The Walk-in Patient
Several weeks ago, one morning at 10am, my nurse received a phone call from a lady who informed her that she was already on the road from Ipoh (a city 370km north of Melaka) and wanted to consult me regarding high intensity focused ultrasound or HIFU for her fibroid. My nurse was unsure as to what to do. There are many investigations that need to be done before one can perform HIFU and here is this patient, already on her way to Melaka planning for surgery. My nurse could not tell her to cancel her trip, return to Ipoh and make an appointment first. She just said ok and informed me.
The patient arrived at 3pm. I had to delay my planned HIFU case, which I was supposed to start at 330pm. After taking her history, performing an examination and ultrasound, I told her that she actually had adenomyosis and that she would first require to undergo an MRI. After that, I would have to perform a simulation whereby she would have to lie on the HIFU machine to see whether she was suitable for the surgery. I informed her that only after that, could we arrange for a date for the procedure to be done.
Her mother asked whether she could be admitted to undergo the MRI and the procedure on the same day. She said that they had travelled all the way from Ipoh and were tired. The patient had, apparently, also taken leave to come to Melaka. I told her it was not possible to do everything they wanted that day. It was a Thursday and I already had a full operating list with 3 laparoscopic surgeries and 1 HIFU, the next day, Friday, my operating day. Aside from this, the patient would require 3 days of bowel preparation before I could perform HIFU.
I do not perform HIFU surgery on Saturdays and Sundays. I also informed her that every day from that following Monday, I was already fully booked for HIFU cases. The only way was to pick another date to perform the MRI, do a simulation and then fix a day for the HIFU procedure. I also reminded her that she herself being a medical staff member, should understand that it is necessary to call to inquire first, get all the information and then make an appointment before coming down all the way from Ipoh to Melaka. Fortunately, she agreed to go back to Ipoh, perform the MRI in her city and send the images to me for assessment and then come down for a simulation and treatment at a later date.
This is not uncommon in medical practice in Malaysia. Prior to the pandemic, I often saw patients from distant places like Sulawesi, Indonesia, coming to my clinic, without appointments, requesting me to perform immediate surgeries. I have always obliged and tried to accommodate these patients knowing how difficult it is for them to travel such distances to Malaysia.
When I started private practice in 1994, work was slow. Nobody made appointments. Patients just walked in. We, the doctors in Mahkota Medical Centre were ever happy to see them since we had very few patients to begin with. As time passed by, when we became busier, walk in patients had to wait longer. We were seeing patients on a “first come first serve basis”. Early in the morning, you would be able to see a long queue of patients waiting to be registered so that they could consult their doctors as early as possible. This was ineffective and a waste of everybody’s time.
Challenges To Adopting An Appointment System
I am perhaps one of the early adopters of an appointment system in this hospital. i tried to educate my patients, especially my repeat patients to call in for an appointment. I informed them that if they made an appointment they would be seen first. The walk-in patients would have to wait until all the patients with appointments, were seen. What I usually did was, whenever there was a time gap in between patients with appointments, I try to slot in the walk-in patients. I also did not give any appointment between 1 and 2 pm, my lunch break , and I utilise this time to see walk-in patients. Of course, the walk-in patients were unhappy. They kept complaining that although they came earlier than the patients with appointments, they were not seen first. We had to keep educating them about the importance of making appointments. I lost many patients because they thought I was arrogant, too busy and refused to see walk-in patients.
When you have an appointment system, you need to allocate at least 15 minutes to a patient and so you can only give appointments to 4 patients every hour. If you work for 7 hours you can only give appointments to 28 patients.. Before the pandemic, I was consulting up to 40 patients during that 7 hours. Even with an appointment system, my appointment list got filled up quickly and the waiting time for an appointment got longer and longer. This upset many patients who kept saying that it was so difficult to get an appointment to see me. I told them that if they wanted to see me urgently and could not get an appointment, they could just walk in and I would try my best to slot them in but that they must be prepared to wait. Even now, many agree to this arrangement but when they arrive at the clinic, they become impatient. They often harass my nurses. My nurses usually take the brunt of their abuse. When my nurses tell me of this harassment, I am usually under immense pressure to see my next “appointment” patient quickly so that I can see the walk-in patients. Even when they are unpleasant to my nurses at the counter, when they enter my clinic they are usually nice and will not complain even though some especially their spouses, will have long faces. I just pretend that nothing happened and continue with the consultation. This can be unpleasant.
The Advantages and Disadvantages of Having an Appointment System
There are many advantages of having an appointment system. First, with an appointment system, you can gauge how your clinic is going to be and if there is a medical emergency, you can call and postpone or cancel appointments so that patients do not have to wait long nor be disappointed that they could not see you that day. With an appointment system, I can also plan my time. For example, I do not see patients on my operating days, which are Wednesdays and Fridays and so patients are informed not to come to the clinic on these days, except for emergencies. Patients are also informed early whenever I am on leave so that they can plan their appointments and are not disappointed when they walk in.
However, there are also some disadvantages to an appointment system. Some hospitals have an online booking system and this is not synchronised with the individual clinics because the clinics have their own appointment system. This leads to confusion. There are also 3rd party business enterprises that sell apps where patients and doctors can log in and this can also create confusion with appointments. Some doctors work in more than one hospitals and appointment system for such doctors can be a nightmare. What happens when a patient calls on the day of appointment and cancels or worse does not turn up for the appointment without informing? In an instance like this, nothing can be done for the wasted time, which could have been used to see another patient. What happens when I have an emergency? Being an obstetrician I can never foresee when a lady will come in labour. Many patients become unhappy and ask me why I have an appointment system when I can’t keep the time. I have to tell them that as a solo obstetrician I have to attend to emergencies and in the future, their turn will come when they go into labour. For these reasons, many of my colleagues still do not have an appointment system and still consult patients on a first come first serve basis.
So what advice can I give doctors going into private practice
- It is good to have an appointment system. Educate your patients to make an appointment and discourage walk-in patients.
- When faced with a walk-in patient do your job and don’t bring it up at the beginning of the consultation. After you have finished, politely tell them that the next time they are coming back to the clinic, it would be nice to make an appointment so that you can plan more time for the consultation.
- There will be that persistent walk-in patient who does not have any respect for your time. I have had such patients who thought they were being very smart by always showing up at 4.30pm or 5pm, just before clinic closed and insisted on being seen. They know that they do not have to wait at that time, as I would have seen all my patients with appointments. With such patients you have to use your discretion. At times, I tell them that it would be the last time I was going to see them and that the next time the same thing happened, I would not accept them. Some of them will relent and make an appointment but most will move away to torture another doctor. Good riddance to such patients!
- Even though it is our job to please our patients so that they will remain ours for a long time, there should be a cut off limit as to how much abuse you can take. So you have to decide where you are going to draw the line regarding walk-in patients.
I would like to thank
My wife Sarojini for editing this article
Dr. Gunasegaran for reading this article and giving good suggestions.