In many countries in the West, outpatient services are primarily provided through standalone doctors’ offices or group practices, or through outpatient services attached to tertiary care hospitals. Patients are seen by appointment in the outpatients’ clinic. The time of the appointment is based on whether a patient is new or has visited before, usually in the past one year, and is thus considered a follow up. New patients are assigned more time, usually 30 to 45 minutes; follow up patients are assigned 15 to 20 minutes. Most doctors’ offices divide the available clinic time into slots for new and follow up patients, and patients are scheduled into these slots according to availability. Doctors will usually accept some overbooking for urgent cases or walk-ins who come for acute exacerbation of a chronic problem.

If the doctor is delayed while coming to the clinic due to an unavoidable circumstance, patients are usually quite willing to wait if the reason for the delay is explained. Often the office staff will suggest rescheduling the appointment if the patient does not have an acute problem or cannot wait. The entire process is transparent, efficient, and pleasant.

This is not the case in India. Some doctors do follow these patterns but the “no appointment” system is more common. Patients simply form a queue in the waiting room hours before the doctor’s arrival, hoping that the doctor will see them according to the first-come first-served rule. It is pathetic to see patients, worry writ large on their faces, crammed into inadequate seating in the waiting room. Waiting times of three to four hours are not unusual and the patient is often so aware of the many others waiting to see the doctor that she/he does not grumble when dismissed with a brief, superficial exam and perfunctory advice.

Why do so many Indian doctors treat their patients so shabbily? Is it because doctors like to see a crammed waiting room that assures them of their importance and popularity? Does a crowded waiting room make a potential patient attribute greater healing powers to the doctor? Is it because the doctor cannot be bothered to train the staff to ask simple questions and sort the patients into appropriate time slots? Is it because they have an uncaring attitude — as long as the patients keep coming, why change? Is it because they distrust patients to respect the time of the appointment? Is it because tax authorities can audit a written record of appointments and increase the doctor’s tax liability?

Whatever the reasons, this practice has unfortunate consequences for the patients and their relatives. I have heard heart-rending stories of patients and their relatives waiting endlessly in the clinic. A relative told me that her mother refused to go to the psychiatrist’s office because the waiting room was crammed with disturbed patients jostling for attention. The emotionally fragile woman got even more upset by watching the other patients’ behaviour. Patients with a physical illness are also frustrated by the long wait and the uncertainty of not knowing how much time the doctor will give them to discuss their problem and suggest a plan of treatment.

What are the consequences for the patient’s health of this growing anxiety in the waiting room? This cavalier attitude to the patient’s physical and emotional well-being violates the most basic principles of medical ethics. Beneficence includes paying attention to the patient’s state of mind, her/his comfort, her/his well-being.

Comparisons with western models of health care are usually dismissed in India with the argument that ours is a poor country without the resources to provide high quality treatment to every one. But providing a pleasant waiting area with comfortable seating and a salubrious environment does not require much money or technology. Nor does instituting an appointment schedule based on severity of illness and familiarity with the patient’s medical condition. These simply require the doctor to think of the patient as another human being and work according to the “do unto others as you would have them do unto you” principle.

Patients also contribute to the chaos of the waiting room by their insistence on seeing the doctor immediately. Medical problems that have been going on for months suddenly become urgent because someone may have read a scary story in a newspaper and a panicky patient wants immediate reassurances from the doctor. For the well-off, being seen by the doctor immediately becomes a matter of status, of not having to wait in queue “because I am an important person”. For example, a senior doctor had got into the habit of dropping into his family physician’s office in the evening asking to be seen. This was convenient for him because he was on his way home from work and his physician’s office was on the way. For a long time, the physician was unable to tell the doctor that he was disrupting his office hours with the unscheduled visits.

Sometimes, even specialist consultants do not schedule appointments for more than a few days in advance, if at all. I commiserated with a friend, a surgeon, who returned after a three-week vacation, about working doubly hard to make up for the lost clinic time. He said that on the contrary, he had few patients because it took days to fill clinic slots. In the US, a well-run appointment system continues to schedule patients into future available slots. So a doctor returning from vacation has a full clinic schedule assuring a continuity of income.

In some instances, long-term follow up appointments even for chronic disease are uncommon because patients tend to hop from doctor to doctor or come in only if there is an acute worsening of their problem. Many come to the city seeking care and return to their hometowns. In the US, even family physicians have a scheduled patient list at least six months into the future. Most have a list of around 5,000 patients and often they will refuse to take on a new patient they cannot accommodate. Some even put their appointment schedule online so that patients can schedule themselves into an open slot.

Family physicians or internists in India seldom maintain a list of patients with chronic medical conditions who are seen regularly in the clinic. The result is that patients turn up in the doctor’s office with an exacerbation of their condition, an exacerbation that might have been avoided had they followed medical maintenance advice and been seen regularly.

At times, the doctor is blamed if her/ his examination and diagnostic tests do not disclose a grave problem during every visit to the clinic. Patients wonder what they are paying for if the doctor is only going to tell them that they are fine. Patients with this attitude thus miss out on valuable preventive care, which a doctor can provide with regularly scheduled follow up visits. Timely preventive care such as vaccination against pneumonia and influenza in winter for the elderly and those with chronic disease; inspections of fasting sugar, glycosylated haemoglobin, and the foot for the diabetic; checking the blood pressure, cholesterol, and exercise tolerance levels of patient with heart disease, etc., are almost unknown in India. The expensive “executive” check-ups in big private hospitals are surely not the same as a preventive strategy tailored by the family physician or internist familiar with the patient’s medical condition?

In a doctor’s office that is ethically run, the time required for a new patient and a follow up patient, along with the fee schedules, would be clearly displayed on the wall. Since the doctor charges for her/ his time and expertise, a new consultation lasting 30 to 45 minutes would cost two to three times the 15-minute follow-up visit, and an internist with an MBBS and MD degree would charge more than a family physician with only an MBBS. If a patient is late for the visit, she /he would have to wait to be seen after the others have had their turn. Patients who don’t turn up are usually not charged, but a repeat no-show patient can be told that in future a cancelled appointment without prior intimation will result in a charge.

An appointment system is a win-win situation. Both doctors and patients benefit from it. It enables a doctor to anticipate and manage her/ his workload. She/he need not have a large waiting room but can run an efficient set-up from a small office. She/he will have a medical record with detailed notes about the plan of action from previous visits. She/he can use her/his time effectively with reduced chances for errors. The list, with its differentiation of new and old patients, will also give the doctor an idea of her/his potential income. The benefits to the patient are evident. If the doctor works efficiently and with few errors, the patient gains. In addition, she/ he does not have to wait long, can wait in comfort without jostling crowds, and can have the confidence that when her/ his turn comes the doctor will see her/ him for the time allotted for the appointment.

None of the above is dependent on funding or technology. Then why is it not implemented? Is courtesy reserved only for the rich?