The Doctor is…Overbooked

At the New York Times’ City Room Blog, Joel Cohen writes:

my wife and I are convinced that all medical students should have to pass Overbooking 101 before they can become doctors.Again and again, we arrive at a doctor’s aptly named waiting room on or before the scheduled time, only to learn that three or four others sitting there have been given the same appointment.

He says doctors need to understand the impact of this on their patients.  I agree, but not just because it’s annoying.

A typical doctor sees thirty patients a day.  Some see even more.

Reflect on that math.  If your doctor sees 30 patients a day, that’s 150 a week, 600 a month, maybe 7,000 a year.

It means that if it’s been even two months since you last saw your doctor, he has probably seen more than a thousand people since your last visit.  It’s why there’s often that moment of disconnect when you see your doctor.  You’re living every day with the fears and anxieties of your medical condition, but your doctor can’t quite place which one of the worried patients you are.  So you have to remind him why he ordered that extra test a few months ago, why you switched medications the last time you were there, how he already ruled out that possibility the last time he saw you.

We all work through these awkward moments- but they are a symptom of a more serious problem.

Doctors who are starved for time in a patient visit are also starved for time to think about their patients, reflect on what is wrong, and find good solutions.  It’s why studies show such alarming rates of incorrect diagnosis and treatment.

But what else can a doctor do?  There’s a room full of patients outside.  Just like there was yesterday, and just like there will be tomorrow.

Evan Falchuk is President and Chief Strategy Officer of Best Doctors, Inc. Prior to joining Best Doctors, Inc., in 1999, he was an attorney at the Washington, DC, office of Fried, Frank, Harris, Shriver and Jacobson, where he worked on SEC enforcement cases.

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17 replies »

  1. Dear Dr. Patsis:

    I currently serve as the Dental Director for an FQHC in East Los Angeles and I would really appreciate if you could contact me and share your approach to lower the no show rate to 9%.

    Thank you

  2. 48 patients in a day is a feat. From a patient perspective, finding out there’s three other patients booked for the same time is stressful. So is seeing your doctor looking like they haven’t slept in five days.

    Don’t get me wrong, I appreciate that doctors are working hard to provide their service despite, well everything. But I can’t help be reminded of the old adage “Never trust a skinny cook”.

  3. I agree with the lady that said you have to set expectations for your patients. If they are late, send them home. When you are running a business and are the sole proprietor you see potential dollar signs running out the door if you do that. But you can’t really operate on fear. If you don’t nip the problem off then you cannot expect the patients to respect what you are asking of them.

    We have a small number of patients that cancel or no show but because we have made the promise to give extra time for new patients, to build the relationship, and spend hours training the staff on how to schedule patients correctly we have a good turnout. If we have an open slot, yes, it is lost production. No one wants that, but that doesn’t mean we are going to let the guy who is 20 minutes late push back the rest of the day.

    I think that patients like to push the limits. They love treating a medical/dental/specialists office like an optional thing. But the truth of the matter is you, your staff, and anyone associated with your practice has to go above and beyond the call of duty, no matter what, to try and make a personal connection with people. If you are too busy maybe it’s time to hire on an associate or partner.

  4. We dentists (the orphan bastard children of medicine) have a saying, “Whatever physicians do (in regard to patient care and delivery) we’ll just do the opposite!” It amazes me that the physician’s offices and especially emergency rooms lack a fundamental understanding of process and flow.
    ….first and foremost I find that Attorney Evan Falchuk while good with simple math he may not be the best source for defining patient throughput (visits). President and Chief Strategy Officer of Best Doctors, Inc. may not serve us as the best process efficiency or effectiveness expert. We are looking for practice efficacy anyway, the right information, given to the right person, at the right time, and in the right amount. That is the driver to better health care, patient flow, and practice bottom-lines.
    The fundamental problem in all these discussions is that you all treat the patient visit as a monolithic block i.e. 10min. 15 min etc. It’s never about the block of time but our failure to understand the concept of value vs. non-value time….as contained by the formula of Process Cycle Efficiency (or value added time/total lead time). Dr. Craig “Quack” Vickstrom clearly has a better gasp of the concept of capacity and capacity utilization rate. 48 patients may be the upper control limit and 16 patients put you into the lower control limit (into the ‘red’) You need to understand takt time (available time vs patient demand) and lead time (the process time + wait time) for both many or few patients seen. Only thru value stream mapping and the removal of waste (defects, overtime, wait times, non-use of essential staff, inventory, motion, errors) will you find yourself able to deliver the expectations patients want and demand…..zero wait times. Then and only then ultimately one starts to see something miraculously happen. People get healthy….but if have a “waiting room” full of patients it’s a sign that your office (internal workflows and processes) are more afflicted and ill than your patients.
    I would know in 3 ½ years I took a Federally Qualified Health Center Dental practice from 3500 patient visits/yr to 13,500 patient visits/hr, decreased no-show patient visits from 33% to 9%, and expanded the practice from 6 to 19 chairs and we averaged about 110 patient visits per day….with improved quality and decreased costs. We must place standards, structure, and systems within our offices and the basic foundation founded on the principles of Lean Six Sigma Design.

  5. When enough people get tired of being sick and tired, perhaps we will have a paradigm shift to prevention rather than reacting to symptoms. that would greatly decrease the wait time and patient load. Yeah, I know that will impact the disease care systems bottom line (Le$$ ring of the Cha-ching!) but then the current care system may actually shift to a health care system. The patients must lead the way.

    Best regards
    Denise W
    Licensed Massage Therapist in NYC happily working with proactive and active people!!

  6. I agree Dr. Vickstrom, this is the same philosophy we have towards massage therapy. If the practitioner is focused on quality care and sets a clear expectation of that, the practitioner will attract those clients who will follow the expectations. We always tell our students that if their clients shows up 30 minutes late to a 60 minutes massage, then they will receive what is left of the massage and can re-book another appointment for a later date. It may agitate the client temporarily, but they’ll soon adjust to the expectation of being on time.

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  8. Although I cannot come from a physicians point of view, I can see that this is alarming for both the patient and MD. I guess my question is, why only 15 minutes per patient and is this really enough time to accuratley diagnose someone? I assume its an insurance thing, but then again I’m green in this area. I just do as most others do and blame insurance. I do not have a physician or see one due to many of the reasons stated above. It almost feels condesending when I do go into the office with a concern (which is rare). So, I wait until its just way too obvious that something is wrong and end up in the ER.

    It’s less embarrasing than ending up in a doctors office for 10 minutes, after waiting 30-45 minutes to get in, and having them tell you that you are fine.

  9. “See where it takes you and your patients.”

    45 minute visits when the patient booked for a sore throat.

    How does that help a doc stay on time?

  10. Overbooking will never go away when demand exceeds supply. Many surgeons contemplate the choice between listening to patients complain about wait times on the day of their visit and listening to patients complain about long wait times for an appointment and choose the former as the lesser of two evils. You can’t alienate your referral base.

    Physicians who are on call also must double people up at times. And the patterns are not predictable, no matter what doctors in other specialties say on the internet.

    But this: “….why there’s often that moment of disconnect when you see your doctor. You’re living every day with the fears and anxieties of your medical condition, but your doctor can’t quite place which one of the worried patients you are. So you have to remind him why he ordered that extra test a few months ago, why you switched medications the last time you were there, how he already ruled out that possibility the last time he saw you.”

    – is nothing other than poor documentation. He obviously is not putting his clinical thought process in his notes.

  11. @Greg

    I deal with the tardy/absent problem by being very on top of it, and discharging patients from my practice who are habitual offenders. I cannot charge late/absent fees in my profession. When patients come late, I see them for whatever time is remaining in their appointment. If it is not enough for their purposes, they can always schedule an appointment for the next day.

  12. Part of the reason for overbooking is the high number of patients not attending appointments, or coming late enough to push back other patients in a doctor’s schedule. Psychologists may charge for missed appointments in order to avoid having to fill that time with another patient. This negates the overbooking problem, and allows the doctor to be on time, largely eliminating waiting for most patients.

  13. Dr. Vickstrom,

    I believe that you can change one patient at a time. Yet I realize that most primary care doctors feels hopelessly “trapped” in the highly dysfunctional US health care system.

    Try asking my two simple questions-

    – How are things at work?
    – How are things at home?

    See where it takes you and your patients.


    Dr. Rick Lippin

  14. “They are medicalizing their psychosocial problems in their lives.”

    No, really? What a revelation. The thought had never occurred to me before. *sarcasm drips from his lips*

    Of course ppl medicalize their psychosocial problems. Our culture validates and encourages that. Do you really think we little primary care peons can counteract that in 10 or 15 easy minutes? To change this, we are going to need to change our culture at large, not just in the exam room.

    I apologize for being mean. But every primary care physician knows this (or should). The problem is doing something about it. My point is: this is way above and beyond our ability to affect. We are going to have to change as a society, as a culture, before we go there.

    Why don’t we start with supertentorial etiologies first? This would be optimal, but there is this little thing called “delay in diagnosis” you ought to be familiar with.

  15. A significant percentage of patients visiting mostly primary care physicians should not even be there. Thay are medicalizing their psychosocial problems in their lives.

    Note what Dr. George Lundberg says on MEDPAGE TODAY about my two simple mandatory questions that primary care docs should routinely ask their patients. That will reduce the patient load burden for primary care docs.

    See http://www.medpagetoday.com/Columns/25472


    Dr. Rick Lippin

  16. Overbooking really is not necessary. If you divide your appointments into 10 or 15 minute intervals, you can see anywhere between 32 and 48 patients per 8 hour day. Assuming you do all dictating, echarting and forms during that interval, each appointment is self-contained. Not a single double book is necessary. You run on time to the minute, and nobody has to wait at all. I have found that 48 patients per day is my upper limit, anyway. Other docs may have other opinions, tho.

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