Practice Philosophy

Practice Philosophy

I wanted to share this essay written by a late senior colleague of mine, Dr. Frederick William “Bill” Danby, who was a dermatologist in New Hampshire.  Although I never had the pleasure of knowing Dr. Danby personally, he was a Fellow of the American Academy of Dermatology, as I am.  His philosophy is my philosophy — an unwavering focus on trying our sincere best to help your skin, using the latest science and medical art, as well as an appreciation for the time and effort you have expended to visit our office.

Because Dr. Danby said it so well, I’ve reproduced his essay here in full so that you know how we try to manage our clinic to be committed to your best care.

Rest in peace, Dr. Danby — and thank you for expressing so well what many of us in dermatology try to do day in and day out, for our patients.


F. William Danby, MD

So why do doctors “always make people wait”? While it may seem otherwise sometimes, we do not do it on purpose. The reasons (and the excuses) are multiple.

Firstly, if we knew exactly what was going to happen at each visit, we could book a special time slot (like dentists do); but a large number of our visits are to find out what the patient’s problem is. Once we have a diagnosis, the treatment time is immensely variable. We may be able to look after the problem immediately, which lengthens the time spent, or we may book another appointment for the future. For example, what should we do with an 80-year-old lady with a skin cancer that needs removing, who was driven in from 60 miles away by a relative who had to take time off work? Should we ask them to return in a couple of weeks? Or should we risk falling behind schedule in the office? We usually give her priority and shoulder the complaints.

Secondly, we have a problem with patients who are referred by their family physician for a single condition but then try our patience with, “While I’ve got you, would you mind looking at this?” This is a very common cause of delay. Sometimes patients even expect other family members to be seen at the same visit! We either risk offending the patient by gently and diplomatically refusing (and risk missing, a melanoma or other serious illness) or risk falling behind again. We do a little of both, as circumstances dictate.

Thirdly, interruptions are an accepted and expected part of our busy day. We try to handle phone messages between patients. While our medical assistants, nurses or other staff can handle some of these calls, many require our direct handling. This interferes with the flow of patients in the office, and it may delay or interrupt your visit. But remember that if you have a side effect from a medication or a problem with the therapy, we will respond to your need at this time and interrupt or delay someone else on your behalf. The alternative is to take a message and call back later. This is not as efficient as we would like with today’s mobile population. If you are in a pharmacy waiting for a prescription refill to be approved, you will not be happy to be asked to come back later.

The weather can also have a devastating effect on our schedule. A bad snowstorm which delays two or three people by a half hour in the morning will mean fitting these people in later in the day. This causes a ripple effect, which is still delaying the schedule at the end of the day. The alternative is to refuse to see the patients when they arrive late, not a popular option.

Emergencies and the unexpected are also part of the problem. If someone scheduled for a minor surgical procedure brings a relative who decides to faint during the procedure, an examining room can be tied up for 15-20 minutes or even longer to allow for recovery. Or if there is a surgical complication, such as excessive bleeding, or a allergic reaction, that can also cause us to get behind. Predicting emergencies is, of course, impossible, so we just do our best when one arises.

Then there is the paperwork problem, all the insurance and personal information and health status documentation we need to collect so that we have as much accurate information as possible when we start to evaluate your problem. You can help by showing up early (15 minutes would be good for a first appointment). Our booking staff will usually tell you about this when you make your appointment. So bring a list of all your medications, if you don’t know what you are taking. Otherwise, it’s very difficult for us to know how to avoid drug interactions.

Even our attempts to smooth the schedule will occasionally cause problems. Because treatment responses are not predictable, we sometimes ask patients to show up for an appointment, but to cancel it if there is no need to keep it. Some people forget to call in to cancel; they wind up as “no shows” at the end of the day. We expect this to happen (there are normally 3-4 “no shows” each day for each doctor) and so we overbook (lightly) to compensate. The good news side of overbooking is that the waiting list is kept shorter; the bad news side is that, about once every two weeks, everybody shows up and we need to hustle to keep up. From the patients’ point of view, the option is between waiting 2-3 weeks for an initial consultation (and risk being kept waiting in the waiting room) or waiting 2-3 months for an initial appointment run on a strict booking schedule. There is one other down side to a strict schedule; it would be necessary to only address one problem at each visit (rash or a mole, or warts or acne, not all at one time). This would cause multiple visits, with additional co pays. We would also have to charge patients directly for missed appointments; neither is a popular option for either doctors or patients.

One other consideration: our doors are always open for emergencies. We will see on an emergency same-day basis any patient whose doctor phones us to provide details justifying same-day service. If you are kept waiting as a result, please remember the same swift response is available in the event that you are unlucky enough to require it.

Finally, consider that, when we do fall behind, lots of people notice and some complain to our staff, some even directly to us. A simple apology is really all we can offer; further time spent in explanations just makes delays longer, adds fuel to the controversy, and can impact your care adversely by distracting us from the priority of providing you the best dermatological care we can. And please, public waiting room complaining just makes matters worse; it won’t improve the situation and just causes bad feelings. Rest assured, neither of us is sitting back in our consulting rooms with our feet up on the desk, making you wait. We’ll try to give you the same extra time, if warranted, that was provided to prior patients. And we might even surprise you and get caught up. The funny thing about all this is that, when we are caught up (or even ahead of schedule), there is nobody around to notice!