Part 2: The Top Five Reasons Why Patients Are Dissatisfied

In a recent patient survey in our medical group, there were five areas of dissatisfaction that were identified. This is the second of the five reasons.

2. Provider's ability to return your calls in a timely manner (10.6%)

A large proportion of a medical practice involves voice communication. As our EMR (Electronic Medical Records) system evolves, we may soon be able to add secure e-mail to communicate with our patients, but right now we predominantly rely on Alexander Graham Bell's invention.

Most medical providers have appointment templates. In our office, we have both 15 minute and 30 minute time slots for patient visits. In some practices, providers are expected to see patients every 12 minutes. Sadly, one of our local HMOs has their providers on 10 minute appointments. Since Time is Money, the more patients that can be seen during the busy day, the better. Or, is it?

It is not unusual for a provider's schedule to be completely booked weeks in advance. In our practice, we have initiated an Advanced Access system: any patient who would like to be seen today, will be seen...today. While this is good news for patients, it can be a major headache for providers.

As soon as the phones open in the morning, the calls begin to flood in. Some are requesting appointments; some are requesting medications based on their symptoms and do not want to be seen; some are requesting refills; and some are simply asking for advice. Regardless of the reason, people need access to their medical provider and they would like to be called in a "reasonable" time frame.

From the moment the medical provider walks through the door, there are patients to be seen. Many have been processed already and are sitting in their little paper gowns, shivering and looking at their watches. In the "old days" (about two years ago), written phone messages attached to huge charts were stacked, often in order of urgency, on our desks, waiting for responses. Now, our computer message board starts to fill up, not unlike our home computers offering Viagra or hot stock tips. Patient messages are not SPAM; they are real people with real problems, and most are expecting an immediate response.

So, who comes first? Should we see the patients that have appointments first, or should we make them wait and immediately call back people who (a) did NOT make an appointment, or (b) may need an appointment but would like to get out of it. In a way, these phone calls are just people trying to jump first in line, so most of us will see the patients that are physically here first. If we do not see the patients close to their scheduled times, complaint will surely follow. If we do not promptly call our messages, complaints will occur as well.

The patients in the room are PAYING for their visit, either through insurance or out of their pocket. The patients on the phone are getting care for free. So far, the medical establishment does not charge for phone advice. Telephone medicine remains a free service.

I am usually provided with a least three different call back numbers: work, home, and cell. It is up to me to decide where the patient might be at a particular time. Usually, I am wrong. If I call work, they just left. I try the cell, I get voice mail. I call home and they have not arrived and the ten year old that answered the phone is not helpful. Three calls; nearly ten minutes. No luck. I try again later. At some point, I get them...

"My husband woke up this morning with pink eye. Can you call in prescription?"

"I am in-between insurance policies. I have been coughing for the last two weeks. I know I have bronchitis. All I need is a Z-pack."

Or, my favorite: "My child has this rash. What do you think it is?" Some of these are not unlike the postings that I get on the WebMD ENT Board. There are people out there who believe we can see through the phone, or through the Internet.

Medical providers must practice a certain amount of telephone medicine, but unfortunately, this is a very risky business. That pink eye could be herpes keratitis - a serious, sight-threatening condition. That cough could be pneumonia or congestive heart failure. And, that rash could be meningococcemia - a life-threatening disease process.

Most medical providers return phone calls between patients (if there is time), during lunch (I am sure you have heard the sounds of chewing, or even worse!), after work (while they are doing charts), on the way home using their cell phone, or from home when they should be spending time with their families. My PA wife works in family practice. Last Friday, she answered more phone calls than she saw patients. Revenue generated for the practice? Zero. Additional time away from home? Two hours. Additional compensation for a salaried employee? None.

After 12-13 hours of seeing non-stop patients, I will finally get to some of the less-critical phone calls.

"It's about time. I waited for you to call back all afternoon."

"How can I help you?"

"Oh, never mind. He seems to be doing better now."

Related Topics:

• WebMD Video: Picking a Physician
• Getting the Most from Your Doctor's Appointment

Technorati Tags: medicine, health and wellness, medical practice, doctors, patients, healthcare

The Top Five Reasons Why Patients Are Dissatisfied, Part 1

Our medical group and administration spends a great deal of time trying to make things better for our patients. Medical care is now a buyer's market, so it is up to us to identify areas of improvement to make our patients happier. In a recent survey, there were five areas of dissatisfaction that were identified that I would like to share with you in the next five Blog posts.

1. Keeping patients informed if appointment time is delayed (14.8%)

As I have mentioned in past posts, medical providers never really know what is behind door number #2. Patients often make appointments for one problem, and then decided to tack on a few more once they have our attention.

Most appointments in our pediatric practice are in 15 minute slots; some are for 30 minutes (such as minor surgeries). On Monday, my first appointment was a 30 minute visit to remove an ingrown toenail. The patient arrived on time; it took about 10 minutes to register them and check the insurance status. It took another ten minutes or so for my medical assistant to take the vital signs, enter the information into the EMR (electronic medical record) and set up the surgical tray.

I was handed the chart five minutes later; twenty-five minutes after they arrived. My 9:00 AM physical had now arrived, and I have yet to do the surgical procedure. Let the patient juggle begin...

I explained the toenail removal procedure to the anxious ten year old girl; prepped the toe, and injected the local anesthesia. Since it takes a few minutes to take effect, I shot in to the kindergarten physical and took the appropriate history. I excused myself after ten minutes, ran back to the ingrown toenail and performed the now, painless procedure.

I gave the family the aftercare instructions, and shot back in to finish the physical. By now, I had two more patients (sick ones) "in the rack." I finished the physical and made it to the first sick one only 15 minutes behind schedule (not bad), only to be faced with a really sick baby that was going to take longer than 15 minutes for sure. To complicate matters, the mother brought another child, equally as sick. Welcome to my Mondays.

As much as we would like medical visits to be clear-cut, predictable, and straight-forward, they rarely are. This is what we deal with every day -- extra, add-on patients, patients that try to get five years worth of postponed medical care done in one visit, illness that are more complicated than anticipated, emergency phone calls, critical laboratory reports, doctor-to-doctor consultations, pharmacy calls, and patient calls. It is no wonder that I got kidney stones a few years ago. I don't have time to drink anything or pee!

Time is money for all of us. Patients are busy people, too, with lives and time commitments just like us. There has to be a common ground. Our patients should be informed that their visit may be delayed, but it is rarely appropriate to offer the reason, and most of the time we are too busy to make an announcement to the waiting room. If they see an ambulance pull up and a lot of activity, then they understand; but when their appointment time is becoming later and later, they start to get anxious.

Hopefully, my patients know that I am not sitting on my butt, drinking coffee with my feet up on the desk talking to my broker. When I enter the room for their visit, I do apologize and offer a general explanation for the delay and quickly get on with their visit in a friendly and non-rushed manner. Most patients understand about unanticipated delays; some do not. I say that I had a very sick child that took some additional time to adequately evaluated and treat and hope that they understand. Some day, I add, their child may need that extra time, too.

My patients are often shocked when I come into the room literally seconds after the medical assistant tells them I will be there "in a moment." I smile and tell them that this makes up for all the times in the past (and in the future) that they had to wait. I pay the price for seeing patients as promptly as I can. That price is that I delay doing my charting until lunch or after appointment hours. Last Monday, I came home at 10:30 PM, long after most of the patients that I saw that day were asleep.

Our group wants us to put up a white board in the waiting room that is frequently updated to let patients know the estimated delay. I guess that is better than having a number like the deli that says "Now serving number 4," or that annoying computer announcement that tells you the average waiting time for your call will be 18 minutes. The white board may work in a single-provider office, but we can have as many as a dozen medical providers working at the same time, each seeing 30-40 patients. That is nearly 500 opportunities for delays. We are going to need an electronic ticker tape circling the waiting room, like Wall Street.

Abby, one of my frequent ENT Board posters complained that she had to wait three hours to see her ENT and she was angry. One of our pediatric urologists routinely has patients waiting this long. Adults are one thing, but having a sick child (or ANY child) wait three hours is a nightmare. We certainly do better than this.

A family practice physician allowed his patients to select the number of ten minute increments of time that they thought THEY would need at their medical visit. Guess what? Patients were much more accurate in anticipating how much time their visit would require than the appointment schedulers or the doctor. Of course, this family practice physician charged accordingly for these ten minute increments. If you want your sore throat addressed, have a mole removed, and have a discussion about your divorce all on the same visit, then book as many slots as you need. Patients are charged accordingly. I really don't see a problem with this method. That's how my car mechanic does it.

An OB-GYN gives his patients a beeper, so they can shop or do other errands. Non-C-section babies arrive without appointments and pregnant ladies understand this.

Maybe we need to see fewer patients per day or hire more medical providers? Maybe we can build in more decompression, catch-up slots in our schedule? I don't really have the ultimate solution, but I would sure like to hear yours.

Today is my day off. I shouldn't even be thinking about this stuff.

Related Topics:

• WebMD Video: Coping with the Wait in Your Doctor's Office


• WebMD Video: Wait-Free Doctor Appointments

Technorati Tags: medicine, health and wellness, medical practice, doctors, patients, healthcare

Anatomy of a Medical Visit

The Miserable Morning

Lindsey woke up in the morning with a terrible sore throat and fever. As she tried to get ready for work, it was clear that she was going to need some sort of medical care.

Did you know that the vast majority of medical care provided in the world is not provided by trained, medical professionals? Before accessing organized medicine, most people try and take care of themselves.

First, you have the issue of pain. Most people with a severe sore throat will reach for their trusty bottle of acetaminophen or ibuprofen. Some people even have a hoard of prescription pain medications lying around, such as codeine or Vicodin. If the pain is bad enough, you skip directly to the stronger medications.

Second, you try and remember what your parents told you to do for a sore throat. Ah, yes, gargling. You grab the box of salt and dump in a healthy amount into a glass of warm water and head for the bathroom. Of course, you soon realize that you have created a saline solution stronger than the Great Salt Lake or the Dead Sea. After a few attempts to gargle with this unbelievable salty solution, you give it up.

Third, you examine yourself. You find a flashlight and a mirror. The throat looks terrible. It is red, angry-looking; not normal at all. This is probably Strep, Lindsey concluded. She wanted to take her own temperature, but had no idea where she put the thermometer. Oh, well, she felt her forehead and concluded that she was hot; about 103 she estimated. Her glands hurt, too.

Again, she searched the medicine cabinet. It was filled with mostly-expired prescriptions that she never finished. Lindsey found some ciprofloxacin, but couldn't remember if it's an antibiotic or something she took for diarrhea. (It's an antibiotic). She had only one tablet anyway, so you swallowed it, even though she knew this was not a good practice.

Making The Appointment

Lindsey looked at her watch. It was 8 AM, so she called her doctor's office. The phone rang constantly. After about 200 rings, a woman answered. Based on the distant, nasal tone of her voice, she knew it is the much-feared Doctor's Answering Service.

"What time does the office open?" She was told 8 AM, so she reminded the answering service that it WAS after 8 AM now. She was told to call back in little while later. She tried again at 8:15 AM, but the phone was now busy. She tried again; still busy. She called in sick for work; and tried yet again. This time the phone was answered but she was put on hold, less than one millisecond after the words "Doctor's Office. Please hold". She waited, clutching her sore throat. She waited some more. She started a load of laundry with the phone resting on her shoulder.

Eventually, the receptionist answered the call. Lindsey briefly explained her problem and asked for an appointment. She was offered an appointment in three weeks. This was unacceptable. She told the receptionist that she would prefer to be seen on the day she was ill; today. The sound of rapid keystrokes filled the silence.

"Can you be here in ten minutes?"

Standing in her robe; hair looking like she lost a dog fight, breath smelling like salted cod, she respond, "Yes, if I can find my time machine." Strep throat seemed to unusually sharpen her normally-suppressed sarcasm skills.

"Well, can you come in at 3:20 PM?"

"I guess I will have to, assuming that I do not die between now and then." The receptionist added her name to the other three people scheduled for the same appointment time.

As the morning progressed, she felt more and more like crap (Crap is a frequently used medical term for extreme malaise, body aches, fever, and frustration). She popped some more ibuprofen and gargled with the brine.

The Waiting Room

Lindsey arrived early, at 2:30 PM, hoping that her medical provider might fit her in earlier. She waded through a sea of coughing people, kids in strollers and approached the front desk. Another woman was complaining about her bill while simultaneously talking on her cell phone. She was told to sign in and be seated. She was also chastised for being early.

She couldn't help but notice the twelve people on the list in front of her whose names weren't crossed out. For one quick moment, she considered sneaking her name higher on the list and writing down an earlier time, but she didn't. She found a seat next to someone who was madly scratching. After sitting there a few minutes watching this display of digging, she spotted another chair near a greenish man holding a barf bucket. She decided to take her chances with the scratcher.

Leafing through a boating magazine, having nothing better to do, she wondered what kind of boat her doctor must have. Somehow, that ticked her off, but she was not sure why. She looked around the crowded waiting room, trying to guess what other people had. That woman definitely has Chlamydia or worse. Both of those children have pink eye. It doesn't take a medical degree to figure that one out. They were wiping their noses and eyes on the chair. An older woman with a walker smelled like pee. Oh, how she loved the waiting room.

Her appointment time of 3:20 came and went. She guessed that this is why it was called the Waiting Room. The barfing man and the scratcher had already been called back. Maybe, she was next. No...there went the pink eyes. It was now 4:00 PM, so she approached the front desk czar. She was told that the doctor was running a bit behind. Running behind what? A turtle? She sat back down.

The Indignities

At 4:18, a medical assistant, thirty years younger than her, mispronounced her first name. She was lead to a scale for the first of her ritual indignities. The medical assistant loudly announced weight so that everyone could hear. She ignored the fact that Lindsey's shoes weighed 16 pounds. A temporal thermometer streaked across her face and she was told that her temperature was normal. Damn! She shouldn't have taken that Motrin, she thought.

She was then led into a small examining room and asked why she was being seen today. Lindsey gave her a five-minute, detailed, chronological history of her current illness, her allergies, and her concern about Strep. After carefully listening, the medical assistant wrote down "sick" and headache on her chart and told her that the doctor will be with her in a moment. Lindsey did not tell her that she had a headache, but that was okay. She had one now.

The Doctor Arrives

A "moment" in doctor-time is really about a half-hour. She wished she still had that boating magazine. She stared mindlessly at the beige walls and the torn anti-smoking poster. Time stopped. A child is screaming in the distant.

Some time later, the doctor barged in without knocking, performed a cursory examination, and pronounced his verdict: It didn't look like Strep. It was just a virus. All she needed to do was take Motrin and gargle.

"Aren't you going to do a Rapid Strep Test?" she asked.

"If you want, but I think it is a waste of money." He swabbed her throat like he was cleaning out a rain gutter and left the room with the swab.

"It will just be a 'moment'," he said. She waited some more.

Another fifteen minutes dragged by.

"Your Strep test is positive, so you will need to go on some antibiotics. Are you allergic to anything?" He was writing before she answered.

He wrote out a quick prescription, and again tells her to gargle with salt water and take Motrin. He handed her a paper to take to the front desk to pay. It was now 5:45 PM.

The Tag Line

Office visit: $75. Strep test: $24. Prescription: $30. The fact that she proved him wrong about the Strep: Priceless.

On the way to the car, Lindsey started to scratch.

The End

Related Topics:

• Call in Sick or Go to Work? Here's Some Advice
• Tired of Co-Workers Making You Sick?

Technorati Tags: flu, strep, doctors, primary care