This problem, waiting, is to me the worse fault in the system.  Almost
criminal, to my way of thinking.  And who among us has not had to wait for
holidays, vacations, etc. to be told lab results.  We try to rationalize
that if the results were bad, we would have been told, so they must be good.
But this is not the case enough times to make the waiting and the waiter
totally nuts.
Jackie
The New York Times
August 20, 2005

Sick and Scared, and Waiting, Waiting, Waiting
By GINA KOLATA

Freddie Odlum spent two terrible days waiting by the phone for her
doctor to call. She had had a CT scan to investigate a suspicious mass
in her lungs and Ms. Odlum, a Los Angeles breast cancer patient, was
all too aware that if the cancer had spread, her prognosis would not be
good.

Her doctor, she said, informed her that he was going on vacation in two
days and "that we needed to 'wrap this up' before he left for a few
weeks."

Photo 1:
http://tinyurl.com/exgok
Caption:
Nicole Bengiveno/The New York Times
In the oncologist's exam room, Pam Breakey, a cancer patient, waited.

Photo 2:
http://tinyurl.com/98m8r
Caption:
Nicole Bengiveno/The New York Times
Being a patient requires, well, patience, but the infusion is the day's
last stop.

"All those clichés when someone is facing a terminal diagnosis are
used because they are true," she said. "Racing pulse, dry mouth, total
self-preoccupation with what-ifs to the point that real life doesn't
exist, willing the phone to ring."

But her doctor did not call.

The next day, the day he was leaving, she left phone messages at his
office and sent an e-mail message saying, "Don't leave without calling
me with the results."

"That night I waited," she said, "jumping at every noise, not letting
anyone use the phone, imagining every scenario."

Her doctor left for his vacation. He never called, not even when he
returned.

The scan did not show cancer, but she could not forgive her doctor.

"This internist had been my family doctor for years," Ms. Odlum said.
"This physician's wife had breast cancer and was treated by the same
oncologist as me."

How could someone whose wife had breast cancer not realize the impact
of being left hanging, she asked, adding, "I never spoke to him again."

Waiting has long been part of medicine. Patients like Ms. Odlum wait
for test results; others spend weeks or months waiting for appointments
or stranded for hours in doctors' waiting rooms.

But health care researchers say the waiting problem has only gotten
worse. Advances in technology have created more tests and procedures to
wait for, and new drugs and treatments mean more people need more
doctor visits. Doctors' appointments for people over 45 increased by
more than 20 percent in the last decade, according to the National
Center for Health Statistics. Emergency room visits increased by 23
percent, although the number of hospitals declined by 15 percent.

Some doctors say they doublebook appointments to make up for patient
cancellations. And doctors say they are pulled in so many directions
that, in many cases, long waits are unavoidable.

"There is nothing magic about waiting," said Dr. Charles K. Francis,
president of the American College of Physicians.

"Most of us have patients in the hospital and patients in the office,"
Dr. Francis said. "Then the patient has to go to the lab, and medicine
is unpredictable."

He added that insurance companies reimbursed doctors at lower rates
than in the past, resulting in intense pressure to see large numbers of
patients. "You have to work long hours and see more patients just to
keep your office open," he said.

Recently, however, patients, some doctors and researchers have begun to
ask why medicine cannot be as accountable to its customers as any other
business. And some doctors' offices and hospitals are starting to solve
their waiting problems by applying techniques that businesses use.

Change cannot come too soon for irate patients like Howard Levine of
Boca Raton, Fla., who endured a two-hour wait before storming out of a
vascular surgeon's office.

"I was in the restaurant business for 20 years, and if I made you wait
in a restaurant for two hours, you would be pretty upset," Mr. Levine
said. "We're not coming there for social visits. We're coming because
something is wrong."

While all waits can be frustrating or even infuriating, the worst, many
patients say, are when they fear getting bad news.

"The hardest waiting," said Pam Breakey, a cancer patient in Michigan,
was the five weeks from when she initially suspected she had breast
cancer until the day she started treatment. Cancer was always on her
mind. And everything required waiting: appointments with the
oncologist, the surgeon and "test after test, I stopped counting at
20."

There was waiting "to learn if the cancer had spread," she continued.
"It had. Then waiting to learn about the cancer cells themselves.
Waiting, waiting, waiting."

Her friends would call, she said, "and I have nothing to tell them."

Her husband looked at her with anxiety, her daughter's voice was tight
with fear. It is, she said, "like waiting to find out if a jury has
convicted you of something awful."

Yet while little can be done about the fact that test results can be
scary, health care researchers and doctors say a lot can be done to
improve the delivery of results so patients are not left waiting for
days or even weeks. And a lot can be done to improve waits for
appointments and in doctors' offices and emergency rooms.

Everyone can change, says Dr. Mark Murray of Sacramento, whose company,
Mark Murray & Associates, helps doctors eliminate waits. "It goes back
to motivation. The principles, the strategies are pretty basic."

A Doctor Sees the Other Side

As a physician himself, Dr. Philip Greenland, chairman of the
department of preventive medicine at the University of Michigan, had
always gotten deferential treatment from other doctors. If he wanted an
appointment, he would page a colleague and ask to be seen that day. He
never waited for test results or for doctors to call.

His epiphany came when his 89-year-old mother broke her hip.

Dr. Greenland and his brother flew to Maryland where their mother was
hospitalized, arriving late on a Saturday night.

"On Sunday at 6 a.m., I said to my brother: 'We ought to get to the
hospital. This doctor is an orthopedic surgeon, and he will make rounds
early. If we're not there, we won't see him.'

"By noon," Dr. Greenland said, "it was apparent to me that we won't see
this guy." A nurse told him that the doctor had been there and gone.

"I was in total shock," he said. "I said to the nurse: 'Get him on the
phone. Page him, wherever he is.' "

The nurse paged the orthopedist, but he told her that he was going into
surgery and that she should ask Dr. Greenland what his question was.
When he had time, the orthopedist said, he would give the nurse his
answer and she could relay it to Dr. Greenland. That only made Dr.
Greenland madder. "I said: 'That's not acceptable. My questions depend
on his answers and I will not play telephone tag all day.' "

Dr. Greenland never got the prompt attention he wanted from the
orthopedist. And he was shaken.

"What was shocking about this experience to me is that it's almost the
only time in my life since I've become a doctor 35 years ago that I
ever experienced medicine directly, from the patient's point of view,"
he said. "What this tells me is that the profession has lost sight of
what medicine is all about. It's not about them. It's not about their
schedule. It's about the patient."

He added: "Doctors are not victims here. If they are unable to handle
the workload, they need more help. If it means inconvenience, they have
to live with it."

No Waiting Here

After five years of practicing medicine, Dr. L. Gordon Moore was
miserable. His schedule was out of control, patients were piling up in
his Rochester waiting room, and they were seething.

"I was starting every patient visit late and rushing to see the next
patient," he said. "I was staying two hours late at the end of the day.
And I was thinking, This is my career?"

But when Dr. Moore asked around to see if there was another way, he was
told, he said, to "suck it up."

When he heard about an idea to apply industrial engineering principles
to doctors' offices, he investigated the flow of work in his own
office.

For example, he asked, what happens when a patient calls needing a
prescription refilled? A secretary writes a note. When a pile of notes
accumulates, the secretary pulls the patients' charts and delivers them
to a nurse. The nurse divides them into two piles, urgent and
nonurgent. It could take a day and a half before a nonurgent refill is
called in. Meanwhile, the chart could be in any of 39 places in the
office.

Dr. Moore opted for radical change. He quit his three-doctor practice
and started a new one.

"I started with one room, an exam table and no employees, just me," he
said.

Instead of having about 2,000 patients, he cut back to 500. Not only
did he get rid of waiting times, but, by getting rid of most of his
office and all of his staff, he eliminated his overhead, making his
practice affordable.

But few doctors are ready for such a solution. Most, Dr. Murray says,
tell him, "Waiting times are not bad, waiting times are acceptable."

That attitude, he noted, is part of the culture of medicine.

"It grows out of that insularity that we get to decide who waits and
who doesn't," Dr. Murray said.

He said that delays often started with the way an office was run.
Doctors assume, he explained, that the most efficient office is filled
with waiting patients, like a company making sure its warehouses are
always full. But companies have learned that there is a cost to keeping
warehouses full. The same principle applies to doctors' offices.

People get mad, Dr. Murray said. And at some point, patients start to
leave.

Long delays are why Roberta Weintraub left her doctor. Ms. Weintraub,
of Beverly Hills, Calif., said that her internist was first-rate, but
that the waits had become intolerable - up to an hour and a half in the
waiting room, then 20 to 30 minutes in the examining room. And, she
said, there was the wait for testing and the wait to get test results.
"I got to a point in my life where I could afford not to put up with
that," Ms. Weintraub said.

Now she pays $1,800 a year to be a patient in a concierge practice, in
which patients pay an extra fee and, in return, get prompt attention.
Ms. Weinstein's new internist, Dr. Judith P. Delafield, says she was
unable to prevent waits when she was part of a conventional practice
and seeing 2,000 patients.

"The handwriting was on the wall for me," Dr. Delafield said. "It was
that everyday packing of your waiting room because you have to see a
certain number of patients." Now she restricts her practice to 600
patients.

"All in all, you can control your life so you can be on time," she
added. "It's a matter of respect."

Long Waits in the E.R.

Last fall, on a day when her husband was restless and violent, Peggi
Durand knew she had to take him to the hospital for a possible
admission to the geriatric psychiatry ward. At age 59, John Durand has
suffered from dementia for seven years and Ms. Durand has cared for
him.

She and her husband arrived at an emergency room near their home in
Malden, Mass., at 9:30 a.m. They began their wait.

"John was agitated when we got there, and the longer we were there, the
worse it got," Ms. Durand said.

"We were still in the emergency room at 3:30 in the afternoon," she
recalled. "There were just waits - waiting for a social worker to
interview him, waiting for a psychiatrist. Then they had to get his
room ready."

Their wait, while long, was not unusual, researchers say.

In one study, Dr. Steven M. Asch, a health care researcher at the RAND
Corporation and the Veterans Affairs Greater Los Angeles Healthcare
System and his colleagues observed that 40 percent of emergency room
patients waited longer than an hour to see a doctor.

That, of course, is often only the beginning. Patients can wait for a
bed, wait to be admitted, wait for a scan. Typically, Dr. Asch and
others say, patients end up waiting for hours, even a day.

Hospitals often ask for forbearance. Long waits arise, they say,
because there are no beds or a flood of patients coming in.

But increasingly, economic factors are causing hospitals to worry more
about long delays. And some hospitals are paying for consultants to
help them reduce waits.

The emergency room can be a lucrative source of patients, said Dr. Saum
Sutaria of McKinsey & Company, the consulting firm, with some hospitals
making $2,000 to $3,000 for every patient admitted through the
emergency room and $250 to $750 for each patient who is treated and
goes home. But when hospitals get so backed up that they have no more
intensive care beds, they go on diversion, sending patients to other
hospitals.

"That is very painful for the hospital," said Paul Mango, a McKinsey
executive, but he added that some hospitals were on diversion 25
percent of the time.

The result is a booming business for companies like McKinsey. The
company finds problems everywhere.

For example, Mr. Mango says, over half the time, when surgery patients
showed up for their operations, simple requirements, like taking a
medical history, were not met. Mr. Mango has even seen patients arrive,
as scheduled, at 5:30 a.m., only to have the admitting staff discover
that they still need laboratory tests. But the laboratory does not open
until 7 a.m.. So everyone waits.

"It costs $60 a minute for an idle operating room," Mr. Mango says.
"There will be three or four operating room technicians, an
anesthesiologist and a surgeon waiting for a patient who couldn't get
through the admissions process."

Another common problem is that doctors wait until the end of the day to
discharge patients, locking up a bed all day. But discharging patients
does not help an emergency room unless someone tells the emergency room
that a bed is free. "Rarely are there good communications," said Dr.
Russ Richmond, also with McKinsey.

For patients, these explanations are hardly enough.

Pam Stephan of Austin, Tex., went to her local hospital near collapse.
She had had chemotherapy, had developed a fever, and now she was
gasping for breath. Her oncology center had put her off for days before
she could get an appointment. Once there, she waited for hours, and
then learned that she was dangerously anemic. "Go to the hospital for a
blood transfusion," she was told.

She arrived at the hospital at 5 p.m., but all the rooms were full and
the wait was expected to be several hours. Ms. Stephan and her husband
went home, an hour's drive, returning hours later.

"Then began a long stream of paperwork, and questions, and more blood
tests, and by 2 a.m., I actually started the three-pint blood
transfusion," Ms. Stephan said.

"I was glad to be through with waiting," she added. But by then, she
said, she was so sick and so exhausted that "dying would have been too
much trouble."

http://nytimes.com/2005/08/20/health/20waiting.html