Karim Kussad of North Andover rarely waits more than five or 10 minutes for his neurosurgeon to see him in the exam room at Lahey Clinic in Burlington.
So last month when 10 minutes passed, then 20, then 30, and no doctor arrived, Kussad wondered what was going on. Ultimately, the 60-year-old patient had to walk out to the nurses' station to ask. At this point, by his calculation, he had been in the hospital for about two hours waiting for this appointment.
"(The nurse) said (the doctor) was called for an emergency in the operating room," Kussad said. "I said, 'What about me?'"
Kussad put his clothes back on and left angry, though he reconciled with his doctor the following morning.
"He called me himself and apologized, and he said just come in anytime right away," Kussad said.
Kussad's story is perhaps an extreme example, but just about everybody knows what it's like to wait for a doctor so long you fear you've been forgotten.
Carole LaMontagne of Hamilton said she sometimes waits as long as three or four hours before getting in to see a specialist in Texas for her respiratory illness. Cindy Ward of North Andover said her husband and daughter both refuse to set foot in one local doctor's office because the wait is outrageous.
"The average wait in his office would be half an hour to an hour," Ward said. "When you got in there, there are six or eight exam rooms. You could wait another 20 minutes."
Long waits for doctors' appointments are so universal, though, that patients like Ward generally accept them without question, and even grow suspicious of a practice that doesn't require a wait.
"There's not a doctor's office in the world where you're going to get in and out," Ward said. "I would be leery of getting in and out of a waiting room in a hurry. ... I don't think it's anybody's fault, and I don't think there's an easy answer."
Dr. L. Gordon Moore, a family physician with an office in a suburb of Rochester, N.Y., begs to differ.
At his practice, patients are almost always offered same-day appointments, whether their visit is urgent or just a routine physical. And when they show up, they're not expected to wait.
"We say when you come in, if it's been more than five minutes, please knock on the door because something's wrong," Moore said.
So last month when 10 minutes passed, then 20, then 30, and no doctor arrived, Kussad wondered what was going on. Ultimately, the 60-year-old patient had to walk out to the nurses' station to ask. At this point, by his calculation, he had been in the hospital for about two hours waiting for this appointment.
"(The nurse) said (the doctor) was called for an emergency in the operating room," Kussad said. "I said, 'What about me?'"
Kussad put his clothes back on and left angry, though he reconciled with his doctor the following morning.
"He called me himself and apologized, and he said just come in anytime right away," Kussad said.
Kussad's story is perhaps an extreme example, but just about everybody knows what it's like to wait for a doctor so long you fear you've been forgotten.
Carole LaMontagne of Hamilton said she sometimes waits as long as three or four hours before getting in to see a specialist in Texas for her respiratory illness. Cindy Ward of North Andover said her husband and daughter both refuse to set foot in one local doctor's office because the wait is outrageous.
"The average wait in his office would be half an hour to an hour," Ward said. "When you got in there, there are six or eight exam rooms. You could wait another 20 minutes."
Long waits for doctors' appointments are so universal, though, that patients like Ward generally accept them without question, and even grow suspicious of a practice that doesn't require a wait.
"There's not a doctor's office in the world where you're going to get in and out," Ward said. "I would be leery of getting in and out of a waiting room in a hurry. ... I don't think it's anybody's fault, and I don't think there's an easy answer."
Dr. L. Gordon Moore, a family physician with an office in a suburb of Rochester, N.Y., begs to differ.
At his practice, patients are almost always offered same-day appointments, whether their visit is urgent or just a routine physical. And when they show up, they're not expected to wait.
"We say when you come in, if it's been more than five minutes, please knock on the door because something's wrong," Moore said.
Moore now works part time for the Boston-based Institute for Healthcare Improvement teaching doctors how to make their practices more patient-centered and efficient.
This approach is not just something he made up, Moore said. Since the late 1990s, researchers have been studying medical practice design and proving that there are solutions.
"The ideas are out there," he said.
Yet in the past decade, Moore said, there has been a "very, very slow rate of adoption of this stuff."
The typical doctor's office is based on the cash flow generated by scheduling appointments every 15 minutes, Moore said. Because a certain percentage of patients will not show up for their appointments each day, Moore said, some doctors double-book to make sure they can pay their bills.
The trouble is, the system doesn't reflect reality. Often a doctor's typical interaction with each patient is 17 or 20 minutes rather than 15, Moore said. Sometimes the "no-shows" show. Either way, the doctor falls behind, and the waiting room fills up.
"It is designed to optimize physicians' times and to optimize finances, even at the very manifest cost of patient satisfaction and care," Moore said.
It would be much more rational to schedule patients for the actual amount of time the doctor is likely to need, Moore said, but doctors don't want to.
"(It's) unbelievably hard to get people to accept that, because they say, 'Oh, my gosh, there goes my revenue,'" he said. "It strikes such a deep chord in these practices. They can't get around it."
The result is more than just inconvenience for the patients, Moore said.
"We know that waits and delays like that are one of the reasons some people skip or avoid coming in," Moore said. "We think that's one of the pieces of the puzzle of why the United States spends so much more on health care and gets such poor results."
So what can a patient do about it?
Ward said she speaks to the doctor at the end of an appointment if she had an unusually long wait.
"I say, 'I'm here because you're a wonderful doctor and you're wonderful to my child,'" Ward said, followed by, "'This is what happened today and I'm going to make it brief, but I don't want to go through it again.'"
Doctors generally are receptive, she said.
"When I find good care, I work with the office staff to make the office experience work," Ward said. "You can't expect it to happen without opening your mouth."
LaMontagne said she writes a letter to the doctor after she's had a particularly bad experience.
"You're lucky if the secretary doesn't just dump it in the wastebasket," she said.
But that's not the point.
"It gives you closure," she said. "It gives you power. You feel like you're in control."
Sometimes, LaMontagne said, she doesn't mind a long wait. For example, when she waits for three or four hours for her specialist in Texas, she doesn't complain.
"I don't mind because when I get into that office I know he's going to take that much time with me," she said.
Other times waiting is excruciating and there's nothing you can do about it, she added.
"The best thing you can do is not get sick," she said.
How long would you wait?
* Karim Kussad of North Andover says he waited about two hours for his Lahey Clinic doctor to show up before confronting the nurses and finding out the doctor had been called away for an emergency. (Lahey Clinic declined to talk about the situation, citing health privacy laws. In a prepared statement, Dr. David M. Barrett, Lahey president and chief executive, said: "We are mindful of our patients' wait times and are always working to make improvements.")
* A Braintree woman waited an hour at South Shore Hospital in 2004 for asthma treatment. When the emergency room staff told her she would have to continue waiting, she dialed 911 from her cell phone and had an ambulance bring her to Quincy Medical Center.
* A Las Vegas man sued his doctor in small claims court in 2003 after he waited almost four hours for his back pain treatment. For nearly three of those hours, he was hooked up to an intravenous line. He won $250.
Passing the time
Cindy Ward of North Andover and Carole LaMontagne of Hamilton both spend a lot of time in doctors' offices. Here is their advice for making the wait bearable:
Bring a really good, absorbing book.
Bring something to drink.
Don't make any other appointments for the morning or afternoon of your doctor's appointment.
Ask before you sit down how long the wait is going to be. Often the check-in desk knows the doctor is running late and will tell you by how much. If it's going to be a long time and it's not a particularly important appointment, ask the receptionist if you can reschedule when it's not so busy.
Have fun with the receptionist. "If they're laughing and fooling around," LaMontagne said, "I'll open up and say something like, 'You're at work. You're not supposed to be having this much fun. How do I get a job like that?'"
Early morning appointments are nice if you can get them because the doctor is likely to be running on schedule. Every practice is different, though. Ask when you make the appointment if there's a time when the doctor's typically less busy.
After 20 minutes or half an hour of waiting, don't hesitate to get up and remind the receptionist how long you've been there. It is possible they forgot you. A polite reminder doesn't hurt.
Case study: a doctor's office with no waiting
Dr. L. Gordon Moore started a solo family practice in 2001 based on the "ideal micropractice" model championed by the Institute for Healthcare Improvement in Boston. His patients get an appointment the day they call, there's no waiting and the typical visit with the doctor lasts a half-hour.
Here's how he does it:
No staff: Moore is the doctor, and also the receptionist, nurse, office manager and billing department. Calls go to his voice mail when he's seeing a patient. He greets patients, takes their vital signs, treats their diseases, submits the bill and turns over the room after appointments. Patients never have to explain more than once why they came in.
Access: Moore gives out his home telephone number and answers all of his after-hours calls, rather than rotating on-call duty with other doctors. It's more efficient, he said, because he knows the background when a patient calls. Patients don't call him at home nearly as often as his colleagues imagine they would, he said.
Minimal office space: Moore rents a 150-square-foot exam room in another doctor's practice for $400 a month that serves as both his office and the place where he sees patients.
Technology: Moore relies heavily on computers to stay on top of clinical recommendations, keep medical records and manage his patients' care.
Few patients: Because his overhead costs are so low, Moore can afford to see fewer patients. He started the practice with the goal of having 1,350 patients, and seeing 12 a day for a half-hour each. His net salary was budgeted to be about $156,000. He accepts private insurance, Medicare and Medicaid, and he also treats a handful of uninsured people.
Recipe for a shorter wait
These are some of the techniques Dr. L. Gordon Moore uses when working with a clinical practice to reduce waiting times:
* Have each doctor or practitioner work consistently with the same nurse and receptionist. They learn each other's strengths and weaknesses, and they communicate better.
* Keep this team close together in the same physical space, ideally within sight of the waiting room. If this is impossible without major remodeling, use walkie-talkies, headsets, mobile phones or instant messaging (pagers seems to be less effective, Moore said).
Some clinical practices make it a rule that the doctor never sees the waiting room, so patients can't grab the doctor and ask why they've been waiting so long. But that's essentially why doctors should see their patients waiting, Moore said.
"Then it's not ambiguous," he said. "Then you actually know, 'Oh gosh, that's my person.'"
* Streamline the check-in process. If the doctor is free, send the patient back immediately and do the insurance paperwork later. Use software that doesn't require you to click through four different screens to enter somebody's insurance information.
* Cut overhead dramatically so you can afford to see fewer patients. If you can implement same-day appointments, for example, you don't need a nurse to do telephone triage and determine which patients can wait to be seen.
* Anticipate surges in patient demand and staff your office to meet it. If you get overwhelmed with back-to-school physicals in August, don't let half your staff take their vacations in August. Offer a discount for kids who get their physical in July.
Doctors should be willing to extend their own hours, too, Moore said. He has worked with practices that are planning multimillion-dollar building expansions to alleviate the waiting room crunch, when they could solve the problem just by working on Friday afternoons.
