Why does it take months to see a doctor?

October 18, 2007 1:26 PM

Is there some kind of crisis with doctors going on?

It takes me 5 months to get in to see my gynecologist. I don't mind so much because she's the best in the area, and it's easy enough to schedule an annual ahead of time, and there's always her nurse-practitioner if I get an infection.

Recently though, things with other doctors have been getting ridiculous. In August, I tried to schedule an appt for September with my cardiologist. They couldn't see me until November, and now just called to say the doctor will be out that day and they can't see me until January. I told them to forget it, I'd find another doctor

My mom tried to get in with the dermatologists in the county - there are only 2. One couldn't see her for 4 months; the other saw her in a month but when she got there, the wait was 2 hours. There were signs all over saying "we're sorry you wait, but we're one of only 2 dermatologists in the county."

Are doctors taking on too many patients, period? I don't see how someone who has something more worrisome (like a spot that needs biopsied, for my mom) can wait 4 months... cancer can spread in that time. Are they also taking too many appointments in one day? Say, every 15 minutes, when an appt plus charting takes 30? If so, why do they do it? Is it just the money or is there something more? Again, I'm concerned for having to wait months for an appointment.

posted by IndigoRain to health & fitness (38 comments total)

Where I am, no there's no crisis or wait time. I get a doctor's appointment same day often, almost always same week. My OB-GYN was same week. As you suspect, it may be a regional shortage of specialists. When I had to go see an audiologist, it did take months.
posted by jessamyn at 1:38 PM on October 18, 2007

Look at it this way: It takes 4 years through undergrad. Another 4 years of med school. And another 4 years to get a specialization like dermatology or surgery, which amounts to $200k in student loans. Then you have to set up a practice, which is a business and you need to invest money to do that. Then you need to get liability and malpractice insurance, which thanks to the legal structure in this country, can cost many millions of dollars a year.

In a rural area, the wealthy population density that can afford higher-margin services like cosmetic surgery or other optional treatments isn't high enough, so to "Get by" doctors need to find ways to optimize their time, which includes lots of appointments and lots of scheduling ahead of time.

Don't like it? Petition for the reformation of our legal system, or move to a bigger city. Federalized healthcare isn't any better, just ask anyone from Canada how easy of a time they have getting in to see a specailist or get in for surgery and they'll tell you.
posted by SpecialK at 1:40 PM on October 18, 2007

It takes 4 years through undergrad. Another 4 years of med school. And another 4 years to get a specialization like dermatology or surgery, which amounts to $200k in student loans. Then you have to set up a practice, which is a business and you need to invest money to do that.

This is also why there's a shortage of lawyers. Oh, wait.
posted by The World Famous at 1:50 PM on October 18, 2007 [2 favorites]

My mom and dad have this problem in their rural area. Wait times can be compounded by things like natural disasters. Their dentist is in Gainsville, TX, which spent a week under flood waters this spring. All the doctors and dentists in town that had to close for several weeks to repair flood damage are now booked solid as they try to handle their usual patient load and all of the appointments that need to be rescheduled.
posted by MsMolly at 1:56 PM on October 18, 2007

FWIW, I live in a large city, and things seem to have gotten worse recently. When I went to docs affiliated with the nearby giant hospital getting an appointment went from reasonable to freaking nightmare (getting a checkup took six months, which is fun when they only write 3-month prescriptions and insist on a checkup before re-writing!).

So I switched doc groups, and things were better -- but now they're getting worse too. Maybe it's my fault. Once I start visiting a doc, they get worse.
posted by aramaic at 1:56 PM on October 18, 2007

I have found that in my area it really varies greatly depending on the doctor & the specialty. To see my primary care doctor herself, I do have to wait months. I have to schedule my yearly physical a year in advance. However, if I am sick, I can get a same day or next day appointment with one of her Physician's Assistants who pretty much do everything she does except for the physicals.

Some specialists take forever to see, like my endocrinologist. She is booked up for months as well. But I really like her and I just go for yearly monitoring, so I'm happy to wait. But then again, when my doctor's Physician's Assistant agreed with me that I should start the process of getting a sleep study done, I got an appointment with a doctor in the Pulmonary Medicine dept the very next week. Although now I have to wait 2-3 months to get the actual sleep study done.

I think not only is it an issue of demand in certain areas, but it's also an issue of triage. Most general practitioners keep spaces open for "sick" visits, so their number of appointments available for physicals and other "healthy" visits are more limited. When you are examined for a potential problem, the doctor also determines the urgency of the problem, and so if it's something where days or weeks are significant, they will find a way to get you seen, most of the time. If it's something that can wait, they might not work as hard to squeeze you in.

Also, it helps if you are an existing patient. Some doctors have long waits to take on new patients, and some won't accept new patients at all.
posted by tastybrains at 1:56 PM on October 18, 2007

Petition for the reformation of our legal system

Defending malpractice claims costs less than one half of one percent of total health spending. And "tort reform" already enacted in some states has led to malpractice premiums going up. So the costs of the legal system are a drop in the bucket and changing the legal system doesn't seem to reduce this at all, but it's a nice red herring.
posted by grouse at 2:00 PM on October 18, 2007 [3 favorites]

This thread would be much more helpful if the OP as well as the other posters took the time to state what region they are from.

I live in San Francisco and have had to see specialists lately. I can see my Primary Care Physician (PCP) in a day or at most two. Seeing a surgeon recently took less than a week.

This might also depend on the type of doctor. When I did have to see a recommended dermatologist here - about a year ago - it did take several weeks.
posted by vacapinta at 2:00 PM on October 18, 2007

I'd guess you have long wait times because you seem to live in a rural area next to a poor used-to-be-urban area next to one of the great metropolises. Undesirable areas have had problems attracting medical types for a long time now.

If you still live in Valparaiso, why not just use physicians in deeper Chicagoland, assuming there are in-network physicians there? PITA to get there, but I assure you there are more than two dermatologists in greater Chicago.
posted by ROU_Xenophobe at 2:02 PM on October 18, 2007

Here's a recent article in the NYTimes about it.

With the "open scheduling" solution, doctors leave up to 70% of their patient slots open for same-day appointments.
posted by ShooBoo at 2:18 PM on October 18, 2007

Data point: north Chicago suburbs here (affluent area), and I only see two doctors (GP, OB/GYN) but never have to wait long for an appointment. Seems like sometimes the GYN is a bit backed up, but nothing like 3 months' wait time. The GP I can see same-week.

There *is* always a wait in the waiting room, however. I thought I had that problem licked by seeing my GYN first thing in the morning, but no, because sometimes he has to deliver babies early, too. Sigh.
posted by iguanapolitico at 2:22 PM on October 18, 2007

It's not necessarily a shortage of doctors. It is, however, that the schedulers for the doctors take on too many patients.

Some doctors' offices just never say "no, we have enough patients already; we can right now only keep up with our regulars". So, maybe a lack of doctors, but at least as likely that the receptionist doesn't understand queuing theory.
posted by cmiller at 2:25 PM on October 18, 2007

I live in Philly. To see my allergist, I have to make appointments a couple months in advance. To see my dermatologist, same thing.

My dentist is often very booked, but they have really long hours, so I can usually find something to work with--especially if I have horrible tooth pain or something.

My GP is also my gyno. If I'm making my yearly well-woman, it's a couple month wait. If I'm hacking up a lung or have some other urgent thing, I can usually get in within a week or a week and a half, but sadly, they often tell me I should just go to the ER (and generally it's not "ER worthy").

So my experience reflects much of what is said upthread: specialists are harder to get appointments with, "maintenance" appointments are booked months in advance, and if you're an existing patient, you can get in in a reasonable time for an urgent matter.

I think you may also have more issues because you're in a rural area, so there are fewer doctors and specialists.

What bothers me is that Philly only has "emergency" care and no "urgent" care like medexpress or redimed. So if I have a horrible cough or ear infection and can't get in to see my GP in a few days, I have to go to the ER and get it taken care of there (really expensive, long wait which is not the case at urgent care). Bah.
posted by misanthropicsarah at 2:31 PM on October 18, 2007

Dermatologists are an especially tricky place to start the discussion. Dermatologists are infamous for "supplier induced demand," and the supply of them in very restricted by training programs. As a result, derm people tell me that they could move virtually anywhere in the country and get instant work. Derm can be high-paying and a great lifestyle (quick procedures! minimal call! essentially no emergencies! patients paying cash!), so it's very competitive to get into the restricted number of slots. The derm residents that I talk to are all very smart and very cosmopolitan.

So, there are two factors at work against your mom getting a derm appointment: 1) Dermatologists can fill their schedules arbitrarily fully by the nature of their work and the restricted supply. 2) Dermatologists (and specialist physicians in general) tend to be people who want to live in major metropolitan areas.

You can make a related argument for cardiologists. You make the money there by being interventional, and so they want to crowd into the hospitals with the best equipment. In big cities they can create specialists groups to get good referral patterns and split up call.
posted by a robot made out of meat at 2:32 PM on October 18, 2007

Don't like it? Petition for the reformation of our legal system, or move to a bigger city.

SpecialK, that's not always pertinent. I have to schedule with my specialists months in advance and I live in a large city. Depending on the specialty it can be that way anywhere. And I've noticed that the really good ones are often not accepting new patients at all.

Basically I'd say it's just a shortage. I feel your pain. I do have a suggestion though--make friends with the head nurse at your doctor's office. I can always call the nurse and weasel my way in if I have an urgent need. The good nurses are incredible anyway--they'll know your chart as well as the doctor does, and it's part of their job to make decisions like who needs to be shoehorned into the schedule or requests for prescription refills. Be sure to give him or her a Christmas card--they work like dogs.
posted by tejolote at 2:40 PM on October 18, 2007

misanthropicsarah: Penn Urgent Care Center
posted by mbd1mbd1 at 2:40 PM on October 18, 2007

If you want to see the doctor who is widely known as the best, there will be a wait. For many surgeries, and many conditions requiring a specialist, it might be worthwhile. You want a surgeon who does a lot of the surgery you're going to have, and does it successfully. If you have a health problem, you may need a physician who will help you find the right treatment. But for your annual pap smear, you could schedule it with another physician at the same practice, and be perfectly confident.
posted by theora55 at 3:10 PM on October 18, 2007

I almost always see my doc within 24 hours. A specialist that removed a sebhorrheic wart from the tip of my nose took 4 weeks.

I live in the socialised medical system of the UK. Things ain't bad all over.
posted by dash_slot- at 3:15 PM on October 18, 2007

ROU_Xenophobe got my location from my profile. I don't go to Chicago because it's an hour and a half drive or train ride, depending on traffic, and that'd just add time and gas expense to the time I'm waiting in the waiting room. For a more urgent problem, yes, I'd look a little farther away for a doctor.

The local off-hours clinic doctor is somewhat of a quack.

Most of the doctors I see, save the OB/GYN, are not "the best" in the area. And like I said, she's not an issue... since I like her so much, I'm fine with scheduling 5 months in advance, since I know when my annual is due, unlike knowing when an illness will strike.
posted by IndigoRain at 3:22 PM on October 18, 2007

I'm in a big city, and recently changed from an HMO to a new insurance policy due to a change in employment. I was shocked to find that under my new system I can often get in to see a doc the same week, let alone the same month... I was accustomed to 5 month wait times and numerous cancellations just to see a doc I had never met and who hadn't read my file.

Based on this experience I think the only crisis going on is one of poor management and greed.
posted by foobario at 4:37 PM on October 18, 2007

SpecialK: Federalized healthcare isn't any better, just ask anyone from Canada how easy of a time they have getting in to see a specailist or get in for surgery and they'll tell you.

Yeeeeeesh, not again. It seems like we just had this conversation.

I am Canadian. My situation is much like Jessamyn's.

jessamyn: Where I am, no there's no crisis or wait time. I get a doctor's appointment same day often, almost always same week. My OB-GYN was same week. As you suspect, it may be a regional shortage of specialists. When I had to go see an audiologist, it did take months.

How many times does a person have to say this to stop Americans from spreading the fallacy that our medical system doesn't work?
posted by loiseau at 5:05 PM on October 18, 2007 [1 favorite]

How many times does a person have to say this to stop Americans from spreading the fallacy that our medical system doesn't work?

I think they have to make a funny/scary psuedo documentary about it narrated by someone who looks like he's trying awful hard to look like Rob Reiner.
posted by The World Famous at 5:39 PM on October 18, 2007 [1 favorite]

My impression is that the doctors with the long waiting lists are often the inexpensive doctors; i.e. the ones who accept the insurance contract rates, particularly HMO contract rates. I just made a next-day derma appointment, with a private practice doctor who I believe is not an in-network provider for anyone. (My PPO covers out-of-network, but at a reduced rate.)

My strategy is to go in person for an appointment, and be willing to ask for referrals to doctors who are available for immediate appointments.
posted by trevyn at 5:42 PM on October 18, 2007

I find it depends a lot on the individual practice. My former gyn and GP had several-month waits. But now I don't have any trouble getting appointments anymore within two weeks for derm, dentist, GP, and gyn. (Though the wait-room time for my gyn is terrible, since she's also an OB.) And my GP has teamed up with her colleague and a nurse practitioner to offer an urgent care option out of her office.

(Sarah, lemme know if you want to try out any of my docs.)
posted by desuetude at 6:05 PM on October 18, 2007

i live in philly.

i have seen doctors at both penn family care (associated with the university of pennsylvania and its hospital) and jefferson hospital.

jefferson is a huge hospital. they have a next-day-appointment policy, assuming that you have already chosen a PCP. you must always call the day before you want your appointment, and they will always schedule you.

the wait at penn can be a bit more depending on the urgency, but it's never been more than 2 weeks. usually it's a few days.

i don't see any specialists. i assume those would be a different matter. but for GP stuff, i can't imagine waiting more than a few weeks.

is it an insurance thing?
posted by timory at 6:57 PM on October 18, 2007

Where I live (Portland, Oregon), it takes months to schedule a routine doctor's appointment, but if I call and say I have a pressing problem she always makes room for me. And if I have a really, really pressing problem, my doctor is part of a group practice that always has someone on call for minor emergencies - they call it their urgent care program. My doctor's office also allows us to just call and talk to an advice nurse. So if I need a prescription refill or just have a basic question about something, I can call this person to have my issue addressed over the phone.

Have you been upfront with your doctors about the urgency of your issues?
posted by croutonsupafreak at 8:13 PM on October 18, 2007

mbd1mbd1: badass. thanks!
posted by misanthropicsarah at 8:50 PM on October 18, 2007

Defending malpractice claims costs less than one half of one percent of total health spending. And "tort reform" already enacted in some states has led to malpractice premiums going up. So the costs of the legal system are a drop in the bucket and changing the legal system doesn't seem to reduce this at all, but it's a nice red herring.

A bit of a derail but... Respectfully, your red herring callout is a straw man. Accounting for the costs of our litigious society in terms purely of malpractice claims ignores the massive cost of the "defensive (expensive) medicine" most doctors are forced to practice as they live in constant fear of getting sued. Just ask any ER doctor what happens when a middle aged guy shows up complaining of heart burn or a dizzy spell. A hospital admission to a telemetry bed, ECGs, cardiac enzymes, a cardiologist consultation, sometimes an MRI of the brain, an echo of the heart, a stress test, cha-ching, cha-ching, cha-ching. The cost of this kind of wasteful practice trickles down mightily into your average consumer's insurance expenses and the overall cost of health care, before a malpractice claim can even be filed.
posted by drpynchon at 10:35 PM on October 18, 2007

You are right that defensive medicine increases healthcare expenses overall, drpynchon, but yes indeed that is a derail to a completely different topic. This question was about why it is hard to find physicians in a specific region, and the overall cost of health care isn't going to affect that. When "tort reform" has been tried it hasn't even reduced malpractice premiums, so it is, in fact, a red herring if your theory as to why there are few doctors in Podunk village is "high malpractice premiums." That doesn't stop people pushing for it for ideological reasons though.
posted by grouse at 12:18 AM on October 19, 2007

Wow, semi-socialised care here in Australia. I can't imagine waiting for more than a day to see my GP unless it was less urgent than a head cold. Certainly there are half a dozen doctors within a ten minute drive that would see me same day. The only wait time I have ever had was to get my daughter allergy tested It took a couple of months to see the nearest specialist, but if it was an urgent need, or if I had been prepared to travel an hour further it would have been much shorter.
Cheer up though, I hear the US has the best care in the world, so if you see a doctor she won't be casting bones or whatever you think happens in Canada or the UK or here.
posted by bystander at 4:05 AM on October 19, 2007

Oh I totally agree grouse. I don't think malpractice premiums have much anything to do with access to physicians at all. If anything, there's actually a substantial financial interest in moving away from the coasts and cities if you're a physician for purely supply/demand reasons. The truth is that I'm not sure why there is such a maldistribution of physicians in the US, though I'm sure there are public health researchers who have good ideas about it.

Moreover, it's not necessarily always the case that access to providers or provider shortages are even the reason why people have to make appointments in advance as the OP describes. There are doctors constantly trying to build practices but if you have an established practice and build a great reputation, you're bound to be in great demand. Sometimes it's simply patient preference and willingness to stick with one particular physician and suffer the wait time because they like the care they receive when they do eventually get in. Some physicians let their practices grow out of hand. Other times it may be dictate by HMO or insurance limitations. I guess what I'm saying is that there's probably a lot of reasons that contribute to problems like these.
posted by drpynchon at 6:18 AM on October 19, 2007 [1 favorite]

My little sister recently developed a nasty ear infection. Luckily, our family pays a ton of money for private, PPO health insurance. So my mom calls a peditrician and tries to set up an appointment for my sister's throbbing, puss-filled ear.

The wait time? Two months.

Obviously, by then any infection would either have cleared itself up or caused my sister to go into septic shock. The scheduling nurse on the phone suggested that they go to the ER (wait time for anything other than a Code-Blue cardiac arrest: ~6-8 hours), which is exactly the opposite of what ER's are for, IMO.

Eventually, they ended up going to a local religious medical charity and were seen within two days. Again, we are a middle-class family with fairly good (and expensive!) insurance. We also live 15 minutes from downtown Houston, so we're not exactly a rural area.

Obviously, Medicine is broken in the United States. Although I'm honestly at a loss to explain exactly why that is. My best guess (and I realize that this is a fairly radical idea) is that our country is simply over-populated.

Other countries with comparable populations (Indonesia, India, China) aren't exactly known for their sterling medical care. It may be that as a population grows, the number of people who are intellectually and tempermentally capable of meeting Western med-school standards doesn't grow in a 1:1 ratio with the rest of the country. If we wan't more doctors, we may need to either lower the bar at med-school or just have less babies.

Food for thought, anyway.
posted by Avenger at 6:26 AM on October 19, 2007 [1 favorite]

I'm in the middle of a high-risk pregnancy and have had lots of appointments with specialists, genetic counsellors and midwives. All of my appointments have been within days. And this is at the best hospital in the area. I've never had to wait more than a couple of days for a doctor's appoinment; when I have called for something urgent I have seen the doctor within the hour (or minutes in my local emergency room or walk-in clinic). My children usually only go to the pediatrician for shots (scheduled within a few days) but the few urgent appoinments (for things like warts) I make are always the same day. My mother broke her hip at 3 pm and at 6 pm she had a new one put in. My father has had bypass surgery, waiting a few weeks at most (he was shopping around for the best doctor). My husband however does seem to have trouble with his doctor but I think it is her lack of time management and overbooking that causes him to wait a couple of weeks for appointments for refills. So, I agree it is probably a regional thing. Of course my (booming) region is supposed to have one of the lowest doctor to patient ratio in Ontario. But I guess things are different here in Canada.

I can't imagine how you cope with such limited access to healthcare, it must be such a worry, my sympathies.
posted by saucysault at 8:19 AM on October 19, 2007

On a macro level, the problem of having to wait "too long" (which I think most people would define as wait times long enough to cause a condition to substantially worsen, like not getting a mole biopsied for four months) is a simple econ 101 matter of supply outstripping demand.

Unlike in a lot of other fields, demand rising doesn't necessarily mean that supply will as well (more people becoming doctors)--the number of residency slots is limited by federal funding, and no one can become a doctor without going through residency. So some people argue that the problem is that we have too few doctors. (The supply side is artificially constrained, perhaps as a result of political pressure from the AMA, whose members financially benefit from limiting the total number of doctors in the market.) In a less direct way, supply is also constrained by state-level laws about who is allowed to perform various procedures--can an physicians assistant or RN do that biopsy for you, or does it have to be a licensed doctor? States that heavily restrict who can perform more "basic" medical tasks end up with a lower supply compared to states with less restrictive laws, even when the two states have the same number of MDs and DOs.

On the other side, some people point out that we have more doctors per person in the population now than we have had in the past, and the issue is excessive demand or excessive demand in the wrong parts of the healthcare market--that is, people going to the doctor for minor ailments, clogging up the emergency room with minor issues, that sort of thing. The rise of plastic surgery and other elective medical procedures being the problem, not the number of doctors. (This is also where you'd find criticisms of malpractice laws and doctors having to perform too much defensive medicine--if they did not have to do so, the reasoning goes, demand would fall to a level that the current supply of doctors could more readily handle.)

On a personal level, if you feel this is really constraining your ability to get quality care, I'd point out that there are different types of insurance that are better at dealing with getting you actual access to medical care. Your average PPO has no ability to force a doctor to see you. In a perfect world, they'd constantly expand their networks so new members had plenty of places to go, but they may not be willing or able to raise their reimbursement rates enough to get new doctors to join the network. Alternatively, HMOs and other managed care plans that use staff doctors rather than a network *are* able to force doctors to see you, and have a direct incentive to make sure you get in early, when a problem is treatable, rather than later. However, HMOs will also restrict the level of care you receive, and a lot of people get really upset with that--many studies have found that utilization of medical care for members of HMOs is something like 30% lower. On a macro level, that's a good thing, but on a micro level, it might really upset you to have a doctor refuse to remove a mole because it's not showing enough danger signs to warrant the procedure.

So, the upshot is that you could either look for a PPO that has a really large network in relation to the number of enrolled members, or you could look into a staff HMO. On a political level, you could send letters to your state representatives encouraging them to relax things like the Nurse Practice Act and other laws regulating whether paraprofessionals can perform basic medicine. On the federal level, you could encourage your representatives and senators to increase funding through Medicare for more GME slots to train more doctors.
posted by iminurmefi at 8:20 AM on October 19, 2007

Croutonsupafreak: Have you been upfront with your doctors about the urgency of your issues?

You bring up a good point; however, what I think is urgent isn't what they think is urgent. When I saw my cardiologist in June, he put me on a new med, Benicar. Since then I sleep 12 hours a day, and can't stay awake more than 12. It's made me gain 25 pounds and be miserable, because I don't have time to do anything. They don't consider that urgent and wanted me to wait for the cardiologist. Since they cancelled me, I've decided that I'm probably not severe enough to need a cardio anymore, and am going to get my nurse-practitioner to wean me off the Benicar. (My problem was palpitations caused by taking Sudafed one time.)
posted by IndigoRain at 1:55 PM on October 19, 2007

2 other thoughts:

My OB/GYN always makes the offer to her patients to call ahead the day of their appointment. When I'm flexible and can come in later in the day (on my day off, for example), I've had them say, "oh she is running late, can you come in at 5 instead of at 1?" This takes one patient out of the rotation (me), letting her catch up on others, so by the time I get there at 5, I have less of a wait too.

Also, insurance isn't an issue for me, since I don't have any. They usually don't find that out until I get there for my first appointment (when I'm a new patient), and I *always* pay my visit costs right there, that day, so it's not an issue of them avoiding me over debt.
posted by IndigoRain at 2:07 PM on October 19, 2007

Defending malpractice claims costs less than one half of one percent of total health spending. And "tort reform" already enacted in some states has led to malpractice premiums going up. So the costs of the legal system are a drop in the bucket and changing the legal system doesn't seem to reduce this at all, but it's a nice red herring.
posted by grouse at 2:00 PM on October 18

Maybe so. I have no idea. But the psychological effects of an idiot jury handing your life's work to someone tends to reduce one's drive to go into the field of medicine and makes those already in it less inclined to take on new patients.

The problem isn't taking on too many patients in many cases, it's stopping accepting new ones once you get to a sustainable size, also.
posted by docpops at 2:44 PM on October 19, 2007

the psychological effects of an idiot jury handing your life's work to someone tends to reduce one's drive to go into the field of medicine and makes those already in it less inclined to take on new patients.

Can't comment on the last part but I've never heard of anyone who decided not to go to med school because they might face a malpractice claim someday. Even if such people existed there would be enough qualified people to the artificially limited med school place they may have occupied.
posted by grouse at 4:52 PM on October 19, 2007