For years, patients did not complain about their surgical care. They complained about not getting calls back.

The frustrating part was that my staff was calling them back. Messages were left. Voicemails filled up. Phone trees were in place. And still, patients felt ignored, staff felt defensive, and I found myself on a constant apology tour.

I assumed this was just how modern medical offices worked.

We had three people answering phones. We were doing what everyone else did. Voicemail, I believed, was inevitable.

What I did not recognize at the time was that the system was not broken because of neglect or poor effort. It was broken because it was never designed for this level of volume. As reimbursement declined, the only viable path forward became higher output. More patients. More calls. More coordination. The infrastructure did not evolve. The load simply increased.

And we absorbed it.

Patients would call back after missed voicemails days later. Staff would try again, only to reach voicemail themselves. Surgery scheduling dragged on. Frustration accumulated quietly on all sides. Because this was happening everywhere, it felt normal. I mistook normalization for inevitability.

When access and responsiveness were finally addressed in a meaningful way, something unexpected happened. The noise quieted. Patients were calmer. Staff stopped apologizing. The constant sense of being behind began to lift.

And only then did the next layer of inefficiency become visible.

Friction and accountability

Once one source of friction is removed, the next one reveals itself.

In December 2024, despite full schedules and properly authorized cases, a third of my operative day canceled at the last minute. Patients who were eager to proceed when they booked decided, as the date approached, that protecting the week before Christmas mattered more. The operating room absorbed the impact. So did my staff. And so did patients still waiting who would have gladly taken those slots, especially in December when deductibles are met and timing matters.

That day did not reveal a failure of care or preparation. It revealed a lack of shared accountability in a system now operating at high output with very little margin for disruption.

For a long time, I believed what many surgeons believe. Declining reimbursement leaves only one option: See more patients. More referrals. Longer days. That logic feels unavoidable. But what I eventually realized is that chaos scales faster than revenue.

Surgeons are not being asked to do more because they are inefficient or unwilling to work. They are being asked to do more because clinical flow is constantly interrupted, and effort alone cannot fix that.

In the operating room, we learn early that faster surgery does not come from moving faster. It comes from economy of motion. Proper setup. Anticipating the next step. Removing unnecessary movement. When flow is right, time takes care of itself.

The clinic is no different.

The greatest source of friction in my practice was not lack of effort. It was interruption. Phone calls. Messages. Clarifications. Last-minute changes. Staff worked continuously, yet nothing felt like it moved forward. Days stretched longer not because we were slow, but because flow was broken again and again.

Uncontrolled scheduling compounded the problem. A canceled case is not just lost revenue. It is lost opportunity. It is staff time wasted. It is idle operating room time. And it is a patient who could have been treated but was not. When cancellations carry no consequence, the system absorbs the cost silently until a day collapses.

Designing for flow

The instinctive response in medicine is to add more. More referrals. More staff. More meetings. But activity is not progress. I have never left a hospital committee meeting convinced we accomplished anything meaningful, yet those meetings consume the very time surgeons need to fix what actually matters.

What helps is not doing less work. It is removing friction.

Patients do not judge care by outcomes alone. They judge the entire experience, from before they call, to when they arrive, to how efficiently the day unfolds, to whether surgery actually happens as planned. Access and responsiveness are not administrative details. They are core components of care.

That realization forced me to keep control of my own time. If an administrator or institution determines your day, your hours will stretch indefinitely. This does not mean working instead of your administrator. It means working alongside them. They help build the framework. Surgeons must help design it. We are the ones who feel immediately when flow breaks down.

This does not mean seeing fewer patients. That is unrealistic. Successful practices still require volume. The difference is seeing the same or more patients efficiently rather than chaotically. When processes improve, revenue often rises 15 percent to 20 percent without adding clinic sessions, simply because wasted time disappears.

The result of redesigning flow is not perfection. It is calm.

On an ordinary day now, patients move through the office in 15 to 30 minutes. There is no simmering frustration in the waiting room. Staff joke instead of apologizing. Operative days move. I leave earlier rather than later. My biggest remaining headache is documentation, a much better problem to have than a collapsing day.

This is not about burnout. It is about chaos versus control.

Private practices are often described as a declining model, yet they still represent a dominant part of the workforce. They survive not by absorbing infinite workload, but by redesigning systems that were never meant to carry this volume.

Working harder is not the answer.

Removing friction is.

Paul Toomey is a surgeon.