Where is everybody? It’s a Wednesday morning, and after 8 o’clock grand rounds I headed back from the medical college auditorium to our practice, and as I walked back into the office our med-tech told me that my first two patients were already in their exam rooms. So I dove right in, starting with a husband and wife there for their annual physical exams, and I set about getting to my morning panel of patients. What suddenly struck me as odd, as I moved from exam room to exam room, with the occasional bathroom break and stopping for a drink of water and another sip of coffee in my office, was that I seemed to be the only one in practice. If I’d had the right kind of shoes on, I would’ve heard my footfalls echoing off empty hallways, reverberating through empty exam rooms, bouncing off the walls of a sparsely occupied waiting room. I’m used to our office being really crowded. Oftentimes when we come back from our noon conferences, the waiting room is packed to the gills, with people spilling out into the hallways, sitting in the chairs by the elevators, or standing around eating from our complementary fruit basket or the hot dog they picked up at the cart out front (and somehow decided this is what they thought their doctor should see them eating). But on this particular morning, I felt like I was all alone. Turns out that one of my partners was out with a stomach bug, someone was off doing research in her other office, someone had taken the morning off because her kids were out of school this week, and someone was seeing a patient at her practice downtown. But where were the residents? Looking at the schedule, I found that several of them were at off-site electives, several were in conference, and a couple were out sick with the flu. And one had gone into labor and was giving birth! I finally found another person seeing patients, one of the interns behind closed doors of one of the exam rooms, and I could overhear their conversation with the patient. Whew, I’m not in this alone. So if we are truly optimizing access for patients, what does all these exam rooms lying fallow really mean? Are these missed opportunities to take care of patients? Do we have patients who were sitting at home yesterday morning wishing they could’ve gotten in to see a provider, but somehow we told them we were not available, that we had no room for us to see them, no access, no space? True, if there are no doctors there, an exam room may not be of much use. But optimizing the use of our space, finding the right balance between access, available providers, available exam rooms, and time, is how you build an idealized schedule for taking the best care possible of patients. For instance, in our practice we have one morning a week that is set aside for administrative purposes, when many of our providers are in meetings and not in clinical practice. But we have sort of “leased” out the space to some other providers, so that now the endocrinology fellows see their patients in our practice on these mornings. The rest of the exam rooms on these mornings are often taken up by doctors reviewing their labs, finishing notes, writing letters to patients, calling patients or communicating via the EMR’s patient portal, or squeezing a couple patients in to be seen. Yesterday’s schedule showed 382 patients who had appointments to see us starting from a few who were added on before 9 o’clock (when all of our providers should be attending Grand Rounds!) until the end of evening practice. At the end of the day, 83 of those patients had not shown up, leaving us with a no-show rate of 21.7%. Not terrible, but not terrific. Yesterday’s record-setting February temperature in New York City may have contributed in some way to the high no-show rate (at the end of the morning my own no-show rate was an alarming and unprecedented 34%). I figure a lot of people played hooky, woke up and felt that Spring was in the air, and thought they really just didn’t feel like going to the doctor that day. Probably if I’d gone looking, I would’ve found many of them in shorts and T-shirts hanging out in Central Park. Is there a way to better match supply to demand, to make sure that every provider’s schedule is completely full, that every exam room is being used to examine a patient? Is that our goal? We are working on several pilots to try and improve this, including more telephone contact with our patients to confirm that they’re coming and ultimately text message and emails for patients to confirm or cancel. And we are trying the use of bump lists of patients who would like an appointment but can’t get in right away who should be able to fill up those empty and available slots, like an airline’s standby list. But I’m not sure how I can fill an exam room that I just don’t have a doctor for. Yesterday, I could’ve put patients into six rooms, but really I find that two rooms is all I can honestly use. While one patient is getting electrocardiogram I can scoot into the next room and see somebody else, but how am I going to make use of the third room? No one is going to talk to or examine one patient while I am in the room with someone else. Perhaps if those patients were spending time in those extra exam rooms undergoing an update of their healthcare maintenance, filling out all of the forms that need filling, getting all their depression screening done and all the other screening instruments and quality measures we need to complete for our accountable care organization and our patient-centered medical home initiative, then maybe I could use these rooms to help further the health of our patients. Use this room and this time to fill out an online health assessment for their Medicare Annual Wellness Visit, then they would be ready for me when I get there. No one is using that room, let’s put a patient in there, and someone to spend some time counseling them on diet, exercise, smoking cessation. Let’s have a patient sit there with a counselor and really work on their medication compliance, go over some educational materials so that they really understand their disease and the implications of controlling it, boost their health literacy. While on most days of the year our rooms are pretty full, if we can use these extra spots around the edges, these alarmingly open rooms, and have other members of the team work with us to take better care of our patients, perhaps those open spaces won’t feel like such a waste of space. And then we won’t feel so all alone. Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home. Source
