Jeff Segal, MD, JD, FACS
CNN.com recently reported the case of Elaine Farstad. An IT specialist from Everett, WA, who became angry when her physician was late for a scheduled appointment, Ms. Farstad calculated her hourly wage rate and billed her doctor for the time she had to wait – to the tune of $100. Interestingly, her doctor sent her a check for the full amount.
In fact, many practitioners are now using cash, gifts or credit for future appointments to “compensate” patients for time spent in waiting rooms.
To be sure, most doctors are not drinking coffee and reading the paper while patients are waiting. More often than not, they are seeing other patients who demand and need additional time. Complex clinical questions rarely reduce to a satisfactory solution in 5 minutes. These unpredictable “interruptions” have a cascade effect, not dissimilar to catching a plane from LaGuardia late in the afternoon.
The airlines have already come up with their solution. While it used to take one hour of flying time to get from New York to Greensboro, N.C., today, the difference between departure and arrival time for the same flight is often closer to two hours. So, if the plane lands within that two hour window, the stat books record it as “on-time.” But, in reality, the passenger had to wait.
The airlines also have another tool. If the departure time is likely to be delayed, they can use automated text and email notification systems to warn the passenger. The passenger can now use the extra time more productively than purchasing overpriced food in the food court. Analogously, many doctors’ offices notify patients if the doctor is behind. And some offices provide pagers to patients so they are not confined to the waiting room competing for year-old copies of Readers’ Digest. Most patients appreciate this courtesy and these methods generally sidestep any anger most patients have for waiting.
I know that when I call tech-support for software snafus, I prefer knowing I will be in queue for 25 minutes as opposed to “unknown” wait. I can leave the phone on speaker and work in the background. When the support technician is available, I am ready to go.
Most patients understand that if they are kept waiting, it is because the doctor was tending to patients before them. They rightly assume that if their problems are complex, doctors will take a reasonable amount of time needed to solve their problem. And the next patient will be delayed.
The airline industry is hardly the best role model for how service should be delivered. But their technique of notifying the “customer” when flights are delayed 30 minutes or longer could be a good idea. The broader issue here is establishing pro-active communication that rebuilds the doctor patient relationship – a relationship that has been under attack for many years. If we can address this greater problem, then I doubt any patients would send their doctor a symbolic bill.
Related:
Thank you Dr. Segal. This is the most thoughtful response I have seen on the issue to date.
Hey Jeff ~ As the physician who posted the original video that CNN picked up to break this story I feel compelled to comment. The primary objective of my 58 sec. video clip was to share Elaine’s story of confronting the double standard in medicine. Patients have to pay fees for missing appts. or canceling less than 24 hours, but physicians who are clearly in error (oversleep, don’t show up to work etc. . ) are not held to the same contract. 99.99% of patients just want a simple apology and an explanation.
Original video: http://www.youtube.com/watch?v=vxF0ISyuvSA
Pamela Wible MD
From MedPage comments:
Dr. Jacob R. Raitt – Jul 08, 2011
Hurrah: I began to do that in 1968 when I had to take my infant daughter to a dermatologist. I called early, told the person who answered that my daughter had diaper rash and how I was treating her. We arrived at the office 15 minutes early, waited more than 3 hours, and when the doctor finally made her presence known she told me that my daughter had diaper rash, and wrote a prescription for the medication I had told them I was using. When I went home, I immediately invoiced the doctor for $75, ignored her bill and compounded interest monthly. When my bill to her exceeded $100 I started action in small claims court. She paid me, and ever since I have always told doctors what I would do if kept waiting more than 15 minutes. Other than in cases of emergency, I have never been kept waiting.
From KevinMD comments:
Jose:
First of all, I am a physician, but the common denominator here
is respect. Recently a family member of mine went to the doctors
office and on the way was stopped by a Police Officer on the way
from the Airport to the doctors office, making her and her husband
literally 5 mins late to his appointment. The administrator told my
uncle that it was too late and that it did not matter why they were
late, but to expect a bill for not showing up on time or canceling
with a 24 hour notice. He was in a hurry and needed a physical
ASAP, he made an appointment for the very next day and to his
surprise waited 2 hrs in the exam room before the doctor
“got to him” no apologies were made and was just told that the
doctor was running a LITTLE late. When he asked to speak to the
administrator and told her that he had been waiting for 2 hours
and without any explanation she said that he was just running a
LITTLE behind, that he needed to be patient. This is what kind of
sent him over the edge, being that he had not received that patience
or understanding just the day before. When he said that he was going
to bill the physicians office for his time and lack of medical attention,
the administrator dismissed his comment and told him that he was
free to go to another doctors office to be taken care of if he was not
happy with the attention he was receiving (which is just what he did).
This lack of respect is what gives many of us a bad name, making
patients feel like we think we are superior to them and think that
our time is more valuable than theirs, alienating us from our patients.
I am so tired of attacks on physicians. There are both good and bad in every profession, but for some reason people feel compelled to attack physicians. It has become an acceptable past time. Just look at congress. They even begrudge physicians earning a decent living, of course they are mostly attorneys. People complain and call them everything but there name, until of course they’re in the emergency room clutching their chest crying for help and they want their doctor by their side immediately.
My husband is a cardiologist with a very busy practice. Patients will sit and complain about waiting, yet when they are in the exam room they are MORE than happy to take as much time as they wish! Do they think the clock magically stops while they are in the exam room with him? Does he cut them short and rush them out because their 15 minutes are up? Of course not! Then the complaints would be, he doesn’t care because he pushes you out the door in order to keep up with his schedule. That’s not how he does things anyway. He listens and makes certain all of their questions are answered before they leave. He runs late because he feels it’s important they each feel their concerns have been met. You would be shocked how many times people will complain that they have been waiting for 30 minutes for their appointment and he has to rush off to the emergency room for a patient that is having an MI. They think it is inconsiderate for him to leave! That has actually happened on more than one occasion!
Here are the facts:
We have become a society of narcissists. It’s all about me. My own little world, population me. How dare he keep ME waiting. How dare you inconvenience me. Never mind the fact that he took longer at the hospital in the morning because a patient was having significant problems. All they care about is that when they come into the office, they don’t have to wait more than 5 minutes and that everyone will dote on them. Well due to the decrease in reimbursement over the years and of course overhead does not exactly go down, most offices have less staff than in the past so the “doting” is now minimal.
Additionally, most people have NO IDEA of the sacrifices the good physicians have made in order to practice quality medicine and to save their bacon! The little league games, the recitals and dinners that have been missed or interrupted. These are things that we as a family will never get back.
As far as charging for missed appointments, this is not common practice although Dr. Wible made it sound as if it were, I know this is not our practice nor any other physician I know. Perhaps she is guilty of that practice. Shame on you Dr. Wible for not standing up for the quality physicians that truly do care about their patients. It’s not all about the clock, some patients need more than their scheduled time, however we never know until they are in the exam room.
Well in the not to distant future, people will be in for a rude awakening. Physicians are leaving private practice and even medicine by the droves due to all of the changes in medicine. Less college grads are entering medicine as well. There will eventually be a physician shortage and people will be looking back at the 30-60 minute wait with fondness and nostalgia, that is when they finally do get an appointment with a specialist.
I am incredibly offended by the fact that people are applauding billing doctors for being behind on their schedules, or even being proud of threatening their doctors with lawsuits if they are made to wait. Mutual respect is always important and if I am running behind, I tell my patients in advance and offer them a chance to reschedule or wait.
Patients do ultimately have a choice…why wait 3 hours if you absolutely have a schedule conflict. If you can’t wait more than an hour, just leave, go somewhere else, and never come back. How can you expect to bill someone for your time when it was ultimately your choice to wait. These doctors just paid off the bills because they did not have time to hassle the situation, and probably not because they thought they were wrong.
Yes, I’ve waited before for a doctor as a patient. Its just one of those things. I’ve waited an hour for a doctor and 3 hours in the ER. I chose to wait and wouldn’t expect to bill them for my lost time as a specialist. Schedules get behind because the patient’s cases are complicated, not because doctors are playing golf.
It means we ,the doctors should now starting telling patients,’your time is up,if you have any further questions you ‘ll need to make another appointment.’
Patient wait times continue to rise throughout the United States. A great deal of this problem, in all actuality, is due to physician offices lack of efficiency. I do not believe this is really an attack on a physician- and it looks like Jeff agrees with me. It is an attack on the industry, an industry that holds many double standards.
There are many different methods to ensure patient satisfaction. For instance, does your office staff greet the patient, exlain there is a wait, why there is a wait, how long the patient should expect to wait, etc. All to often, physicians are inclined to allow people with relatively low educations, manage their office. There is a reason Wal-Mart hires elderly people to greet everyone at the door.
In my opinion, 95% of patient complaints have to do with the office staff. If a patient is going to be upset, it is generally because the staff treats them as if they are a burden.
Physicians need to truly evaluate the way their staff provides service to their patients. Simple things make patients happy. Have coffee available for the patients, exlain delays with honesty, remove signs that are intended for complete morons (You must pay! signs), have staff be professionaly dressed (take pride in their work- scrubs are ugly), etc.
Then, above all esle, if you have wait times that average over 15 minutes, do not charge for no-shows and late check-ins. Rather than charge them, have a policy that states if it occurs 3 times, the patient will no longer be seen at the office, and then discharge them if it occurs. I can assure everyone, if you no-show for the patient 3 times, they will not come back.
A side note- I am not condoning paying a patient for waiting. In reality, the physician who paid the patient needs to look at whoever is writing his checks. It would never be considered a valid bill. I am sure this physician has someone approving checks that are going to a lot more places that are not vendors for the practice.
Enough is enough already!!!!!!! When patients will have each appointment be like a day at the emergency room in terms of waiting and care mabie they will get that their lack of respect for physicians was a huge part of the medical system falling apart! !!!!!1
He should have never sent the patient the money.
An apology should suffice.
While we have it in all our forms that there is a missed appointment fee, I never bill it.
I have had patients say the same thing to me in the past. “I should bill you for the time you kept me waiting.”
My response is should really be, if you miss an appointment, it is a 300$ charge. I should also bill you for phone calls, letters, etc.
We always tell impatient patients to schedule first appointments of the morning or afternoon.
Frankly, I think they are rude and do not mind if they go somewhere else.
I also remind them that there are sicker and dying patients in the waiting room. Guilt still works.
i’m leaning more to agreeing with Dr. Wible. i’ve seen lots of arrogant physicians who seem to feel they are more important than their patients, about as many as patients who feel the sun rises and sets on them. Since there are way more patients than doctors, it suggests to me that doctors may be guilty as charged. Everyone knows that emergencies will come up but when doctors consistently run late for no reason that i can see, then they need to come up with a better way of doing business. Unfortunately that’s one reason that the non-doctors have such a following; they give good customer service. With modern technology, no-one has to be left in the dark about delays; that gives patients options on what they want to do. It’s not about their being selfish, it’s about us caring for the patient in all aspects of their lives.
I do not pay patients for being late, but I definitely apologize and explain to them that I was delayed by patient(s) who needed a little more time than usual to sort out some difficult problem. These people are the source of my income and they deserve the simple courtesy of an apology for delayed service. They have lives, too!
They told us in Medical School that the most important issues generally come out at the end of the visit (usually as you have just signed off the patient’s encounter in the EHR!!!). They were right, and it’s up to us to deal with that fact, regardless of how inconvenient it may be.
@Disgusted!!
Awesome response. I too am disgusted by patients who give so little respect to the people who are trying to make you feel better. You do not have restaurant reservations and you are not in line at starbucks. If you are a patient, you have an appointment with someone who has spent years in training and sacrifices events in his/her own life to care for patients. most of us still abide by the oath we took at med school graduation. I am quite certain most patients do not want to be the one appointment where the doc hurries up to get back on schedule.
Patients also need to look at themselves. How many times does a patient arrive at the appointment time rather than the 15 min early they were asked to to fill out paperwork only to take another 30 min to fill out the paperwork. They have missed their appointment and need to be fit back in the schedule. How many times does a patient whip out a laundry list of complaints in addition to new ones when they are scheduled for a 15 min follow up and/or need a procedure done at that time.
@Dr Wible– you comment regarding your rationale for payment confuses me. Most doctors are not late because they oversleep or do not show up for work. most doctors run late because they are taking care of patients. To use this as an excuse for paying a patient off suggests guilt of the same.