She lived up to that and I wish we could have taken her with us when we moved to another state.

  2. I plan on 2 hours from my appt time with any given doctor. (then they ask me to come 15 min early to sign in, I’m chronically EARLY and wind up there 20 minutes before the time given ..which means I’m there more than 30 minutes before my appt, at least)With *most* of my docs, this works well .. with my neuro I’m in and out before my appt time. With pulmo usually I’m leaving 20 min after appt time. With orthopod …well, he’s the exception. PCP can be anywhere from leaving when expected (for 30 min appt slot that usually lasts about 10 minutes) to late, with the occassional in and out.

    I’m rarely annoyed with doctor’s waiting times.

    My husband plans on getting there when his appt is scheduled (IE .. parking in the parking lot AT 11 for an 11 AM appt, is acceptable *rolls eyes*) and expects to be taken back immediatly. He is scheduled for 30 min appts and expects to be leaving by 11:30 (as in, in the car pulling out at 11:30)

    And he gets antsy and anxious and upset at the wait.

    Honestly, I think it’s about time management for the patient as much for the doctor. Appropriate planning on other events that day (don’t schedule a noon lunch when you have an 11:15 doctors appt!)
    Knowing what to expect can change expectations and THAT .. can change everything.

    I learned all this through trial and error, and a new patient letter I got from a doctor who gave the expectations he had, and ones he hoped to meet with his patients. Which including allowing the appropriate slot of time for appts.

    That being said, if a doctor asks me to come in, it doesn’t fit into my schedule, so they talk me into coming in an hour before my class starts and I TELL them my class starts at 1o, if I come in at 9, I’m walking out at 9:40 to go to my class. It’s never failed to get me in and out … they know my expecations in that case. (they’re also very supportive of my schooling ..that helps)

  3. I often wish I could be given a realistic ETA, at the offices I’ve waited at, but I can why the office staff don’t want to volunteer that the doctor’s an hour late. It’s far less awkward to knit for an hour in a waiting room, knowing you’ve fed your parking meter sufficiently, than it is to pull the knitting back out once you’re in the exam room in your underwear.
    We’ve been to two different pediatricians who were in the habit of having you wait with a naked baby in an exam room for upwards of half an hour, which is miserable (and these were well baby checkups), and the same office then can’t find an exam room when you’re just in for a booster vaccination, and only need 30s of the nurse’s time.

  4. Have you ever thought about using a Kanban board to visually illustrate for your patients where you are in terms of getting to their appointment? Making work visible is remarkably powerful and allows you to communicate with patients. They are generally quite simple – my personal Kanban at work is just a white board with three columns (my backlog, in progress, and completed) and sticky notes tracking discreet pieces of work (“appointments” in your case). You could assign each patient a number if you didn’t want to use their names (or better yet – Llama 1, Llama 2, – hell, let them pick a super-hero name!). If you really wanted to go out all out, you could put up all the other pieces of work you have to complete during the day and put those up there too so your patients could visibly see why you might get behind, etc. Just a thought.

  5. I understand the predicament PCPs are in. For a good doctor, I’ve waited over 2 hours for my appointment, when he was having a bad day. I won’t always take it lying down, though…
    I changed PCPs in the spring, after 6 years with the same doc. I had intakes with three new doctors: the first came slamming into the room and told me to restrict my answers to “Yes” and “No”, as he only had 15 minutes to do the intake. Even though I cooperated, he treated me as if I was the problem, like I was there just to be a giant time sink for him.

    The second doc, on our second appointment together, left me waiting in the exam room for 1-1/2 hours, and when I went to the nurses’ desk to inquire, I was told she had left the building for a meeting.

    On to doc #3, who also asked me to answer “Yes” or “No” to her questions because she only had 20 minutes to do the intake. In her case, though, she was very respectful, and clearly acknowledged it was the system’s fault, not mine. She got a good picture of my complicated case despite the short answers I gave. Needless to say, I went with doc #3.

  6. I know the best doctors in my city. Invariably, they have very long wait times. Is this a coincidence? I think not.
    Like you, I run hopelessly behind schedule.

    Iphones, Twitter and FB have made these long waits more tolerable…Wait that could be a blog topic.

  7. If I may be so bold to condense this excellent post into three words: Effectiveness over Efficiency. While it’s good to stay on schedule, it’s so much better to provide excellent medical care. Good job.

  8. I don’t mind waiting for the doctor, as there have been a few times that I’ve been the patient causing the schedule to go awry. I prefer being left in the waiting room “comfy” chairs over being left in the exam room simply because it’s easier to entertain myself when there are other people to talk with, or watch. I always bring a book.
    What I REALLY hate are waiting rooms that are too small for the practice and those that have TVs.

  9. Having moved from city to city during my career and having several specialists during my geriactricness, I truly appreciate the doctor who is willing to LISTEN and answer questions. I try to respect this willingness by keeping the visit short and to the point. The one doctor (from thirty years ago) who is still on my “Doctors From Hell” list is the PCP who, when asked to look at a growth on my shoulder said, “Yeah, that’s cancer. Go make an appointment with the nurse. I don’t have time this!”

  10. The only thing that bothers me is when people answer them when I am in the room with them. I am surprised they would put that sign out, it is inaccurate. They probably have another reason (not bothering others, etc) but still, putting up a false sign in the waiting room is not a good thing.

  11. I went to a neurologist for awhile and while waiting for him to come into the room I could hear him on the phone making plans for lunch at noon. He came in and saw me for eight minutes and left. I guess his lunch was more important. I was important too and I didn’t go back to him again.

  12. My Doctor doesn’t make appointments at all its first come first served.I find when I need to see him because I haven’T got an appointment I tend to sit with more serenity and acceptance that might just have to wait a little longer if there the waiting room is already full.Normally the waiting time is about an hour,it can sometime be longer if an emergency calls through and they then get priority.I live in a small town so that makes this method makable,but I think if Patients KNOW roughly how long they will have to wait then its less of a problem.At other Doctors the receptionist will often suggest I go and do my shopping or get a coffee etc, and come back in an hour,so that I don’t end up wanting to climb the walls.Most Doctors these days have coffee machines and refreshments to distract for a while too.There are some Doctors that obviously take on TOO many appointments,but mostly with my GP I have found that they have been genuine and have always taken the time to try and listen and help.

  13. “Iphones, Twitter and FB have made these long waits more tolerable…Wait that could be a blog topic. ”
    You mean all the signs in the waiting and exam rooms saying to turn off your cellphones because they interfere with the medical equipment are BS? I’m shocked!!!!

    I know it is a slippery slope. Where do you draw the line? It seems like use in the waiting room should be okay, but not the exam room (so you are ready when the dr. comes in), but sometimes my exam room wait time is longer.

    It doesn’t bother me to not use my cellphone if there are signs asking you not to; however, as a mom with a traveling spouse, I am very uncomfortable when they ask that devices be turned completely off. I know the dr. has his phone and pda and whatever else powered on.

    My teenager had to explain the sound coming from an ortho’s pocket after we left. “That was his phone. It says, ‘droid’, isn’t that cool?” Actually, it was disturbing until I found out what it was.

  14. Wendy S. Harpham, M.D.

    My staff and I did everything we could to keep me on schedule without compromising the quality of patient care in my solo practice of internal medicine. All my patients knew that if I was behind it was because, like Dr. Rob, I was caring for someone who needed the time, time they’d get if it were them.
    1) My staff kept waiting patients in the loop, giving them updated assessments of how long it would be so they could choose what they wanted to do. If we saw that we were getting behind, we’d call patients who had not yet left home or work for their appointment, so they could come later and spend as little time waiting as possible.

    2) Sometimes I could have my staff begin some instruction before the visit that I knew I’d request for after the visit.

    3) My office had robes in each exam room for patients, so they wouldn’ t freeze. And we kept a nice variety of up-to-date magazines as well as 3-ring notebooks filled with comics in the reception area and exam rooms.

    These measures didn’t speed things up, but they made whatever wait was necessary easier.

  15. My current GP recently switched practices. The practice he’d been with for years recently changed ownership, and their new mantra seemed to be “five minutes per patient, to maximize profits”. My GP ended up taking out a personal loan to buy himself out of that practice. He said “I didn’t go into medicine to make money, I went into medicine to take care of people who need me. Five minutes per patient isn’t gonna do it.”

  16. “They probably have another reason (not bothering others, etc) but still, putting up a false sign in the waiting room is not a good thing. ”
    False signs definitely set the stage for non-compliance. You would think they wouldn’t want to get that ball rolling the minute you walk in the door.

    Other people talking on phones sometimes bothers me (although I am an avid eaves-dropper), but my irritation quadruples when people talk on phones while blatantly ignoring all the blatant signs blatantly posted about blantantly asking you not to talk on the phone. Enforce your signs or take them down.

    I cannot believe patients answer their phones while you are with them. I’m sorry. I’ve had to once or twice, but have always asked permission – ‘it’smyhusbandcanItell himtopickupmyotherdaughterplease????’ – and it never happens during the course of a ‘normal’ visit, and we do not chat – “we’re still here, you need to get her”. I think our providers have understood it was necessary in each instance and not disrespectful of their time.

    I’d love to see a blog of things patients have talked about in front of you when they answer a call in the exam room! Surely they could let it go to voice mail if all they had to say was, ‘I’m at the dr., I’ll call you back”.

  17. I envy your patients! I’ve been with the same primary-care doctor since I finished college, about 20 years ago. I feel that I’m just another cog to him. He interrupts mid-sentence, obviously trying to hurry things along. Being in good health I just go for a physical every 2nd or 3rd year, and the occasional sore throat or something (maybe every 5th year). I don’t really feel any sense of “medicine”, just a working relationship; he can prescribe and refer, he has training, and I don’t. But he might as well be doing it via Skype with a video connection for all it matters.

  18. I like Jean’s response, as we must’ve had the same neurologist. During several appointments while I sat in a patient waiting room, I overheard mine on the phone down the hall making date plans with his girlfriend, scheduling a car service appointment, and having flirty chats with his receptionist. No wonder that, when he finally walked into the room to see me, I wasn’t too pleased to see him.

  19. I think you handle it well. I’d rather have a doctor pay full attention to me for the necessary time and have to wait a little longer for it, than to be rushed through my appointment that starts right on time.

  20. It’s laudable not to rush through our patients’ appointments, and to give all the time they deserve and need. I think, however, that many of us have not properly valued the waiting patients’ time. They’ve got lives and stuff to do. I have heard it suggested that patients should be reimbursed for waiting time in our offices. Interesting concept that would go far in improving our on-time performance. Now, if the airline industry would do the same.

  21. Our pediatric group is huge and they are very close to on time and are willing to spend whatever time is needed. We usually get an appointment within a couple of hours of when we call for sick visits and we are in and out in an hour or so. The trade off is that you don’t really know which dr you will see, but for most kid stuff it doesn’t really matter. We can ask for a specific dr that is in that day (they rotate through multiple offices) and depending on which office you choose, “your” dr may always be there. On time is huge for me since I am usually picking up the other kids and so forth. Our orthopedist is always late. REALLY LATE. We have been told she is an hour or more behind when the office hasn’t even been open more than an hour. But she is a wonderful both as a person and a dr, so we keep waiting. Not happily exactly, but she is worth it in the long run.

  22. Melissa,
    “I chose my last family doctor based on good reviews about spending time with and listening to patients.”

    AMEN!! For me personally, that is the number one and two criteria that I look for in choosing a doctor or any other health care provider. They can have all the competence they want, but if lacking in these two criteria, what good is their competence. I want a doc like our Rob here, who will build a real relationship with me and my family. . .like in the good ol’ days when they had time. Also, to put in my two cents worth re health care reform — doctors should be paid for their TIME not just procedures. Once that becomes the norm in these United States, we won’t have all these 5 minute visits, so unsatisfying to both doctor and patient.

  23. Well, I appreciate the time a doctor spends with me, not rushing me, and actually listening to what I have to say as well as drawing info out of me with relevant questioning. The majority of my doctors have reasonable wait times and I have no complaints at all about them. I do have a wonderful rheumatologist whose office visits take up literally, ALL my afternoon when I have an appt. with him. While it’s very difficult to wait in the waiting area 2- 3 hours (!), then have to wait another hour back in the exam room, I have found that taking a nap on the exam table works for me! LOL This is his usual wait time and he has many patients – the waiting are is always full – and most patients, esp. like myself who’ve been with him for a few years now, just see it as the price they pay for a doctor who truly listens to his patients and does his very best by each one.

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