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I Have to Wait How Long?!?!

David Epstein, MD, MS, FAAP discusses why it takes time to be seen for an acute illness and what makes up a medical visit.
We’ve been hearing a lot about long wait times in emergency rooms, clinics, and urgent cares across the country. And, we have yet to fully enter the winter season which is traditionally worse, when it comes to respiratory illnesses…especially in children. So, why have we had such long wait times? The obvious answer is that there are large volumes of sick people going to the emergency rooms, clinics, and urgent cares. But, the answer requires a little more in-depth discussion because one could say that the medical teams should just see the patients quicker to get more people seen in and out in an expeditious manner, so people don’t have to wait hours to be evaluated.
Discussing the anatomy of a medical visit may shed some light on why it takes the medical team some time to see a sick patient. The medical visit can be broken down into three stages: the registration/triage stage, the actual medical evaluation stage, and the discharge stage. Each stage has its required tasks and function which takes time.
The patient encounter starts at the registration/triage stage of the medical visit. Unless someone rolls in via an ambulance to the emergency room, a patient requires registration to put all of the necessary demographic, insurance, and contact information into the computer system to populate the electronic medical records before the medical visit takes place. Also, there is usually a formal or informal triage system to make sure that the patient is stable enough to wait until they are seen by the medical team. Triaging involves a brief medical assessment of clinical stability and the need for immediate medical attention. At this point, some patients are pushed to the front of the line, if their clinical condition is less than stable. So, it is not always a first come, first serve situation. Those who are more clinically stable may have to wait longer, while those who are sicker are seen first.
Next, the main part of the visit entails the clinical encounter where the assessment and management occur. The nurse or medical assistant will obtain a brief history of the illness and vital signs, such as heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation. With kids, body weight must be obtained because almost all medication dosing for children is based on their weight. So, a body weight needs to be obtained for pediatric patients. Next, the clinician sees the patient and obtains a history of the present illness and other pertinent pieces of information which may include underlying chronic medical issues, medications being taken, prior surgeries, allergies to medication, and other general background information if they were not obtained by the admitting nurse or medical assistant.

After the clinician obtains a full history from the patient or the patient’s family, then he or she needs to perform a physical exam. Once the history of the present illness, prior medical information, and the exam are completed, then a diagnosis is made and supplementary laboratory studies may be required to confirm the diagnosis. Furthermore, medications may be required to treat the patient immediately for the current illness or injury. This whole process takes time which may be as quick as 10 minutes for straightforward problems to hours for more complicated issues. This doesn’t even include times where procedures may be required to be performed, such as suturing lacerations, removing a foreign body from the nose (common in kids), doing a fluorescein eye exam to look for a corneal abrasion, or a host of other procedures that require time and focus to complete successfully. Sometimes, patients require intravenous fluid administration for dehydration or breathing treatments for asthma that require the patient to stay in the facility for monitoring and further treatment. This requires the clinician to intermittently reassess the patient to decide on further courses of management. The reassessment process will further prolong the time it takes before seeing a new patient.

The time required for obtaining information about the illness or injury and examining the patient, obtaining lab tests, or performing procedures also depends upon the cooperativeness of the patient.
Negotiating with a toddler or young child about anesthetizing a wound and closing it with stitches is usually not a productive conversation. Also, obtaining a history from someone with a complex underlying medical history will extend the conversation because understanding the context of an illness or injury is crucial to making a correct diagnosis and managing it appropriately. There are many other instances and conditions under which obtaining efficient evaluations and efficiently managing medical conditions are fraught with stumbling blocks that prolong a medical visit.

Finally, after registration/triage and the medical evaluation, the patient is ready for discharge. But, it is not just a simple exit from the clinic. Prescriptions may need to be faxed or written out for the patient to take to the pharmacy, discharge instructions need to be given, and checking the patient out of the system are just a few tasks that round out the visit. These tasks help ensure that the patient knows what to do after the visit, when to follow up with the medical team again, what things to watch out for in case his or her clinical condition worsens, what medications are needed to take and how to take them, as well as understanding their medical condition. The discharge process is important to smoothly transition patients home or to the next level of medical care, if required.

The process of assessing sick patients in the emergency room, clinic, and urgent care is a complex orchestration of events. While parts of the processes can be made more efficient and faster, the ultimate goal is to provide quality care. Registration/triage, medical evaluation, and discharge do take time. In order to not compromise quality under the duress of quantity, there has to be some acceptance that one will have to wait while others are guided through the process. Some patients require shorter visits depending on the complexity of their illness and others require longer visits. Shepherding patients through the process of a medical visit does take time. So, the next time someone asks “why do I have to wait so long to be seen?”, you have the answer and understand what the medical team is dealing with during these times of surging patient volumes while they try to maintain the best quality of care that they can.
How would you improve the emergency room, clinic, and urgent care wait times?

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2 Responses

  1. The doctor-patient relationship is at the heart of the entire healthcare system. I think we’ve lost that perspective because of all of the “noise” throughout the system. Doctors need sufficient time to properly diagnose and treat, and like snowflakes, no two patients are exactly alike. Doctors go through a lot of training to be doctors, but patients are not properly trained to be patients. We don’t always follow treatment plans, we forget to bring our list of meds, we overuse Dr. Google, etc. A big part of improving our overall healthcare system should include a review of the patient stakeholder group, not just the doctor stakeholder.

    As an aside, I do think the scheduling function within the healthcare system needs work. Through AI and other means, I think practices can more efficiently allocate their scarce doctor resources. This is based on my experience in healthcare administration working with a wide range of specialties, from OB/GYN to Orthopaedics.

    Great post, Dr. Epstein!

  2. Deron,

    Thank you for your comments. I like your insight about “patients are not properly trained to be patients”. It is a difficult balance because the patients are the ones with the stress of illness and the unknown. I don’t entirely blame them for their interactions and behavior. Not all patients and families act the same and it is usually the outliers that cause us the most stress. So, it is more likely a vocal minority. In any case, as long as we all work together and do the best we can, a lot of unsatisfactory medical interactions can be avoided. Thank you, again, for your insightful comment. I really appreciate it!

    Sincerely,

    David

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