The importance of first impressions
Forming my own first impressions of the practice in Chico over the last few days has made me reflect on what a patient might feel when entering their surgery or making an appointment. The first contact will usually be with reception staff either over the phone or in person. Although not part of the consultation itself, this interaction is part of a patient’s journey and could either enhance or impact negatively on their experience.
There has been heavy criticism of this element of patient care in the UK press recently as, through the use of surveys, some members of the public have voiced their dissatisfaction with the way things currently work. As a doctor myself, I am aware of problems that arise through certain practice systems but was particularly struck by the high number of people unhappy at their interaction with reception staff when reading the BBC article ‘Receptionists ‘put people off seeing doctor’’ (http://www.bbc.com/news/health-37605573) The piece highlights one of the main issues as patients feeling uncomfortable in having to disclose symptoms to reception staff with 39.5% of participants relating to this in the Journal of Public Health survey. In terms of my work this year, the article made me consider how this phenomenon might impact on patients presenting with emotional distress and mental health needs and how, in other countries, this might be managed.
With that in mind, I distributed the BBC article to a small group of receptionists at the Chico practice and met with them the following day to hear their thoughts on their roles as ‘front of house’ and how they felt things in this practice compared to the UK in general.
They began by explaining that many clinics operate differently in the States but as both had worked at this practice for a few years they could quite clearly define their role here and discuss the pros and cons as they saw them.
“There are two of us to every provider; a front office and back office”
In contrast to the UK, each practitioner in the surgery (a doctor, physician’s assistant or nurse practitioner) has their own team and ‘pod’. The structure of the pod includes a reception desk where one member of the team will be stationed at all times and three clinic rooms. One of these rooms is the permanent office of the practitioner and it can be laid out as they choose as patients will never be seen in this room. The other two rooms are for consultation. Without clutter but fully equipped they are laid out with the conversation in mind; there are no desks, only chairs facing each other and a screen on a side table to look up lab results or old notes.
When a patient arrives they will check in with the ‘front office’ assistant and then be ‘roomed’ by the ‘back office’ assistant. This process means patients are rarely left for long periods in the waiting room even when a provider is running late. Vital signs are checked as standard and the patient is asked about their symptoms so that any relevant samples can be taken before the doctor comes in.
The subject of disclosure of symptoms came up very quickly in our discussion as both receptionists commented they had been surprised by the reported reluctance of UK patients to talk about their reason for seeing the doctor with other staff.
‘When I ask people, I want to know a quick response so that I can prepare, but people will often say more than I need to know, they will give a lot of detail. I keep saying ‘you need to tell the doctor all of this’. In that way, it is the opposite’.
Patients are asked for their complaint when booking appointments over the phone and also when being ‘roomed’ before seeing the doctor. We explored the potential benefits of this system in providing a further familiar face for patients during their visit and a further space for them to voice their concerns. I wanted to establish, however, whether this was only really effective because of the small and permanent team approach, i.e. seeing the same assistant and doctor each time. One of the receptionists was able to offer insight into this through comparing her work in this clinic with a previous job in a surgery that had operated in a more similar way to the typical UK practice.
‘I’ve worked in both systems and I feel this way is better. You get to know people well and it also helps in triaging. Patients like it when you know their name, they like the personal approach.’
The ‘pod system’ also promotes patient privacy and individuality, meaning they perhaps feel more at ease in discussing their issues in public space.
One of the most obvious differences I have noted during my first few days here has been the nature of the ‘presenting complaint’ in consultations, in that the majority of patients I have seen so far are there for a routine review rather than an acute problem. Whilst in the UK, routine reviews do make up a bulk of the work, I don’t feel regular ‘check-ups’ are scheduled at quite the same frequency or number. A patient at the Chico practice can expect to be seen every 3-6 months as routine, especially if they are known to have any chronic conditions or are on any medications. A patient of my age with no known health problems would still be seen annually. Whilst there are obvious benefits to this, the ability to pick up on any issues early being one, I wonder what effect it has on patient expectation and indeed on the expectations of the healthcare providers. We explored this idea further as one of the receptionist commented:
‘ Some people come in monthly just to check in’
It is not the frequency of a certain patient’s attendances that would be so alien to UK GPs; we certainly have patients who attend often, but perhaps the attitude towards a patient ‘checking in monthly’ without obvious reason or cause. This small example begins to open the huge subject of how a private insurance-led service differs to National health, how in a more pressurised environment we have to perhaps think differently and manage our patients more on their immediate needs. This was reflected again as I asked the receptionists if they felt patients ever came in too often? This wasn’t a situation that was familiar to them as again they reiterated that patients will always have follow up arranged so seeing them frequently is the norm.
At this point we moved back to the BBC article as they wanted to comment on how unusual they found the idea that receptionists in the UK might not want patients to come in.
‘In this article it seems as though patients are being put off seeing the doctor, with us it’s the opposite. We want them to come in.’
I was keen to explore this further and quickly established that this desire came from the wish to fulfil the strict follow up plans put in place by their provider, the desire to do a good job but also to avoid hassle further down the line of patients requesting medications that had run out or calling to chase referrals. Patients coming in regularly in a planned way makes the administration side easier.
The nature of this private system, as above, is a huge topic and an area I am only beginning to come to grips with. Therefore when considering any question it is important to think about the part the system itself plays in the answer. In the context of this example, a patient coming in for an appointment means a very different thing in terms of income than in the UK.
Whilst patients are encouraged to attend their appointments, a problem the staff do face is patients ‘not grasping that it is not a walk-in clinic’. As patients are guaranteed to see their own doctor here, they do of course build a relationship which can, the receptionists explained, lead to very high expectations.
‘It is dependent on the provider, but some will make every effort to see established patients that same day and there are allotted ‘sick slots’’
The staff are trained to advise patients if they need urgent care that moment they should attend the immediate care facilities in town but most are reluctant to do so as wait times can be long and it would mean seeing a practitioner who they are not known to.
I wanted to know what it was like for these receptionists to be involved in triaging patients as this is often the area that comes under scrutiny in the UK. Some people back home understandably feel that they do not want someone without medical experience making decisions about their care and indeed Dr Maureen Baker of the Royal College of GPs comments in the featured article that ‘they are not in a position to do so’. However, triage in some way will always be part of the role of a person who has first contact with a patient and I was interested to know how that worked here.
‘When you work in this field, triage is a big part of the job’
Both receptionists acknowledged that triaging was an important part of their job and usually felt confident in doing so. When out of their depth they were happy to pass on the query to their provider who would suggest a plan of action. The practical structure of the ‘pod system’ allows for this easily. Opposed to may practices in the UK where reception staff may often be on a different floor to doctors, the reception staff here see the provider after every consultation and so can have regular communication. The ‘back office’ role also extends to performing treatments or investigations after consultations such as ECGs, exercise oximetry or trial of nebulisers. This can make for an efficient use of time for the patient.
The receptionists felt much of their comfort with triaging came from their training and they queried whether this might be appropriate for UK reception staff. Both are certified medical assistants and the yearlong training for this position includes competencies in phlebotomy and medical terminology as well as the use of communication skill scenarios. I agreed that I thought their training very likely contributed to a better patient experience and advised them that the NHS were looking into better training for receptionists in the UK.
It is fair to say that this practice runs very efficiently, the atmosphere is generally calm and unless there is a particular discord between a patient and staff member, which can happen, altercations are few. Some of the benefits for both patients and staff here seem almost luxurious at times and when thinking that, it is vital to remember that I am seeing a particular practice within a very large country. The surgery here offers attentive care to its patients but sadly is not available to everyone. They are limited by space but also in the types of insurance they can accept. Whilst I am impressed by what I see, I have to remember that this is not everyone’s experience, far from it in some cases.
Thank you to the team who took the time to speak to me and to the BBC for providing quite a talking point!