The Perception of Time

by William D. Esteb

One of the reasons why patients don't opt for continued maintenance care is because the care you provide takes too long to get. Many offices function under the misguided notion that patients are most concerned about the length of time they spend in the reception room. And while this aspect is important, it is like the blind men feeling different parts of the elephant and perceiving an elephant to be different than it really is. How patients perceive the time spent in your office changes during the course of their care.

First Appointment Time

Because of a lack of understanding about chiropractic or apprehensions about consulting a "bad back" doctor, many patients neglect their spine or wait until they are desperate before making their first phone call to your office. Many new patients wait until their fear of the stroke or paralysis they've heard chiropractic care could cause, is eclipsed by their discomfort. Finally, they have nothing to lose! As the insurance industry continues to crumble and the economy remains tight, you'll notice this problem will get worse. Consider the challenges of building rapport with an increasing number of patients who are incapacitated and in a hurry for relief so the financial burden of care can be lifted!

This, combined with the "one-visit-for-the-high-powered-prescription" belief they've been taught by their medical doctor, sets the stage for an uncomfortable first-visit scrimmage played out in many offices. The unfortunate results of these misunderstandings endanger compliance, retention, referrals, and the healing process.

For new patients, time is measured by how long it takes for pain relief. During this earliest stage of care go easy on the chiropractic science and philosophy. Communicate hope while explaining the reasonable expectations they should have, based on similar cases in your office. Ask patients for a length of time that they'd be willing to suspend judgment to allow chiropractic care to work. Will they give it five visits? Fifteen visits? Get a large enough commitment so there's a good chance they'll sense some progress, but small enough that you don't confirm their fear that "once you start you have to go for the rest of your life." Use those initial visits to educate the patient and enlarge their understanding and appreciation of a chiropractic lifestyle.

Routine Visit Time

As their symptomatic picture improves and their visits become more routine, a patient's perception of time changes again. Now comfortable with you, your staff, and your office procedures, coming to the office has become a pleasant diversion for the day. The urgency of the earlier visits has been replaced with a more relaxed mood. Many patients spend more time socializing during this period of their care and devour your reception room magazines. Some are even put out when they are called to an adjusting room in the middle of an article about some prominent celebrity's latest heartbreak. Time in your office is a refuge from the real world. Where else can you go and have your insurance pay for being loved, cared for, and really appreciated these days?

Of course if you're paying out of your own pocket for these visits, the perceptions are much different! Without effective patient education and streamlined office procedures, this is when many cash-paying patients jump ship. What started out as an effective form of natural pain relief has turned into an expensive and indulgent personal luxury. It's not the time they're wasting by being in your office in a relatively non-symptomatic state, it's a financial consideration. If patients send you signals that suggest they don't feel worthy of continued non-symptomatic care, it may be time to consider using the Haagen-Dazs Strategy.

In Faith Popcorn's book, The Popcorn Report, she describes a trend called "Small Indulgences." It's based on the notion that while most of us eat ice cream, more and more we're doing it as a reward for being good. We tell ourselves we've been good little boys or girls and we award ourselves with a more expensive premium brand. It's a small indulgence we've earned by being so good the other six days of the week.

When patients are feeling better and finances cloud the issue of rehabilitative or wellness care, it may be wise to adapt this approach to their continued chiropractic care. "I'm delighted you're feeling better Bob, and while we haven't been able to work on repatterning and reeducating the associated soft tissue involvement, we'll always be here. Stop by once a month or so and allow us to pamper you with some type of continued chiropractic care so you're less likely to suffer a relapse."

Maintenance Care Time

Now both time and money issues change again. Most offices with lots of cash-paying wellness patients have developed some type of wellness care fee arrangement in their office. If you want more of these types of patients, you must give some thought to how you're going to make non-symptomatic preventive care affordable. Your usual and customary adjusting fee is too expensive for someone who is feeling fine.

If getting wellness care adjustments exact too high a price in terms of the amount of time in your office, maintenance patients will be less inclined to return several times a month for a tune-up. Using the old yardstick of measuring reception room waiting time is no longer effective. Instead, measure Door Slam Time.

Door Slam Time is the elapsed time from when patients slam their car door to step into your office to the time they slam their car door to get on with their life. Forget about the Disney notion of "keeping the line moving" or "storing patients" in drab adjusting rooms with double digit plastic numbers glued on the doors! What patients are measuring is how much total time out of their increasingly busy life does it take to get adjusted? How much time are patients spending when they slam their car doors at 5:15 PM and march into your office? Put a watch to it. Is the cost of maintenance care in your office in terms of either time or money preventing patients from adopting a chiropractic lifestyle?

If you want to help manage a patient's perceptions of time and so you can better meet or exceed their expectations, it first takes a sensitivity to a patient's concept of time and the willingness to consistently communicate these issues. Here are two suggestions:

1. "Why did you wait 34 years before coming in?" Many of the underlying causes of spinal-related health problems in adults got started at birth or in childhood. "Ever fall off a bicycle or out of a tree?" Explain the adaptive qualities of the body and how their current symptomatology may be the result of some uncorrected event that occurred years ago. Help patients put their current health complaint into a longer-term perspective, rather than "something happened when I bent over last week."

2. "How long do you think it took for that bone spur to form?" Again, this helps reposition their expectations for recovery since their problem has obviously existed for longer than the last couple of months they've been getting headaches. An effective approach many dentists use is to compare the "age" of the patient's teeth and gums with the patient's chronological age. "Mrs. Smith, you have a pretty good spine for a 65 year-old, but it says here that you'll be 42 in September!" Buy time for your chiropractic care recommendations to work by explaining the consequences of their previous neglect. After all, it's their spinal problem, not yours.

While you can never be sure if these metaphors can help change a patient's perception of time, there are things you can do to help reduce office time as an issue affecting patient compliance throughout the stages of their care:

1. Measurement. Increase your awareness of time-related issues by having your staff time each patient's reception room waiting time and door slam time. In small print in the appointment book record the time each patient walks in the front door (W1), the time they "go to the back room" (W2), and the time they walk out the front door (W3). Then plot the elapsed Reception Room Waiting Time (W2-W1) and the total elapsed Door Slam Time (W3-W1) throughout the day. (You may need to instruct your staff to do these measurements secretly so you don't change your behavior and corrupt their findings.) Get reliable information to motivate you to implement some of the following suggestions and then remeasure the waiting times several months later.

2. Sell your talent not time. How long does it take to adjust your spouse? Why do you spend so much longer adjusting your patients? Make sure patients understand they're buying your talent, not your time! "Because I've been at this for 12 years, Mrs. Jones, and I have delivered hundreds of thousands of adjustments, it's going to take me about three and a half minutes to evaluate your condition and adjust you on your future visits. Now, I can stretch it out to 10 or 12 minutes, but if I do, I can't help as many people as I'd like to and you've probably got other things to do then to talk about the weather or who won the game last night. So with your permission, I'd prefer to give you 100% of my focused attention and experience so you can go enjoy your new health. Now, at any time you'd like to discuss any aspect of your health or treatment in our office, I'd be honored to invest the time to answer any questions." If you'll just explain why and remind them of the benefits of brief visits, most patients will be delighted. If not, you've arbitrarily capped the size of your office and the impact you can make in your community.

3. Compute the value of a minute. This is an eye-opener for doctors who squander valuable time because they're unaware of it's real cost (or worth). How much is your time worth when you're in high gear at 5:30 PM? Not that money should be the basis of every office decision, however, remind yourself of this figure the next time you're talking about the weather or sports scores with a patient. Take the total collections during the peak hour of your day and divide by sixty.

4. Reduce physical barriers. Now that you know how much a minute costs, how much does it cost you to take the 10 steps from adjusting room one to adjusting room three? How much does it cost to open and close a needless door? How much does that 8 second ride up and the 8 second ride down on your adjusting table take? Am I being too petty? You decide. But when I ask patients in focus groups how "full" they perceive the office to be at the time they get adjusted and I hear 90% or 95% full, the choice is to work at removing capacity blockages that are measured in seconds, hire the management headaches of an associate, work on growing the off-peak hours, or resign yourself to the fact that your office is as big as it's ever going to get.

In the old days when everyone had $100 deductibles and didn't stay for preventive care, it was easy to run the office because for the most part all the patients had similar perceptions of time. A fifteen minute wait in the reception room, a seven minute encounter with the doctor, some unsupervised therapy and presto, they were on their way. Today, as deductibles soar and fewer patients even have insurance, adapting your office procedures and wisely spending your patient's time resources are more essential than ever.

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My Report of Findings
Originally published in 1993
240 Pages
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