A tiny, trivial example of the ups and downs of general practice. A patient has had rib pain for nearly a week. At a random point in time a relative decides she should see a doctor. Having made that decision, she expects an immediate response from the doctor and an immediate appointment at a time of her choosing.
This post by Dr. Crippen hits home. Our practice went to "open access" a while ago, and in an academic practice (7-8 physicians, but only about 3.5 FTE), I’m not convinced that it works very well. We supposedly modeled it after successful programs at UNC and USC, but after hearing a combined presentation by them at STFM, it doesn’t really sound like they’re doing complete open access either.
One of the arguments we had about the idea of open access was whether we should encourage "immediate gratification" among our patients. This would then mean approximately four thousand calls the week before school started to get in for school physicals because we’ve told the patients "you just have to call and we’ll get you in that day or the next for a routine issue." It just seems to encourage bad planning. And there were some patients – who had been with the practice a while, who absolutely hated the system. For a while, we NEVER scheduled anyone in advance – so people who wanted to walk out with an appointment for three months, could not do so. Then we relaxed that restriction, but didn’t have schedules made far enough in advance. In addition, the plan of allowing some patients to schedule immediately but encourage most to call back the week of the needed appointment was a level of complexity that escaped our office staff.
It all comes down to to what extent the business definition of "customer service" (the customer’s always right), and my definition of "medical service" (I wish I could think of a concise definition to fit the parenthetical format) overlap. I can think of several reasons why patients would want to be seen immediately:
- a true medical emergency – These are pretty rare in family practice, certainly in an urban environment where there’s access to the ER.
- a need for certainty – "I want to make sure it’s not [sinusitis/otitis/pneumonia/dehydration/whatever] like it was last time." Never mind that things can change – I’ve been on both ends of the visit-for-URI-followed-by-visit-for-OM-three-days-later saga.
Some of our patients immeidately assume that something was missed rather than understanding the progression of illness.
- a misplaced understanding of our preventive capabilities – "I want to make sure it doesn’t go into [sinusitis/otitis/pneumonia/dehydration/whatever] like it did last time." No matter of patient education concerning the lack of effectiveness of decongestants in preventing complications, or the lack of utility of prophylactic antibiotics will deter these patients from asking us to fulfill their impression of the promise of primary care – to make their symptoms go away quickly and not progress to something worse.
- immediate gratification – "Now that this is an issue, I must deal with it immediately" – I wonder if this is a result of the "Getting Things Done" time management culture. Problems must be dealt with quickly and definitively in order to enable use to deal serially with the next problem. I overstate this to make a point – life is pretty complex for our patients, so illness is tremendously inconvenient. Some people are more tolerant of this inconvenience than others, I guess – but serving them all in a customer service capacity can be frustrating. The looming threat of malpractice litigation also drives up the stakes…what if that person really couldn’t have waited three hours? It’s not the truth that’s sought in such matters…so just the threat is powerful enough to change our behavior.
- the final reason is that our patients are deperate – the disorganization of office communication systems results in long hold times in the phone system, lack of timely call backs from physicians and nurses, and general patient dissatisfaction. Everyone is aware that a person standing in the waiting room, demanding satisfaction will accomplish the needed task, and so our patients will resort to this. I imaging the patient’s niece that Dr. Crippen desribes knew this also – frustrated by her experience in the NHS, she assumed that showing up would get her problem solved more quickly than calling and waiting for the usual communication to happen. I’m not always as forceful as Dr. Crippen was in this instance – though if i were on home visits, I think I could feel reasonable about that choice. Usually, I would be taking time from my research activities – which wreaks havoc with my planning capabilities (pretty deficient to begin with…). I would also, as did Dr. Crippen apparently, take my satisfaction from the patient, who seemed to acknowledge the situation, and was not angry.
I don’t think that medicine should exactly follow any particular business model – whether it be Deming’s QI, or customer service theory. There are definitely things that medicine could learn from those models, but the complexity of human biology and human relationships and the need for valuing the needs of our practice over the needs of the individual require that we redefine these models for our context. It would also help tremendously if we could influence the culture of our patients to understand this. On an email discussion list, someone once brought up the point that health care cannot be a human right, but can at most be a universally agreed upon entitlement – otherwise, those that provide health care would have no right to their own lives, but would be obliged to serve at all times and anywhere. Even though that seems like an obvious difference, I worry that the semantic difference has a greater hold on us than we think.