Do I have any doctors in the audience? I have a question for you.
Today I had a prostate biopsy. It was scheduled for 8 am, which meant I had to get up at 6 am in order to take the required antibiotic and then give myself an enema.
Next Friday I get the results. In a 7 am video call.
When I was up at City of Hope last year, I went into the day hospital every morning. This was not a time sensitive thing: it was mainly to give me a couple of hours of IV fluids. But they insisted on booking me to come in at 7 am every single day. (I eventually switched to a 9 am slot, but only after some truly superlative whining and moaning.)
A few years ago Marian had some minor surgery. She was required to present herself at 6 am.
And of course there are the famous 4 am blood draws every morning when you're in the hospital.
I think you can see where this is going. Why the insistence on scheduling procedures in the dead of morning? I know the official excuse: we have to do it in the morning because we have patient consults in the afternoon. But come on. You could do it the other way just as easily. Or you could do procedures early on some days and late on others, which would accommodate patients of all preferences.
Partly this is just the usual gripe of us night owls about how the world is run by early birds who think nothing of brightly saying, "Hey, let's get an early start on the day and have a 7 am staff meeting." (But who would be lynched if they suggested staying late for a 6 pm staff meeting.)
But mainly I just want to know the answer. Why are doctors like this? I realize you were all tortured during your residencies and the senior doctors just laughed if you complained, and believe me, I sympathize. But that's no reason to take it out on your patients for the rest of your lives.
So what's the deal?
Golf.
If you mean being able to pay for golf, I guess. If you want to make a living you have to see as many patients in the office as possible, late morning to whenever. If you're on hospital service for your practice, you have have to get any procedures done before the consults start piling up -- which will start right after the other docs do their (early) morning rounds.
This is the right answer. They want to come in and rip through their stacked appointments so they can make their early afternoon tee time. The patients come in early to get prepped and ready so the doctor’s time is optimized.
I can't say why, but can I whine about how as a med student and resident I was expected to be at the hospital at 6:15-6:30, examine every patient on my list (waking them up), collect all their lab results, formulate a plan and start writing the progress note prior to rounds, which started at 7am?
During my pediatric residency I figured out that every 5 minutes I could get there earlier meant I could go home 15 minutes sooner in the afternoon/evening, but I still couldn't do it. I was there until 6pm most days.
It's mostly a hospital phenomena. These days my first office visit is at 9am and it's a beautiful thing (I see patients until 6pm, but that's OK when you start at 9.)
Yes, you can whine!
But why did showing up 5 minutes earlier mean you could save 15 minutes on the other end?
Because the hospital was quiet in the morning, so I could write my note. The longer you stayed on the floor, the more likely you were the only MD around and all the nurses would come to YOU with their issues/questions/problems.
If I came in early and had my note basically written, I could present my patients in rounds, finish off the notes, and then just a few more things to do. I kept finding myself working on notes at 4pm, when my more organized colleagues had decamped. Things just got less efficient as the day wore on.
I remember back in medical school noticing that as a medical student I was driving a beater car and I parked in a remote lot (I had to take a shuttle bus in to the hospital) and I was working under residents who drove slightly nicer cars and parked in the lot next to the hospital.
We were all working under attending physicians who drove nice cars and parked in an underground garage (warm and dry in the winter, cool in the summer) under the hospital. It's an interesting culture.
"... interesting culture." I think you meant cartel.
Perhaps more of a guild.
Now it seems when I drive across town to see a specialist, I have to pay $12 -$15 to park in a lot while I am seen (even for 15-30 minutes). Many folks seem to profit on the medical profession.
The profit on medical is astounding. My mother fell on Thursday evening (right as I was getting on a flight back home to Orange County) and Olympic Ambulance in Lacey, WA transported her NOT to the closest hospital (7 minutes away) but to one twice as far away for what I can only assume is Medicare billing fraud as they charge by the mile and I'd bet my last dollar they are private equity owned.
Somehow I'm pretty sure this type of stuff is rife everywhere in the medical industry.
Olympic Medical is a scam, but it's a scam enabled by law. Two ambulances answer every 911 call here, a real ambulance and Olympic. At the scene, they decided if it is a real emergency or a less serious emergency. If it is a real emergency, the inexpensive publicly funded ambulance takes the patient to the hospital. If it isn't serious enough, Olympic takes them and gets to bill thousands. It's kind of ridiculous. We could probably raise taxes an extra ten cents and just have a real ambulance service and to hell with Olympic.
I like early because the traffic is much lighter. Also, it seems the facilities are less crowded - as opposed to mid-day.
Always been a mystery to me. Long ago somebody tried to explain it as having something to do with people's bodies responding better to surgery if it was done early in the day. But that might just as well mean they'd have more time to react and patch things up if something went wrong or unexpected.
@drfood4 seems on track to say it's mostly a hospital thing. Many outpatient centers in my experience seem to be much less compulsive about scheduling same-day surgical procedures at the crack of dawn or before (my big exception was for a surgeon who also practiced at a hospital). Though outpatient center staff usually has to be there by 7, if my sister's experience as anesthesia assistant is anything to go by.
We like to settle the issues on stable patients early, so to be ready for emergencies, surgeries, and unexpected events the rest of the day. If you want labs for morning rounds at 7, you have to be drawn at 5.
This is an easy one.
Doing all the routine stuff early leaves more time to tackle emergencies and screwups before the end of the day.
Patient consults aren't where the emergencies come from. They come from procedures.
This. I’m betting on this being the ultimate reason “why.” I don’t work in medicine, my field is transportation, and in my field, problems (delays, missed connections, etc) snowball all day long and we don’t really recover from any of them until a hard reset happens overnight when we shut down completely for about 4 hours and start the next day anew.
I imagine the same thing happens in medical settings… as the day goes on, more unpredictability in the day’s events occur (random walk-ins that have to be seen immediately, screwups from the morning that have to be mitigated, etc), and so they want all the predictable big stuff to happen as early in the day as possible. I’d bet that if people were scheduled for surgeries in the afternoon, there would be a lot more “oh we can’t get to your surgery/test/labs until later because of a crisis we have to do with right now” delays that would also annoy Kevin.
Not that it covers everything of course, but would you rather have a 12 hour fast prior to something at 7 or 8 am, or one at 3 or 4 pm?
Maybe having people fast overnight improves patient compliance.
My preference would be a 12 hour fast that ends at 11am. 4pm would be preferable to 7am. I prefer seeing 7am if I haven;t gone to bed yet.
Not a doctor, but have friends who are.
The big drivers of the weird hospital scheduling is that everything starts with the Operating Room, and works out from there. OR's are hugely expensive, and require a large staff to be in place; the goal is to maximize OR use while the OR is open. And in a normal hospital, an OR also has to handle emergencies, so unpredictability increases as the day goes on (there are many more emergencies in the afternoon and evening).
If a surgeon is going to be in the OR at 9:00 AM, he needs to see patients before that - probably 7:30-8:30. (Since he's the doctor in charge of the post-surgical patients, it wouldn't be good if he were unavailable because he's in the OR, and didn't have fairly up-to-date info on the patients.) Before he can see patients, their vital signs need to be up to date. So nurses start taking blood pressure, blood for blood tests, etc at 5:00 to meet the surgeons needs - but then they alse take the vital signs from non-surgical patients, because that's the time that they do vitals.
And for outpatients, it's way easier for people to fast overnight than through the day.
This type of scheduling reminds me of a similar issue: school schedules. Recently, it was found that adolescents don't exactly thrive at 7:20 am, and many schools have started changing their schedules to a later start time, mainly to raise test scores. In our district this led to a kerfuffle over start times at the other schools, bus schedules, athletic schedules, etc. Any time you change one thing in a schedule, a cascade of changes is needed. And every thing currently on a schedule has a constituency.
FWIW, our district managed the switch, and my last few years teaching high school I was almost always the first one to arrive -- at 8:00 am. So I was among the first to leave, since I was able to get my preparation done without interference or interruption and proceed quickly to grading papers. I had a colleague (dept head, no less) who came in at the last minute and left even earlier than I did. I found out he gave assigned readings in class to honors and AP students and did his correcting then. I soon followed suit. I never lost the habit of prepping in the morning though. Luckily I had my own coffee maker.
Because that’s how we’ve always done it…
While we're whining about medical scheduling, may I air a similar grievance about doctor's offices? I am a night person, but I hate spending hours in waiting rooms more than I hate getting up early, so I regularly ask for the earliest appointment of the day. At my primary care office (at the time) I discovered that they routinely scheduled multiple patients for the same doctor's first time slot, so it was a race to see who got there first. At my ENT, they didn't do that, but they scheduled the doctor's first seven appointments for 7:30, 7:35, 7:40, 7:45, 7:50, 7:55, and 8:00. (You could see it right there on the sign-in sheet.) So why are they always backed up with a crowded waiting room? They schedule it that way.
Occasionally -- well, more than occasionally -- I have taken the opportunity to point out to a doctor if I have had an unusually long wait. In my experience they usually make sympathetic noises, roll their eyes, and blame the front office scheduling staff, as if to say: agreed, but what can I do about it? Yeah, it's tough out there for these doctors, working for The Man.
Many primary care doctors are working for the man, that is, the insurance companies and other larger organizations that demand that patient visists be
15 minutes with the actual doctor.
Also, part of queueing theory says that the most expensive resource - the doctor - is never waiting. That means you are.
While this seems irrational to you, offices do this as a rational response to the unpredictability of how long a patient encounter will take and so that their staff are maximally utilized.
For the physician to be maximally efficient in clinic she should move from patient to patient with very little time in between. This is literally the only way to keep a "clinic-only" (primary care, some specialty services) practice generating revenue. During time the physician isn't seeing patients all the staffing costs and fixed infrastructure costs accrue and they aren't generating revenue.
For proceduralists and surgeons the clinic has to see a maximal number of patients in order to generate patient flow to the actual source of revenue (procedures / operations) so they can be a little less efficient, but not much.
With that view in mind, lost patient time (and the aggravation it causes) becomes a minor issue. From a patient point of view, sure, what's the harm of having the doctor sit around for 10 minutes not generating revenue since their 9am appointment finished 10 minutes early and the 930am appointment didn't show up early. From a doctor's point of view if you repeat that a few times per week (or per day) it's a catastrophe, even worse when patients cancel on short notice or no-show appointments entirely.
Another potential aspect to consider is hospital bed turnover. The OR will drive demand for surgical inpatient beds. Depending on the model your hospital is using using your specific outpatient procedures might fit best in the early morning.
When it comes to how an OR works there's lots of other things to consider other than the surgeon: availability of Anesthesia, Perfusion, Recovery Room beds, Nursing, cleaning staff (for OR rooms and Recovery & Inpatient beds), there may even be be internal supply chain considerations in getting the right equipment cleaned and delivered back to the OR in time.
The reason for this? Probably the medical equivalent of the old 3-6-3 rule for bankers. For doctors, it probably goes something like, " In by 3AM, see 6 patients, have a 3 martini breakfast (or maybe a 3 hour nap)".
I always try to schedule the earliest appointments, whether for routine visits or tests or procedures minor or major.
Why? There's less traffic to drive through early on, it's easier to find a space in any nearby packing lot or garage, and doctors aren't yet running behind on appointment or procedure start times.
Same here. Nothing bad (probably) has happened yet. Also, the entire staff will still be “fresh,” AND they’re in a better mood, at least on mornings after they got a decent nights rest. 12 hours later and most people are wasted.
Perhaps the job is somehow more suited to morning people. Maybe they dominate the staff. And maybe (work with me here) that’s why things are the way they are?
I use the same stategy for schedule service for my cars. At least the IC car. The EV car rarely needs service, and generally gets an automatic referral to the electric car specialist on the rare occasions it does.
I am a terrible patient for doctors. They're going to have to work with my schedule and if they can't manage that what did they spend all that time in med school for?
The thing that's been missed ...almost any procedure or blood test requires that you've not eaten for 8-12 hours. Someone else can explain why eating messes with blood work, but food in the stomach is a nightmare vomit under anaesthesia.
They seem to figure - rightly I suppose - that its easier to go to sleep, delay the morning meal a few hours than it is to skip breakfast and lunch.
And ... probably a dated assumption that you have a factory shift to get to and its easier/more efficient to to not have their work day overlap with your work day.
As a night-owl physician I would absolutely love if we could shift hospital operations forward by a few hours.
Anyhow, some comments:
1) the "4 am labs" thing is getting better -- at least for medical services (still a problem for surgeons, related to below). The primary reason labs were drawn so early was so that by the time a physician, or in teaching hospitals a team of them, came by each patient's room to formulate the day's plans ("rounds") the lab results were available. It's inefficient for patients and physicians to dedicate time to developing a patient's daily plan before the test results that will influence that plan are available (whether physicians are judiciously ordering only tests that are actionable is a whole different convo).
As hospital lab equipment has gotten better and computerized resulting has sped up result transmission many places and teams have moved away from 4am lab draws and moved them forward to something like 6am or 7am depending on the tests. Similar changes have happened for x-rays and other studies.
2) As mentioned by some people above a lot of this flows from when ORs begin their day. There are two primary reasons for operating rooms starting early in the morning and the main one hasn't been mentioned yet: people don't like being hungry. Various geographic anesthesiologist associations (in the US it's the ASA) all agree agree that people undergoing scheduled anesthesia should be fasted from solids for 6 hours pre-op. There's lots arguing about clears and opaque fluids and time frames for those, but usually it's 4 hours for opaque fluids (eg milk) and 2 (or 1) hours for clear fluids.
Since most people are naturally fasted in the morning, having them skip breakfast is a minor inconvenience. There's solid data that the later your starting time for a semi-elective surgery, the higher the odds that patients don't adhere to the guidelines and their surgery gets cancelled (because of fasting rules it's hard to fill vacancies in an OR schedule on short notice).
This is one of the primary reasons most people admitted to the hospital will have surgery later in the day (they're captive and we can enforce the annoying fasting rules more effectively upon them) while outpatients take up the morning slots. It's also why hospitalized patients are sometimes kept fasted for excessive amounts of time (so that they can be moved to fill new vacancies on short notice).
Because surgeons are beholden to the OR schedule, for their patients in clinic or in the hospital they need to be fitted in around the surgeon's OR time. This is why surgical teams (historically) round extremely early in the morning and see clinic in the afternoon once they've wrapped up their cases in the OR.
3) There are also a variety of things that are illegible to patients that have to do with staff utilization and resourcing. For instance in the pediatric sedation clinic that I run we have three dedicated MRI slots per week into which we can schedule children who need sedated scans. MRI time is valuable and not particularly fungible (some scans can only be done on certain days due to staff availability) so on those my pediatric sedation staff are unavailable until the afternoon. Hospital staff are often utilized in different ways and their other obligations may not be particularly time-flexible which makes something that can clearly be done at any time need to be done at a specific time.
4) Someone already covered the "as the day wears on more unforeseen things happen" effect above, which is largely just a result of more people being awake and moving through the world and the hospital system; so putting as much of the controllable stuff in the morning leaves the rest of the day to fix the new things.
5) Hospitals and clinics are also beholden to the chosen schedules of the rest of society. Eg. having a clinic whose operating hours poorly overlap with local pharmacies is a good way to annoy your patients when they have to wait until the next day to fill a prescription because you live in a suburb without 24h pharmacies. Urgent cares don't really deal with this since patient expectations are wildly different.
Strong institutions get to set their own schedules, and people like 9 to 5 jobs that lets them have weekends off. Look at banks and the government.
As an early bird I'm thrilled abut this, but it isn't so consistent for me. I have lithotripsy for a kidney stone scheduled for 1PM in a few weeks. What I want to complain about is how convoluted and overworked the healthcare industry is and why it's taking over a month to deal with a painful kidney stone? Not sure showing up in emergency room would have helped time wise.
"Emergency room", ha. My spouse went to the ER with what turned out require emergency gall bladder removal. It was around 6am when we got there. After 3 hours, he was moved "backstage" out of the waiting room and into cublcles with beds. Another 4 hours and a doctor looked at him. Hours later, he was move by ambulance to another facility and late that night, the surgery took place.
The ER isn't like on the teevie. You. Will. Wait And it doesn't matter how much you moan and writhe in your chair.
I can't believe that the biggest answers took the longest to get to, but I see they've been mentioned above. (My wife was a long-time cath lab tech...)
1 - Shit happens. Any procedure that takes longer than it should delays the next procedure. Two in a row create more of a delay... And there's that law that states that everything takes longer than you think it will, even if you take that into account.
2 - I'd much rather skip breakfast than skip breakfast, lunch, and maybe dinner. And as much as I hate waking up at 0 dark thirty, most of the things I'm going in for entail a nice nap, so it's my wife who bears the brunt. And (see above) as a long-time cath lab tech who was forever on call, she's used to it. And when it's her turn to go in for a procedure, I have no problem napping. In fact, I'm napping right now!
Hofstadter's law states that a project always takes longer than expected, even when the law is taken into account. By far the truest maxim about medical care.
Just popping in to ignorantly gripe about an important, yet scheduled surgery where I had to be there by 5 am, long before sunrise. Fasting, of coure; no liquids, of course. Surgery scheduled for 8am. Okay.
And it took place around 6! PM.
I will write a witty comment later, but I’m too tired right now. Had to get up at 4:30 am and haul my wife into the hospital for her ankle surgery.
As a physician who has become a frequently carved-upon patient for the last 20 years, I am happy to get things started early because I know if a procedure is scheduled later in the day it will almost certainly be delayed because of the interruptions and unpredictable events that occur on a regular basis for physicians. And having endured two surgeries that lasted 10-11 hours each, I know that someone behind me probably had their surgeries or appointments cancelled because my abdominal surgery turned out to be more complex than originally planned. Shit happens, and it happens often.
I don't remember what time my knee replacement surgery was (Queens Presbyterian about 8 years ago) but I woke up around 7 pm after not eating since the night before. I was starving. I asked about food and they said the kitchen was closed. (WTF?) Someone went to find some food anyway and came back with two slices of the cheapest kind of bread with a few micro slices of turkey lunch meat in between. That was it. I was grateful for anything, if kind of surprised by the jail food level of it.
I was there for two nights. I'm not that picky and will eat about anything, but the food was consistently the cheapest possible with no thought about anything including nutrition. After decades of all the increased awareness of food quality and nutrition, Michelle Obama and Jamie Oliver's school food focus and all the rest, the food was better when I was in a hospital in San Francisco for surgery in 1978.
Thanks everyone for the interesting and informed responses to this non-political question.