The Waiting Room

SEPTEMBER 18, 2007

It's one of the things people hate most about going to the doctor's office: waiting. You show up 15 minutes early for your appointment, spend 15 minutes filling out paperwork, another 30 minutes waiting reading your National Geographic from 2001, then you get called back. Progress! This will all be over soon!

You get to the back room, talk with the PA/RN for a few, then bam, another 30 minutes of waiting in a cold room, except this time they don't even give you the common decency of a 6 year old magazine. Bastards. Finally, an hour and a half after first arriving, a knock! The doctor enters, time for them to listen intently to your story, give guidance, immediately offer a remedy that will cure all ails, and you leave engaged in laughter and smiles. Except instead, the doctor talks to you for 5 minutes, doesn't seem to really listen, then slaps a piece of paper in your hand and send you on your way.

Today, I'd like to tackle two issues: why all that damn waiting? and also, why all that damn waiting for such little face time?

First... all that damn waiting.

Most people are under the impression (as I was for a long time) that when a doctor is in clinic, he is making his way around in a big circle through the clinic, seeing a patient, finishing, moving to next patient, finishing, etc. The reason the doctor is late either because of a difficult patient or because he's just slow. I will now in the longest run on sentence ever attempt to capsulize what a doctor is ACTUALLY doing while you're waiting.

While you are waiting, the doctor is following up on tests run on patients earlier in the day, receiving requests for referrals on more patients, requesting referrals to other physicians, receiving phone calls from patients with questions, receiving phone calls from fellow physicians with questions, receiving phone calls from hospital/clinic staff with questions, receiving phone calls from the press asking questions (yes, this happens), attempting to finish up out-patient notes on all the patients they have seen before you, reading up on the few assorted difficult cases of the day, getting paged incessantly for any variety of reasons, seeing the patient(s) before you on the day's appointment list, and attempting to preview your chart as you are in the waiting room.

Ok, I may have squeezed an ounce of sympathy out of that hardened heart of yours, but it truly is impressive to see the multitasking the physicians I've been around pull off on a daily basis. 

Now... why so little face time?

At the beginning of the day, the doctor previews his or her appointments scheduled for the day. They know you're coming up. While you are waiting in the room, they are looking through your chart. If you're a follow up for surgery or something of the sort, they are looking at any x-rays/MRIs/CT scans that you may have on file. They are reading notes from previous physicians if you are a referral. Generally, they have a pretty good idea of what is going on before they even step foot in your room.

In medicine, we have what we call a differential diagnosis, which is basically to say, a list of things we may think be going on with you in order of decreasing likelihood. As we gather more information, certain things move up and down the list.

Even if the doctor is not quite sure of what is going on as they knock on your door, they already have a few ideas. That is when they begin to ask you questions about the symptoms to add to their differential diagnosis. Most doctors have it nailed what's wrong with you within a period of 5 questions. Yes, they are that good, or rather have so much experience that when a certain set of responses come from the patient, well, one doctor described the diagnosis as "a trigger finger reflex - you just KNOW." So while you're still hashing out the how the only reason you were even AT the picnic where you broke your ankle was because your ex wife's brother who you thought was a nice guy was sneaking around with your mother and you were there to break his jaw but had a change of heart because the children were around but that's when you tripped over the dog, which your ex-wife got in the divorce, that bitch, your doctor has already clearly figured out what's wrong, already has a plan of treatment, and is smiling and nodding because he likes dogs and has an ex-wife as well so he can relate.

This is the conundrum of the doctor visit. Your doctor wants to stay and hear about your embarrassingly promiscuous mother, but the phone calls for referrals, about referrals, from patients, from doctors, from press, from staff, the pages, the emails, the charts, the difficult patients are all backing up outside that little room you two are in. And while your doctor loves talking about picnics with you (they really do), they don't NEED to hear about it because they already know exactly what is wrong with you and how they want to treat it.

So you end up waiting 90 minutes for 5 minutes of face time. Is there a better way to do this? I have no idea. But there's two things that your doctor truly appreciates. (1) That you are a good patient, because these are a lot more rare than you'd expect and (2) That you might be willing to let him move on to the next person because you two have gotten you to where you need to be, because that extra time you free up will be sorely needed for dealing with those patients in which things are difficult.

They call it the rule of 20/80. 80% of your patients will be a joy to work with, with a clear and present problem and realistic expectations of how that problem will fix itself with treatment. But the other 20% of the patients will be a pain in the arse, and those 20% will suck 80% of your time. So while you are waiting in your room, your doctor may be next door trying (hoping) to make a patient understand that no, he may never be ABLE to be a wildfire firefighter again because he was in a motorcycle accident where he broke 28 bones in his body, split his pelvis in two, and has enough screws and plates in him to put together a piece of ikea furniture (true story). But hoping the patient could at least lower his expectations a little bit, simply because when they peeled him off the asphalt they had to shock his heart 3 times and put him into a coma for 3 weeks, so its honestly a miracle that person is even sitting there to begin with.

I don't know where I am going with this. All that is apparent to me is that inside every doctor is this war. They want to spend as much time with a patient as the patient truly wants, but simply, physically, cannot. How much personal connection do you balance with necessary brevity? Because when the doctor has to sink that 80% of their time into those 20% category of patients, ultimately, it's not just you who ends up waiting, it's the doctor - waiting to finish for the day with all those phone calls, pages, emails, and cases. And waiting to go home for the day.