I know this one. I'm a rural solo practice doctor. I have patients call my cell phone to make appts. I see nearly all of my established patients same day. I have daily walk ins which are by definition same day. Also, I am a published researcher on certain mathematical simulations.

The article used the term 'doctors' only later breaking the term down into doctors seeing people for diseases whose course is days (primary care and colds) vs. months (dermatologists) and implicitly including others with very long courses (neurologists). The pattern of disease is not comparable.

For primary care, the instance of disease and patient visits follows an extremely non-gausian distribution. Infections are epidemic. Each individual 'flu' goes from not being present at all to hitting everyone. Weather causes chronic lung disease to flair in the entire susceptible population on the same day. Distribution of patients needing drug refills is mal-distributed by schedules of holidays and pay cycles.

Disposing of patient load can be viewed in the dichotomy of disposal functions of pharmacokinetics: absorption or excretion driven. In absorption functions, you are waiting for the patient to arrive. In disposal, there is a number of patients, and they await disposition. Up to a point, the more that come in, the more that are seen in a given time. That would be the most efficient use of everyone's time.

As 'doctors' is an overly broad term, 'patient' is equivalently imprecise including as it does, those waiting for a signature and those waiting taking a complex history including not only looking up all of the patient's clinical data, but also the newest literature on her medications and conditions and their interactions. Setting aside the very small number of complex patients into the future, as a backlog, prevents a logjam for the entire office. The distribution of patients and number of hours in the day becomes less uniform and less predictable and less regimented as efficiency and frankly, medical care improves.

Thank you for that, I was chafing at this horrendously oversimplified analysis of workload managment.

Certainly she was generalizing, and I think she would agree that some complex patients can be spaced out. But her overall point, that problems cropping up today should be dealt with today, holds. I learned in residency that if you put of something until tomorrow, it only gets added to the pile of problems tomorrow brings.

In non-medical business, time management people always advise that your In Box should be empty at the end of the day. If you can't get done today, why would you have time to get it done tomorrow? Again, the exception is a problem too complex to handle in one day. But exceptions like this only prove the rule. If you don't get caught up on the little stuff, how will you find time to handle the big?

Actually, the argument for the feasibility of open access does not assume a normal distribution of demand for service. In response to your post, here's the explanation from Prof. Linda Green, one of the authors of the Columbia University study I cite in the article:

"We assumed that daily demand is binomial which is based on each patient individually generating his/her own demand for care. But the issue that this reader is raising is not really about the specific probability distribution that we are assuming, but the underlying assumption of what’s called “stationarity”, i.e. that the daily demand rate is not dependent on the time of year (which is a different issue altogether). We ourselves acknowledged, in the section on “Achieving the right balance”, that there will likely be seasonal, and perhaps, day-of-week variation in patient demands and we briefly talk about making adjustments for these. What’s important to keep in mind is that though this model is admittedly simple (as we state ourselves), it is the first tool to explicitly model demand variability and help physicians make decisions about patient panel sizes based on their own data and judgments of how they want to manage their practice."

Another point about variability of demand, one that Mark Murray has made: while some of the variability is indeed out of doctors' control (flu season, for example), other spikes in demand are healthcare's own doing. For example, Mondays tend to be the busiest days because doctors don't typically work on the weekend. So doctors can do their best to smooth out some bumps--and work flexibly to deal with the rest.

Marina

Of course, the real problem in medicine is that doctors are taught nothing, and I mean NOTHING, in medical school about the business of running a practice. Knowing nothing, they tend to bristle when business types come in and tell them what to do. But most of them, myself included, could learn something. Well, actually a whole lot.

I spend more time in medical school learning about the plague than I did about running an office smoothly. And yet, it is obvious that delays in physician access present a much more significant danger to the average American than the plague.

I am thinking about getting an MPH degree to address this weakness in my learning. It is sad that, after 8 years of post-baccalaureate training, I wound need yet more school to do my job.

Unhappily, there are more than one set of mathematical simplifications going on here - first of all, we have little knowledge of what are safe queuing assumptions to begin with - my suspicion is that we are really dealing with highly asymmetrical bactrian distributions, where the primary concentration can be approximated by an Erlang function and the secondary concentration may be normally distributed about a subsidiary function well into the distribution.

But this in turn assumes that the functions are in fact intelligible in purely statistical terms. Operations research has long known that mechanically sampled processes (like patient arrival patterns) differ from random or pseudo-random ones in many ways.

The net of the article seems to suggest that quality improves if one deals with non-uniform distribution of workload honestly and in accordance with the understanding of the medical profession (before it became simply a 'branded business model').

That, I believe, we can all agree on.

I often wondered why don't doctor's offices or clinics have 2 doctors. One for appointments and one for walk-ins? I have personally walked OUT of walk-ins from the long wait.

The community health centers I work for tried this several years ago. For it to work, you must have a stable and reasonably sized panel. We found we were "out" of appts by 8:30 a.m. It was a little like a radio station promotion (lucky caller #10). We rotate with at least one provider handling acute/same day. Our waits for chronic, pregnancy, well child etc are two to three weeks so we try to get our patients to schedule their next appt before they leave. Wish our waits were shorter and there was more flexibility, but demand (patients ) exceeds supply (providers) and is ever growing. We just can't grow fast enough.

I go to a primary care practice which has 6 doctors, each with their own assistant, and nurse practitioners too. If I call today, usually they can see me same day or at latest, the next. There's always someone available, and if my own doctor is out, another wil cover. And the NP's can handle a lot of the basic stuff, like giving shots or checking out that rash... I've seen NP's atleast as often as I have the Dr., and the quality of care was no less. It's the best-run practice I've ever been to.

I also see a counselor and a psychiatrist at a clinic that can always be there when you really need them. If it's the dr.'s day off, the nurses will get a hold of him, and there is a crisis line and respite 24/7, so you're never stuck w/o help and it integrates seamlessly with your regular care. Very well-managed.

But, still, people should use common sense and courtesy, save the last-minute appointments for when it's urgent/sick visits, and schedule the routine visits in advance and remember them, write them on the calendar, keep a date book, whatever it takes. I am the most disorganized person I know, but since I started carrying a little datebook with me at all times, and all appt.s go directly in it, I have missed only a couple (since I missed my bus; I did remember, though).

All the comments in this column are very interesting. I am a foreigner from a country that often is referred as part of the Developing World that has lived in rural PA for 1 year, Rhode Island for 1 year, and NYC suburbs for 1 year as well.

Getting an appointment to see several different specialist and also a family doctor has presented the same issue time and again; a terribly long wait. This ranges from 4 weeks for an aching tooth to 4 months for a check up.

This has led to my traveling back to my country and get all the medical services I need perfomed twice a year. This specialists (including a dermatologist, cardiologist, orthodoncist, ophthalmologist and general practitioner) have seen me no later than 3 days from the day I called. Granted, these are top of the notch specialists.

But if it can be done in an impoverished "Developing World" country for those who can afford it, I do not understand why it can not be done in USA, which to all foreigners is presented to be the best nation in the world.

(And to prevent any misundersantings, let me clarify that I work here legally and have medical insurance paid for with my own hard earned money)