Pediatrics, Late Appointments and Chaos

You never know what is behind door #2…

When people have an appointment at 10:45 AM, they more or less expect to be seen at that time, or at least, shortly thereafter. Staying on schedule is a goal that all medical providers strive to accomplish, but unfortunately, we never know what is behind door #2.

When I worked in family practice, it was not unusual for people to not be truthful about the reason for their appointment. Not wanting to share private information with the front desk, they might say “sore throat”, but in reality they are having some serious pelvic pain and think they have a venereal disease. The sore throat visit can be orchestrated between physical exam appointments since it is quick and easy; but a diagnostic exam for a woman with abdominal pain is quite involved. When this happens, we have to deal with it, and unfortunately, the other patients will not be seen at their appointment times, perhaps, for the rest of the day! It takes just ONE unexpected event like this to cause schedule chaos.

Then, there are the “Oh, by the way” people. You will spend 25 minutes of a 15 minute appointment slot, only to be faced with an unexpected peripheral issue. As you are leaving the room to rush to your next patient, someone will ask, “What do you think about this black mole on my arm?” Arrrghhhhh! Not that the black mole isn’t important. It may be more important than the original reason for the visit, but now we face a dilemma. Should we deal with this “Oh, by the way” now, or have the patient reschedule? Maybe they won’t come back and that possible melanoma will spread? We face situations in the clinic like this every day.

In pediatrics, there is always an entourage of people in the room. It is not unusual to see several uncontrolled siblings, one or more women (one of which could be a parent), a possible grandparent, a mystery person, some strollers and luggage. At least one person is talking on a cell phone and there are sounds of a hand-held video game. (Cell phones are going to be another upcoming blog!) One kid is always rolling around on my wheeled stool, bouncing from one wall to the next. Another child is playing with a $500 medical instrument or pounding on the computer keyboard. Have I set the stage properly? Once order has been restored to the room (sort of), and once the sick child is discovered among the crowd and the proper woman is identified as the real mother, the visit can begin. No sooner than the exam is complete, the prescriptions have been written, and you are making a mad dash for the door and the quiet of the hall, you hear those words: “Can you take a look at his ears, too?” Of course, you don’t have a chart; you don’t have time; and you know this will be a free visit, you take a quick look at the other child. Why? It will take less time to peek in the ear, than the proper alternatives.

People are complex. When you schedule a woman for a routine pap smear, this is what you are planning to do. However, when you enter the room, you are faced with a crying, depressed individual in a paper gown. Clearly, a pap smear is not her main issue today. You patiently listen to her version of the divorce and custody issues, and what a bastard her husband is, or how she may lose her job. You wait and you listen. Tactfully, you try and look at your watch, but you always get caught. Sometimes, you will decide to triage – take care of the situational depression first, rescheduled the pap. Sometimes, and more likely, you do both. This is a 45 minute visit (at least).

Out in your waiting room, people are stirring. They are making quick arrangements for people to pick up their kids at school, or cancelling other appointments. They are waiting and people HATE to wait (even though we call it a WAITING ROOM!). And, I understand that they are ticked. I hate to wait, too.

My next patient has been waiting a nearly an hour in the room. I don’t want to go in there, but this is my job. My first goal is to defuse the angry. I apologize for the wait, acknowledge their anger for being inconvenienced. “I am sorry that you had to wait today. I had an unanticipated medical crisis that took more of my time than anticipated. Sometimes, people’s medical problems take more than just 15 minutes. I hope that you understand. Someday, YOU will need more time, and I hope the people that have to wait for YOU will be understanding as well. So, how can I help you today?” We both smile, tensions have released, and we complete the visit. As I exit the door, I hear, “Oh, by the way…”

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