The Cost of Waiting for the Doctor

My Experience

For a good portion of the last decade I rarely went to the doctor and I rarely had any encounters with the medical system at all. That of course changed when my wife, Stephanie, became pregnant with twins almost 4 years ago and now that we are close to having our third child I have had lots of recent encounters with the system.

The reason I'm writing this post though is that I have become frustrated by how often a medical appointment time appears to be a very loose guideline (and never in a good way) for when you will actually get beyond the waiting room. Just last week our ultrasound appointment was 45 minutes behind schedule and two weeks before that the Obstetrician was over 60 minutes late for a 10 am appointment...

Why Being Late is Rude

I was hoping to find a solid link for this section that clearly explained why being late is rude but that turned out to be harder than I expected. It seems that most articles I could find take the fact that being late is rude and selfish as self-evident. Lot of articles (like this one or this one) simply state that these actions are selfish or rude but don't fully flush it out so I guess I will.

Being consistently late is in this category because the person you are late to meet has to be idle while they wait for you and cannot do a more valuable activity. If you are consistently late you are implying one of three things:

• that this negative consequence on someone else does not matter to you (i.e. you are selfish)
• that you don't even realize your actions are negatively impacting someone else (i.e. you lack any self-awareness at all or you completely lack empathy)
• that you understand the consequence to the other person but you believe your time is more valuable so the lateness is justified (i.e. you are rude). If you're not sure why this is 'rude' then just imagine someone explained to you that "I know I'm late but I make 3x as much money as you so the economy values my time more and it makes sense for you to wait for me and not the other way around...". Also, the definition of rude is ill-mannered, discourteous and insulting and I think most of us would consider that statement insulting...

Are Doctors Different?

It seems that a lot of doctors are getting tired of their customers (yeah we're the customers) complaining that they are late and are fighting back. They come up with a lot of excuses for their lateness like:

• The patients show up late
• The patients ask about more than one condition at an appointment
• Doctors are asked to 'fit in' urgent patients throughout the day
• Some patients have issues that just take longer than scheduled
• Patients need to be consoled
• Doctors have to do administrative things that aren't part of the schedule

Now I'm not going to dispute the fact that all of the items cited above won't cause a doctor to be late - because they will (and do). What I am going to dispute is that any of these things are excuses at all. If the items listed above happen so frequently that you are running late for more than 80% of your appointments then you have a scheduling problem. These reasons are no better of an excuse than me being late for work everyday because I didn't account for morning rush hour. Sure it happens everyday but I 'should' be able to get to my office in 15 minutes instead of 30 because that's how long it takes if there is no traffic. Guess what there is traffic and I have to learn to factor that into my schedule or I get fired!

Why Don't Doctors Buffer?

Considering that the items that are causing doctors to be late are frequent and predictable (like rush hour) you would think the solution is easy - just plan for it. Just like I leave the house 15 minutes earlier to be on time for work couldn't doctors just make all the appointments for 20 minutes instead of 15 or leave 30 minutes unblocked at 10 am and 2 pm so they can catch up? Of course they could but they don't want to...

And the reason they don't want to is amazingly obvious - money. As most Canadians don't pay anything out of pocket for medical services we don't often think about how our doctors are paid. That said, the majority of dollars earned by physicians comes from a fee-for-service model (for example $8 billion of the $11 billion spent on Ontario doctors in 2012 came from this model).

As you can see from the article I just linked a fee-for-service model means that a doctor gets paid a flat amount for a particular service. That means that every appointment to discuss allergies earns a doctor the exact same amount (i.e. how long it takes doesn't matter). In practical terms that means that the more patients a doctor sees, the more they earn.

So if you were paid like this what would you try to do? I know I would try to see as many patients as possible and I would try to get my appointments done as fast as possible. Furthermore, there are other occupations that use this kind of model and an hourly payment model so we can consider the impact it has. One of these occupations is automotive mechanics. So how do automotive mechanics respond to the two different models - they work faster when they get paid 'by the book' (the equivalent of the fee-for-service model).

Given that doctors have a fee-for-service model and that humans in other occupations with the same model try to maximize their earnings by going fast it seems obvious to me that doctors would also try and maximize their earnings the same way. So if you were a doctor with this model and wanted to maximize your earnings what would you do? Well I would make sure that I never had any downtime between patients. Downtime means I'm not earning and that doesn't make sense so I would schedule my appointments as tight as possible and try to never be without a patient...

What's the Cost?

Now the whole point of this post wasn't just to convince you that doctors are greedy jerks. I actually don't blame them. Doctors are people too and almost all people respond to the incentives they are provided - and we incent doctors to see as many people as possible. If we want it to change we need a new incentive system (although this also doesn't mean they are altruistic saints either). That said I am more interested in the economic cost of this unfortunate system.

To determine the cost of all this excess waiting requires a number of assumptions about average wait times, the economic productivity of the people waiting, the number of people waiting, the number of doctors, etc. Which means I'm probably not going to come up with the right number. The value I am going to come up with will be a reasonable approximation of this cost but by no means is it the absolute correct value. For this reason I'm going to be a little conservative with my assumptions in order to increase the probability that the real cost is actually higher than what I come up with. Now without further adieu the calculations:

After working through all the numbers I come up with about $3 billion/year or $39,000/physician. Before I started this exercise I expected the number to be large but I was still startled by the 10 digit number that came back. Especially because this undoubtedly understates the cost of waiting for medical professionals as I'm only counting physicians (i.e. waiting for an ultrasound tech or another medical professional wouldn't be in this number) and I'm only assuming that one person is waiting for the appointment. I suspect it's usually one person but I know there are cases where it's more than that so assuming 1 is the absolute lowest it could be.

Regardless of the true number though the fact of the matter is that there is a very real cost when doctors keep patients waiting and because the practice is so common it results in a huge economic cost. So next time you're sitting in the waiting room waiting to see the doctor just look around the room, count the people, estimate how late the doctor is and then multiply by $28/hour...then send the doctor an invoice (just like they do when you waste their time).