Physicians

Running Behind

Rob Lamberts

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 time frame.  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….

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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10 replies »

  1. Great read. The perfect balance of wanting to provide great patient care, respecting patient’s time and respecting your time as well. This is best described as art since it’s by no means a science. Science can be scripted and defined. Art can’t and that’s why it won’t ever fit nicely on a schedule.

  2. I have much less stress since I stopped looking at the clock so I have no idea how far behind I am. I usually see patients within 15-30 minutes of their scheduled appointment and like you take the time that they need, not how much is scheduled. I know it’s 5 PM when my receptionist leaves and by that time I usually have only 1 or 2 more patients waiting. I do schedule physicals for an hour because that’s how long they take no matter how much or little time you schedule them for.

  3. Dr. Connie, there is no fee for “maintenance and support” with DrChrono.com’s iPad EHR. One time simple implementation fee and then a success billing rate is all you pay. All support and maintenance is free plus we provide you with a free iPad for joining.

  4. Outcomes measurement_Walker sts: “The beauty of HIT and HIE and standardized, interoperable, automated medical data, standards, guidelines, Health 2.0, etc. is that we may be able soon to approach even better care and in more efficient time constraints…but the reality of that world is not here just yet. Keep being a great doc…”
    How does any one know any one is a good doc? Just because the hatted one writes well does not make him a good doc or a bad doc. How is clinical judgment measured? How is clinical decision making measured?
    I heard of a medical center in east central Pennsylvania that makes claims and is mentioned in President O’s speeches, but a trial lawyer informed me that the same hospital could not use its EMR to produce the complete medical record, accidentally or on purpose. It is big on EMR HIPAA violations, using it to punish any one it considers “disruptive”. One doc got it for looking at hsi own record without permission.

  5. Rob, Great post. I feel exactly the same way. Given the current state of healthcare delivery in the US, it is impossible to provide thorough and high-quality care while simultaneously being prompt. Thank God there are some docs willing to take the ‘heat’ for being ‘behind’ – and not sacrifice quality of care. I’m sure some would argue, ‘it is up to the patient to be prepared and efficient; if their care doesn’t fit into the 15 minute slot, have them follow up’ and ‘health maintenance items are public information, and not my responsibility to sell to patients’ etc. That just doesn’t work for my conscience – and I ‘sell’ primary and preventive care nearly every visit – even acute ones. Not to mention the discussions of cost of one test vs. another, or one medication vs. another, or the little issue they only get up the courage to ask at the last minute after vetting me to see I actually care and am worthy of their trust…sorry, if other patients can’t wait for that, I’m probably not the right doctor for them. The beauty of HIT and HIE and standardized, interoperable, automated medical data, standards, guidelines, Health 2.0, etc. is that we may be able soon to approach even better care and in more efficient time constraints…but the reality of that world is not here just yet. Keep being a great doc…

  6. The hat pic was taken from my Facebook page. I am “friends” with the editor and that is the one he chose. It was actually a gift from a patient from Ecuador (where they actually make Panama hats). I wrote a post on it about how patients can pick you up on a bad day.
    Complain to the editors about this “tedious” picture if you don’t like it. I didn’t tell them to use it.
    Sorry Connie. Obviously your EMR was poorly implemented, as our efficiency is much higher than it would ever be without. No matter how good the product is, a poor implementation will kill you. I think implementation is actually more important than the choice of the product itself.

  7. I have gotten behind ever since I foolishly purchased an EMR that is costing me 950$ per month for “maintenance and support”. When my butcher gets behind in his orders, his customers taste a new delicacy.

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