I think this vastly oversimplifies the problems associated with getting an appointment to see a doctor. I am a child psychiatrist. There is an estimated need for about 12,000 child psychiatrist by 2020, but there will only be about 8,000 practioners. I see the effects in my own practice on a daily basis, where the wait to see me is about 3 months, and I struggle to have a follow up of even an abbreviated time in 2 months. Same day scheduling would not be practical, as I need information from schools and therapists.

In addition, I find the restaurant example to fall apart (or at perhaps to support my views?). Locally, most restaurants do not take reservations. When I show up at dinner time, there is often a wait of several hours, which discourages people from staying. Perhaps in urban settings with a greater variety of choices in both restaurants and physicians, this analogy holds better, and maybe medical access could be simplified. But for now, the restaurants don't do any better at getting me access to food than I do at providing access to treatment. In both cases, I think the solution is to have more providers, a task not easily accomplished when the training period for child psychiatry at least is 13 years of post-high school education.

I understand that a restaurant not taking reservations is a problem. But what if the restaurant took your reservation and still expected you to wait (with no grumbling) for an hour or more?

There is an amazing arrogance among most doctors in this country. What makes you feel that your time is so much more valuable than mine, that you expect me to make an appoinment and then ask me to sit happily in your waiting room, when I have my own work to do?

At last most restaurants know how to thank me for my patronage....

Do you think the doctor is sitting around smoking cigs and drinking from a pint flask while seriously ill people lounge in the waiting room? He's working, doing diagnosis, talking to the patient, pondering a problem, sewing up a sucking chest wound, reattaching limbs, and flat out doing paper work.

Yes I really hate waiting an hour for an appointment I made 2 weeks ago, but I don't seriously believe the doctor is making me wait for his own sadistic pleasures.

hopefully though, they are too busy seeing patients to reply! i understand your frustration, billstein, and i definitely think they should do abetter job with scheduling, but i do not believe that most doctors feel contemptuous of your time. what i would question is why they need to book so many patients in the first place. at one point in time, doctors wouldnt take new patients. the way a lot of these HMOs seem to be set up, i dont think they're allowed (or perhaps can't afford) to turn people away.

why does dberne have a 3 month wait at her practice in the first place? being an effective doctor, especially when dealing with psychiatry, requires having a relationship with your patient so that you can accurately diagnose and treat conditions. doctors complain all the time about patients not giving them the relevant information to diagnose them with, but the truth is that most people can't tell the doctor out of the blue what is relevant and what is not. back in the day, a doctor had a chance to get to know you well enough that they would more easily be able to tell when something was abnormal for you, personally.

yes, we need more practitioners, but we also need more personalization. i wish dberne would expound on why the practice is set up with so many patients that it can't really handle. but you can't just blame the doctors for this. i blame the insurance companies and i'm sure there are others at fault. but the question becomes how do we proceed from here on out..

also, i would like for people to remember that doctoring is not the profession it once was. it once used to be considered an automatic good living to become a doctor. my brother just finished his residency and i've seen him struggling financially due to having so many debts from med school to pay back, not to mention all the different insurances, licenses, etc... that they have to pay for.

so dont think of doctors as being in some elite economic class not caring about the little people or their time. (sure, some of them are, but that's in any profession) what we need is a system that will encourage doctors to spend more time and care with patients, in turn keeping them healthier, and keeping insurance costs down.

My waiting times are generally small - I usually see people within 5 minutes of their scheduled time. If I run later, the receptionists tell people about the esitmated wait; and it is almost always because someone brings up a problem that cannot be resolved within 15 minutes.

I used to run a private practice that I could control how long I scheduled each person for, and I could routinely give a lot more time to people. However, I also would close the practice for several months at a time to new referrals. I had to close the practice when the other three child psychiatrists in the area left the hospital (two left the area, and the the third now has a cash-only practice). In order to see services continue for the indigent and to maintain inpatient services for kids, I closed the practice and accepted the limitations of the clinic model.

I don't pretend this is an ideal model, and I wish I could see people for much longer times with less time between appointments. However, the problem remains one of supply and demand. The original point of the article, that same day access can solve this, is clearly not going to be a one-size fits all. Most docs I know are not motivated just by money- there are easier ways for smart people to earn a living- but by a sense of responsibility to meet clinical demands.

Also, I am a "he", not a "she"...

why is it acceptable in speech to use he to represent male or female if you dont know the party's gender, but not acceptable to use she?

thanks for the reply. if i understand you correctly, then the problem is not just supply and demand but also how your practice is set up. private practice v. HMO system. another frayster mentioned that the HMOs actually have quotas for how many patients a doctor is supposed to see, etc.... why are these people involved with how a doctor runs their practice anyhow? i think we need to work on making you guys more autonomous again...

Before I go on, let me say that I am married to a MD/gynecologist, and I am very familiar with how medicine is practiced and the pressures facing doctors.

What would I have you do? First of all, schedule people realistically. A few weeks ago, I had an appointment to see a GI doctor. I intentionally took the first appointment of the morning, and was surprised to find two other people in the waiting room. When I asked, it turned out that we were all scheduled for that 8:30 appointment. I ended up waiting a half hour in the waiting room (while the doctor was on the phone) and another 40 minutes in the exam room. When I asked about the double/ triple booking, she said that she was obliged to, because some people don't show up. When I asked why I was scheduled for the time she was on the phone, she just shrugged. This is why I say her time was more important than mine... Triple booking means that she was bound to start her day behind time. And the explanation, that people don't show up, justy means that rather than chance having idle time, they intentionally make me waste my time.

Meanwhile, I got back to my office an hour later than I realistically anticipated. What if people had appointments to see me in that time? They didn't because I'm more careful with their time.

"why is it acceptable in speech to use he to represent male or female if you dont know the party's gender, but not acceptable to use she? "

Why don't write NOW and the ALCU, I'm sure they'll provide you with an answer you're expecting. Until then, I guess those pesky societal norms will have to inconvience you.

Get over it, one bad experience and you're suddenly condemning everyone.

Rather than take one data point and extrapolate to everyone, might I suggest simply picking better doctors and/or recommending that the doctor get a better OA. You might consider that it's not just the doctor's fault for your minor crisis in life.

>>In both cases, I think the solution is to have more providers, a task not easily accomplished when the training period for child psychiatry at least is 13 years of post-high school education.

dberne (and anyone else), I'm curious why you think that it is unlikely to tackle this problem by increasing the number of providers. While I recognize that there are many more ways (requring less schooling) for smart people to make a good living than perhaps in the past, I still know many, many people who by outward appearances at least are going to great lengths to get into medical school (spending a fortune on applications and applying many years in a row while bolstering their application through unpaid research and internships in between). And they are generally also aiming for specialties that require many years of training after obtaining an MD. I know that some of those fields (e.g. cardio-thorassic surgery) probably pay better than pediatric psychiatry, but I still gotta believe that financial incentives aren't the only motivation behind getting an MD (b/c I think a person who could qualify for any of the very difficult to get medical residencies/fellowships could probably also make a lot of money in other less stressful ways).

What I see, however, is that except for the truly exceptional students (and by that I mean perfect MCAT scores, A+ averages, extensive extra curriculars and research) many people are being turned away from medical school (including those who have A averages and very good MCAT scores etc...not exactly the bottom of the barrel). Some of these people persist and go to schools in the Caribbean etc knowing that it will be harder to get a US residency but doing it anyway. I recognize that b/c my parents are both physicians and so are many of their friends I see a biased view of the population that esteems medical degrees beyond reason...but I see similar attitudes and behaviors in a wider cross-section of people than just the ones I know through my parents.

What I don't understand is why medical schools have become so exclusive. (I honestly don't know whether it's difficult to open a new school, whether it's impossible to increase admission in existing schools, or whether schools try to maintain their cache by making admission more difficult). What I do know is that excellent doctors come in all varieties and from what I've seen the current screening process for getting admission into a US med school is bordering on ludicrous. Of course if I have a choice I'll always want the best doctor I can find but in my experience that isn't always the one who had the most impressive application, and no matter what seeing an terrific doctor who has time to see you and understand your condition is better than not seeing the world's best doctor at all (or 5 months after your condition has deteriorated).

Anyway, this post ended up being longer than I expected, but you are not the first person I've heard dismiss the possibility of greatly increasing the number of providers available, and I'm curious as to why you think that's the case.

I can't speak for other specialties with any real knowledge, but in the case of child psychiatry there are several obstacles to increasing the numbers. First there is the basic length of training - it is a 5-6 training period after medical school; equivalent to a general surgery training (after which you get paid a child psychiatry salary, not a general surgeons...). Secondly there are stigma issues. When a medical student announces an intention to enter psychiatry, there are often a chorus of "real doctors" saying "Why do you want to waste your training with psychiatry?" Then to decide to enter child psychiatry specifically means spending an extra year or two in training, plus having the temprament to work in child psych, which is very rewarding (at least in my point of view), but also very challenging. As one of my friends pointed out, at least in geriatric psychiatry, the families are glad to have you help, even if you can't change the outcome.

There are also concerns about training programs having enough people to do research and training of residents (since working in academic medicine means taking another financial hit). Finally, given the degree to which child psychiatry is in shortage, we will likely never meet the projected demand, especially when there are constant pressures to choose something else.

Ultimately, what I intended to convey is that there are so many factors working against increasing the supply of child psychiatrists that I don't think we will see the numbers needed to relieve the issue of having a shortage, not that having more docs would not solve the problem. I appreciate your observation that most people are not motivated by simple financial gains. I think this is generally true, although I admit I know some people that seem to be all about the dollar.

In response to deduction's comments, I think the issue of how a practice is run does make a big difference. Most larger clinics have a variety of business people making decisions about how to keep the coffers flowing, without regard to clinical utility. This is part of the problem, in my opinion, with the inefficient system of insurance companies each having their own set of rules and reimbursements. I'd be all for having a private practice again if I knew that the kids and the community were still getting served somehow. We need about 4 more child psychiatrists here to reach that goal. Do you know anybody willing to relocate?

In response to billstein's experience, the clinic I work at was having a terrible problem with no-shows (upwards of 30%) and wanted to double book. I stood firm on this one, since the appointments were already jammed too close together to do my best work, and instead I got them to invest the time to call people the day before their appointments. This has improved the no-show rate significantly. I think any practice that has a big no-show rate needs to first look at why patients are not showing up and try to address this. Otherwise the problem perpetuates itself in the form of patients feeling that the scheduled time is more of a suggestion than an appointment, so they don't show up, so the no-show rate stays high. I was in a good position since (a) I was the only child psychiatrist left on staff, and (b) I had "real world" experience in getting patients to show up, since in private practice, no-show means no pay, which means no practice. My private practice had a no-show rate of under 10%, usually due to weather or other unavoidable issues.

• Interesting thread. Dberne, I think you're getting at the core issue when you say it's about supply and demand. Open access isn't magic, and if there's a genuine shortage of supply, there's no scheduling system in the world that's going to prevent waits. But advocates of open access would say that adding patients to the end of a long queue is only going to exacerbate the problem. The further out the wait, the less efficient the system becomes (because of triage) and the more risky it becomes clinically. It's troubling, to say the least, that a mentally ill patient may have to wait months to talk to a doctor or get needed medication. (Dr. Murray told me that a mental-health clinic he worked with successfully implemented open access, and the result included fewer hospitalizations and fewer suicides.)

  Again, it's not be possible to make open access work everywhere--some regions, in particular, have severe shortages.
  

  Marina
  

I promised myself I'd let this die, but this one needs an answer.

Do I think he's sitting around? Well, the last time I saw my neurologist, I was kept waiting almost an hour. Eventually, a drug rep, whom I happen to know (I'm married to a MD, remember?), walked out of his private office, and I was finally called in.

So here's an idea- take patients, who have to take time off from work and even reschedule their clients' appointments first, and let the reps- who are paid to be there- wait.

>Get over it, one bad experience and you're suddenly condemning everyone.

What makes you think I based my opinion on "one experience"? This is a continuing problem, and I think if you actually read the comments you'll see I'm far from alone.

And how dare you refer to my experiences as a "minor crisis"? You have no knowlege of my health problems. That arrogance is exactly what I condemned in my first post.

Those damn drug reps have got to go. Doctors see them as a necessary evil as they are the ones who supply the samples he/she hands out to you. If they really want the samples, they are obliged to give of their (your) precious time. In my experience no physician truly enjoys listening to some former college athlete in a shiny suit tout their company's new wonder drug when he/she could be seeing patients.