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The right appointment, at the right time, every time. How in the somewhat chaotic system we have can we figure out a better way to make sure everyone gets the care they need, the right care, at the right time?

The Convenience Factor

From a patient's point of view, they want to see their doctor, or perhaps even any doctor or other members of their coverage team, in a way that is convenient for them, at a time that is convenient for them, that satisfies their particular health needs at that moment. First of all, they have to be able to reach their practice, either through the telephone, or through a patient portal, or through some sort of chat-bot or web-based application.

Then there have to be appointments that are convenient for them, and that match the particular acuity of the issue they are hoping to address today. For an acute broken bone, or the worst headache of their life, this might mean a trip to the emergency department. For a sore throat or suspected COVID-19 infection, this might be an urgent in-person visit or even a video visit.

For routine care, this should be an appointment with their primary care doctor or a member of their care team that knows them, at a time that is convenient to the patient. And for an annual physical, well, this should be with their primary care doctor, the person who knows their healthcare situation the best, who won't need to re-create the wheel every time they are seen.

Scheduling a 'Good' Appointment

From the point of view of the practice, there are so many factors that go into scheduling a "good" appointment. At a large academic practice like ours, where many of the full-time attending physicians have multiple other duties, such as administrative and departmental leadership roles, supervising residents in their practice sessions, and dedicated research time, they often have limited practice schedules and availability that can cause all sorts of scheduling challenges to crop up.

Unless someone has nearly unlimited practice sessions, such as a full-time practitioner in private practice, there is often a really long wait for either urgent, routine, or annual visits with an attending physician. The residents present additional challenges, in that they only spend about a quarter of their time in the outpatient setting. For the residents at our institution, this is what we call a 6+2 schedule, where the residents rotate through our practice for 2 weeks, then are away for the next 6 weeks doing inpatient rotations and electives.

As I've described before, our residents rotate through these cycles in teams, what we call "pods", such that there is an A resident, a B resident, a C resident, and a D resident, each taking sequential 2-week blocks of time at our practice dedicated to outpatient care. While a resident is away from us for those 6 weeks, if a patient of theirs needs to be seen on an urgent or semi-urgent basis, we try, and we hope, that they will be seen by a member of this team, their pod, who are all working under the same attending physician for continuity and hopefully cross-covering each other and communicating well together to help co-manage complex patients. We look at the data that's generated to tell us who our patients see, and who the residents see in their practice, to take a look at how we are doing.

The Continuity Indexes

There are two important measures of continuity, what we call the continuity indexes. Each of these measures tells us something about the quality of the appointments we are scheduling, and suggests areas for improvement. The better we can make these two measures, the tighter the continuity, the better patient satisfaction and provider satisfaction tends to be. Patients love seeing a provider they know, and providers love taking care of patients they know.

When a patient has a low continuity index, and they see lots of different providers, we often find that there is miscommunication, over-ordering, over-testing, and over-referring. When a continuity index is high for a patient, when they primarily see their primary care provider for almost all of their visits, care tends to improve, things don't get duplicated, and a better bond begins to develop between the patient and their doctor, with higher levels of trust and compliance and so many other tangible and intangible factors.

The nuts and bolts of making this happen have to do with the templates that we build for the schedulers, and how closely they stick to the scheduling rules. So often we hear from them that patients insist on coming in to see somebody, anybody, they don't care who they see. Unless we do a better job of triaging and asking the right questions, we run the risk of watering down this continuity, scheduling "bad" appointments which tend to have a high no-show rate and lower satisfaction for everyone involved.

In these cost-cutting days, especially when the people answering the phone are being pressured to get through a call as quickly as possible, it's hard to get across to patients that they are much better off waiting and seeing their own primary care doctor, even if it takes a few days or weeks. The better we communicate this to patients, the more we will be likely to improve continuity and build up trust. (Of course, there are exceptions, and if someone needs to be seen, they should have an appointment, no matter what.)

Many of my friends at private practices in the community deal with this in a different way, offering the next available with the patient's primary care provider, and if that doesn't work there are several providers standing by on a day-to-day basis who have set-aside appointment spots to do interim/acute care. These patients are seen to address one or two issues, an upper respiratory tract infection, or a new headache, or a rash, or an urgent pre-operative evaluation. Then they are returned to the ongoing care of their primary care provider.

It is unlikely that were ever going to get to perfect continuity, either from the patient's point of view, or from the providers. But the more we can do to make sure that the right appointment happens at the right time, the better off everyone's going to be, and the better we'll be able to deliver the best care to our patients.

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