One of my biggest pet peeves in life is tardiness. I hate it when other people are late. It’s as if they are not respecting my time. But you know what? I hate being late myself even more. In fact, I cringe at the thought. Conscientious, successful people are on time.
So you can imagine that nothing irks me more than being late myself. But I am late — 10 minutes, 30 minutes, sometimes even an hour. And what’s worse? It happens on a daily basis. Yes, I’m late almost every single day as a primary care doctor.
This makes me feel overwhelmed and frustrated. It’s the one aspect of my profession I truly wish I could fix.
But I’ve had to accept this unacceptable situation as the reality of working in primary care in the United States. It’s a complex problem that is out of my control, and it’s a hard pill to swallow. However, that doesn’t mean I can’t try to offer a solution. And this podcast episode is my attempt to do just that.
This week I’m going to give you a snapshot of what a common morning in the life of a typical primary care doctor looks like — warts and all. Next week I will propose a new process to help minimize this issue as much as possible.
A day in the life of Dr. Tardy
Dr. Tardy is a great doctor. She cares about her patients, she tries to do the right thing for them, tries to take the time to listen without making them feel rushed. She doesn’t like to take any shortcuts when it comes to patient care. That means that she tends to run late.
Here’s a typical schedule in the life of Dr. Tardy, a primary care physician who works in a large group outpatient setting. It consists of 11 patients, scheduled in 20-minute time slots:
- 8:30 Mr. Never-Goes-to-the-Doctor
- 8:50 Ms. UTI
- 9:10 Ms. New-Stroke
- 9:30 Ms. High-Copay
- 9:50 Little-Junior-1
- 10:10 Little-Junior-2
- 10:30 Ms. Diabetes
- 10:50 Mr. Needs-a-Navigation-System
- 11:10 Ms. Sadness
- 11:30 Mr. Follow-Up-Blood Pressures
- 11:50 Mr. Acid Reflux
First patient: Mr. Never-Goes-to-the-Doctor
The first patient on the schedule is brand new to the practice. Forgetting that he needs to arrive at least 15 minutes prior to his appointment to complete paperwork and processing, he arrives at 8:30 a.m. He doesn’t come to the doctor’s office very often, and he scheduled this appointment over six weeks ago – do we blame him for forgetting this small detail?
Thankfully, the swift-working front desk staff do their magic to rush his processing…but it’s now 8:40.
The medical assistant calls his name and takes him to measure his vital signs, and places him in the exam room. By now it’s 8:45.
Most doctors are now using electronic medical records and a progress note for the patient visit cannot be opened until the patient is actually processed and roomed. Once that happens, Dr. Tardy comes in to see the patient. It’s now 8:50.
She’s already running 20 minutes behind schedule, and it’s only the first patient of the day. Not good.
Back to the doctor’s desk
Thankfully, the patient is pretty healthy, so the visit takes only 15 minutes to complete.
Dr. Tardy heads back to her desk to start the same process for the next patient. Her flow is interrupted, however, as one of the nurses seeks her out to show her an abnormal electrocardiogram (EKG) she performed in the nurse clinic. The doctor has never met this patient, who belongs to the patient panel of another doctor who is out on vacation. Dr. Tardy needs to search the patient in the electronic medical records, study the medical history, and compare the current EKG with her previous one in order to determine the next step of action.
This is an urgent issue; she cannot simply ignore this EKG. The process takes her at least 5 minutes. She is now running 25 minutes behind.
Next patient: Ms. UTI
Thankfully, the next patient is also healthy. She has some urinary symptoms, and it’s pretty straightforward. Dr. Tardy orders the appropriate tests and provides her the proper treatment. This one took only 10 minutes to treat and 5 minutes to document. Woo hoo! We now can subtract 5 minutes and are only 20 minutes behind.
Next patient: Ms. Stroke
The next patient is a hospital follow-up. An 87-year-old woman who suffered a stroke since Dr. Tardy last saw her. She is now unable to speak clearly and requires a family member’s presence to help facilitate the visit. The doctor also needs to request the records to be transferred over from the hospitalization in order to get the medical details.
Thankfully, the wonderful medical assistant did that prior to her visit … phew!
How long will it take to peruse the packet of hospital notes from her 10-day stay? After reading the novel-length paperwork, here’s what Dr. Tardy determines will need to be accomplished during this visit:
- The patient requires referrals for multiple specialists: physical therapy, speech therapy, neurology. Each one of these referrals takes time to submit.
- The family is frustrated because they cannot care for her at home and multiple psychosocial aspects of a stroke need to be addressed. The patient is depressed, and the family is understandably shaken up. They look to Dr. Tardy to ease the pain and provide support and guidance, not to mention help in coordinating her living placement. Dr. Tardy listens to her patients.
- The patient is also diabetic, and her blood sugar levels are out of control. Dr. Tardy needs to address that urgently. After all, diabetes is a contributing factor to the stroke in the first place.
All of this needs to happen in a 20-minute patient slot. Not possible. Dr. Tardy tries really hard, and this visit miraculously takes only 30 minutes to complete and another 5 minutes to document. Now the doctor is 35 minutes behind.
Back at the doctor’s desk
Dr. Tardy gets interrupted again in between patients because of a critical lab value on one of her patients. The patient must go to the ER, and Dr. Tardy needs to call her to explain to her exactly why it’s imperative that she be seen ASAP. The patient doesn’t want to go because of a high hospital copay. Dr. Tardy must convince her to go anyway. This takes another 5 minutes to achieve, and Dr. Tardy is now 40 minutes behind.
Next patient: Ms. High-Copay
The next patient is a 45-year-old who complains that she needs all 4 of her medical issues addressed today because she has a $60 copay and it’s a financial hardship for her to come for more frequent visits. She wants to discuss:
- her high blood pressure
- her low back pain
- her depression symptoms
- and she wants her pap smear done
Dr. Tardy explains that unfortunately time does not allow her to handle all these things in one visit. She suggests that they can complete the pap smear at a future visit since there are no copays for preventative screenings due to Obamacare.
Ms. High-Copay is not thrilled to have to return, but reluctantly agrees. Dr. Tardy cannot help but feel slightly uncomfortable with the reaction she receives. After all, Dr.Tardy is human and she cares about her patients. This visit still takes Dr. Tardy 30 minutes to complete and by now she’s 50 minutes behind.
Next two patients: Little-Juniors-1 and 2
Mom brings in her two kids – they have been struck with the same bug and are coughing and sniffling every which way. Dr. Tardy does save some time, however, because she can address both kids’ conditions to one parent.
Great! She saves 15 minutes here, placing her at 35 minutes late. How lucky.
Next patient: Ms. Diabetes
Dr. Tardy’s next patient is a 58-year-old woman with diabetes. She comes to Dr. Tardy for her 3-month follow up and to discuss how she can quit smoking because she knows that it, along with diabetes, is a risk factor for heart disease.
Dr. Tardy wants to make certain that the patient has all the resources and tips she needs to succeed, so she takes her time addressing this issue, along with discussing the management of diabetes – both conditions are time-consuming and vital. After all, she doesn’t want Ms. Diabetes to end up with a stroke like her previous patient.
At the end of the 20-minutes, just as Dr. Tardy is about to close the visit, Ms. Diabetes discloses something that cannot be ignored.
“Wait, Doctor, there is one more thing…” She admits that she’s been experiencing chest pain for the last three weeks, and this is the reason she finally decided to quit smoking.
Dr. Tardy needs to evaluate this chest pain very thoroughly and cannot tell Ms. Diabetes that she needs to return to discuss this at a future visit. It must be done now. She takes a more detailed history, performs an EKG, and discusses the next steps and management with the patient. This takes her another 20 minutes to complete, and places her 55 minutes behind.
The next patient is 15 minutes late – he is brand new and got lost attempting to locate the clinic. The practice, like many others, has a policy to accept patients up to 15 minutes after their scheduled appointment time.
Ans since Dr. Tardy is late herself, it’s not an issue this time. But what if next time she is actually on time? Then she’d be running late due to a GPS snafu.
Dr. Tardy’s next patient was scheduled to discuss tingling in the hands and feet. But during the visit she reveals multiple other complaints that don’t seem to be connected: abdominal pain, shortness of breath, feelings of anxiety.
Dr. Tardy, having a great sense of intuition, suspects that there may be something deeper going on and works hard to get the patient to open up.
After some extensive detective work, Ms. Sadness starts to cry uncontrollably. She reveals that not only has she been battling depression for a few years, but that she now “Wishes she were dead.” Dr. Tardy finds this comment disturbing and spends a great deal of time trying to understand the level of depression and to determine if the patient is seriously suicidal.
Ms. Sadness reveals that she has thought about killing herself by swallowing a bottle of pills belonging to her husband. She has never quite gone through with it but thinks about it each and every day. Dr. Tardy realizes that Ms. Sadness needs help right away. After all, Dr. Tardy has taken an oath to “Do no harm” and she cannot allow Ms. Sadness to simply walk out of this exam room after revealing these disturbing plans.
Is this a 20-minute visit? No. But how is the person scheduling the appointments supposed to know that this visit would require much more time? The patient simply made this appointment for “tingling in the hands and feet.” This visit took 40 minutes to complete, and Dr. Tardy is now running over an hour late.
Last patients of the morning
Thankfully, the last patients scheduled for the morning are understanding and wait for Dr. Tardy. She sincerely apologizes to each one, as she does to every single appointment she is late for.
By the time Dr. Tardy ends her morning, she is scheduled to see her first patient of the afternoon. It’s a relief to reset the schedule once again, but this means that not only does she not have a break in the day (which doesn’t really bother Dr. Tardy), but she also has no time for returning patient messages, reviewing lab results, or refilling prescriptions. This means taking on about 2 hours at the end of her day to complete these tasks after her jam-packed afternoon schedule.
And this is a typical morning for a primary care physician in the United States. Are you tired yet?
Who is to blame?
Who is at fault here? Is it Dr. Tardy? Is she too accommodating? Could she have ignored that “By the way, I have chest pain” comment at the end of the visit with Ms. Diabetes? Could she have ignored that financial hardship plea? Should she have ignored the urgent patient lab values or that abnormal EKG reading that could have potentially placed those patient lives in jeopardy?
Should she have allowed the suicidal patient to simply walk out of the clinic?
If not, then do we fault the current health care system model in the United States that underpays primary care doctors for each visit so that they are required to see more and more patients in a shorter amount of time? Do we blame the medical practice that requires 20-minute appointment slots for each patient in order to survive? Should they stop allowing patients to be 15 minutes late in order to maintain good business practices?