Getting there is half the fun

Yeah, right. Your six-year-old wakes up this morning with a really sore throat, a cough and a fever. Or maybe she has an earache. Or perhaps you've found a lump in your breast. Your family doctor's telephone receptionist gives you the run-around, "Our next open appointment is in six weeks. If you're really concerned, go to the hospital emergency room . . .would you like their number?"

No, thanks, you already have their number. A doctor who has never seen you before, and likely will not be on call the next time either, will put an automatic thermometer in your kid's ear, glance down her throat, and give you a prescription for a cough syrup you've already tried at home. See your doctor in three days if there's no improvement. Your doctor's already-full schedule is not the ER doc's problem. You'll get a bill for several days worth of your wages, and are no better off than before you came in. The ER doc is reasonably sure your child will be better soon, but he fails to convince you.

This really doesn't need to happen. You shouldn't have to use the expensive ER for an urgent, but non-emergency problem just because no doctor's office has any time open.

Doctors who allow the front desk to fill their appointment schedule chock-full ahead of time are not thinking things through. Common sense will tell any primary care doctor that many people's sickness appears without warning and they need help today, not next week or next month. And people merely needing a follow-up visit usually don't care if their next appointment is seven days or seventeen days from now, as long as they know they have one..

During my partnership days, my partners' habits drove me crazy. They all booked all their time in advance; one doc overbooked two extra people for each hour "because someone might not show up." Our large waiting room was usually full of irate patients, some of them waiting two hours after their appointment time. My partners were good doctors, but were clueless about office management, as long as the office looked busy. "The patients can always get in; they just have to wait a while if we're busy."

I decided I could run an office better by leaving the partnership and going solo, and I did.

Here is what works: The doctor sits down with his staff and they decide how much the average routine visit takes of the doctor's time. Not how long he'd like it to take, but how long it really does take, according to the people who work with him. Say, for example, that on average he can handle four visits per hour. More complex problems—a new patient, or a new pregnancy— might take 30 minutes or an hour, and so would have one or more extra time slots assigned. In my own practice, I could usually handle repeat office visits in 15 minutes. Saving some time for hospital rounds, record-keeping, minor surgery, etc. each day, I usually had around six hours per day for patients' office visits.

I told my receptionist she could fill two 15-minute slots for each of those hours ahead of the day. A third one each hour could be filled from the phone calls from people who wanted to get in that day for something they thought urgent. The fourth slot each hour was saved for walk-ins. People rarely had to wait more than 10 minutes beyond their appointment time, unless I had emergency surgery or a baby delivery in progress.

Was it a problem to have an occcasional empty appointment slot? Not for me it wasn't. I used the time to return phone calls,sign or dictate letters, catch up on my medical journals, order supplies, or enjoy a cup of coffee at my desk. My patients were more relaxed, and so was I, not having to keep pace with an always over-full schedule. I found that it's not always necessary to bring someone in every month just for a blood pressure check or a blood sugar, once their condition stabilized.

Not every patient who only had a question required an appointment; sometimes the question could be handled by phone. My receptionist always brought the patient's record to my desk along with the call-back number, She only called me out of a patient's exam room if she judged the call truly urgent, or if another doctor was calling about a patient, but I tried to answer the less urgent calls as soon as possible.

This system of scheduling even gave me time to see occasional people who hadn't been able to get an appointment with their own doctor. Many had a problem that could be dealt with in a single visit, after which they could go back to the other doctor again.

So - Doctors, rethink your appointment scheduling. Packing your schedule full ahead of time causes tension, always trying to keep up, and it makes your waiting patients fidgety, even miserable if they are feeling pain or are otherwise ill. You'll also be more at ease if you get in the habit of starting on time, and limiting the length of your coffee break. (Read the newspaper at home.)

Receptionist, If the doctor is unavoidably behind schedule (and hey, it can happen) let the patients know. If the doc is way behind, offer to reschedule them. If he's avoidably behind very often, let him know.

Improving Medical Office Efficiency

I recently talked with two acquaintances, about a week apart, who had complaints about their doctor's office. Neither of these families had ever been patients of mine, but people tend to bring up medical subjects when they learn that I write about medicine. Both had complaints about their doctor's office help.

"It was embarrassing," one told me. "The doctor told his office girl to make me an appointment with the urologist (kidney specialist), and she made one with a doctor who turned out to be a neurologist (brain specialist). The neurologist sent me to a urologist not far away, and didn't charge for his own office visit, but why wouldn't she have known the difference?"

The other patient had had at least six back surgeries over the years (laminectomy) and no surgeon would now touch his scarred back. His local doctor was trying to manage the pain on various pills and patches, some of which eased his chronic pain, but not the "lightning spasms" that struck when he moved wrong. Additionally, over the years, he had developed reactions to some of the medicines, and the doctor was trying a new one. Medical insurance refused to pay for it. The doctor's office clerk said she would try and straighten the matter out, and would call him back.

She never did, not even to let him know the problem. He finally called his pharmacist to see if he could afford to pay for it himself, and found to his horror that a month's supply was priced at $525.00, half his entire monthly income, Presumably, the clerk could have found that out, but if she did, she never let him know. Presumably, also, the doctor should have known the price of the new medicine, but salesmen rarely mention that. Most doctors subscribe to a service that publishes latest drug prices, however.

Such things happen when new help is hired and isn't taught what the job involves, beyond how to fill the doctor's appointment book and send out the bills. Often there is frequent turnover of staff, either because of low pay, poorly qualified help, or poor instruction.

I learned, early on, to pay my staff a little more than the going pay rate, and to make an office instruction book covering phone etiquette, appointments, unhappy patients, inability to pay, emergencies, unavoidable delays, prescription refills, salespeople, etc. and updated it as needed. Knowing the price of my patients' medicines was my responsibility, and I tried to keep up to date and practical. I learned to try the more familiar, less expensive medicines first before going on to the "latest new drug" unless there was some specific reason to go directly to the latter.

The way our patients perceive us depends a lot on the people we employ. If you don't enjoy training new help every few months, Doctor, pay attention to them - the nurse, the technician, the clerk, the janitor, everybody, so they will stay with you. Competence and caring count, both yours and theirs.

Your office staff is one of your biggest assets. Treat them right. Don't leave it all to an office manager.

Mr. President, Medical Computer Systems Aren't that Simple

"When everybody has computers, communication will be efficient, and medical costs will come down." This is what medical experts say.

Yah. Just about everybody in medicine already has a computer. It just can't communicate with all the other computer systems. Remember the 9/11 Commission report about New York's twin towers? Firemen's radios weren't on the same wavelength as the police, and City Hall had still a different system. Communication was chaos.

Recently a friend told me that because the U of Washington medical center in Seattle designed it's own computer system, our local Kootenai Medical Center can't communicate with it directly, but had to send his MRI report by a disc delivered by the postal service. His treatment was delayed by three weeks.

Doctor groups, insurance carriers, and government offices are in the same situation. Each listened to a different salesman, whose product was always "the best", and they spent hundreds of thousands of dollars buying, installing, training in the use of, and maintaining, their system, only to find out that the hospital or the next office down the road had a different system. They aren't about to pay out that amount of money all over again. "Let the other guy match up with me" is the common attitude.

Never mind that there are hackers out there in cyberspace that can break into any system. Only last month the news was full of someone who had accessed the social security numbers of millions.

Never mind that there are now double the number of clerks in every doctor's office, to transcribe the dictation for the records, and each clerk has to be paid. Never mind that the average patient's medical record has ballooned to ten times the number of pages it used to be before the computer age - computers can print it all out in a few seconds, but how long does it take to read through all those pages to find the information you are looking for?

Never mind that computers can crash, or records disappear into cyberspace, if there is no hard copy backup.

And never mind that doctors and nurses still make medication errors even with everything computerized. The data is only as reliable as the typist and the reader.

Computers are a necessary advance in medical information transfer, but so far they are not money savers. And mis-information can still spread—even more easily spread—by computer.

"Now, Dear, we don't really know that yet."

My friend, herself a retired RN, has two stories to tell. The first happened when she was in her third pregnancy, with a past history of rapid labors, and she arrived at the hospital's emergency entrance "with a continuous contraction."

"I need to go to the delivery room," she told the nurse.

"Well, first we need to get your name, address, and name of your insurance." The nurse was proceeding by rote.

"I need to be in the delivery room!" gasped her patient.

"Everyone is in a meeting just now," soothed the nurse. "Now, your name?"

"HERE COMES THE BABY!" That finally focused the nurse's attention.

Fast forward fifty years: My nurse-friend has been referred to a gastroenterologist by her family doctor. A nurse practitioner is taking her history.

"I have upper abdominal pain. My GP found GI bleeding and a low hemoglobin."

The nurse smiled patiently. "Now, dear, we don't know that."

My friend had her family doctor's lab reports, but as often happens, the specialist only accepted reports from his own lab, "to eliminate error."

Before he would treat her, he required a gastroscopy (passing a scope down the throat and into the stomach to take a direct look.) "We're pretty busy," the patient was told, we can schedule you for six weeks from now." No medicine was supplied for the interim.

My friend returned to her family doc who gave a prescription for Prevacid. Taking that for six weeks healed her pain, and the gastroscope showed a stomach that by that time was almost normal.

Were she my patient, I would have just given her the prescription at her first visit and called in the specialist only if she wasn't improving after a week. Tests for blood in the stool, anemia and for Helicobacter (a common cause of duodenal ulcer and bleeding) can be done in the office. A scope should be done to rule out cancer, but the cancer will still be there when the specialist gets around to doing it.

My question to the specialist and his nurse would be, "Why don't you know that? Why didn't you confirm or disprove the family doctor's data at first visit, at least look at his lab reports, and save your patient time, worry, and money?" Sometimes it seems like no one listens to anyone else.

Nurses versus Surgeons

Seven a.m. in the surgical hallway of Fort Anonymous U.S. Army Hospital on a dark December morning. Nurses in clean surgical scrub attire hurry between Central Supply and operating rooms with bundles of instruments and sterile drapes. Others wheel patients on stretchers, each to an assigned operating room. Anesthetists check their gas machines and syringes as the surgical teams gather at the scrub sinks, cleaning hands and forearms the required five minutes with antiseptic soap.

“I can’t find my scrubs!” a surgeon complains to the chief operating room nurse as she walks by, her eyes checking her nurse lieutenants as they go about their assigned tasks.

The chief nurse stops to look at the surgeon, then at the nearly empty rack where surgical scrub suits for the operating rooms are stored. “Why do you suppose that is?” she asks him.

“It’s not my job to know why that is,” he fumes. “My job is to be in the Operating Room fifteen minutes from now, ready to operate. Where are my scrubs!”

“Well, let’s think a minute,” she says. “How many scrub suits are hidden behind your desk in your office? How many stayed on the floor in the intern’s lounge when you changed back into street clothes last week? If you don’t put them in the laundry hamper, Major, they don’t get picked up. I can’t give you what I don’t have.”

“I don’t care about that,” the major snaps, “what we need in this OR is one of those scrub-dispensing machines!” He stamps off down to the laundry department to harass the workers who unload the laundry delivery truck each day. But they really couldn’t do anything about scrub suits the truck hasn’t picked up, and therefore can't deliver again.

“Dispensing machines don’t solve the problem,” the chief nurse remarks to her assistant. “The hospital in San Antonio had them when I worked there as an instructor. You have a card to insert, you punch in your size, and out comes a scrub suit. But the surgeons can’t be bothered to dump them back into the machine’s bin at the end of the day and get their card credited. If they don’t return them two days in a row, the machine voids their card and they come screaming to the nurses again.”

She turns her attention to another surgeon who is demanding a certain surgical instrument NOW. ”Dr. B is using it in Room 3,” she said. “We can have it resterillized in about 20 minutes.”

“My patient is on the table now. I need it now."

“It’s already in use. You didn’t think of that when you changed your scheduled time for this case, did you,” she says patiently.

“Look, I’m a surgeon. Surgeons operate. Nurses get instruments ready. If that one’s in use, get me another one from the supply house.”

“The supply house that sells that instrument is in Omaha,” she says sweetly. “I can ask them to send it urgent express, and we can have it for you on Wednesday. Otherwise we have to wait till Dr. B’s case is finished in a few minutes and we resterillize the one we’ve got.”

“I’m going to bring this up in staff meeting.” He strides angrily off down the hall.

“Do that,” she calls after him. “I’ll give you the serial number and cost figures. It’s expensive.”


Five hundred people attend the all-hospital Christmas dinner a few days later. Part of the entertainment after the meal is Christmas carols. Each group of tables is assigned one verse of “Twelve Days of Christmas.” The operating room crew’s tables are assigned to sing “seven swans a-swimming” with each successive verse.

“Colonel, Ma’am?” A nurse lieutenant leans across the table. “Seven swans a-swimming sounds kind of dull,” she says. “How about ‘Seven surgeons screaming’?”

“No,” says another nurse, “They don’t actually scream. What else could we say?”

The chief OR nurse lets them work it out. They finally agree on “Seven surgeons whining.” The chief nods. This isn’t her idea, but it expresses the thought.

“The Colonel says it’s okay,” is whispered from nurse to nurse down the row of tables.When the sixth verse of the song finishes, their verse is next.

“On the seventh day of Christmas my true-love gave to me-" The surgical nurses rise as one and sing out, “seven surgeons whining–"

There's a pause in the large hall. “I don’t think those are the right words,” the song leader says from the head table. “Let’s try again. On the seventh day of Christmas my true-love gave to me–"

The surgical techs rise again, “Seven surgeons whining-"

In the following silence, two or three voices from the surgeons’ tables are heard, “Hey, now, what is this?”

“See?” a nurse exclaims triumphantly, “there you go again!”

Later, as the party breaks up and people are saying their goodbyes, the chief surgeon and the hospital commander come over to the chief surgical nurse. “Colonel, what are you doing to those nurses?”

“Wasn’t my idea,” she says. “But, ya know, sometimes they need a little morale-building. See y’all Monday morning!”