A study released last week reported that less than half of acute care cases are treated by primary care physicians (A Quarter of Acute Care Delivered in Emergency Department, Sept 7, Hospitalist News). Much of the coverage has centered around what fraction of patients end up at emergency rooms and what fraction are uninsured. The number that caught my eye is that two-thirds of these emergency room visits came after hours or on weekends. Arguably, this is not bad from an operational point of view. Assuming that we as a society are unwilling to pay primary care physicians enough for them to make themselves available to all patients at all times, it make sense to pool available resources off hours. This is not to say that acute cases should be going to the emergency room (we are here talking about sore throats and fevers), but if two thirds of the need for acute care really do occur outside of standard operating hours, it is hard to say that it is wrong that only 42% of acute care patient see their primary care physician.
The other side of this, though, is that some number of acute care patients try to see their primary care physicians and can’t get a timely appointment. The question then is what can be done to open up physician schedules to reduce delays for appointments and delays once one gets to the office. One approach that has been put forward originated out in California at Kaiser is called “open access.”Vodpod videos no longer available.
An accompanying Boston Globe article (A new practice: The doctor will see you today, Jul 14) discusses a family physician who moved his practice from a traditional schedule to open access. Here’s how they describe the change in how patient’s requests are handled:
Dr. Dennis M. Dimitri, a family physician, runs a pretty unusual office. Few appointments are accepted in advance. Instead, patients call in the morning and are assigned a time slot later that day. Some patients walk in without calling ahead.
The outcome of this lack of advance planning? No one has to spend weeks trying to wrangle an appointment, and once patients arrive, they rarely wait more than a few minutes for the doctor.
To put that in perspective, the article reports that it takes on average 63 days to get an appointment with a family physician in Boston. Several factors make this work:
The system works because of several simple factors. It reduces the number of patients who don’t show up for their appointments or who call in with an emergency and plead to be squeezed into an already full schedule. Both numbers can be high in a traditional practice, so doctors regularly overbook and then fall further and further behind.
Also, doctors using open access usually see patients at consistent 15-minute increments, rather than the more common 10-minute intervals. Not all appointments take the full 15 minutes, so the doctor has flexibility if one patient needs more time or there are emergencies.
Note that stretching appointment slots to 15 minutes actually cuts into capacity — assuming that the 10 minute slot was adequate for the job. What I suspect is that the old 10 minute slot was frequently not actually enough to get the job done. Thus the doctor was probably prone to running late while the office staff had to carve out special, longer slots for more complex cases. Moving to 15 minutes is probably a more reasonable schedule that can be maintained over the day.
Two further points are worth noting. One is made is hinted at in the article: This will not work for all medical settings. Take physical therapy. I had a student several years ago who worked in the physical therapy clinic at Chicago’s Children Hospital. She frequently had patients whose age was measured in months not years so everyone was dependent on parents to get patients to their appointments. But when you start talking about single parents or even two working parents, getting a child to the clinic was non-trivial but facilitated by having a consistent schedules. That is, a single mother could make this work if her child’s appointment was always Tuesday afternoon. Clearly, it would be bad for the parent and the patient to have an appointment that jumped around in an unpredictable fashion. As soon as you talk about chronic conditions that require regular visits, open access can be hard to implement.
A second point is that open access requires greater flexibility from the clinic. If the goal is to do today’s work today, some day’s are going to be long. Consider a clinic schedule with 20 slots per day. Some days there will be 25 requests to be seen. If the 20 slots are a hard limit, patients must adjust and some will face a delay in being seen. But doing today’s work today means the clinic must adjust. The 20 slots can no longer be a hard constraint. Open access then could mean some long days.