Beware of cranky old guard

If you have been in health care for any length of time, I am certain you have confronted one or more Cranky Old Guards, or COGs. These COGs are health care veterans who reject innovation and fiercely defend the status quo. The COGs come in a variety of sizes and shapes, but they all share one attribute: preventing innovation and change. They are comfortable in their own shoes and in their comfort zones and want the health care system to remain as it is. The COGs that I have encountered during my 44-year career in health care, when offered a new approach to the beleaguered health care system, will offer this rejoinder: It’s not invented here, thus squelching any innovation. In this article, I will describe three ideas that were initially rejected by the COGs but, after implementation, significantly improved the delivery of health care services to our patients.

Health care employs one in nine Americans. The health care budget exceeds $4 trillion. Health care consumes one-fifth of the GDP. Unfortunately, health care costs are increasing faster than the rest of the economy. With all the bloated expenses of the current system, we don’t have improved outcomes, lower neonatal mortality or access to care for many underserved populations. Instead, we are focused on expensive sick care or on delivering care after disease occurs, rather than on preventing illness before patients become sick and need expensive health care services. Warren Buffett appropriately called the ballooning health care budget a “hungry tapeworm” on the American economy.

“There’s no chance of not waiting [for the doctor], because they call it the waiting room.” — Jerry Seinfeld

Three examples of COGs delaying innovation

1. Importance of being an on-time physician

Why is it necessary for the doctor to be on time? I am reminded of a story of a patient who was always 30-45 minutes late for his appointment. When the receptionist asked about the chronic delays, the patient said, “When I arrive at the designated time, I always wait 30-45 minutes. So, I thought I would wait at home or in my office!”

I have had the opportunity to visit several hundred medical practices over my 40-plus-year career, and I am often asked what is the “best” idea to improve and grow a practice. Finding that one best idea is like searching for the Holy Grail or the Ark of the Covenant. There is no single idea that will enhance or grow a practice.

If I had to select one idea or one suggestion that is within the doctor’s control, it would be seeing patients on time. If the doctor is always late for their patients, they send the message that the doctor’s time is more important than the patient’s. This is hardly the message that we want to send or the impression we want to make on our patients. The patient compares appointments they had with their accountant, lawyer, dentist, or even their beautician or barber. People don’t wait to see these professionals, and they don’t expect to wait to see their physician.

I have seen firsthand that COGs frequently arrive late for clinic appointments in the office. As a result, patients are not seen in a timely fashion, and the schedule falls behind before the first patient is seen. This leads to lower patient satisfaction scores, increased staff anxiety in managing patients’ complaints and ultimately physician burnout.

When the COGs were confronted with the situation, they responded that the patients are not in the rooms at the start of the day, so their solution is to arrive 15-30 minutes or more after the clinic start time.

A scenario that is probably familiar to all physicians occurs when a patient has the first appointment at 9 a.m. The patient checks in at 8:45 and is not seen by the doctor until 9:30 or later. As a result, the patient is upset; the staff is trying to calm the patient who has been waiting for 30 minutes, and the staff is also trying to mollify the patients who are now more than 45 minutes delayed in seeing the doctor. The doctor becomes anxious about the delays, and the doctor and the staff work through their lunch hour and will essentially spend the rest of the day playing catch-up.

What is the outcome of this scenario? You will have unhappy patients, and your patient satisfaction scores will plummet. Your online reputation will hover around 2-3 stars, which is slightly below average. Your staff will be stressed, which will ultimately lead to costly staff turnover. The doctor at the end of the day is exhausted and is courting burnout, which will negatively impact their health. In summary, a cloud of negativity will hover over the practice.

On the other hand, if the doctor regularly arrives 10 to 15 minutes before the first patient and sees every patient on time or within 15 minutes of their scheduled appointment, patients will be delighted with their care. They will tell others about the positive experience with your practice and that you were an on-time physician. This creates positive word of mouth for your practice and will generate many new patients. Consequently, staff morale will increase, and staff will be dedicated to enhancing the patient experience. It is important to understand that being on time is one aspect of your practice that you can reasonably control. The cost of being on time is negligible. The cost of being late can be exorbitant.

If we are honest, there’s less reason for doctors being late today to see patients than one or two decades ago. Why? Now, most primary care doctors and internists do not provide in-hospital care. Doctors turning over care for their hospitalized patients to hospitalists do not make morning and afternoon rounds, which are often accompanied by delays, thus making the doctor late to start seeing patients in the office. Most patients receive hospital care from hospitalists; therefore, doctors’ first destination in the morning should be the office.

How long are patients typically expected to wait before seeing a provider at your practice? If back-ups and extended wait times are common, consider investigating the cause. While many assume a difficult or complex patient slows the system down, it is in your practice’s best interest to investigate the matter further. For example, smoothing the scheduling template and providing clinicians with appropriate time blocks for each patient can help prevent frequent delays.

Keeping patients abreast of increased wait times is crucial. When they receive updates, they are more likely to feel in control and able to make the necessary changes to their schedule for the day ahead. While you may be stuck at the office all day, your patient should not have to be. Consider how your wait times impact the remainder of their day, including potential issues with transportation, childcare, medication/eating schedules, caregiver availability, etc. Many practices are offering telemedicine visits to give patients the convenience of seeing their provider from wherever they are.

Time is not your friend when it involves patients waiting to see you. You can lose patients by failing to value their time. However, developing a reputation as an on-time doctor is one of the best ways to establish a positive image for your practice, improve your patient satisfaction scores and enhance your online reputation.

2. COGs’ resistance to transitioning from paper charts to the EMR

Many middle-aged and older physicians didn’t grow up with digital technology, so adapting to EMRs can feel overwhelming and push doctors out of their comfort zones. Resistance often stems from steep learning curves, disrupted workflows and feeling like the system prioritizes data entry over patient care. During the early implementation of EMRs, doctors were spending more time looking at computer screens than at patients. For older doctors who spent their careers being eyeball-to-eyeball with the patient, data entry and looking at the computer screen are disorienting, and the transition from paper to electronic records was met with resistance from the COGs.

Other reasons include concerns about patient privacy, fear of making errors in a digital system and the perception that EMRs reduce face-to-face time with patients. Some physicians also feel that templates and drop-down menus don’t capture the full clinical picture, leading to frustration with documentation that feels impersonal or incomplete.

3. COGs’ failure to embrace telemedicine to provide care for patients rather than face-to-face encounters in the office

COGs maintained that face-to-face contact with the patient is necessary. They think they can discern subtle body language cues that can’t be seen in a virtual visit. In 2020, there was a paradigm shift as COVID-19 reduced office visits. At that time, live-stream video wasn’t new, but applying this concept to doctor visits changed how and where medical care could be delivered. COVID-19 forced COGs to embrace virtual care, both by necessity and expedience. This was accompanied by CMS’s decision to pay for virtual visits at the same rate as in-office visits. Now, there are many instances in which safe and efficient care can be delivered virtually. According to the AMA, the percentage of physicians using telehealth in 2024 remained nearly triple the rate before the onset of the 2020 COVID-19 pandemic.

COGs create barriers to progress in health care, preventing new solutions from being implemented. They squelch enthusiasm, and morale plummets. The answer is not to ignore the COGs but to tap into their wisdom, wealth of knowledge and years of experience. Perhaps the answer is to convert COGs from adversaries to allies.

Neil Baum, M.D., is a professor of clinical urology at Tulane University in New Orleans, Louisiana. Dr. Baum is the author of several books, including the best-selling book Marketing Your Medical Practice: Ethically, Effectively, and Economically, which has sold over 225,000 copies and has been translated into Spanish.