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    Wednesday, July 25, 2007

    Waiting for Dr. Godot: Why do so many people have to wait to see a doctor? Here's a good explanation, from the comments of that last link:

    Here are a laundry list of reasons that we have such a long wait time:

    -- Increasing the number of doctors is not likely to really help the problem if you consider costs as an issue, though you could calculate exactly how many more doctors are needed so that no one should ever wait. If you assume that supply/demand pricing rules are suspended, this would increase the average cost per customer/patient dramatically. In reality, this would just reduce the income of each doctor, which is not the incentive needed to attract more people to the profession.

    -- Most importantly, patients arrive randomly but likely with high clustering. A doctor's office waiting room during flu season is probably much busier and the lines are likely much longer. The same can be said for other causes of doctor's visits: weather, major events (the start of school), etc. If patients got sick in regular and predictable ways, there would be MUCH lower waiting times. So, the odds that you are at the doctor are probably highly correlated with others, so get ready to wait. This is also why doctors have plenty of free time (once established)... they work their tails off half the time and can putt around at the golf course the other half (more like 90/10).

    -- There is no threshold for acceptance into the queue or for processing. Since it often takes just as long to diagnose someone as sick as it does to diagnose them as healthy, there's no cutting corners. This increases the variability of the average treatment time, as some patients are clearly just down with a cold while others may have serious cancer. Increased variability of treatment time greatly increases the average wait time. Plus, doctors book in 15-minute increments of time. No one takes exactly 15 minutes to treat. If the treatment takes 30 minutes, the waiting time increases. If the treatment takes 5 minutes, a good doctor will draw it out to 15 minutes (you do want a good bedside manner, right?).

    -- Like airlines, many doctors overbook their appointments to cover no-shows. Unlike airlines, doctors don't have sophisticated operations departments and years of data to tell them when this is a good idea and when it isn't. Additionally, no-show frequency is likely not-so-random. Someone is probably more likely to skip an appointment the day before Thanksgiving, for example. Since there is no easily implementable system, over-booking will cause longer wait times in the simple "better safe than sorry" method that most medical offices likely use.

    -- A single queue is always better than each server (doctor) having its own queue, but that's not the system we have in place in most scenarios. If no one was allowed to have their own doctor, the system would be a lot more efficient on the surface. This increases, perhaps greatly, the average wait time. (If I was told that my doctor would see me in 3 days or I could see some random doctor today, I'm not sure what I'd do. This model only works in emergency situations, and even then not so well.)

    -- Doctors are usually unable to divide their time between patients to prioritize. You may be there with a sore throat that takes two minutes to diagnose and treat, but the person requiring 30 minutes of time (which may not have been expected... high variability, remember) is forcing you to wait. If the doctor could take a look at the queue, make a snap judgement and handle the low-hanging fruit, the line would be much shorter. However, that means that that 30 minute treatment just turned into a day-long endeavor as the serious treatment is preempted by minor problems.

    -- Convenient appointment times are very similar amongst people. Want a 5pm appointment at the dentist? Book it now months in advance. Doctors don't want to work early or late. In today's dual-income households, there's less flexibility for appointments. I know doctors that begin their day at 6:30 or 7am to see patients, but they're done by 3pm (or start late and end late), but these are still rare. A lot of inefficiency is just due to the fact that you cannot make their next open appointment and the doctor doesn't want to be at the office all day and night.

    And Jane Galt's theory is also correct:

    My theory: general practice physicians have four categories of patients.

    1) New patients needing a routine physical.
    2) Old patients needing a routine physical.
    3) Old patients who need to be seen relatively urgently ("I'm having dizzy spells")
    4) Old patients who need to be seen right away ("I have a 103 degree fever and I'm coughing blood)

    They manage their schedules so as to give the least priority to group number one. Specialists, on the other hand, have three groups of people:

    1) People needing a diagnosis
    2) People needing treatment
    3) People who might be undergoing an acute crisis

    Number three gets priority, but is fairly rare; numbers one and two are roughly on par with each other, and depending on the specialty, 1 might even have the edge.

    All of the above are true. It is a problem with multiple etiologies. I would add one more - if the receptionist wants to get home by 5PM every night and has no incentive to add patients to the schedule, the wait for an appointment will be longer.(Productivity bonuses help eliminate that obstacle.)

    Some physicians are trying to fix the wait problem by using something called open access scheduling. Here at Medpundit, LLC, we usually see people with an acute problem the same day they call, or at least 24 hours within calling, depending on the problem and the schedule/staffing that day. When I refer patients to specialists, the wait is longest for endocrinologists (up to six months) and dermatologists (six weeks.) Most other specialists take 2-4 weeks for routine problems. However, if someone needs to be seen sooner (for medical reasons, not personal reasons), they usually get in within a day or two.

    posted by Sydney on 7/25/2007 12:05:00 PM 1 comments


    In our 3 person FP ,we have been using open access for 2 years.We have rarely not been able to see any patient who called that day. This is true for routine and preop PE'S ,well child care,and acute illnesses. Only rarely are we not done by 5:30 PM.This includes having almost all charts completed.
    It is a complex system to initiate,and sounds counterintuitive: but it is working incredibly well.Patient ,doctor,and front office staff satisfaction is very high.
    Another benefit is an incredibily low no show rate.

    Wm Barrett MD

    By Anonymous Anonymous, at 4:34 PM  

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