Sunday, November 29, 2009

Reflections from the Clinic at Grady: The Vicious Cycle

The "deuce":
Sometimes the only thing that precedes the departure


"I don't wanna

I don't wanna
I don't wanna

I don't wanna

I don't wanna wait in vain. ."

Bob Marley's "Waiting in Vain"

"Can somebody please grab that?" I spoke out over the doctor room while gesturing to the blinking phone line. Four rings later, I reached over someone's half full Starbucks cup to greet the caller myself.
"This is the Green Pod!" I announced musically.
"Dr. Manning," said Mrs. J, our clinic receptionist, "I have a patient up here at the front desk that just got here for a 9:20. What do you want me to tell her?" It was one of the most everyday conversations one might overhear in the resident clinic.

I balanced the phone on my shoulder while writing on a prescription and scanned the clock hanging on the wall. 10:24 a.m. Before I could answer, Mrs. J. added, "She had to go to financial counseling first, and just made it back." Then she lowered her voice and said, "Girrrrl. She look like she 'bout to cry up here. Please let me check her in or otherwise it's 'bout to be drama."

The hard sell probably wasn't necessary. When I was new at this, I used to always walk up to the front desk to get the full rundown when a patient was late. Now I just ask a few simple questions. How late? Is this a recurring problem? Why is the person late? Oh yeah--and is the person an elder or disabled? That usually gives me more than enough ammunition to make a decision--and saves me a walk.

So as it turns out, this is a patient who is rarely late and happens to be well-established in our clinic. Patients who are seen regularly at Grady and who do not have commercial insurance (the majority of our patients) must go through a process called "financial counseling" which determines how much assistance they qualify to receive. Because employment and income situations are often dynamic, this "financial counseling" must be done at least every few months. This encounter results in the patient being issued a "Grady Card," which, if you don't pay close attention, will expire on you like that. (Insert fingersnap here.)

Okay, so this patient did arrive to the clinic on time, but neglected to account for the fact that her expired Grady Card would require some face time with financial counseling. I suppose one could argue that if she has been coming here for years that she should have known that her Grady Card might need an update. I wanted to just say "tough luck" but then I thought about her 9:20 appointment. I asked myself what the likelihood was that she would have actually been seen at 9:20 a.m. (I won't answer that.) So back to the patient. She's never late, keeps her appointments, and waits for us when we run behind? "Check her in," I told Mrs. J. and hung up the phone. Check in the patient for her 9:20 appointment at 10:30.

The Vicious Cycle

And so the vicious cycle begins. It starts with good intentions. First appointment is at 8AM, and the doctor comes out of the blocks galloping hard and fast. Or the doctor may start a few minutes late out of the blocks. . . . .either because they need to answer a few phonecalls or pages, review a chart or two, or maybe just because he or she can't seem to find a matching pair of socks for their child before getting them to school. The patient (interesting that this is what they are called now that I think about it) patiently, and sometimes not-so-patiently waits. Either way, the 8AM patient goes first, and perhaps the 8:30AM patient is seen at 8:37AM. The 8:30 AM patient just needs a medication refill and a blood pressure check. Blood pressure is high today, no big deal since the patient is out of medications. Patient is a "regular"--pretty straightforward--including small talk should take no more than 10 - 12 minutes. "Oh, by the way, doc, should I be worried about this little twinge I keep getting in my chest?" Damn. Patient smokes, has high blood pressure, and high cholesterol. Anything in his chest is newsworthy, and yeah, should be worth worrying about. "It's just a twinge, kind of like a pressure, but not pain. It comes out of no where when I'm just sitting there." Pressure not pain, yeah, not good. Next comes an EKG, more discussion, and more time. 9AM patient is gracious when they are escorted back at 9:20AM. Whew. Maybe this one will help the doctor catch up. Or not. Two minutes into that visit, the nurse knocks on the door to hand the doctor the EKG of the 8:30AM patient. Very abnormal. Page Cardiology. Draw some labs. Excuses self from the room to arrange a plan with the cardiologist.

Doctor finally returns to the room. 9AM patient is still gracious, even though it is now 9:38AM. "Somebody having heart troubles is important, doctor. It's okay." Gracious patient is also, as it turns out, not eating, not sleeping well, can't concentrate. Starts crying during the encounter. "I'm sorry, doctor. I don't usually do this." Take full history to screen for depression, make the diagnosis. Teach patient about anti-depressants and make sure that this is not a situation where the patient is suicidal. It isn't, but the patient is still visibly upset. 10AM. Rushing her is the wrong thing to do. Finish up at 10:09.

9:20AM patient is annoyed that she is not called back until 10:10AM. Rightfully so. Rolls eyes and folds arms hard when walking toward the room. "This is some bullshit!" she huffs looking at her watch. It actually is. Doctor needs to say something conciliatory. "We are so sorry, ma'am." Patient not having it. "Yeah, y'all are sorry. Sorry as hell." Ouch. Guess the only thing that could be worse is putting her in the room at 9:20 and not actually coming in to see her until 10:10. She probably would have met the doctor with a flying kick the minute he or she opened the door. (I'm just saying, it could happen.)

It's a vicious cycle that I've seen spiral out of control at just about every outpatient clinical environment I've ever been in. Sure, some places are worse than others, and sure, some offices have so much staff and technology that they run only a little late. But no matter how fancy, shiny, high tech-y, concierge-y, or non-indigent care accepting-y they are, they too get off schedule a bit--more often than not. It's definitely not just a "Grady thing."

My dad and I talk about this often. He is no fan of the "vicious cycle," and even more, he absolutely does not appreciate the fact that the doctor often doesn't acknowledge their tardiness at all. In fact, it's nothing for my dad to wait fifteen minutes and then throw up the deuces to the receptionist. ("Deuces": two fingers symbolizing the "peace sign"; a slang gesture used either with a statement or just as a nonverbal cue to say you are leaving, usually abruptly.) Yeah, so Dad is not shy at all about the "deuces"--nor is he shy about letting them know, like that 9:20 patient, just what he thinks about being seen well after his appointed time. (Fortunately, my father's language has gotten less colorful than that of "9:20" as he's aged.)

Daddy's doctor: "Hey there, Mr. Draper! How you doing?"

Daddy: looking real annoyed--"Not good. My appointment was at 1PM and it is now 1:39PM."

Daddy's doctor: Half-genuine reply--"Sorry 'bout that, Mr. Draper. Blood pressure and labs look good today!"

Daddy: Deuces

Isaiah throwing up a "deuce"

Okay, so the late thing is one part of it. Dad's doctor was a half hour late, and Dad had stuff to do. So the doctor walks in and acts like he didn't just leave a grown a-- man with business to tend to waiting for thirty minutes. To me, that's the other big part of the problem. No profuse apology, no preemptive strike in the waiting room, no nothing. It's inconsiderate, and it's the perfect recipe for getting a few choice words from my father--followed by the "deuces".

In that doctor's defense, it is probably something he learned in residency and medical school--we are conditioned to think that the "vicious cycle" is par for the course, and that patients should just fall in line. Interestingly, they usually do. At least, most of the time. I suppose it's kind of like the "theory of learned helplessness." The rats thrown into water who profusely try to swim their way out, but eventually, with repeated failed efforts, just lie there the minute they hit the water. What's the use? Nothing will change. Learned helplessness. The rats stop swimming, the patients stop fighting, and they stop planning anything important after appointments with us--unless, of course, they can manage to be the first patient of the day.

My dad has made me think about this differently. I can't always control things running a bit behind, but I have made some modifications in an effort to be more considerate. As the lead physician, when I see things getting off schedule, I'll go into the waiting room and thank people for being so patient. If a resident physician is running late by quite a few minutes, I may ask another doctor to see their next patient sooner, or I will offer to see the patient myself. Sure, it's a "work around" and not always ideal for a patient that wants to see their own doctor, but it does respect the patient's time, which folks seem to appreciate. Most important though, is that I immediately identify the elephant in the room as soon as I see the patient.

"Good morning, Mrs. Moore. Listen, I'm so sorry that you had to wait to see us. I really appreciate your patience. Your time is just as precious as ours, and I don't like waiting either."

Sometimes that makes all the difference in the world. A simple, genuine acknowledgment. Before they even get the opportunity to tell me that "this is some bullshit," I do my best to beat them to the punch. (Sorry to use the expletive again--I tried it with the word censored or as "b.s.", but it just didn't have the same effect.) I also recognize that the same folks that have waited for us over and over again, sometimes have bad days, too. Like the lady at the front desk whose Grady Card expired--I felt we owed it to her to return the favor. At least this time.

Okay, so I know my dad is reading this, shaking his head and sighing audibly. I know, Dad. We could space the patients farther apart to allot more time, but then our availability would be significantly decreased. We could shut folks down when they start adding in their "by the way, doc's" alerting them of our "3 problem only" policy. That seventy year old guy who musters up the courage to tell his twenty-eight year old female doctor that he is having trouble "with his nature" and "maybe could we talk about them Viagras" had better get that out in the first five minutes or else there will be no waltzing around the kitchen for him. (Like all those happy folks on the erectile dysfunction medication commercials.) Again, Dad. It's a vicious cycle that's hard to break. How do we simultaneously connect with our patients and keep it moving? I still struggle with that every time I'm in clinic.

I have a few thoughts, but they definitely aren't perfect solutions. For starters, those of us who are clinician-educators can keep on teaching the residents to be more efficient--and our staff, too. Those in private practice can do the same with their staff, too, I guess. More efficient, yes, but never at the expense of that human connection. If it takes you an extra minute to tell me that your grandson was deployed to Iraq or that you just became a deacon at your church, I'm giving you that minute. Maybe I can multitask more, checking your pulse while you tell me about your son winning the spelling bee, and perhaps I can palpate your thyroid while you give me your recipe for the perfect sweet potato pie. This way, we indeed connect--and your wait for me is not in vain.

So, on behalf of empathic doctors everywhere, I apologize to every patient who has patiently and even impatiently sat in an uncomfortable chair reading outdated National Geographics or watching a channel that cannot be changed--all because of our "vicious cycle." Yes, your time is important. No, it is not cool that you are asked to reschedule for being twenty minutes late when we usually are. And even more, I am even more sorry for those who grimace and bear the delay only to be rushed once their late doctor finally arrives. Not cool. Besides, who wants to wait in vain? Not Bob Marley, not my dad and certainly not you, either.

So, yeah, I checked her in, and probably delayed things even more.

And yep, Dad, I'll say it before you can--this stinks. Or as the 9:20 AM patient put it so colorfully- this is some bullshit.

1 comment:

  1. Well Dr. Manning, this is more than a day late and a dollar short. I found this post by clicking on the suggestion below today's blog post. I just have to say that I threw the impatiently waiting towel in the day I was worked in to get an ultrasound, mammogram and 8 biopsies in one day. I was the patient that made all the others wait, and I was probably the sickest patient in the place. It is a terrible place to be. When I'm waiting on my doctor I remind myself of that day and continue reading my kindle.


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