Patient Lateness and Asymmetry

Last weekend, my girlfriend and I were flying home from Houston to Seattle.  I needed to check a bag, so our goal was to arrive about 80 minutes before our flight.

On the way to the airport, there was a large accident that delayed traffic, and by the time we returned the rental car and arrived at United's check-in, there were 48 minutes until the flight left.  We were told by the United agent that the airline recently changed their policy to requiring check in 1 hour before the flight if we were checking a bag, and therefore we were bumped to standby on the next flight, which was leaving 3 hours later.

Obviously, this was not an ideal situation for us, and we have some questions about whether United was being honest with us (e.g., United's own website says you need to check in 45 minutes before your flight in Houston, not an hour).  But on some level, that is besides the point.  No matter how good our intentions (we did have a time cushion when we left), no matter how valid our excuse (there was in fact an accident that caused a delay), United is absolutely correct in that we are not entitled to having the plane wait for us.

When we got to the gate, the plane that we were originally booked to fly to Seattle on was delayed 35 minutes.  On some level, I did have a feeling of bitterness "Why does United get to leave late, but if we arrive late, there is no consequence?"  The reason, of course, is that the relationship between passenger and airline is NOT a symmetric relationship.

When passengers are late, it is generally for things that are under their control.  We gave ourselves a 20 minute buffer, but if we really, REALLY wanted to make the flight, we could have given ourselves a longer buffer.  When the airlines are late, however, it's usually for things that are out of their control (weather, the incoming plane is late) or safety.

Moreoever, imagine a world where the airlines DID wait for every passenger.  What would happen?  How likely is it that any plane would leave on time?  Obviously, the plane would be late all the time.  If the plane waited for EVERY passenger, then the on-time rate for departures would be only as good as the on-time rate for the most delayed passenger. 

So, as much as I was disappointed to hang out in the Houston airport for an additional 3 hours (.... which turned into 3-1/2 hours, since our later flight was delayed by 30 minutes), I understood and ultimately agreed with the airline's policy.

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On a related note, one of the most frequent complaints by patients is that they hate when their physicians are late to start their appointments.  I get it.  I am a patient too, and it's frustrating when I am waiting for MY doctor for over 30 minutes, and I am especially appreciative when a doctor's office runs on time.

So, an important question is "why do doctor's run late?"  I suspect, based on the anger I read from patients on the internet, that at least some patients think there is an evil cabal of doctors hanging out in some super-secret country club, drinking spritzers and conspiring with new and creative ways to waste patient's time.  

This is, of course, not true.  I don't like being late anymore than the patients do.  There are several reasons, and at least some component can be attributed to behavior of the doctor.  I have colleagues who don't show up at the office until hours after their day started, and that's obviously not considerate to the patient.  

However, in my experience, and certainly in my practice, that is a very small portion of why I run late.  First of all, it's rare that I run more than 20 minutes behind- it typically happens 3-4 times per week.  It's important to me to run on time, so I track my behavior to make sure it doesn't become a pattern.

One reason we can run behind is emergencies.  In my particular practice, I don't have that many emergencies, but when they happen, I do have to stop anything else I am doing.  If I have a 60-year old runner who develops chest pain, shortness of breath, and an irregular heartbeat, I need to get him to the emergency room.  That will delay every other patient for the remainder of the half day, but emergencies have to take precedence.

Another reason I may run behind is calls from other physicians, physical therapists, or clinical partners.  I encourage my clinical partners to use email (which I can check between patients if I get the rare free moment), and if someone calls, I'll ask if it's something they need me to address promptly.  But if someone calls, it's usually for something urgent.  I've had clinic interrupted because what I thought was a routine spine MRI turned out to be a rare tumor, or because the vascular surgeon wanted to make sure I had already ruled-out certain pathologies before he started expensive and intrusive testing.

Emergencies and phone calls may account for perhaps 5% of delays, and my behavior certainly accounts for some- probably about 10%.

Another big factor is that some patient's just need a little more time.  
- Sometimes it's because I pick up something unexpected on history or exam.  Beyond the fact the history and exam will take extra time, I now want to spend a few extra minutes contextualizing the information I learned for the patient.  
- Sometimes patients have an excellent question that warrants a longer explanation.  There are times where it's more than we can address on one visit, but if I can explain something in 10 minutes and save a patient an extra trip, I try to do so.
- Sometimes patients need some emotional support.  I had a patient yesterday morning who just had a close relative die.  Beyond expressing empathy for empathy's sake, I need to also make sure they have a sufficient support structure to help them with their stressor.

Patients who need more time than we anticipated is a big factor- probably accounts for 40% of my delays.  I do not double book, and I book longer appointments than the norm (which, by the way, is a lot less profitable than working a high volume practice, and it is devastating to our bottom line when patients no show), but even with accounting for this, I cannot always predict which patients need more time.
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So I've accounted for about 55% of why I run late, which is not that often.  What accounts for the other 45%?  By far, the biggest factor is late patients.  Unfortunately, one late patient can throw the entire day off.  

I book longer appointments than is typical of most doctors (which, by the way, costs me a lot of money, but unlike some stereotypes, we don't do everything for money)- 45 minutes for a new patient.  We ask patients to arrive 30 minutes before their appointment to fill out paperwork, although we do give patients the option to fill out their paperwork ahead of time if they prefer.  We've worked very hard to refine our paperwork to get rid of unnecessary fluff, but it still takes time to fill out.  My goal is to be a good steward of the patient's time and money, so I want to start my visit at the designated time and give them my undivided attention.

Let's run through an example of a patient who shows up at 8:05 am for an 8 am new patient appointment with a check-in time of 7:30 am.  My appointment runs from 8am-845am, but by the time they finish filling out paperwork, measure their vitals signs, check of Meaningful Use criteria in the electronic medical record (as required by insurers), I will be lucky to be in the room with the patient by 8:25 am.  That leaves me 20 minutes to do something that I scheduled for 45 minutes.

Beyond condensing the entire visit, there are a few other downsides to patient lateness:
1. The patient is usually not in the right mental frame of mind for the visit.  If they are late, it's usually for some reason (running behind with their kids, traffic, a meeting ran over), and their mind is otherwise occupied.  One of the most important reasons to arrive early is to help the patient clear their mind and get in the right mental state for the visit.  Indeed, we design our intake forms as a journey to help the patient learn what information we will try to gather, so they can think of their answers in advance.  The harried, hurried patient is not in the right frame of mind to do this.
     I had two late patients yesterday, for example.  My second late patient is a very sweet woman who apologized for being late, and then tried to cram all of her history into 2 minutes.  I then spent several more minutes slowing her down so I could take an appropriate history.  This made me late for my next patient, who fortunately was very understanding.  (I also gave him a Starbucks gift card as an apology for being late).

2. The patient needs the time more than I do.  If I give a patient a diagnose of a "grade 2 tibial-sided medial collateral ligament sprain" - I immediately understand what that means, but the patient needs time to contextualize that information.  More than anything, they often need a pregnant pause so they can reflect on what they just heard.  That is extremely hard to do when you are trying to do 45 minutes worth of work in 20 minutes.


So, the patient who arrived 5 minutes late to their appointment (but really 35 minutes late for their check in) may push the entire morning 1/2 day back by 15-20 minutes.  If you throw in any other factors (phone calls, patients who need more time, emergencies), and the whole day gets backed up even more.  This is what happened to me yesterday- the second late patient pushed me back for the rest of afternoon.  I could "make up time" by truncating everyone else's visit because someone before them was late, but I made the deliberate choice to prioritize giving everyone else their full allotted time.

And this brings up an important point- mathematically, the expectation SHOULD be that physician's run on time less frequently than patients.  Much as with the airlines, once one patient is late, the options are:
1. Don't see that patient
2. Truncate that patient's time (which is very hard to do, for reasons noted above.  In particular, they are so harried by their lateness, they don't engage in the visit as well.  As a rule of thumb, late patients take longer than patients who show up on time.  In part, a high proportion of late patients are not great with time management)
3. Truncate the time of the other patients who did show up on time
4. Run late for the remainder of the patients in that half day

Sometimes a late patient in the morning half-day can cause a backlog into the afternoon.  I don't take a long lunch, and sometimes I have lunch meetings, or calls with insurance companies that can take 30-40 minutes.  So it is not uncommon that the 1 late patient in the morning can cause my entire day to back up.  

Yesterday for example, I had a patient who showed up 45 minutes late for his 30 minute appointment, so I saw him at lunch and didn't take any lunch time for myself.  I am not a martyr, by the way, and this does stink.  I would like a lunch break- after having a morning of high density cognitive work, it helps to have a break to allow my mind to reset.
      During that lunch that that I was seeing the late patient, I received a phone call from the athletic trainer for one of my college athletes in another state.  I called the athletic trainer back after I saw the late patient, but that pushed me 8 minutes into my first patient of the afternoon.

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Beyond the logistical nightmares of late patients, it's stressful.  One of the underrated challenges of being a physician is the health cost of going from one intense conversation to another.  Even the very pleasant conversations are a stressor, albeit a delightful one.   I just received a very nice email from a patient about how he made 4 positive changes in his life and how it's helping his low back pain.  I'm delighted and this will be one of the highlights of my day.  

But it also takes emotional energy.  It's challenging to go from one conversation where I've been expending a high amount of cognitive energy, stop on a dime, and then walk in another room and be ready to give a patient my full attention.   

One common outlet I use for this is talking to my partner Garrett.  During the course of a typical day, we'll stop and have 2-3 five minute conversations, mostly about a patient care decision we wanted to run by the other person.  I think this is an important part of care, both in terms of sharpening my clinical acumen, but also giving my brain a brief respite before seeing the next patient.  Because I feel that even more than my time, my patients deserve to have my mind fully engaged when I see them.

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The bottom line is that I really don't like being late for patients.  I think it's rude, and to the extent that I can control the issue, I want to.  There are some factors I can't control (emergencies), and there are some factors I can control but something else takes a higher priority (spending extra time counseling patients who need it, taking calls from other clinicians who call me).  I've adjusted my schedule as much as I can by not double booking and making longer appointments, but there is an upper limit before I would go bankrupt and have to close the practice.

The one factor I just can't seem to control, though, is late patients.  The one place I know that doesn't routinely have late patients is on site military hospitals.  As one career officer told me last weekend - "if I'm 1 second late for my check in time 15 minutes before the appointment, my appointment is cancelled."

I've asked my physician friends what their rate for late patients has been.  In our office, it's probably 1-in 5 or 6.  Many of my colleagues estimated their rate was well over 50%.  The lowest I heard anyone say was 1 in 10.

I tried researching this on resources like PubMed, but there was not a lot of information. My motivation is trying to improve my "on time" performance by addressing the largest contributing factor, which is late patients.

So I reached out to the "Dear Mona" column on the 538 blog.  Mona's niche is researching statistics on hard-to-answer questions like what % of people pee in the shower, or how long should you wear your socks before they start smelling.  I've historically been a big fan of Mona's column, as she will typically cite multiple sources for her claims, and usually expressed a healthy skepticism if the initial answer doesn't match her expectations.  I figured that Mona would research multiple studies on "What do dogs and cats swallow?" she would put due diligence in trying to find an accurate answer to my question.

This is the letter I wrote to Mona:

"Dear Mona,

I am a physician, and like many, the bane of our existence is patients arriving late for our appointments.  I would estimate this happens for about 1/3 of patients, but I would love some hard data.  I've had a hard time finding definitive numbers.  I'd love if you would do a column on this topic.

Thanks,

Gary"

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Mona published an answer to my question on her blog published on her blog on September 25.

How did Mona do?  Well, she cited one article.  Obviously, this is not as pressing an issue as peeing in the shower or figuring out what dogs swallow, but I was disappointed that she based on her conclusion on one article.  In particular, this article cited a late rate of 1-in-13.  Outside of military clinics, this sounds like a massive outlier, since it is a rate substantially lower than any clinician I know.  I had hoped she should would have approached that result with the same healthy skepticism she has given to other topics.  She seemed quite willing, however, to take this one articles result at face value.

Mona's column was 656 words.  Here is the breakdown on those words:
- Words used answering my question: 184 words
- Words used to comment on doctor's being late: 200 words
- Words commenting on lateness in general: 272 words

So, it doesn't appear that it Mona's priority was to answer my question, but rather to change the discussion into a commentary about doctor's being late.  It's her column, and she can do what she wants with it, but I would consider this a form of low level doctor criticism.  It's by no means the most inflammatory I've seen this week, but is part of a larger and unfortunate trend in the media to bash doctors.

I'll take some responsibility.  My phrasing "bane of my existence" is harsh, and implies that my issue is disliking the patients.  I can see how that might get Mona's feathers ruffled and how she might have felt a need to put me in my place.

A better wording of my actual sentiment would be "I don't like being late for patients.  I know it bothers them.  Moreover, if hurts every patient downstream for the rest of the day.  It also hinders every communication the remainder of the day, and makes me incrementally a worse doctor.  Since, by far, the largest factor contributing to my lateness is patient lateness, I'd like to do something about it, partially for me, but mostly for the other patients who are affected.  To help me address this issue, I need some data to help assess the scope of the problem.  Do you have any actual data to help solve this issue?"

That's a more honest expression of my feelings.  It also makes for a less entertaining column.

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Mona's column has a comments section.  As of 10/1/2014, this is the breakdown of the comments:

Clearly positive toward physicians: 7 comments
Clearly negative toward physicians: 10 comments
Neither pro/con physicians: 9 comments

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So, what do I conclude from all of this?

I'm not sure.  The problem I am trying to solve is this- I want to have a high "on time" percentage with my patients.  To the extent that I have data, I am significantly above average in this regard, but I'd like to be better.

I've been working with our team to get better on the 55% that is within our control.  I would like to tackle the 45% that I've attributed to patient lateness.

I also, sadly, recognize that public sentiment is not on our side.  Based on the amount of words in Mona's column and the comments in her column, there is a slight predisposition to view physicians more negatively than positively.

One solution is to ignore the issue.  I don't think that is the right approach.  Hopefully, this blog post at least enlightens patients on some of the issues we are trying to think about, and I am certainly open to suggestions on how we can get better.