When Dr. Timothy Malia of Fairport, New York, runs behind schedule, he passes out five-dollar bills to everyone in the waiting room. And when Dr. Cyrus Peikari of Dallas, Texas canceled his appointments for a family emergency, he gave each patient 50 bucks for the inconvenience.

Most doctors apologize. Few offer cash. Others get creative: Dr. Gwen Hanson of Bellevue, Washington gives out Starbucks cards; Dr. Sharon McCoy George of Irvine, California, doles out movie passes; and I award gifts from a giant wicker basket by the door.

As America inches toward patient-centered care, some doctors are leading the way.

I transitioned from assembly-line to patient-centered medicine in 2004 when I invited citizens in Lane County, Oregon, to design their own clinic. I led town hall meetings, collected 100 pages of testimony, adopted 90% of the community’s feedback, and opened one month later. Our community clinic is thriving. But I’m always looking for new ideas.

Who is accountable for wait time?

Then my friend Elaine disclosed, “If I’m kept waiting, I bill the doctor. At the 20-minute mark, I politely tell the receptionist that the doctor has missed my appointment and at the 30-minute mark I will start billing at $47.00 per hour.” More often than not, she gets paid.

I reported her story on my YouTube news channel where it was picked up by CNN and over 11,000 other media outlets. Ultimately, Elaine’s waiting room remedy became the lead segment for a “Patients’ Bill of Rights” series on ABC World News.

Why all the fuss? Patients, frustrated by excessive waiting, have had no immediate recourse. Until now.

Amid the media frenzy, I met up with a patient named Pam. She billed two chiropractors and a neurosurgeon. The neurosurgeon waived her balance; both chiropractors paid up. One offered a bottle of wine from his private collection and promised prompt service upon arrival for future appointments — ahead of scheduled patients — because, he said, “those people don’t mind waiting.”

Comments from news stories confirm Elaine and Pam aren’t unique. Jacob Raitt, a retired pharmacologist, writes:

“Hurrah: I began to do that in 1968 when I had to take my infant daughter to a dermatologist. I called early, told the person who answered that my daughter had diaper rash and how I was treating her. We arrived at the office 15 minutes early, waited more than three hours, and when the doctor finally made her presence known she told me that my daughter had diaper rash, and wrote a prescription for the medication I had told them I was using. When I went home, I immediately invoiced the doctor for $75.00, ignored her bill, and compounded interest monthly. When my bill to her exceeded $100.00 I started action in small claims court. She paid me, and ever since I have always told doctors what I would do if kept waiting more than 15 minutes. Other than in cases of emergency, I have never been kept waiting.[1]”

From anger to empathy

We’ve all waited for the doctor. But why so long? Here’s the not-so-simple answer:

Physicians cannot set, charge, or receive proper payment because government and insurance companies control reimbursement. In other words, there’s no free market for physicians who accept insurance. By boosting the volume of patients seen, they buffer the loss from low reimbursement, resulting in production-driven practices that pack up to five exam rooms per doctor to cover ever-increasing overhead.

When physicians enter the exam room, they have no idea what multitude or complexity of problems they’ll encounter, nor the insurance hassles, paperwork, and phone calls they must endure to adequately care for the patient.

Patients believe doctors are insulated from economic distress. Yet with high medical school debt, low reimbursement, and 24/7 call duty, some physicians earn less than minimum wage. I know doctors who can’t afford their own health insurance; fortunately, their kids meet federal poverty guidelines and are enrolled in Medicaid. Recently, a physician friend confided she’s defaulting on her student loans.

For the promise of loan repayment, some doctors take government jobs with no control over their schedules. Myria Emeny, MD wrote in an email (June 2011): “When I worked for the community health center it was mandatory that a patient be put in every 15 minutes — didn’t matter if they needed an interpreter or were elderly and very sick or disabled and needed extra explanations — didn’t matter. Patients waited for me two or more hours … I worked through lunch and continued past the time my nurse left.” After years of self-neglect from working inhumane schedules, doctors burn out.

Doctors taking responsibility: Victims no more

In our automated and alienated medical system, both patients and doctors feel dehumanized and commoditized. Will invoicing doctors solve the problem?

While it’s easy to blame doctors, patients bear some responsibility. One person writes: “Wait time too long? Leave. Can’t leave? Then stay. Your doctor is running late but can’t bend time. And frankly, if you show up for an appointment still fat, smoking, and not taking your meds, then you’re wasting their time, and everyone else’s time in the waiting room. Maybe they should send you a bill.”

In fact, the underlying issue is: We all must be responsible for our actions — and inactions. A patient named Colin challenges, “I have negative hope that lawyers and politicians in DC have the capacity to fix any one of the thousand problems with health care if physicians cannot come to a consensus on a ‘simple’ issue of should physicians bear responsibility for running late.”

One physician admits, “At my old job I was routinely scheduled to have three patients in the 8:30 am time slot. There’s no way I could finish seeing all those people before the next three scheduled in the 8:45 am time slot.” A patient contends, “The fact that you have to see [12] people an hour because the insurance companies are screwing you doesn’t change that fact that long waits waste our time.” The truth is: when both patient and physician sign contracts with insurers, both carry equal responsibility.

But physicians are more capable of fixing long waits than patients. As the business owner (or employee agreeing to work for a group), physicians consent to the creation of this situation and should be challenged to take responsibility for it.

Dr. Timothy Malia took control of his medical practice by lowering volume and working a humane schedule. He says, “I do what I can in the part of the world I have some control over, most often just the 10 feet around me.” Imagine if we all did the same.

Informed scheduling

One solution: Offices must clearly inform patients what to expect before they arrive for an appointment. With open-hours scheduling, patients sign in and are treated on a first-come, first-served basis. With wave scheduling, patients are booked at the top of the hour and seen in order of arrival. Most common is stream scheduling — assigning one time slot per person, with overbooking for same-day appointments.

Uninformed patients are often in for unpleasant surprises. After a long wait, one patient confides, “I started asking people what time their appointment was for and it turned out there were four of us with the same appointment time. I switched doctors.”

While informed scheduling may seem to be a simple fix, it’s also a threat to standard operations, as many practices maximize efficiency and benefit financially by having people wait for free.

Just a little respect between doctors and patients

Most physicians are compassionate and caring. But one woman recalls waiting in the exam room for almost two hours while her doctor was “calling all his friends on the phone and telling them about his fabulous Florida deep-sea fishing trip”

It’s basic: mutual respect is a prerequisite for a healing relationship.

José, a physician, shares a personal anecdote. Pulled over by a police officer on the way to the doctor’s office, José’s uncle was five minutes late for his appointment. The administrator told him it didn’t matter why he was late and to expect a bill for not showing up on time or canceling within 24 hours. He rescheduled for the following day and waited two hours in the exam room for the doctor. No apologies were made. José summarizes, “This lack of respect is what gives many of us a bad name, making patients feel like we think we are superior to them and think that our time is more valuable than theirs, alienating us from our patients.”

Doctors have hundreds of reasons why they run behind and claim it’s never due to lack of respect for patients. Yet many offices charge patients late, no-show, or cancel fees, while physicians miss appointments with no reciprocal financial obligation to patients. The assumption: patients don’t have as legitimate a reason for tardiness or missing appointments as physicians.

From paternalism to partnership

Some believe waiting for doctors is a fact of life. Not so. Whether physician or patient, here are five ways to avoid delays at the doctor’s office:

1. Schedule smartly. While physicians should select the scheduling method that works best for their workflow, patients should be offered informed consent when it comes to scheduling. Choose offices that allow reasonable time intervals for appointments.
2. Communicate clearly. Whether by mouth, text, or tweet, clinics must inform patients of delays. And patients should state the real reason for their appointment at the beginning of the visit.
3. Practice mutual respect. Patients: be on time, on task, and compliant with agreed upon treatment plans from previous visits to prevent schedule delays for other patients.
4. End the double standard. If offices charge patients no-show, cancelation, or late fees, patients have a right to invoice doctors who miss their appointments.
5. Vote with your feet. Physicians and patients have choices. Dislike how you are treated at a medical clinic? Find another clinic. Fed up with insurance? Bypass third parties with cash. All across America, doctors are using their energy, creativity, and love of medicine to create medical sanctuaries for patients. Celebrate what works.

Pamela Wible pioneered the community-designed ideal medical clinic and blogs at Ideal Medical Care.

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