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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.

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Marina Krakovsky: I did read about that study, which compared the waiting times for the two types of visits. The study didn't examine the reason for the disparity, though your explanation certainly seems like the most likely, and that's deeply disturbing. Talk about the changing face of dermatology.

Interestingly, the "changing mole" study I mention in my article found virtually no difference in the waiting times for Medicare patients versus other patients.

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Richmond, Va.: That opening fact, that "the wait time for a doctor's appointment in the United States is one of the worst among peer nations" is all the more interesting, because a long wait is the most common arguement against national health care! Now we have proof that aruguement is unwarranted, we can have an intellectual converstation about national health care without the false scare tactics. Thanks.

Marina Krakovsky: Not so fast. Nations with national health care do have long waits. Depending on which stats you look at, Canada's waits are worse than ours, and the UK's are better but not anything to crow about. And what works in one country may not work in another. But as with so many things, a lot depends on the actual execution.

I do think that even in the current system, misaligned incentives—for patients, doctors, and insurers—is part of the problem.

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Richmond, Va.: They manage to do it fine that the neighborhood "doc in a box," where there are no appointments—it's first come, first served.

Marina Krakovsky: Yes, and doesn't that make you wonder how they manage to do it?

But if you haven't experienced long waits in these clinics, maybe part of it was luck. It seems to me that a strictly first-come, first-served approach can create long waits in the waiting area, unless there are lots of extra doctors just in case. Open access isn't that radical—patients make appointments for a specific time during that day.

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Washington: I loved your article because I recently had a major problem with this ... I had a skin infection and really needed to say a doctor ASAP, but my regular doctor's office said there were no openings, even for emergencies, for two more months. Luckily after about a dozen calls I found someone who would see me, but turning down a patient who really needs help seems almost like malpractice. Why don't doctors do more to fix this delay problem? Should we just go to the emergency room in those types of situations?

Marina Krakovsky: Yeah, what happened to "do no harm," right? But look at it from the doctors' point of view. If it took a dozen calls to find anyone who could see you, I'm guessing there's a genuine doctor shortage in your area. And if that's the case, no scheduling system is going to solve the problem.

Individual doctors can only weigh their options and the trade-offs involved. Do they increase their hours? Do they send patients to urgent care? Do they stop taking on new patients altogether? Or do they tack you on to the end of a very long queue? The last option may be well-intentioned, but we now know it creates all sorts of problems and makes the whole system less efficient.

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San Mateo, Calif.: I enjoyed your article and the fact that it is producing discussion on a topic that needs addressing for all involved, including doctors and patients. The comment from Bethesda, Md., brought up the ER issue, i.e. the congested ER waiting rooms because of a patient's inability to be seen by his own primary care physician, because of alack of open access. As you cited via Palo Alto Medical Foundation in your article, I can attest to its ability to efficiently and effectively handle patient care with its same-day scheduling.

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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.

COMMENTS

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

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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

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(9/13)

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