BMC Health Services Research BioMed Central

Research article Open Access

Willing to wait?: The influence of patient wait time on satisfaction
with primary care
Roger T Anderson*1, Fabian T Camacho1 and Rajesh Balkrishnan2

Address: 1Department of Public Health Sciences, Wake Forest University Health Sciences, Medical Center Boulevard, Winston-Salem, NC, 27157
USA and 2College of Pharmacy and School of Public Health, The Ohio State University, Columbus, OH, 43210 USA
Email: Roger T Anderson* - rtanders@wfubmc.edu; Fabian T Camacho - fcamacho@wfubmc.edu; Rajesh Balkrishnan - balkrishnan.1@osu.edu
* Corresponding author

Published: 28 February 2007 Received: 6 September 2006

Accepted: 28 February 2007
BMC Health Services Research 2007, 7:31 doi:10.1186/1472-6963-7-31
This article is available from: http://www.biomedcentral.com/1472-6963/7/31
© 2007 Anderson et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: This study examined the relationship between patient waiting time and willingness
to return for care and patient satisfaction ratings with primary care physicians.
Methods: Cross-sectional survey data on a convenience sample of 5,030 patients who rated their
physicians on a web-based survey developed to collect detailed information on patient experiences
with health care. The survey included self-reported information on wait times, time spent with
doctor, and patient satisfaction.
Results: Longer waiting times were associated with lower patient satisfaction (p < 0.05), however,
time spent with the physician was the strongest predictor of patient satisfaction. The decrement in
satisfaction associated with long waiting times is substantially reduced with increased time spent
with the physician (5 minutes or more). Importantly, the combination of long waiting time to see
the doctor and having a short doctor visit is associated with very low overall patient satisfaction.
Conclusion: The time spent with the physician is a stronger predictor of patient satisfaction than
is the time spent in the waiting room. These results suggest that shortening patient waiting times
at the expense of time spent with the patient to improve patient satisfaction scores would be
counter-productive.

Background with primary care [6-10]. However, waiting time is but

The literature on patient satisfaction with primary care one aspect of health care that patients' value, and its cen-
indicates that key attributes of health care valued by trality to patients' assessment of their primary care visit
patients are patient-centered, including time spent with compared to other aspects of the health care experience is
the physician, willingness of the physician to listen to the uncertain. Time spent waiting is a resource investment by
patient, and expectations for treatment [1-4]. An anecdo- the patient for the desired goal of being seen by the physi-
tal source of dissatisfaction with health care reported by cian and therefore may be moderated by the outcome. In
patients is having to wait a long period of time in the a typical practice, patient waiting time and time spent
office (Anderson, Barbara, Feldman, in press [5]), and sev- with the physician are to some degree counter-controlled.
eral studies have documented the negative association Since the amount of daily clinic time per physician is a
between increased waiting time and patient satisfaction fixed asset, portioned out by patient demand or volume,

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the more time on average a specific physician spends with ing information were collected in this study (e.g., name,
an individual patient, the longer will patients have to wait address, of medical number) and expedited IRB approval
to see that physician. This leads to the testable hypothesis was obtained to conduct analyses of de-identified data.
that the effect of waiting time on patient satisfaction must
be considered in the context of time spent with the patient Statistical analysis
to be meaningful. If our hypothesis is correct, physicians Multivariate regression and logistic regression models pre-
who fall behind in their patient schedules and end up hav- dicting the three satisfaction ratings were estimated using
ing both long patient wait times and shorter visits with the the Generalized Estimating Equations (GEE) method
patient will achieve significantly lower patient satisfaction implemented in the SAS System v9 (GenMod proce-
scores than physicians who have both long patient wait dure)[11] In order to adjust for clustering, an exchangea-
time and long patient visit times. ble working correlation matrix was specified where the
observations were clustered according to clinic. The
Methods default robust standard errors in proc GenMod were used.
This study was conducted from the responses of a national All models were adjusted for patient reported age, gender,
cross-sectional, online survey of patient's satisfaction reason for visit, and first visit. Age was modeled as a con-
(DrScore.com) that collected anonymous patient ratings tinuous variable based on its observed close approxima-
of U.S. primary care physicians for patient advocacy tion to a linear response to an overall rating of patient
research and to produce patient satisfaction report cards satisfaction with physician seen. Assessments of covariates
for physicians. The survey focused on the most recent out- such as type of health care organization, severity of illness,
patient visit and used a list of U.S. physicians that permit- and race were not collected in the study survey.
ted patients to look up their doctors and access the survey.
Participation in the survey was advertised to patients on a Results
public radio show (The Peoples Pharmacy), through Table 1 displays the descriptive characteristics of the study
patient advocacy groups, and through on line search sample. On a scale of 0–100 (highest), the mean satisfac-
engines. The survey asked patients to both rate their phy- tion with doctor score with the overall practice were each
sician on several dimensions of health care experiences, as approximately 74. The majority (roughly 60%) were ages
well as provide specific comments about aspects of care 25 to 44, 74 percent were female. Of the visits rated,
that were most excellent or most in need of improvement. 13.5% were a first visit, 28.4% were for routine evaluation
Questions were rated on a scale of 0 ('not al all satisfied') or management. Approximately 25% of respondents
to 10 ('extremely satisfied'). Two patient satisfaction reported that they waited more than 30 minutes to be
scores were considered as outcomes in this study: ratings seen; and 11% reported spending less than 5 minutes with
of the provider (Physician Care, 9 items) on the thorough- the doctor, 27% spent between 5 and 10 minutes, while
ness of care, physician communication and follow-up, lis- 62% reported spending more than 10 minutes with their
tening, demeanor, discussion of test results, answering doctor.
questions, treatment success, and including the patient in
decision processes; a second rating was of the practice In univariate analyses, time spent with the physician was
(Office Practice, 5 items) and included items on continu- found to be (Spearman rank) correlated with overall
ity of care, convenience of facility, referrals, hours, and patient satisfaction rating at r = .51 compared to r = .31 for
ability to meet health care needs of the patient. For both waiting time in the office. In Table 2 are the results from
scales, the summed scores were scaled from 0 to 100 by the multivariable regression analysis for the Doctor rating
taking the item mean and multiplying it by 100, repre- scale considering all model predictors. Overall, 43% of
senting compete satisfaction on all characteristics meas- the variance in patient satisfaction was explained by the
ured. final set of predictors (p < .05) included: age, first visit,
reason for being seen (routine versus other reasons), wait-
Patient waiting time at the last office visit was measured ing time, and visit time. A similar set of predictors and
by asking the patient to recall the amount of time he/she results was obtained for the Practice scale score. Each of
waited before being seen by the physician for a scheduled the latter variables were independently associated with
appointment. Response categories were: 1–5 minutes patient satisfaction (adjusting for all other factors). Those
waiting time in office, 6–15 minutes, 16–30 minutes, 31– with a first visit with physician were each associated with
60 minutes, and more than 1 hour. The shorter time inter- lower patient satisfaction than shorter waiting times and
vals at the start were chosen because pilot data showed longer visit times. Of all variables considered, time spent
that approximately 70% of the patients waited below 15 with the physician was the most powerful predictor of
minutes. Perceived time spent with the physician was patient satisfaction, explaining 28% of the variance,
measured as < 5 minutes, 6–10 minutes, and > 10 min- almost 3 times larger than waiting times (data not
utes, also assessed by patient recall. No personal identify- shown).

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Table 1: Baseline Characteristics of the Study Population satisfaction score of 92.7. The same general pattern of
results is true as well for the Practice mean (Figure 2).
Parameter Case Group (N = 5003) Mean (SD)
↓ [Range]
Discussion
Doctor Care Score 73.62 (35.89) [0–100] This study is among the first to examine the relationship
Practice Care Score 73.96 (30.02) [0–100] of patient reported waiting times and visit time on overall
Age group (%) patient satisfaction. We found that of the two time-based
Less than 18 6.76% measures, time spent with the physician is most powerful
18 – 24 21.87%
determinant of overall patient satisfaction. However, the
25 – 34 24.27%
35 – 44 36.78%
combination of long wait times and short visit times pro-
45 – 64 10.01% duced the lowest level of patient satisfaction observed in
65 + 0.32% the study, and suggests that both measures are important.
Male Gender (%) 25.70% This suggests that clinics facing operational constraints on
First visit to office (%) 13.47% physician staffing concurrently with high patient loads,
Routine exam or check-up 28.40% will face accelerating patient dissatisfaction as physicians
Wait Time category
reduce time spent with patients and patients have to wait
Less than 15 min 37.92%
15 to 30 min 37.56% longer to be seen. Patients currently give physicians con-
30 to 60 min 14.89% siderable leeway in waiting times as long as they feel they
60 min + 9.63% get adequate time with their physician. Our study suggests
25.22 (20.47) that long waiting times and short visit times are a toxic
Visit Time category combination for patient satisfaction and one that provid-
Less than 5 min 11.11% ers and practice mangers should avoid if they are con-
5 to 10 min 26.86%
cerned about patient-centered measures of health care
10 min + 62.02%
quality such as patient satisfaction. While having suffi-
cient visit time with the physician is of paramount impor-
tance, we hypothesize that short visits with the physician
The relationship of waiting time, the primary focus of this are more negatively valued as waiting time increases
study, on the patient satisfaction ratings was found to be because the patient's resource investment (time) is higher
moderated by time spent with the physician. Figure 1 dis- and is likely appraised as a poor trade for the obtained
plays perceived waiting time effects by levels of perceived outcome. There was no evidence of an interaction of wait
time spent with physician. For example, among those times and visit times. Thus the results displayed represent
who reported waiting 30–60 minutes to see their physi- additive effects of both time-derived variables rather than
cian, the mean Physician care scale score was 18.0 when < buffering, or effect modification. Still, the cumulative
5 minutes was reported spent seeing the physician versus effects of waiting time upon patient satisfaction are influ-
78.7 when > 10 minutes was spent with the physician. The enced by physician visit time. There are several limita-
most satisfied patients were those who had brief waits (< tions of this study to consider. First, the internet survey
15 minutes) and longer visits, with a mean Physician Care likely resulted in a biased sample by selectively attracting
respondents who were experienced using the internet and
Table 2: Predictors of Doctor Rating using Mixed Model willing to complete a survey regarding patient satisfaction.
Regression (N = 5003)§ The survey completion 'response rate,' comprised of those
who accessed the survey site and chose to complete the
Dependent Variable⇒ Predictor Doctor Care Score β
Variables ‡ (se) survey is not known, but is likely to be low. To this extent,
the data and results may not be generalizable to the larger
Intercept 37.00 (1.74)*** population of patients in the community. To gauge the
Age§§ 0.082 (0.036)* robustness of our results across settings, we examined the
Male Gender -0.22 (0.88) effects of waiting time and visit time in a companion
First visit to office -12.57 (1.74)*** study we have recently completed on drivers of patient
Routine exam or check-up 4.97 (0.84)*** satisfaction in a large academic primary care organization
Waiting time§§ -0.39 (0.021)***
(Camacho et al, in press[12]). The latter study achieved
Visit time§§ 3.78 (0.089)***
Interaction First visit with Waiting time -0.14 (0.049)** approximately an 80% response rate using a survey deliv-
Adjusted R2 0.43 ered at the point of care, among N = 2535 patient volun-
teers. We found in this newer study that both waiting time
Notes: and visit time were significant predictors of overall patient
*P < 0.05 level, **P < 0.01, *** P < 0.001 satisfaction, and willingness to return for care. Another
§ Includes a random effect for subject.
§§ Continuous approximation.
limitation is that this study assessed self-reported wait and

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Satisfaction with Physician Care and Waiting Time in Office by Level of MD Visit Time

Physician Satisfaction score

100

90

80

70

60

50

40

30

20

10

0
< 15 min 15 – 30 min 30 – 60 min 60 min

Waiting Time

< 5 min spend 5 10 spend > 10 min spend

Figure 1

Satisfaction with Practice and Waiting Time , by Level of MD

Visit Time
Practice
100 Satisfaction Score

90

80

70

60

50

40

30

20

10

0
< 15 min 15 – 30 min 30 – 60 min 60 min +

Waiting Time

< 5 spend 15-30 min spend 30-60 min spend

Figure 2

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visit times. It is possible that recall basis is present such 9. Bar-Dayan Y, Leiba A, Weiss Y, Carroll JS, Benedek P: Waiting time
is a major predictor of patient satisfaction in a primary mili-
that satisfaction with the overall doctor visit influenced tary clinic. Mil Med 2002, 167(10):842-5.
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between time and satisfaction may be spurious. However, Satisfaction with an Outpatient Care Visit. J Fam Pract 1997,
45(5):418-25.
a comparison performed by Dansky[6] between actual 11. Lipsitz SH, Fitzmaurice GM, Orav EJ, Laird NM: "Performance of
and perceived waiting times shows only a slight overesti- Generalized Estimating Equations in Practical Situations,".
mation with no significant differences (using 323 sub- Biometrics 1994, 50:270-278.
12. Camacho F, Anderson RT, Safrit A, Jones AS, Hoffmann P: The Rela-
jects) between both measures. Finally, we did not examine tionship between Patient's perceived Waiting Time and
effects or correlation from health care system variables Office-Based Practice Satisfaction. NC Med J 2006,
67(6):409-413.
such as type of primary care physician, health plan or
organization model
Pre-publication history
The pre-publication history for this paper can be accessed
Conclusion here:
The time spent with the physician is a stronger predictor
of patient satisfaction than is the time spent in the waiting http://www.biomedcentral.com/1472-6963/7/31/prepub
room. These results suggest that shortening patient wait-
ing times at the expense of time spent with the patient to
improve patient satisfaction scores would be counter-pro-
ductive.

Competing interests
The lead author (RA) serves as a Director of DrScore, a pri-
vately held patient satisfaction research firm which sup-
plied data for this study, and has received no financial
compensation for this work. The co-authors have no com-
peting interests to declare.

Authors' contributions
RA led the design and conceptualization of the study, and
the results report. FC performed the analyses and contrib-
uted to the written manuscript. RB contributed by refining
the manuscript and measurement models. All authors
read and approved the final manuscript.

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