Medical Examiner

Available Jones, M.D.

What if all patients could be seen on the day they call?

Marina Krakovsky was online Sept. 6 to chat with readers about this article. Read the transcript.

Illustration by Mark Alan Stamaty. Click image to expand.

Why do we have to wait days, weeks, or even months for a doctor’s appointment? Such delays have become so routine that they seem normal. But if some of the most popular restaurants can take same-day reservations, why should run-of-the-mill doctors routinely make patients wait and wait and wait?

In fact, they shouldn’t. The challenge of reducing waiting times is a classic queuing problem in operations research. Professionals in all sorts of service industries, from restaurants and hotels to banks and department stores, have faced it in one form or another. Most of them handle the juggling of clients  far better than physicians, despite the lower stakes. Mounting evidence shows that doctors can see patients quickly, too—even in perennially backlogged practices—and that when they do, they benefit themselves and the people they treat.

The road to reform is called “open access” (or “advanced access” or “same-day scheduling”). Dozens of papers have been published showing how practices around the country have done it, starting in 2000, when Dr. Mark Murray and colleague Catherine Tantau wrote about their experience of reducing the wait at a Kaiser Permanente clinic near Sacramento from 55 days to just one. Since then, clinics in Texas, Illinois, Minnesota, and elsewhere have similarly cut down patients’ waiting times. The Palo Alto Medical Foundation offers same-day appointments, as does the Veterans Administration, the Mayo Clinic, and even some solo physicians.

When a patient calls in the morning asking to see a doctor who uses open access, the office offers an appointment for that same day. Why are there openings available? Well, the main reason most doctors defer today’s work to some time in the future is that today’s schedule is clogged with appointments made weeks ago. Doctors following the same-day scheduling model, on the other hand, are free today because they saw yesterday’s patients yesterday. Using open access, doctors might still schedule some early-morning appointments in advance, for follow-up visits or for patients who actually prefer a future appointment. But the key is that they keep most of their time free for same-day visits and fill up their schedules as the day goes.

This sounds simple, and it flows easily once the system is up and running. But getting open access off the ground takes hard work. Doctors have to chip away at their backlogs, a task that typically takes several months of overtime. That’s because during the transition, practices must meet their earlier obligations while at the same time offering same-day visits, to keep future dates clear. They also have to cope with fluctuating demand: If Monday is always the busiest day of the week, the office has to work longer hours on Mondays for open access to run smoothly.

Doctors also have to make sure their practices don’t take on more patients than they can handle. The total number of patients in a practice, called the panel size, is crucial because it determines the demand for service on a typical day. Obviously, the larger the panel, the higher the number of expected daily appointments, and if demand outstrips supply, waits are inevitable. Yet many doctors have no idea whether their panel size is too large. They track only the patients they see, not the patients who wanted an appointment but didn’t get one. That’s a formula for underestimating actual demand for service.

Taking into account the total number of appointment requests is the first step to open access, but it doesn’t do the trick on its own. It seems like common sense to balance the number of daily appointment slots with the average daily number of appointment requests. But a mathematical model built by operations researchers at Columbia University shows this intuition to be wrong. That’s because demand varies from day to day, and not always predictably. If the average number of appointments is 20, for example, some days there may be 25 and other days only 15. Scheduling 20 slots every day won’t work because extra service capacity can’t be transferred from day to day: The unused slots from slower days cannot be recouped any more than empty airline seats can be sold after takeoff.

The only solution is to build in a margin of safety in the form of more appointment slots than an average day will ever use. That sounds like wasted capacity, but it’s actually more efficient than filling up the appointment book in advance. That’s because the further in advance patients make appointments, the likelier they are to miss them. A no-show rate of 30 percent is not uncommon. According to one study, many patients don’t understand scheduling systems and find long waits insulting, so they think nothing of missing their appointment without calling to cancel. All these no-shows also add up to waste and lost revenue—the very problems traditional scheduling would seem to prevent. The strange upshot: By juggling too many patients, doctors lose income even as their backlog grows longer and longer.

But to dig themselves out, doctors have to take a leap of faith. Open access rejects the time-honored and seemingly sensible distinction between urgent and nonurgent visits, instead assuming that even routine checkups can be done on short notice. Some doctors who are sick of squeezing in very sick patients reserve a few slots each day for urgent appointments. Called the “carve out” approach, this works a little better, but it introduces new problems. There’s less time for nonurgent needs, so patients have to wait even longer than in traditional practices if they’re not in dire straits. And distinguishing between a problem that’s urgent and one that can wait requires constant and costly triage. It also gives priority to the squeaky wheel, encouraging patients to squawk the loudest or stretch the truth about their condition. In the end, there’s little gain: Most patients in carve-out as well as traditional practices can’t see their doctor on the day they call.

That’s not merely frustrating—long waits can worsen a patient’s condition. The experience of Liz Contreras, a 28-year-old in Washington, D.C., is fairly typical. As she relates in her blog, Contreras waited three months for a skin cancer diagnosis because she couldn’t get an earlier appointment—only to be told that she had a mole that was cancerous, and that she would have been in trouble if treatment had been withheld much longer. Research also shows that long waits make patientsless likely to get necessary preventative care, such as immunizations and mammograms. Several studies have linked delayed access to higher death rates.Practices that have switched to open access, on the other hand, report higher measures of clinical care, greater patient satisfaction, and even lower costs.

And yet, doctors who see patients on the day they call remain the minority. In a recent study from the University of California at San Francisco, researchers phoned dermatologists around the country complaining of a changing mole, and found the average wait for an appointment to be about 38 days (and much longer in some regions). Other specialties may fare better, but primary care physicians—who for many patients are the gatekeepers to specialized care—keep patients waiting far longer than they need to. According to a recent Commonwealth Fund study in several countries of “sicker adults” (those with a history of serious illness or hospitalization), the wait time in the United States is one of the worst among peer nations. Only 30 percent of sicker American adults surveyed could see their doctor on the same day, far fewer than in the United Kingdom (45 percent), with its oft-maligned National Health Service. And almost one-quarter of Americans reported waiting six days or longer—the second-highest fraction of any nation surveyed.

Successful restaurants understand that long waits lead to no-shows and lost income, which is why many of the most popular places don’t allow reservations until at most, say, a month in advance. In the restaurant business, deftly balancing supply and demand enables most places to take same-day reservations. Likewise, doctors should stop deferring for weeks and months what, with proper planning, can be done today. We can’t wait.