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Interactions with the health care system – a visit to the doctor’s office

Posted Mar 17 2010 5:30am

I was doing some exercises Monday night and I tweaked my wrist during a moment when I lost my focus (and balance). After a night of discomfort and pain, I decided to try and see my doctor to rule out anything serious. I did some searching on the internet and found a good article titled “ ulnar-sided wrist pain ” which provided some very detailed information about the different types of pain in the wrist.

Scheduling the Appointment
I tried to schedule an appointment with my family doctor who is part of a group practice at the local medical centre. Unfortunately, when I tried calling in the morning, all of the lines were busy. It seems that every time I try to call the medical centre, the lines are always busy and that it’s practically impossible to schedule an appointment. Fortunately, the medical centre is only a few blocks away so I made the trek to make an appointment with the faint hope that they might be able to see me soon. No luck, but they could see me at 5pm later that day (Tuesday). Question – why does the receptionist have to ask what the problem is? Isn’t that something of a personal and private issue that should be discussed only with the patient and his health professional(s)?

Arriving and Waiting
Against my better judgement, I arrived at the medical centre 15 minutes early and checked in. There was the asking of for the health card and then I was asked to sit and wait. I ended-up waiting about 45 minutes before my name was called. I really didn’t notice the time passing as I brought some reading material (the December 2009 issue of Harvard Business Review spotlighting Innovation). I only thought about the time when I finished an article or when someone sitting next to me was called by the nurse.

Watching
Sitting in the waiting area, I tried to observe what was happening. Most of the patients looked bored as they sat and waited. The receptionists were busy chirping on their headsets and taking appointments or receiving newly arrived patients. I noted a clerk filing documents in the health records – she had a good sized stack of nearly 15 cm in height. Given how many pieces of documentation a medical centre receives, I can understand some of the frustration of trying to convert to an electronic system. There are just so many business processes that need to be synchronized in order to transition from paper given all of the potential inputs a patient’s record can have.

Seeing the Doctor
After walking into one of the exam rooms, the nurse asked me my name and then asked if I was seeing the doctor because of my wrist. She nodded and then asked me to take a seat: “the doctor will see you shortly” and then left the room, partially closing the door. After a few minutes, my family doctor walked in and asked me how I was doing. I told him that I hurt my wrist and wanted to make sure I didn’t do any serious harm. He asked me how I did it, examined my (right) wrist and compared it to the other, noting that there was some swelling and heat in the area. He poked and prodded different areas of my wrist and had me do some movements to test my range of motion. His diagnosis was that it was probably a sprain and indicated that wrist injuries are notoriously difficult to diagnose because of the complexity of the joint. He said there’s a small possibility of a fracture and ordered an x-ray. His final words were that if the pain persists after three weeks then I probably did something serious. Otherwise, I need to wait and see because the pain my “go away in a few days” or take weeks to months to heal.

Off to the Xray!
I walked over to the in-location x-ray service and presented the order to the clerk who was reading a book and looked very bored. After showing my health card, I was asked to wait for the technician. I heard a typewriter in the background as I waited. Once the technician called me, I was taken to the back and asked to deposit my things in a small cubicle before being led to the x-ray room. I had four shots taken of my wrist of different angles. Two of them had to be taken again as the film didn’t develop. As I waited for the x-rays to be processed, the developing machine looked like it was made in the 1970s. I also noticed a large plastic container with two different liquids. I forget the names of the two fluids, but they apparently need to be mixed. I got a chuckle from the hand-drawn line near the bottom with the word “refill”.

The technician gave me the processed x-rays and then I walked them back to my physician. He was with a patient so I waited just outside of the nurse’s station. The doctor walked out a minute later and we looked at the x-rays at the station. I know I couldn’t see any fractures, but I don’t really know how to spot a fracture. My doctor agreed that there was nothing wrong and sent me on my way as he moved to another exam room to see another patient.

Some Thoughts About My Visit
All in all, I was at the doctor’s office around 70 minutes and I interacted with my physician, a nurse, the receptionist, and the x-ray technicians for maybe 10 minutes total. As I examined how the very busy medical centre operated, I was trying to see if electronic solutions could make a significant impact on the practice. At first glance, I would have to say “no” as everything seems optimized to the physician’s needs – the nurse or office staff provide everything for the physician and patients are made to wait until the doctor is ready to see him/her.

From a cost perspective, would a computerized system (including electronic lab results and x-ray/diagnostic imaging) make much sense? I don’t know. The patient information is still stored via paper and much of it seems to be arriving from external sources. Notes are taken on paper and stored in the filing area which has very little physical cost compared with an electronic system which would have licensing fees, hardware, and electricity costs. Perhaps some of the clerks who do the filing could be let go or assigned different tasks. I can’t see much productivity gain in terms of having electronic imaging as the physician seems to be operating at near 100% utilization in terms of time.

What would make a big difference to a patient, however, would be an electronic scheduling system which could be accessed either by phone or on the Internet. But, I see this as being unlikely in the near future as the physician and the medical centre would lose power over its scheduling. Right now the receptionists act as the gate-keepers, restricting access to physicians.

I think the ‘last mile’ of physician offices is something that needs to be addressed as a great number of health care interactions take place there. Yet, I can understand why there is some reluctance to move toward electronic/computerized tools. The business case does not seem readily apparent. Some form of time-motion study using ethnographic methods and a formal business case should be conducted to take a look at this issue. Physicians are not the ones who are inconvenienced by paper based systems (as far as I can tell), especially if there is little information sharing outside of the physician’s office. I’m not blaming physicians at all – in fact, I think they get a bum rap sometimes because they are easy to pick on. Most of them are trying their best to navigate a system that is broken and doesn’t really support them to try and do more than operate their offices like a business. Physicians are people who have bills to pay and probably get frustrated too.

One final thought before I end this post (my wrist is starting to bother me now), with so many patients waiting to see the doctor, there has to be a way to make that time useful, either to the patient or some health care service. I was wondering if the medical centre could have a sign that indicated the approximate waiting time to be seen so that I could take a step outside or do something if the wait is 30 minutes or longer. Restaurants have the pager system that calls waiting patrons when their table becomes available. Couldn’t something similar be developed for physician offices? But why would the physicians care? They have people waiting regardless. Again, the challenge remains that patients are not at the centre of the system – the physicians are. Until we address this issue, then I can’t see meaningful changes occurring.

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