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How should patients who arrive late be handled?

How should patients who arrive late be handled?
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Fred N. Pelzman, MD

Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine. Pelzman’s Picks is a compilation of links to blogs, articles, tweets, journal studies, opinion pieces, and news briefs related to primary care that caught his eye.

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Fred N. Pelzman, MD (click to view)

Fred N. Pelzman, MD

Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine. Pelzman’s Picks is a compilation of links to blogs, articles, tweets, journal studies, opinion pieces, and news briefs related to primary care that caught his eye.

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Traffic comes to a complete stop.

Although this may not seem like such an unusual thing in New York City, during the week of the United Nations (UN) General Assembly meeting, things get crazier and more congested than usual.

Every avenue and cross street becomes a parking lot, full of sweaty, frustrated drivers and their passengers.

And our patients as well.

On the third day of the General Assembly meeting, after the end of our afternoon practice session, one of my fellow attendings came in and said, “What do you think we should do about this patient who arrived over an hour late?”

Since almost everyone I had seen that morning had been late and mostly apologetic (although it was really not their fault this time), it seemed like an easy answer.

The late patient is a part of the tradition of the practice of medicine. In our practice, patients are brought from far and wide, from every part of the city (and beyond), and get to us in multiple ways, on subways and buses, patient transportation vans and livery services, often traveling great distances and for hours on end to get to us.

We should be honored they make the effort.

And we’ve heard every excuse there is. The Access-A-Ride van didn’t pick me up; he was an hour late. The President is in town and traffic is a mess. That sinkhole opened up again on Park Avenue and I barely escaped being swallowed. My dog ate my homework.

Years ago, we would have endless battles between the providers seeing the patients, the registrars trying to check them in, and the patients themselves.

It would go something like this:

Patient arrives late. Registrar informs them that they are late (much to their surprise), and since they are late (or missed their appointment entirely), they may not be able to be seen today.

The patient would almost always request that the registrar explain to the doctor why they were late and ask if they could be seen. The registrar would go and find the doctor, at which point the doctor would say since they were late they should probably just reschedule. The patient would not be happy with this answer, more back and forth, and before you know it, everybody would be having chest pain, and more often than not, the patient would just be seen.

So we decided to finally try and put an end to all this stuff, and created a policy that stated that our goal is to take care of our patients, that we are here to provide a service, and that we often run late, our patients run late, and life happens. Why not try to make every effort to see everyone who gets here, almost always (of course there are exceptions), if we can?

Recently, a patient arrived about 3-1/2 hours late for his initial visit at our practice; his appointment was in fact the last appointment scheduled for the day.

There were very few of us left here, the cleaning crew was finishing up, and everything was pretty much shut down. The front desk staff, who was finishing up its work, shutting down the computers, and getting ready to go home, came to tell us that this gentleman just arrived and asked if we would be able to see him.

After some discussion, we realized that we really didn’t have the capacity to start entering data into the system, putting in orders, getting the necessary labs done, so we made a few little exceptions, sent in the one medication he needed that night to a local pharmacy, and rescheduled him to see us for real the next morning.

So far, my record for the latest patient is 23 hours. A patient of mine who is habitually late arrived in the practice and told me, “Good news, Dr. Pelzman — I’m way early for my appointment.” When I told her that her appointment was in fact yesterday, she was unfazed and just carried on with the visit.

We’ve talked about different ways to make sure that patients get here on time (such as reminders to try and get here before the start of the appointment and assisting with transportation), because getting here on time theoretically helps us take better care of them. We are less rushed, we can focus on them without worrying about the four other patients already checked in, and it’s never fair to make someone who’s on time wait while we take care of someone who was late.

But every provider in the history of medicine has themselves run late, sometimes very late, sometimes excruciatingly late, to the point where patients repeatedly come and ask what the holdup is all about.

So insisting that they be here on time may be a noble goal, but it’s just not a very realistic thing, and unlikely to ever truly be universally achieved or enforced.

People have suggested that patients be charged a late fee if they break appointments or are continuously late, mostly an attempt to discourage the practice. Interestingly, in studies looking at this, patients seem to always comment how they were never reimbursed for their time when they had to wait while the doctor was late, so fair is fair.

So last night, when yet another patient was late, and the UN had clearly created gridlock nightmare on the streets of New York, I told my partner that the amount of effort and energy we usually put into discussing whether or not to see a patient could usually be better put to use actually just seeing the patient.

Better late than never.

Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine. Pelzman’s Picks is a compilation of links to blogs, articles, tweets, journal studies, opinion pieces, and news briefs related to primary care that caught his eye.

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