Late patients

[Trismegistus4]

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Here's another item on the list of "things you don't know to ask about when you interview for your first job": late patient policy. Before I started my current job, it never occurred to me to think about this. New patients are supposed to get new patient paperwork in the mail, and bring it in filled out, but of course sometimes they don't. Also there's the matter of getting their insurance info on file and collecting their copay, and all patients are supposed to get their vitals first. Thus, our official materials tell new patients to get here 30 minutes before their scheduled appointment time, and for follow-ups I believe it's 10 minutes.

When I started here, we were extremely strict about late patients. I was the first psychiatrist in a new satellite office, and the staff told me they actually stick to those times at the main office downtown, and make people reschedule if they are late. I thought I could be "nice" and see new patients even if they're "only" 15 minutes early, and follow-ups as long as they're on time. So, for the first few months, that's what we did. It might seem excessive, but if I had a new patient at 8AM and they literally walked in the door at 7:46, they would be told they were late and had to reschedule, and that slot would be counted as a no-show for me! And if I had a 2PM follow-up and they walked in the door at 2:01, same thing.

I realize this might seem too good to be true (if, like me, you don't like being busy) and the party would have to end sooner or later, because administration wouldn't like the missed revenue. But I grew accustomed to it. I would have several "no-shows" per day which were actually just late patients, and I could use that time to get other things done: respond to emails, respond to patient messages, just go get a cup of coffee and decompress from an earlier difficult patient interaction, or catch up on notes. This last one was most important, because as I've posted elsewhere, I just cannot get notes done during appointment times. I just don't think I will ever get out of the med student/resident mentality where you go off and take separate time just to do your notes, which is why I need to switch into low-volume inpatient work. I'm stuck late at the office every day finishing my notes.

After a few months, our medical director sent out an email saying we had to see patients who were 10 minutes late. I have no idea if this was her idea or administration's and she was just the messenger, but there was no discussion. Nobody solicited my input. The decision was just handed down from on high. Then, a few months ago, in response to some inconsistencies at the different offices, and some shenanigans that were going on (e.g., therapists noticing their last patient of the day had canceled and asking the front desk staff not to re-fill that slot if anyone calls in wanting to be seen,) she and the therapist supervisor sent out another email saying we now have to see people who are up to 15 minutes late. Again, no discussion, the decision was just handed down from on high.

This has been particularly difficult, because not only did the earlier strict limits result in more "no-shows," they also made these freed-up time slots for me longer. I knew from the beginning of the time slot that I would have the next 30 to 60 minutes free. If 2:01 PM hit and my patient was not there, I knew I had the next 29 minutes to not see a patient. I could really concentrate on another task, like finishing notes. Now, if that happens, I can start to work on my other notes, but I have to keep clicking back over and checking my schedule every 1-2 minutes, to see if the 2:00 patient has arrived. And if they have, up until 2:15, I have to see them.

The worst part is that I then get behind. The aforementioned email said "the patient will make every effort to accommodate their lateness," but that's easier said than done. If the person's a talker who is hard to cut off, no matter how much I tell them "we only have until 2:30," we will inevitably end up going over. Then I'm ushering them out of the office at 2:32, and not bringing back the 2:30, who was there at 2:20 like we tell them to be, until 2:33. And the entire rest of my afternoon is off.

The end result, is that, by the principles of classical conditioning, we are teaching everyone to be late. We are rewarding people who get here late, and punishing people who get here early. People don't get their vitals done before seeing me; they have to get them on the way out, which means I don't see their vitals. Or I could choose to accommodate their lateness further by having them get their vitals first even though they were late, putting me even farther behind. To listen to our medical director talk, it seems that's what she does. I think also, a lot of people assume we must work like any other doctor's office, where appointment times are somewhat imprecise because the doctor keeps going in and out of the room, and they "squeeze people in." Again, seeing people who are significantly late reinforces this, and then we can't work the way we really want to, where we have dedicated, fixed appointment times to spend with each patient. Since we started doing this, I have definitely noticed an increase in lateness. Far fewer people are actually getting here 10 minutes early like we tell them to, and MANY people get here 1-2 minutes after the appointment time starts. Among people who get here substantially late, for some reason 9 minutes and 11 minutes stand out as two common times.

I realize the initial standards were probably unrealistically harsh (after all, a new 8AM patient had to get to the office earlier than the doctor did in order to be seen! I could walk in at 7:55 and the patient who had gotten there at 7:46 would already have been turned away.) But I feel our current standard takes things too far. What is everyone's clinic's late patient policy? I'm not planning on staying in this job and am sure I'll go back to inpatient for the time being, but if I ever do outpatient again, I'd like to know what's reasonable and realistic, what might be accepted during negotiations.

(I might add that I'm not a go-getter who is very concerned about productivity. I'd rather have a few "no-shows" scattered throughout the day to catch up on other work, than make more money.)

 

[sweetlenovo88]

I create a 15 minute cutoff myself into a 30 minute appointment to be in front of me or the clinic would just bring them in whenever. If they are late and are talkers, I tell them since you are late this will be a brief visit without any major med changes. If that is not ok, they can reschedule. I don't have trouble completing notes on time before the next visit which can be delayed 5-10 minutes. Only a couple of them throughout the day are late though.

 

[erg923]

Here's another item on the list of "things you don't know to ask about when you interview for your first job": late patient policy. Before I started my current job, it never occurred to me to think about this. New patients are supposed to get new patient paperwork in the mail, and bring it in filled out, but of course sometimes they don't. Also there's the matter of getting their insurance info on file and collecting their copay, and all patients are supposed to get their vitals first. Thus, our official materials tell new patients to get here 30 minutes before their scheduled appointment time, and for follow-ups I believe it's 10 minutes.

When I started here, we were extremely strict about late patients. I was the first psychiatrist in a new satellite office, and the staff told me they actually stick to those times at the main office downtown, and make people reschedule if they are late. I thought I could be "nice" and see new patients even if they're "only" 15 minutes early, and follow-ups as long as they're on time. So, for the first few months, that's what we did. It might seem excessive, but if I had a new patient at 8AM and they literally walked in the door at 7:46, they would be told they were late and had to reschedule, and that slot would be counted as a no-show for me! And if I had a 2PM follow-up and they walked in the door at 2:01, same thing.

I realize this might seem too good to be true (if, like me, you don't like being busy) and the party would have to end sooner or later, because administration wouldn't like the missed revenue. But I grew accustomed to it. I would have several "no-shows" per day which were actually just late patients, and I could use that time to get other things done: respond to emails, respond to patient messages, just go get a cup of coffee and decompress from an earlier difficult patient interaction, or catch up on notes. This last one was most important, because as I've posted elsewhere, I just cannot get notes done during appointment times. I just don't think I will ever get out of the med student/resident mentality where you go off and take separate time just to do your notes, which is why I need to switch into low-volume inpatient work. I'm stuck late at the office every day finishing my notes.

After a few months, our medical director sent out an email saying we had to see patients who were 10 minutes late. I have no idea if this was her idea or administration's and she was just the messenger, but there was no discussion. Nobody solicited my input. The decision was just handed down from on high. Then, a few months ago, in response to some inconsistencies at the different offices, and some shenanigans that were going on (e.g., therapists noticing their last patient of the day had canceled and asking the front desk staff not to re-fill that slot if anyone calls in wanting to be seen,) she and the therapist supervisor sent out another email saying we now have to see people who are up to 15 minutes late. Again, no discussion, the decision was just handed down from on high.

This has been particularly difficult, because not only did the earlier strict limits result in more "no-shows," they also made these freed-up time slots for me longer. I knew from the beginning of the time slot that I would have the next 30 to 60 minutes free. If 2:01 PM hit and my patient was not there, I knew I had the next 29 minutes to not see a patient. I could really concentrate on another task, like finishing notes. Now, if that happens, I can start to work on my other notes, but I have to keep clicking back over and checking my schedule every 1-2 minutes, to see if the 2:00 patient has arrived. And if they have, up until 2:15, I have to see them.

The worst part is that I then get behind. The aforementioned email said "the patient will make every effort to accommodate their lateness," but that's easier said than done. If the person's a talker who is hard to cut off, no matter how much I tell them "we only have until 2:30," we will inevitably end up going over. Then I'm ushering them out of the office at 2:32, and not bringing back the 2:30, who was there at 2:20 like we tell them to be, until 2:33. And the entire rest of my afternoon is off.

The end result, is that, by the principles of classical conditioning, we are teaching everyone to be late. We are rewarding people who get here late, and punishing people who get here early. People don't get their vitals done before seeing me; they have to get them on the way out, which means I don't see their vitals. Or I could choose to accommodate their lateness further by having them get their vitals first even though they were late, putting me even farther behind. To listen to our medical director talk, it seems that's what she does. I think also, a lot of people assume we must work like any other doctor's office, where appointment times are somewhat imprecise because the doctor keeps going in and out of the room, and they "squeeze people in." Again, seeing people who are significantly late reinforces this, and then we can't work the way we really want to, where we have dedicated, fixed appointment times to spend with each patient. Since we started doing this, I have definitely noticed an increase in lateness. Far fewer people are actually getting here 10 minutes early like we tell them to, and MANY people get here 1-2 minutes after the appointment time starts. Among people who get here substantially late, for some reason 9 minutes and 11 minutes stand out as two common times.

I realize the initial standards were probably unrealistically harsh (after all, a new 8AM patient had to get to the office earlier than the doctor did in order to be seen! I could walk in at 7:55 and the patient who had gotten there at 7:46 would already have been turned away.) But I feel our current standard takes things too far. What is everyone's clinic's late patient policy? I'm not planning on staying in this job and am sure I'll go back to inpatient for the time being, but if I ever do outpatient again, I'd like to know what's reasonable and realistic, what might be accepted during negotiations.

(I might add that I'm not a go-getter who is very concerned about productivity. I'd rather have a few "no-shows" scattered throughout the day to catch up on other work, than make more money.)

You have alluded in previous posts that you are adverse to confrontation? OP psychiatric practice is rife with the need for confrontation with your patients...albeit in a therapeutic way.

Stressing ultimate responsibility, self-efficacy, and internal locus of control (generally anyway), are all important aspects of the this work. Unless there is/are marked transportation problems or SPMI, this scenario would not seem to be meeting the ideal practice patterns of any psychiatric professional (MD, psychologist, or therapist)? When you lack some degree of control over the overall practice, I think it is even more important to bring the issue of tardiness out at the outset of the session. This is not fun. I didn't enjoy this aspect of professional practice either, and it (among many others) is why I left.

 

[TexasPhysician]

I think 10-15 min late for a 30 min appt is fine to see. It is your responsibility to have discipline enough to finish on time. Cutting the patient off due to their tardiness will reinforce being on time.

 

[Fan_of_Meehl]

Unfortunately, many administrative (non-clinical) types don't understand that enforcing boundaries with psychiatric patients is actually, generally speaking, the most therapeutic and professionally-appropriate response.

 

[splik]

Thankfully I rarely have to see patients now, and they are a selected bunch so they are always early, but I remember having to see patients no matter now late they turned up (yes this was the policy in one clinic I worked in). If I felt I did not have enough time I did as sweetlenovo88 said, and told patients no changes would be made to their medications etc in this visit. I am also very good at cutting patients off, even if it means literally pushing them out the door (i would do this by getting up, opening the door, putting my hand on their back, telling them i need to get the next patient, and telling them 'let me show you out'). your clinic sounds like a disaster. its bad to let late patients take up too much time, and it's even worse they turned away patients who were early.

 

[ryerica22]

Thankfully I rarely have to see patients now, and they are a selected bunch so they are always early, but I remember having to see patients no matter now late they turned up (yes this was the policy in one clinic I worked in). If I felt I did not have enough time I did as sweetlenovo88 said, and told patients no changes would be made to their medications etc in this visit. I am also very good at cutting patients off, even if it means literally pushing them out the door (i would do this by getting up, opening the door, putting my hand on their back, telling them i need to get the next patient, and telling them 'let me show you out'). your clinic sounds like a disaster. its bad to let late patients take up too much time, and it's even worse they turned away patients who were early.

So, in theory, the patient could show up one hour late and you would have to see them?

 

[splik]

So, in theory, the patient could show up one hour late and you would have to see them?

yup. this was when in an HIV clinic with indigent/hard to reach patients. there was a lot of pressure to see pts regardless of when they turned up, even if it was just for 5 mins to keep them engaged. i have hardly any pts right now but they either a schlepping hundreds of miles to see me, or are physicians, so i dont have this problem in my current work situation. i actually sympathized with the former situation, which was v. impaired patients with life-limiting medical comorbidities that needed treatment and we did what we could to get them in. if that were not the case, i would not be happy seeing someone for an ADHD eval etc who turns up 5 millions hours late.

 

[Merely]

yup. this was when in an HIV clinic with indigent/hard to reach patients. there was a lot of pressure to see pts regardless of when they turned up, even if it was just for 5 mins to keep them engaged. i have hardly any pts right now but they either a schlepping hundreds of miles to see me, or are physicians, so i dont have this problem in my current work situation. i actually sympathized with the former situation, which was v. impaired patients with life-limiting medical comorbidities that needed treatment and we did what we could to get them in. if that were not the case, i would not be happy seeing someone for an ADHD eval etc who turns up 5 millions hours late.

Why are people traveling hundreds of miles to see you?

 

[WingedOx]

I generally follow the guidelines above within limits, and my VA is good about letting me set boundaries with perpetually tardy patients, which isn't the case everywhere.

The one situation I'm nearly always forgiving with late patients is if another appointment in the hospital has caused them to be late, I'll go out of my way to squeeze them in since that's out of their control.

 

[hamstergang]

I've set for myself the same guidelines that some of my residency clinics used, which is to see patients so long as they show up before halfway through the appointment slot. If patients show up after that, I let them know that there just isn't enough time to perform an appropriate and safe evaluation without making everyone else after that very late. If there's a break coming up shortly, I will offer them to wait to be seen in that time, otherwise I will provide refills and ask them to reschedule.

Most patients are ok with this. Some have gotten very angry with me for not letting them have a 10 minute visit. I have once or twice tried to squeeze in a visit (not to appease someone angry, but because I was naive) and there's just no way to keep it short enough. Even if a patient shows up at the halfway mark, then I try to do the visit faster but still run at least 5 minutes over into the next slot.

Thankfully, my current job has no problem with me doing this basically however I want.

As someone said already, a difficult piece to this is being productive in the unknown amount of time you have when a patient is late. Do I have enough time to get that phone call done? Should I do some of the quick and easy parts of the note? Answer an email? Go to the bathroom? It really ends up wasting more of my day than it seems it should.

 

[smalltownpsych]

For the unproductive time when I am waiting for a no show (our policy is 15 minute grace period), I either do a couple notes or jump on SDN!

 

[WingedOx]

For the unproductive time when I am waiting for a no show (our policy is 15 minute grace period), I either do a couple notes or jump on SDN!

More the latter. You'd figure I'd be more productive since I gave twitter up for lent.

 

[WisNeuro]

You guys need to really try this only seeing 1-2 pts a day thing. It's working wonders for me.

 

[WingedOx]

You guys need to really try this only seeing 1-2 pts a day thing. It's working wonders for me.

I should try to move up to a supervisory/admin role for some 'executive time' built into my schedule.

 

[smalltownpsych]

I should try to move up to a supervisory/admin role for some 'executive time' built into my schedule.

I just got off the phone with a guy talking about a potential job with an admin role with some direct care just to keep my skills sharp. I hope I can make it work. This patient after patient after patient grind is...

 

[ryerica22]

yup. this was when in an HIV clinic with indigent/hard to reach patients. there was a lot of pressure to see pts regardless of when they turned up, even if it was just for 5 mins to keep them engaged. i have hardly any pts right now but they either a schlepping hundreds of miles to see me, or are physicians, so i dont have this problem in my current work situation. i actually sympathized with the former situation, which was v. impaired patients with life-limiting medical comorbidities that needed treatment and we did what we could to get them in. if that were not the case, i would not be happy seeing someone for an ADHD eval etc who turns up 5 millions hours late.

Ok, so you could easily stay there till midnight if you adhere to that policy. Did the clinic have any set hours? were you being paid for overtime work/documentation?

 

[ryerica22]

Also, as this thread is mostly focused on outpatient settings, do you guys type your notes as you are interviewing patients?

 

[Trismegistus4]

Damn, sounds like this 15 minutes/halfway through the appointment limit is standard. Oh well; it was fun while it lasted.

You have alluded in previous posts that you are adverse to confrontation? OP psychiatric practice is rife with the need for confrontation with your patients...albeit in a therapeutic way.

Stressing ultimate responsibility, self-efficacy, and internal locus of control (generally anyway), are all important aspects of the this work. Unless there is/are marked transportation problems or SPMI, this scenario would not seem to be meeting the ideal practice patterns of any psychiatric professional (MD, psychologist, or therapist)? When you lack some degree of control over the overall practice, I think it is even more important to bring the issue of tardiness out at the outset of the session. This is not fun. I didn't enjoy this aspect of professional practice either, and it (among many others) is why I left.

I would rather be passive and avoidant, and have the front desk staff confront the patient by telling them they're too late to be seen. 😀

Seriously though, while I don't see myself moving into administrative work anytime soon, I encounter a new reason to hate outpatient just about every day, and can't wait to go back to inpatient where you work at your own pace.

I just got off the phone with a guy talking about a potential job with an admin role with some direct care just to keep my skills sharp. I hope I can make it work. This patient after patient after patient grind is...

Someone else used the illustration of a "drive-through" as an analogy and I think that's apt. The next person is always waiting...

Just by chance, I had a bunch of open slots on my schedule today. I only had 11 patients on my schedule; 2 of them no-showed, 1 was actually too late (i.e., more than 15 minutes,) so I saw 1 new patient and 8 follow-ups. So I had random chunks of downtime scattered throughout the day, and the last patient was out the door at 4, at which time all I had left to do was finish three follow-up notes. And I thought to myself, "this feels like how it should be. If I had a job where every day was like this, that would be a job I could be content with."

(Unfortunately, that one who was too late is a stimulant-demander who's convinced she has ADHD, and got herself rescheduled for tomorrow. 😱)

Also, as this thread is mostly focused on outpatient settings, do you guys type your notes as you are interviewing patients?

I do, but only in the sense of "taking notes." So after the patient leaves the room, I still have a lot of spelling and punctuation cleanup work to do, plus making sure the mental status exam is accurate and the plan up-to-date. It's a huge problem for me and a facet of outpatient work I will never get used to. I need separate, dedicated time to do my notes.

 

[DD214_DOC]

I was in an admin position and ran my current clinic and supervised/managed its entire staff for about a year, until someone permanent could be hired. The position had its own unique set of headaches but also some great perks. The primary benefit was having control over workflow and other processes, and I was in the position to actually develop and enforce policies regarding important aspects of what we do such as boundaries and limit setting. I also was able to actually significantly decrease the amount of silly referrals from primary care. Another benefit was a 50% clinical workload, which was a nice break.

Of course, since I moved back into a full-time clinical position everything I managed to accomplish completely fell apart or was even reversed by the new chief, but it was still a good experience and something I'd be interested in pursuing in the coming years.

 

[SpongeBob DoctorPants]

The policy at our clinic (and it was the same at my fellowship program) is that a patient can arrive up to 15 minutes past their appointment time (even new patients), and anything beyond that would require my permission to let them be seen.

I agree with many of your feelings... that it tends to reinforce arriving late, which leads to you running behind and having to catch up on notes later, etc. However, I also have a productivity incentive attached to my income now, so I don't necessarily mind seeing someone late as long as I can keep it brief and the visit won't interfere with the next appointment. I also give some leeway to those who have particularly good excuses or are traveling a great distance. (For example, one of my patients lives 3 hours away and I don't think I could ever refuse to see them if they arrived late after waking up at 4 AM and driving 160 miles to our clinic.) Sometimes though I've thought it would be nice to hang a sign in my office which says something to the effect of "As a courtesy to our patients who arrive on time, those who arrive late will only have time for one problem to be addressed."

 

[FlowRate]

As someone said already, a difficult piece to this is being productive in the unknown amount of time you have when a patient is late. Do I have enough time to get that phone call done? Should I do some of the quick and easy parts of the note? Answer an email? Go to the bathroom? It really ends up wasting more of my day than it seems it should.

Not sure what others think about this idea. If it's a few minutes past the appointment time and the patient is not in the waiting room or checked in, then just do whatever thing you were planning to do. Sure, they're paying you for the therapy hour, but you are also a human being who has to do things and can't be at their beck and call every single second of the day when they're not even clearly going to show up.

 

[DD214_DOC]

Not sure what others think about this idea. If it's a few minutes past the appointment time and the patient is not in the waiting room or checked in, then just do whatever thing you were planning to do. Sure, they're paying you for the therapy hour, but you are also a human being who has to do things and can't be at their beck and call every single second of the day when they're not even clearly going to show up.

I will do small things that don't take up much time in the 10-15 minute period for a late patient. The first 5 minutes I use to do my usual chart review so it's already out of the way. I get really frustrated/angry if I get into something more complex or time consuming and then I'm interrupted, so I know better than to even start.

After the 15 minute point (or longer for a new patient), if they show up then what I do really depends. If it's a patient I know well and have seen for some time, and there's no history of arriving late, I'll probably just see them. If it's a chronically-late patient, they reschedule. If it's a relatively new patient and I don't know them well enough to determine if I can accomplish what I need in the time that remains, they reschedule.

I used to offer to either see them for whatever time remains in their appointment, even if it's just 5 minutes, or they could reschedule. I quit doing it, because once you meet with them, you're responsible for addressing whatever they bring to you regardless of how much time is available.

 

[Dr. Wexler]

Thus, our official materials tell new patients to get here 30 minutes before their scheduled appointment time, and for follow-ups I believe it's 10 minutes.

Disclaimer: Physician but not a psychiatrist.

Policies like this just confuse patients. Set the time for what time you want them to be there. That means they might not see the doctor until after their actual appointment time (taking into account screening, paperwork). And most patients will be okay with that. Especially if they had a 1PM appt and didn't see the doctor until 1:20 because they spent spent 10 minutes filling out paperwork, 10 mins getting checked in and then saw the doctor.

Telling someone to be there at 1230 for their 1PM appt (which means they're late if they show up at 1240 I guess) is a sure fire way to upset patients. And god help you if you don't see them right at 1PM then.

More than 10 minutes late to see me? I'll make the decision but you'll likely have to reschedule. If I do manage to see you my nurse will make a point of saying that we are doing the patient a favor. On the flip side, I don't allow myself to run behind. Wouldn't be fair to make patients be on time if I'm not. I actually think I have gained some patients not because of my skills as a physician but just because I run on time.

 

[Trismegistus4]

Not sure what others think about this idea. If it's a few minutes past the appointment time and the patient is not in the waiting room or checked in, then just do whatever thing you were planning to do. Sure, they're paying you for the therapy hour, but you are also a human being who has to do things and can't be at their beck and call every single second of the day when they're not even clearly going to show up.

I think what @hamstergang and I were thinking is that if the patient is late, you have to maximize all the time you do have with them, so you have to go out and bring them back as soon as they arrive. Whereas you're saying "hey, if the patient's not there at 8:05, go do something else. If they get shortchanged on time because they wind up checking in at 8:06 but you didn't see they were there and go out and grab them until 8:14, that's their problem for being late." Which sounds good on paper, but doesn't work out well in practice, because as @HooahDOc said, once you've brought them into your office you're responsible for addressing whatever concerns they bring up. And also, that just reinforces lateness further--they're just going to think "hey, the doctor doesn't come out and get me until 8:14; why get there any earlier?"

I appreciate all the suggestions in this thread, but in reality, I don't like working and I like no-shows, and this place is not my own business so I don't care about the bottom line. What I want is not to teach the person who shows up at 2:05 to show up at 1:55 next time. What I want is to not have to see the person who gets there at 2:05.

 

[michaelrack]

I think what @hamstergang and I were thinking is that if the patient is late, you have to maximize all the time you do have with them, so you have to go out and bring them back as soon as they arrive. Whereas you're saying "hey, if the patient's not there at 8:05, go do something else. If they get shortchanged on time because they wind up checking in at 8:06 but you didn't see they were there and go out and grab them until 8:14, that's their problem for being late." Which sounds good on paper, but doesn't work out well in practice, because as @HooahDOc said, once you've brought them into your office you're responsible for addressing whatever concerns they bring up..

you don't have address "whatever concerns they bring up" other than taking care of any life-threatening emergencies and setting a time for follow up for other issues- "you are no longer suicidal now that you are on remeron but you are gaining weight- I will refill x 1 month and let's have you come back next week to talk further about this"

 

[Liquid8]

I appreciate all the suggestions in this thread, but in reality, I don't like working and I like no-shows, and this place is not my own business so I don't care about the bottom line. What I want is not to teach the person who shows up at 2:05 to show up at 1:55 next time. What I want is to not have to see the person who gets there at 2:05.

If you just want to see less patients, book them in for 1 hour reviews and aim to finish up in half an hour. Use the rest of the time to finish up your notes so you can get out on time. This option would probably alleviate some of the stress of the clinic wanting you to see patients who are 15 minutes late for half hour slots.

If a patient is running late and you really don't want to see them, you could either ask your reception staff to call them and reschedule the appointment or do it yourself. It's probably not reasonable if a patient has arrived only 5 minutes late, but if it's 10 minutes over and they still haven't arrived yet I don't think it's unreasonable to find out where they are.

 

[DD214_DOC]

you don't have address "whatever concerns they bring up" other than taking care of any life-threatening emergencies and setting a time for follow up for other issues- "you are no longer suicidal now that you are on remeron but you are gaining weight- I will refill x 1 month and let's have you come back next week to talk further about this"

Legally, this is correct. However, knowing that the additional work generated when they immediately go to file a complaint with patient advocacy for, "not addressing their concerns" as well as the almost daily phone calls about the issue are probably more time-consuming than just addressing the issue then, it doesn't make sense.

 

[Trismegistus4]

you don't have address "whatever concerns they bring up" other than taking care of any life-threatening emergencies and setting a time for follow up for other issues- "you are no longer suicidal now that you are on remeron but you are gaining weight- I will refill x 1 month and let's have you come back next week to talk further about this"

What @HooahDOc said. It's easier to let them run 2 minutes over to make them feel like you addressed all their concerns, than it is to literally force them out the door and deal with the complications from that.

If you just want to see less patients, book them in for 1 hour reviews and aim to finish up in half an hour. Use the rest of the time to finish up your notes so you can get out on time. This option would probably alleviate some of the stress of the clinic wanting you to see patients who are 15 minutes late for half hour slots.

That's an intriguing idea, but you're essentially suggesting converting to a half-time job. There's no way administration would allow that. I don't have a say in how many patients I see. I have half-hour follow-up slots and that's that.

If a patient is running late and you really don't want to see them, you could either ask your reception staff to call them and reschedule the appointment or do it yourself. It's probably not reasonable if a patient has arrived only 5 minutes late, but if it's 10 minutes over and they still haven't arrived yet I don't think it's unreasonable to find out where they are.

I'm not a fan of the idea of calling and finding out where they are, if only because that makes us the initiators of the problematic thing patients sometimes do, which is call to say they're running late. This is problematic because people feel that calling gets their foot in the door, so to speak, so they think they're going to be seen whenever they show up. Several times, a patient scheduled for, say, 11:00 has called at 11:01 and told the front desk staff they'll be there at 11:10. Then in reality by the time they actually wait at a few more unexpected red lights, park their car, walk into the building, take the elevator, walk down the hall, walk into the waiting room, and walk up to the front desk, it's 11:20, and they're expecting to be seen because they called and let us know they were running late. Calling them to see if they're running late just invites that.

Incidentally, inspired by my day today, here's another frustrating thing that often happens involving late patients:

2:00: my 2:00 patient isn't there.
2:02: my 2:30 patient checks in (maybe they just wanted to allow extra time, maybe they just got done with lunch with a friend and had nowhere else to go for 20 minutes, who knows?)
2:14: my 2:00 patient checks in.
2:15: I go out and call the 2:00 patient back, and the 2:30 patient gets to sit there and observe someone who got there after him getting called back before him.
2:32: I finally manage to get my talkative 2:00 patient out the door.
2:33: I'm calling back my 2:30 patient, who had the decency to get there 28 minutes early, 3 minutes late.

This happened twice to me today. Not with such exaggerated numbers, but with 2 separate pairs of back-to-back patients, the later one on the schedule arrived very early, and the earlier one on the schedule arrived late, and I had to see the late patient who didn't even get there until after the next patient on the schedule did.

 

[hello1234!]

Why didn’t u see your 2:30 patient who checked in first before seeing your 2:00 patient who came late?

 

[birchswing]

As a patient I have never seen any of these machinations in practice. You arrive; the place looks like a disease-ridden airplane terminal with children crawling all over, people coughing, sniffling, packed to the gills. You're seen in the next 1-3 hours. There are no appointment *times*. Just a general chronological order. And those drug reps dressed like flight attendants breeze by you with such confidence and get to skip the queue. What world is this where people are seen at their actual appointment time?

 

[SpongeBob DoctorPants]

2:00: my 2:00 patient isn't there.
2:02: my 2:30 patient checks in (maybe they just wanted to allow extra time, maybe they just got done with lunch with a friend and had nowhere else to go for 20 minutes, who knows?)
2:14: my 2:00 patient checks in.
2:15: I go out and call the 2:00 patient back, and the 2:30 patient gets to sit there and observe someone who got there after him getting called back before him.
2:32: I finally manage to get my talkative 2:00 patient out the door.
2:33: I'm calling back my 2:30 patient, who had the decency to get there 28 minutes early, 3 minutes late.

Why didn’t u see your 2:30 patient who checked in first before seeing your 2:00 patient who came late?

While you are respecting your 2:00 patient's 15 minute grace period, I agree that it would probably be best to see the 2:30 patient first in this situation. If it was a few minutes earlier, let's say 1:58, then I would still wait for the 2:00. But after 2:00, that patient is technically late, so I think it would be acceptable and appropriate to see the next patient if they are there. If and when the 2:00 finally arrives, they can be informed upon arrival that because they were late, their appointment just got taken and they are now scheduled for 2:30. This will likely condition them to arrive earlier next time.

 

[Liquid8]

I'm not a fan of the idea of calling and finding out where they are, if only because that makes us the initiators of the problematic thing patients sometimes do, which is call to say they're running late. This is problematic because people feel that calling gets their foot in the door, so to speak, so they think they're going to be seen whenever they show up. Several times, a patient scheduled for, say, 11:00 has called at 11:01 and told the front desk staff they'll be there at 11:10. Then in reality by the time they actually wait at a few more unexpected red lights, park their car, walk into the building, take the elevator, walk down the hall, walk into the waiting room, and walk up to the front desk, it's 11:20, and they're expecting to be seen because they called and let us know they were running late. Calling them to see if they're running late just invites that.

There’s a difference here. The patient who calls to give advance warning that they’re going to be late usually still wants to keep the appointment and see you.

The reason I am suggesting that you call the patient is so you can get the outcome you want by convincing them to cancel. If they’re more than 10 minutes late and still haven’t showed up, you can simply tell them it would be better for them to cancel rather than having to rush through things too quickly. As you’ve already said you don’t care about the bottom line, maybe offer to waive any late cancellation fees. If they still insist on coming, then you can set some limits by making it clear that they will only have the remaining time to the next appointment.

If they take the option to reschedule, then you tell them that you’ll sort it out with reception. Tell your staff the patient has called to cancel. Ask them to please call the patient back later to rebook – but when they have the time, because it’s non urgent 🙂

Anyway, like others have suggested I think you should seriously look at working somewhere else. The decision about having to see patients who arrive late should be at the discretion of the treating doctor, not arbitrary rules made up by practice staff.

 

[Ceke2002]

Standard procedure when I was seeing my Psych, was that the appointment time would generally be held if I called in advance to let them know I was running late (eg medical emergency on the train causing a delay while they waited for the ambos to rock up) - although if my appointment was at 11, and I turned up at 11.20, and appointment run time was 30 minutes, then I only got 10. If my Psych had a patient who had arrived early for the appointment time after mine then he'd take them in first and just swap me to the next time instead. That would also happen if I was the one who happened to be early and the scheduled appointment before mine hadn't shown up or rung by about 5 past.

 

[michaelrack]

I am sure glad I turned down a recent part time psych job offer and decided to expand my inpatient work instead

 

[futuredo32]

For my pp, if they come late, it is fine, but it is taken out of their visit. If they are 25 min late for a therapy or therapy/med appointment, they get 20 min. If it is a med check and they totally blow too much time to do anything , I charge them for a no show and tell them they need to reschedule. When I worked at a CMH it was a nightmare, no one was on time, it didn't matter, there was no rhyme or reason to who I saw first second third,etc..

 

[Orgone]

The "list of things you don't know to ask about" is why I'm glad I did locum tenens the first 2 years out of residency. Gives you a chance to see what you like/hate without the full commitment. Kind of like "casual dating".

And if the administrator Sith Lords get too obnoxious . . . au revoir!

 

[TexasPhysician]

Why didn’t u see your 2:30 patient who checked in first before seeing your 2:00 patient who came late?

If this is an insurance-based practice, I would do this 100% of the time.

Even in my cash practice, I sometimes do this. 5 min late and my staff will call you. Don’t answer or quite late and I’ll see the early patient first. That actually benefits the late patient as they get more time, even though delayed.