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Docs on DemandMarina Krakovsky talks with readers about same-day access to physicians.


Posted Thursday, Sept. 6, 2007, at 6:18 PM ET

Marina Krakovsky was online at Washingtonpost.com on Thursday, Sept. 6, to discuss doctors' offices where patients don't wait long to be seen. An unedited transcript of the chat follows.

Marina Krakovsky: Hello everyone! Marina Krakovsky here—glad to be here and looking forward to your questions.

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Midwest: Hi—thanks for the article. I thought that it was standard practice to schedule regular exams in advance, but that most clinics leave room in the doctor's schedule for urgent visits. It seems this offers the best of both worlds—the patient can plan a regular physical far enough in advance to make arrangements for work or child care, and the doctor has the flexibility to work in patients who need help immediately. Are you familiar with this model, and why don't you think it works?

Marina Krakovsky: You're describing the so-called "carve-out" model, and it is indeed a very common approach to scheduling. It's better than booking up all your slots in advance, but it has its problems, too, some which I touch on in the article. It's inefficient because it requires lots of triage to determine what's truly urgent, and it gives patients a perverse incentive to basically lie about their symptoms. Also, because there are fewer same-day spots for non-urgent visits, the wait for non-urgent visits is really long.

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Beltsville, Md.: I read your article. This is why I have Kaiser Permanente; I know that if I get sick and have to be seen that day that they will fit me in—even if I don't get to see "my" doctor, I will see a doctor. Their everything-under-one-roof system just works.

Marina Krakovsky: It's interesting that this trend started at Kaiser, with Mark Murray's work there. It seems hard to believe that such a behemoth can be made to run more efficiently. Should be an inspiration for others. Not being able to see your own doctor is a real problem, though. A friend who's a pediatrician at a Kaiser our here says she often has to see other pediatricans' patients, and that's definitely not the ideal of continuity of care. Mark Murray's solution worked better because it eliminated waits and improved access to your own doctor.

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Bethesda, Md.: What a great article. I think that waiting times are one of the biggest issues in medicine today. I myself have ended up in the ER for issues that might have been able to wait 24 or 48 hours, but couldn't wait the three weeks it took me to get an appointment at my primary doctor (and don't even start on specialists)! It seems to me that getting the health insurance companies to push for this would be the easiest way to see it implemented for average patients. Any idea if that is happening?

Marina Krakovsky: I haven't heard of insurance companies taking a stand on open access. Seems like it would be a good idea in the long run, what with the superior clinical outcomes. But as long as insurers get paid based on the number of patients they cover—not on how many claims they pay out!—my hunch is they're not going to rush to endorse open access.

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Anonymous: I am a Physician Assistant who does a lot of same-day urgent care visits. You did overlook one other issue with scheduling—the patient who expects only their schedules to be considered. If I already have four people scheduled right after lunch, but you "can't make it" at 11 a.m. or 3 p.m., then maybe you aren't that sick that you have to be seen today. Those other four people deserve to have their appointments respected also. And if you have been sick all week, calling at 4 p.m. Friday and demanding to be seen is not all that reasonable a request given that not only the provider but his/her entire staff may have other obligations after 5 p.m., including children at daycare or a second job. There are only so many hours in the day, and if 40 people call today I may not physically be able to see all of them. I try to accomadate people who need to be seen for illness or injury, but a little common sense and respect for others—including your provider and their staff—seems in order also.

Marina Krakovsky: You bring up a good point: some of the problems stem from patients not understanding what goes on in the office, and the ripple effects of their individual choices. (Likewise, doctors should understand how they affect their patients' lives by having them wait, even in the waiting room weeks after the appointment was made.)

But I would also ask why the doctor is scheduling four people right after lunch—how is one doctor going to be able to see them all at once? The doctor is probably used to some no-shows, but what if they all do show up on time? You're probably going to have three disgruntled patients.

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Edmond, Okla.: Studies have shown that it takes considerably longer to get into a dermatologist's office to have a mole evaluated for possible malignancy than it does for botox injections, which are cosmetic and are paid out-of-pocket by the consumer. Don't the lower rates of compensation and lengthy claim-submission processes used by health insurance companies and Medicaid provide a financial incentive for doctors to mismanage their practices by overbooking and delaying patients whose lower-paying but neccessary treatments will be covered by insurance, while catering to more lucrative cosmetic procedure patients?

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Marina Krakovsky writes mainly about ideas in science, culture, and business. Her work has appeared in Discover, the New York Times Magazine, Psychology Today, and the Washington Post.
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Remarks from the Fray:

Most of the discussion was about acute/subacute visits and ignores huge primary care responsibilities. It sets up a system where the backlog is almost always large. You have to schedule ahead -- for convenience and malpractice issues you can't just tell someone to do it themselves. With health maintenance and follow-up visits for hundreds or thousands of patients most of the day is full. After that it's MD preference. I have worked with doctors who refuse to schedule a patient after 2PM (to do follow-up, calls, paperwork, and finish up the visits from the morning) and doctors who stay as long as is needed until every "I need to see a doctor today" visit is done. I like (and follow the example of) the latter.

Yes, it's difficult with insurance limits and the wait for a "new patient" appointment slot, but trying to find a doctor who will always see you within a day is worth it. Many exist, but MD's (outside of the few trolling for cash-paying botox visits) still resist advertising shorter wait times, so it's frustrating to wait 2-4 months to see a new MD just to find more of the same lack of responsiveness. It's just the bias of training to not appear to look for business -- maybe that would put a competitive pressure on other MD's if they saw their patients moving away to better, more responsive MD's.

Also, amongst the biggest reasons for a wait is simple supply and demand -- subspecialists limit their numbers severely by only training a set number per year (and subspecialty licensing generally requires going through an official training program, as does getting hospital privileges for most better quality hospitals).

--coutneyandphoney

(To reply, click here.)

What we do in medical care is triage. We assess who needs attention more than others. So to mention triage as though it's burdensome is not really relevant. Then to go on to say that the Palo Alto Medical Foundation works well because of a system that is exactly triage, shows a lack of understanding of the dynamics of medical care. Just because someone believes he/she has a condition that warrants immediate treatment does not mean that's the case. Sorry. We're used to immediate attention in the U.S. and that's one of the reasons we have these complaints.

Doc in the boxes can keep a more regular schedule because they aren't anyone's primary care provider, or at least they aren't supposed to be. So they don't end up having the sometimes long conversations that can occur at visits about people's lives. They also don't usually perform physicals or other potentially lengthy counseling visits unless they are contracted to do so.

What this article could have been about is the way the medical system can use all of its staff to provide better care. Sometimes counseling can be done by a nurse, or a nutritionist, or other staff, and doesn't have to be done by a physician. But a practice needs to be reimbursed for that time and not just for the doctor's time. It may be that the doctor, believe it or not, is not the most knowledgeable source about things like all of the possible birth control options, and a health educator would do better. These alternative staffing options are what needs to be discussed to get people the right care they need for their own particular issues. Then time is saved care needs. But then patients need to recognize that the doctor is not always the one who will be advising you and that needs to be OK.

--sundance22

(To reply, click here.)

(9/13)

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