To the Editor:

The authors of “Same-Day Appointments: Exploding the Access Paradigm” [September 2000, page 45] illustrated the problem of patients obtaining an appointment in a reasonable amount of time in large primary care clinics. Reducing a 55-day wait in large clinics is commendable. However, in most smaller practices, the wait for acute-care visits is no longer than 24 to 48 hours, and this short, reasonable wait is often vital for the following reasons.

In primary care, many patients present to the physician with nonspecific symptoms early in the course of an illness. The majority of these patients prove to have self-limited illnesses that will improve with time and minimal symptomatic treatment. However, many serious illnesses also begin with nonspecific symptoms initially thought to be of viral origin. Often the passage of a couple days will separate the majority of self-limited illnesses from the occasional serious one. Seeing more patients on a same-day basis will only increase the following: the chance of physicians incorrectly diagnosing a viral illness, the use of diagnostic studies to find the occasional serious illness and the need for return visits because of the difficulty inherent in making an accurate diagnosis at the onset of symptoms.

The same-day appointment may look attractive to managed care marketing departments and some patients, but it may not always be the best way to practice medicine.

To the Editor:

I just finished reading the article about same-day appointments and was dismayed to say the least. The authors make several assumptions that may hold true where they practice but definitely do not hold true in my two-physician family practice or my community:

• If we opened our schedules to every patient in our rapidly growing suburban community who wanted an appointment, we could easily work 24 hours a day, seven days a week — with each of us seeing 40 or 50 patients per day.

• If we decreased the number of routine appointments and increased the number of same-day appointments as the authors suggest, the waits for health maintenance appointments would worsen from the current 30 days to something astronomical.

• The authors say that physicians can reduce backlog by taking care of more patient complaints “today.” In my practice, almost every patient has a laundry list of “oh, by the way” complaints that I used to try to evaluate. However, this brought me close to burnout and regularly kept me 90 to 120 minutes behind schedule. I’ve now learned the survival skill of saying “no” when a patient wants me to care for a plethora of chronic problems in one visit, and I’m much closer to being on schedule.

• The authors say demand isn’t insatiable, but after 12 years of practice in various environments, I heartily disagree. Demand can be insatiable, particularly when other physicians in the community are not good listeners. As soon as patients find out who will listen to them and hear all their complaints, they’ll flock to that physician in droves, quickly overwhelming him or her.

I’m not sure what the solution is, but it is surely not the type of schedule the authors suggest!

Authors’ response:

While we appreciate Dr. Markman’s comments regarding same-day appointments, we now know that this approach has as great if not a greater effect in pure fee-for-service environments. Building a system that reduces waits for all patients actually reduces demand. We have two concerns about the division of patients into urgent and routine queues:

• Despite the fact that some patients with self-limited illnesses do clinically improve, all patients asked to wait are less than satisfied and some do find other ways to enter the system (be it through other providers, urgent care or the emergency department).

• Segmenting the “really ill” from the “not-so ill” and the “they can wait” categories takes work, rework, triage, inclusion/exclusion criteria and creates three waiting lines. It’s next to impossible to manage three lines of wait without extending the “they can wait” line. So patients who have long relationships with us must wait even longer.

Pulling the work into today, in a sense, has nothing to do with clinical issues. It’s operational: If we create two queues — the urgent and the routine, we have to create a carve-out method to distinguish the two. When we do that, we have built a system that simply won’t work.

We would also like to address a few of Dr. Costello’s points:

• If there are more patients than a practice can handle, pushing the work to the future won’t make it go away. Instead, it will disappoint lots of patients. Measure the demand, calculate the supply and determine if there is a mismatch. If the demand and supply are in equilibrium, a wait is not necessary.

• We don’t suggest decreasing the number of routine appointments or increasing the wait time for routine appointments. In fact, we suggest quite the opposite: Offer an appointment for any problem on the day the patient calls.

• While saying “no” to patients’ needs may seem like a survival strategy, in reality it assures nonsurvival. Reducing the work of each visit increases the total visits, which increases the rework: a second parking space, receptionist, nurse, set of physician questions, etc. The marginal time spent handling more problems is far less than the work of repeated visits. In health care today, we push demand work to tomorrow in order to protect today, but what we need to do is pull the work into today in order to protect tomorrow’s capacity.

• Reducing demand by not pleasing patients is actually the opposite of what we recommend, which is to listen to patients in the office and before they get there. Our studies have shown that patients want dignity, respect, a quality experience in the office and easy access to their chosen physician even before the visit. If we attract new patients because of these activities, we can rationally grow the practice.

We’re confident that the changes we advocate lead to improved satisfaction for patients, staff and physicians, improved clinical outcomes and enhanced revenues. In addition, responding to our patients’ needs and desires for better continuity and reduction in waiting time speaks to the heart of what family medicine is all about.