At a recent faculty meeting, the attendings in our practice were asked about their availability for new patient appointments. The vast majority reported that due to time constraints and patient volume, they had closed their panels to new patients.
For those of my partners with open schedules, the wait for new patients to be seen was averaging 2 to 3 months, a few up to 6 months. The time to the third next available revisit (an industry standard for schedule monitoring) was several weeks.
The department of medicine has a strong desire to increase/improve access to primary care, as a way to bring in more patients from our catchment area, and to provide fuel for the fire that is our large academic medical center.
More patients means more laboratory services, more consultations with specialists and subspecialists, and more admissions to the hospital. In our view it also means more people getting primary care, which is a good thing.
The problem is, we are also finding it more and more difficult to take care of the patients we have, and patients do not have the ability to get in and see us when they want to.
Expanding and ensuring access is a complicated process, with many different models such as open scheduling and advanced access having been tried, with variable success.
In my own practice, I work in a model of advanced access, trying hard not to book out future appointments 3 months ahead (these kinds of appointments tend to have a very high no-show rate), telling my patients that if they want to be seen in a particular week, they should call then to be seen.
Seriously, we all as providers should only be managing a panel of patients of a size such that we can see them when they need/want to be seen. There will always be some overflow, some interims, some urgent appointments that need to be scheduled during a time when we’re not in practice. There are days when we as clinician educators are teaching all day long, not in practice at all.
Our nurse practitioners have expanded our coverage ability, and will frequently see patients for urgent interim appointments when we cannot. The resident’s fractured schedules present a whole other set of access issues, with our pod team system working to fill this need.
One of the nurse practitioners in our practice recently saw a patient who was transferring care to us, who had an urgent need for an appointment (a splinter buried in her finger). He was able to examine her, perform a digital block in the office, and remove the offending splinter, saving her a trip to urgent care.
We have all been through the experience of being sick, and finding ourselves in need of seeing our doctor, the covering doctor, another health care provider, somebody.
The first hurdle is getting through on the phone, the second hurdle is the person answering the phone, the third hurdle is the person controlling the schedule, and the fourth hurdle is proving you’re sick enough to be seen.
The literature is full of studies that have attempted to figure out the optimal panel size for a practicing internist, but I think we all know when a panel gets too big. We have all seen that patient on the schedule, and said, “Boy, that name does not sound familiar. Is that really my patient?”
Time to downsize.
There are many ways to improve access in the patient-centered medical home model. These can include the use of an extended care team, with the ability for interim appointments to be handled by providers other than the PCP. Also additional types of appointments such as group appointments or disease specific appointments for patients with multiple diseases where all of their issues cannot be handled at one single appointment.
Looking back at my schedule from yesterday, the patients who were added to my schedule because they “absolutely positively had to be seen” included “still not feeling well,” acute low back pain, and fevers without localizing symptoms.
The effect of this on my already full schedule led to a fairly busy day, which started out with an elderly patient with seven medical problems, all of which were not doing well, and she was mad at all of her subspecialists. A recipe for falling behind, for not being able to pay attention to each patient in the way in which we really think they deserve.
Tell me what works for you. “Frozen” appointment times in the electronic health record that “thaw” less than 24 hours from the time slot? Overbooking on initial visit times? Electronic scheduling, where patients are allowed to insert themselves into any available appointment times? Or even complete open access, where no future appointments are scheduled (except for the most complex, or maybe those patients that need to know that an appointment is waiting for them in the future).
Access takes many different forms, and improving it will take quite a bit of effort. The solutions may be protean, but should be worth that effort.
Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home.
