Of patients and doctors; the social cost

After stating in my previous blog the problem, as good engineers do and I'm one, let's make a gross analysis of the impact of this practice. To start with, except for the San Juan Metropolitan area, public transportation is practically non existent in Puerto Rico. That means that every patient has to take his or her own vehicle. The first obvious consequence is on city traffic and congestion. If you look at the times patients have to go to the doctor’s office to write their name down in the roster, it’s the rush hour in the morning or in the afternoon. That's right doctors, you are helping make traffic worse at rush hour. And in the country with the highest concentration of motor vehicles per capita in the world ...

But the problem becomes even more interesting when we include parking space in the picture. Of course, early birds will get the best spots. The rest will have to drive around for 10 to 15 minutes, at best, looking for someone leaving a parking place on the street or parking lot. Yes, as expected, parking lots are packed all the time, and the vehicular space rotation is very low. Cars will stay parked for several hours and so, your best option is to continue driving until someone leaves an empty space. The 10 to 15 minutes I gave above is my empirical estimate. Now, there are three clear outcomes up to now: unnecessary and increased gas consumption and air pollution, these two caused by driving around searching for a parking place, and parking congestion, not to mention the frustration, anger and stress.

Now, allow me to use my very rusty knowledge about classic telephone traffic (before VoIP and other digital systems) and extrapolate it to parking congestion analysis. I’ll avoid being mathematically formal. When I studied telephone traffic a long time ago, the traffic unit was the Erlang. One Erlang is one call using a telephone line for one minute. Let’s now define a parking congestion unit as one parking spot busy for one hour. For brevity, let's give this unit a name: a "Car-lang". I just came up with this name so that it sounds similar to the telephone traffic unit. Probably, vehicular traffic engineers have an appropriate name for it but I don't know it. With this definition we can say that each patient generates 3, 4 or 5 Carlangs since his or her car will occupy a parking space for 3 to 5 hours, the waiting time in the doctor’s office. Let’s be optimistic and suppose that it’s just 3 hours. Then, each patient generates 3 Carlangs. (Doctors, I’m making you look not too ugly). Suppose a doctor sees 40 patients per day (believe me I know some doctors see more than 40 patients per day). Each doctor is responsible for 120 Carlangs, and I'm being easy on the waiting time and not too bad on the number of patients per day.

Now let’s imagine the doctors gave appointments by date and time (imagination is our only hope for the time being) and let’s use a pessimistic estimate of the waiting time of 1 hour. In this case the parking congestion generated by each patient is 1 Carlang. Assuming again that a doctor sees 40 patients per day each doctor giving real appointments would generate 40 Carlangs. The math is simple. By giving an appointment by date and time the parking congestion is reduced to a third, at least! That means lower parking cost for the patients, significantly reduced congestion and higher vehicular rotation in the parking spots. Guess what else: higher probability of finding a spot, thus reducing driving time searching for a place to park. And since patients need to go at the time of the appointment instead of the rush hour, there is a better distribution of traffic over time of the day in the cities. And the parking issue does not stop here. Even the parking businesses would make more money. Why, you ask? The first hour in a parking lot is most of the time the most expensive. The customers that generate the highest gains are those that leave their car in the lot for less than one hour.

Now let´s analyze the monetary aspect due to time absent from work. If the waiting time is 3 hours the patient for sure has to ask for at least half a day of leave. And this is optimistic. In many cases patients miss a full day of work. Again, I'll go easy on doctors. Assume that each patient is absent half a day, 4 hours. Assuming the patients earn $7 per hour, the cost for the patient's employer or to the patient is $28. If instead of missing 4 hours the patient had to be absent 2 hours, the cost would halve! As I said, this is an optimistic estimate because many patients earn more than $7 per hour and many loose a full day of work. Doctors, in addition to your cost, which is around $30 for non-specialist, which you charge to the insurance company, you are generating a high cost to the system. Your real cost is at best $58 per patient. Of course for a specialist this cost is significantly higher.

The impact does not stop there. There is also a health impact. A reunion of sick people in a waiting room is propitious to share bacterias and virus, in other words, spread infections. Add the stress of a long waiting time and you have low body defenses. The perfect soup to get sicker. And what about diabetic or hypoglycemic patients? They better take some food along or ...

And there is a cost for the doctors too. First they have to pay additional hours to their secretaries since they arrive two to three hours before the doctor does. Second, the waiting room needs to be larger as the number of people in the room is larger. If instead of 15 or 20 people in the waiting room there were only four to six the size of the waiting room would be significantly reduced. Plus the air condition system could be smaller and reduce the electricity bill. And water? Yes, water too. The shortest a person is in a place, the waiting room in this case, the lowest the probability that person is going to use the bathroom.

Surely there must be additional costs due to this hideous practice but I guess I got my message across, so I'll stop here.

Of patients and doctors; in Puerto Rico you’ve got to be patient to go to the doctor

This is probably the first of a small series of blogs about this issue, so bear with me and my concern...

When I had just arrived to Puerto Rico it caught my attention that many, if not most of the people passing near my table when I was eating would say “buen provecho” or as Shakespeare would’ve put it better “bon appétit” (oh, pardon my French). And, what does it have to do with doctors and patients? Not much, but it may explain the courtesy sentences used by Puerto Ricans in different occasions. One of them is “que salgan pronto”, which translated to English means “I hope you get out soon”. No, it’s not the sentence used when visiting a prisoner; it would certainly make sense there; but no, it’s the one sentence every person going out of a doctor’s office would say to all remaining there. Sadly, it makes sense if you are a patient because you have probably been waiting to see the doctor for several hours, so the best wish anyone can hope for you is to get out soon!

I’d be surprised if no one had written about this before, especially foreigners like me, because the doctors’ appointment system in Puerto Rico is different from at least the other two countries I’ve known: Colombia and USA. At least in these two countries doctors give appointments by date and time so patients get to the doctors office a few minutes before the time of the appointment. Well, since time is money, Americans would plan the day ahead and may get there calmly; but some Colombians may rush into the traffic to arrive there right on time or a couple of minutes late; but they will make it. In the waiting room the waiting time may range from a few minutes to an hour or so, tops. Occasionally the doctor will reschedule the appointment due to an emergency; but all this is only natural, and understandable; or should I say bearable.

Now, let’s move to the enchanted island. If you call a doctor’s office and the secretary gives you an appointment with date and time, play the lotto that day. You’ll hit rich. The odds of such thing are extremely low. So far I haven’t had such wonderful experience. The second best, but don’t play the lotto since this is more likely to occur, is to get an appointment for a given date and you get to choose morning or afternoon.

If your appointment is in the morning you are told to arrive from 7:00 till 10:30, or something like that, and write your name down on a roster. Now, you may think that if you get at 7:00 you’ll get turn 1 or 2 and the doctor will see you at 7:00 and you’ll leave by 7:30. Well… I’m sorry to disappoint you but the doctor will get to the office around 9:30 or 10:00, so if you got turn number 1 the doctor will see you by 10:00. Yes, you will have to wait at least three hours. If you got other turn, you’ll have to wait 3, 4, 5 hours, maybe more. But also, you will probably see an admonition on the door, counter or wall that reads something like “If you are called by the doctor and you are not in the waiting room you will loose your turn”. Therefore, if you want to sneak out of the office, do it strategically or else…

Now, if you want to get turn number 1, don’t get to the office at the time they open because, I assure you, there will be 5 to 10 people ahead of you, maybe more. Your effective waiting time may be longer than 4 hours: half an hour to an hour outside the doctor’s office and three hours in the waiting room till the doctor arrives.

Now, let’s say you are not an early bird and choose the afternoon. You are told to arrive from 1:00 to 2:30. Now, let’s say you want to play it smart and go in the morning to write your name down on the roster… Think again. The secretary will tell you that you have to wait until 1:00. You may make number 1 in the afternoon but you will have waited several hours anyway. Now, you may say that since the doctor is in the office since 10:00 you will be called at 1:00… Wrong again. The doctor will have a backlog from morning appointments and will start to see afternoon patients by 3:00. Again your waiting time is longer than three hours.

If you think what I have narrated so far is bad, hold your horses. Worse things exist. There are doctors that give appointments by date, period. You have to go in the morning, or at the time they open the office, write your name down and see what turn you made. Yet, there are doctors that don’t give appointments! You just show up in their office at the time they open and … you know the rest of the story.

If you think this sounds terrible, let me reaffirm you on that; it’s hideous. I wonder whether someone, an illustrious university professor or a consultant has studied the cost of this practice. I’d love to see such study, but show it to me before doctors know about it. Surely doctors would try to make it disappear.

Open market economy

"I don’t doubt for a moment that you are good, hard-working people who have done what you did to help your families. Unfortunately for you, you committed a violation of federal law."
MARK W. BENNETT, a federal judge, to illegal immigrants sentenced to prison terms in Iowa.

This is open market economy, isn't it? "Good, hard-working people" sent to prison!

This sentence appeared as the quotation of the day in the New York Times of May 24, 2008.

Politically incorrect or un-politically correct

How would a politically correct person call a black person from Senegal, Kenya, South Africa or any other country in the African continent, “African Senegalese”, African Kenyan”, “African South African” or, in general, “African African”?
This question has been in my mind for quite some time, probably since I was talking to a very good friend of mine, American of course, a couple of years ago. At some point in our conversation in a small café in Palo Alto, he referred to my ethnic group as “Latino” and I believe he felt embarrassed since he apologized to me. He then asked me if I preferred to be called "Hispanic". I answered that anyway he or anybody called me was fine. I really didn't care then, and I don't care now.

I started to realize then how Americans, in an attempt to look egalitarian have resorted to adapt names to the different ethnic groups so that in public they do not hurt anybody. I know my friend didn’t mean any harm and was not trying to be politically correct with me. I' sure he's not racist. But looking at the hard facts, racism still exists; and it exists regardless of the way blacks, yellows or any other ethnic group is called.

In my view, these names are just euphemisms to be politically correct. But frankly I prefer to be un-politically correct or politically incorrect, but treat everybody with respect. Blacks, yellows, reds, browns or any person born in the USA is as American as any white American. Blacks, whites, reds browns or any person born in China is as Chinese as a yellow Chinese. And the same goes to any group, religious, ethnic, etc. born in any other country. In the end, respect for other people it’s not in the way we called them but in the way we treat them.