Why I Am Always Late

Disclaimer: nowhere in this article is there any specific mention or discussion of any patient of mine, or anyone else’s. Patient needs come in flavors and it is quite possible that one may randomly identify with a description below. However, the scenarios given herein are purely fictional, only based on years of encounters with thousands of people. Eventually, nature repeats itself. If anything in this essay describes you, or someone you know, it is by pure coincidence.

I confess, I am one of those physicians. I frequently run late, and keep patients waiting. I‘m not always late. But frequently I am. I know it, and I know patients hate it. Waiting for the doctor to come in is one of the top complaints on patient satisfaction surveys. It has become a major medical stereotype, the bane of going to the doctor. (It has also given us many funny memes, so there’s a positive.) The reason I, and many of my colleagues, persist in our state of lateness is many layered, and I think its time to talk about it.

A late doctor is frustrating to patients. Some get infuriated. I get that. I’m a patient too. But as a physician, I also know the other side. Often, when I (finally) arrive, the perturbed individual quickly calms, and we proceed without tension. When I do have someone who wants to convey how displeased they are, I find that the perception is very personal. That is, they feel not only that it is entirely my fault, but that they are being personally slighted. Some people really do think I purposely keep them waiting! There are people out there, much to my amazement, that think doctors still take 2 hour lunches and lounge luxuriously in their offices. So much distress in human relationship comes from a single place: misunderstanding.

I was recently reading a book by Thomas Hager, scientist turned medical writer. His 2019 book Ten Drugs: How Plants, Powders and Pills have Shaped the History of Medicine opens with a look at the pharmaceutical load people consume. In his introduction he quips, ”In the 1880s, doctors were family counselors good at diagnosing ailments and providing solace and advice to relatives, but almost powerless to alter the course of killer diseases. Today, physicians are able to work miracles of lifesaving that their brethren a century ago could only dream of. They are also all too often overscheduled, data-stuffed technocrats more comfortable reading lab reports than holding a patient’s hand.”

Some of this statement I agree with, some I don’t. There are many miracles of modern medicine out there, for certain. But mostly, as any patient with a chronic illness can tell you, its also a lot of symptom suppression and often with a price. In some ways we have taken a step back in the healing process – a subject for another essay. So, this is a bit of hyperbole. But it’s the last sentence I take issue with. I can't be sarcastic enough to convey my reaction to being described as a “data-stuffed technocrat”. After giving up a decade of my life to nothing but study, literally (and ironically) ruining my health for the sake of learning how to improve that of others, my colleagues and I are being publicly reduced to computer technicians. What’s this got to with wait times? Hang in there, its not really a digression…. Overall, Mr. Hager is a very interesting writer who is very well educated, and experienced. I quote him not to chide him, but because this small quote holds the two main points of this essay.

Firstly, he is absolutely right, times have changed and we are over scheduled and drowning in our own technology. Gone are the two hour lunches and the casual days in an office. If there ever really was such a thing. The system that modern physicians operate under actually inhibit the doctor-patient relationship and therefore the very foundation of the art of medicine. The system only generates money if you are ill, think about that….

The second is Mr. Hager himself, actually. Despite his long career as a scientist and researcher, he is not a doctor. He was never a starry-eyed first-year medical student, walking through the front doors of his grandiose university school, about to embark on a journey that, no matter how many hours of shadowing other physicians as an undergraduate he accomplished, he could never imagine how he would reemerge on the other side. It’s not his fault. No one can know the task of delivering modern health care, except for those that actually do it. Experience imparts the best wisdom. But sometimes story telling is a close second.

Reader, I want to take you into my world for a day. I want to help you understand why your damn doctor always keeps you waiting. And why you should be very pleased that she does.

Come with me to clinic. Office hours start at 8:30 am in my world and run til 6:30 pm. I usually try to get into the office 30 minutes early. I live on a farm, have a blended family spanning ages 8 to 17 at home. I have my own personal projects, and often bring work home with me. So late nights and delayed mornings are a norm. Early arrival is not always possible, I’m usually on the dot.

Arriving at work, I have a stack of papers that magically regenerate outside my office door, and more sitting in an electronic queue in our EMR (electronic medical record). Paperwork is hard to average. Between physical and electronic I would estimate about 60-100 mostly multiple-page documents daily, that need my review. Also waiting in the EMR docket are telephone encounters - messages from patients, nurses, home health aides, insurance agents, pharmacists, etc, that require call backs, refills and often, further paperwork. These run 10-30 a day, depending on the day of the week, the season, and the phase of the moon. Phone calls come in regularly, and I often need to make my own, often the essential physician-to-physician communication. Especially as a general practitioner, I often need to speak with specialists. The latter can only occur during the hours of 9-4, roughly. Which is smack dab in the middle of my clinic hours.

So, we hit the ground running, so to speak, and go from there. While I am descending upon the paperwork/call back pile the first patient is roomed. Patient #1 just needs refills, so they come and go quickly, but the next one has somehow snuck past the ER and presented with chest pain and shortness of breath. The nurse comes in and interrupts patient 1 and me as they are leaving , to tell me patient 2 does not look good. I ask her to go back and finish getting vital signs before anyone gets too upset. I get patient 1 out the door now a little later than I should, and attend to #2 who probably is just having a panic attack, but he is complaining of chest pain, and he smokes, he is over 30…. so off to the ER we go.

While I’m signing off to the ER physician, patient 3 arrives a tad late and patient 4 arrives early. Both get roomed immediately and are now both are waiting. I see #3 and move on to #4. Patient 4 is miffed because I didn’t accommodate the fact they were early. I calmly explain (not for the first time) that coming early to a doctor’s appointment and expecting to be seen (early) is not a reasonable expectation. But both are relatively straight forward and out the door we go. I hustle back to my office and manage to rip through two telephone encounters and sign some papers.

Somehow the late/early pattern gets repeated by patients 5 and 6. This time however, before I can get away from my desk a patient from yesterday is on the phone, very upset, the nurse doesn’t know what to say and pleads for me to come to the phone. I deal with the phone call and now 5 and 6’s wait times have extended. I get through with patient 5 but desperately need to call 5’s specialist to close the communication loop (5 is very sick) and so simply make time to do it by making 6 wait…. even longer. I get a reprieve with patient 6. She is a long time patient, likes me lots, and genuinely smiles when I pop my head in the door apologizing that I will be 10 more minutes. Somehow, there are people out there that ‘get it’, though surprisingly it is usually not the Thomas Hagers of the world.

This little circus runs its course through another 12-16 patients, repeating the pattern sometimes with mounting complications. I get everyone out, staff and all, by 7 pm and sit down for the next 1-2 hours to try to gain some headway on the paperwork, make sure medication orders went to the pharmacy, call back on critical labs and imaging, and follow up with final results of the day.

I’d love to blame paperwork for my chronic tardiness. But its really the patients that take time. When someone needs extra explanation, I stop and do it. For their sake and mine. Patients with chronic illnesses now easily take 4-8+ different medications daily. Not to mention having to navigate the world of specialist appointments, understanding lab and imaging results. Its not just confusing, its dangerous.

When someone is crying, I stop and work with them. If someone needs an in-depth discussion on a subject, I give it. You wouldn’t know it to look at me, but I frequently have patients make close follow up appointments to discuss subjects further. Rome wasn’t built in a day. Life is messy, and a medical clinic cannot be a tidy package with everyone fitting neatly into their 15 to 30 minute time slots.

I usually see 18-24 patients a day. For the record, in a 10 hour clinic day that is a low number. My girlfriend’s mother is a family physician in Boston, and sees about 35 patients a day. God bless her. I don’t know how anyone can receive quality medical care if all your patient slots are 15 minutes long. She’s a good doctor, smart lady, she cares. Its not her, its our system.

So, yes, Mr. Hager, we are over scheduled to be sure. The why of that is the topic of another essay. But let it be known, sir, that there will never come a day when I am more comfortable with the damn EMR than I am holding someone’s hand. No one I went to medical school with got into this business to be a tech-savvy-eye-contact-avoider. I hold hands, and do my best to walk people through the dark. It is for this that you wait for me.

To be sure, Reader, there are docs out there that are always punctual. But there isn’t one that doesn’t have a day like I do, no matter how specialized. And because I know this, I am extremely wary of seeing one that is. Either they have an amazingly staffed office with incredible efficiency - stuff not seen in rural America to date - or they are not answering their phones. Or, more likely, they stick to that 15 minute technologic-centric visit, the one Mr. Hager described in the opening pages of his book. A couple of years ago I had to see a surgical specialist at our major state university hospital. I had an 8:30 am appointment. I was aware that this physician not only had clinic, office rounds and surgery days but also taught for the university’s medical school. This means he starts a lot of days between 4-6am and ends…. who knows? It took 45 minutes for his PA to walk in the door and an hour and half for him to appear. With residents and medical students in tow. He was excellent, made me feel heard and expressed concern, reviewed an 8 year old CT scan I had hand carried to the appointment, addressed my husband directly and had me imaged with results by the end of the day. Wow. I waited for him happily because I get it. I know exactly what he was doing before he saw me: he was in the fray of his profession, being excellent.

I remember a particular shift when I was in training and did a lot of hospitalist care. I had 3 patients on my service of 27 that were being discharged that day. One of them threw an epic tantrum on the floor, because at 4:30 pm the poor fellow had yet to see me. nHe just wanted to go home. I must’ve been paged 4 times over this guy. I get it, I do, I felt bad - he wanted to go home (I did too, funny enough) and I was the barrier to his exit. Everyone explained how full the hospital was and how busy it made everyone. Still, this guy was going to annihilate us on his patient satisfaction survey. This is very damaging for a hospital or clinic’s bottom line. I finally got up there and walked into his room and… spent time and talked. He still left displeased but stopped being verbally abusive. So that’s something. I wasn’t upset with him, he thought he had been forgotten. I suppose he is still among the many who believe doctors take 2 hour lunch breaks.

At one point in my residency, I rotated with a local internist. He was that doctor that all the residents loved. Getting a month with him was a sought-after time period during training. I would meet him at the hospital and do rounds with him in the morning, and then run ahead of him to his clinic. Every morning without fail, his waiting room would already be full! Full of smiling patients who were all patiently waiting, reading, knitting, drinking coffee, chatting. They all felt the same as the residents: this man was worth waiting for. I recall leaving his office thinking that this was my goal: to be worth waiting for.

Not too long after residency I read a magazine article about the author's personal experience with his doctor. You see, he had a doctor he loved, but he broke the relationship because of the doctor’s wait times. The writer went on to find a very punctual replacement and… greatly disliked the care. The new doctor rushed, made poor eye contact and generally conveyed no real sense of listening. Back to the old doctor the writer went, now armed with new appreciation, and a book to pass the wait time.

I often tell my children that you can have anything you want, but not everything you want. We cannot do it all in a lifetime, or a day. I cannot be the sympathetic, hand holding, eye contact-making, verbally effective practitioner that I was trained to be AND be the robotically-efficient technocrat that the federal government requires AND address all the issues at hand AND make it happen in 15 minutes. Well, sometimes I do. Mostly I don’t.

This essay was not intended as a plea to get myself off the hook. As with all I post here, it is simply for the purpose of shedding light. I hope that is does. And if nothing else, consider this: in a rushed, multitasking world, I would like to invite you to embrace a wait time, wherever you are, as reprieve. Life is lived entirely through perspective, after all. But beyond this, Reader, I wish for you to find someone in life worth waiting for. Whoever that may be.