Ethical considerations for direct scheduling of patient appointments

Direct scheduling refers to patients scheduling their own appointments, often through online portals.1Ganguli I. Orav E.J. Lupo C. Metlay J.P. Sequist T.D. Patient and visit characteristics associated with use of direct scheduling in primary care practices.JAMA Netw Open. 2020; 3e209637https://doi.org/10.1001/jamanetworkopen.2020.9637Crossref Scopus (16) Google Scholar This scheduling method has gained popularity among nonurgent care providers to enhance patient convenience, curtail empty patient appointments, and reduce administrative burdens.1Ganguli I. Orav E.J. Lupo C. Metlay J.P. Sequist T.D. Patient and visit characteristics associated with use of direct scheduling in primary care practices.JAMA Netw Open. 2020; 3e209637https://doi.org/10.1001/jamanetworkopen.2020.9637Crossref Scopus (16) Google Scholar Despite the growing interest in and implementation of direct scheduling systems, there remains little ethical analysis of the practice. Dermatologists and other physicians in nonurgent settings should be aware of the growing use of direct scheduling and understand its benefits and limitations. Direct scheduling offers many benefits to patients and their providers. A 2013 survey found that 77% of patients wanted primary care providers to offer online appointment scheduling, suggesting a strong patient preference for this service.1Ganguli I. Orav E.J. Lupo C. Metlay J.P. Sequist T.D. Patient and visit characteristics associated with use of direct scheduling in primary care practices.JAMA Netw Open. 2020; 3e209637https://doi.org/10.1001/jamanetworkopen.2020.9637Crossref Scopus (16) Google Scholar Direct scheduling may also improve patient continuity of care, but this finding may be unique to routine medical examinations and/or not independently attributable to direct scheduling.1Ganguli I. Orav E.J. Lupo C. Metlay J.P. Sequist T.D. Patient and visit characteristics associated with use of direct scheduling in primary care practices.JAMA Netw Open. 2020; 3e209637https://doi.org/10.1001/jamanetworkopen.2020.9637Crossref Scopus (16) Google Scholar Patient control over scheduling is also associated with lower no-show rates.1Ganguli I. Orav E.J. Lupo C. Metlay J.P. Sequist T.D. Patient and visit characteristics associated with use of direct scheduling in primary care practices.JAMA Netw Open. 2020; 3e209637https://doi.org/10.1001/jamanetworkopen.2020.9637Crossref Scopus (16) Google Scholar,2Yanovsky R.L. Das S. Patient-initiated online appointment scheduling: pilot program at an urban academic dermatology practice.J Am Acad Dermatol. 2020; 83: 1479-1481https://doi.org/10.1016/j.jaad.2020.03.035Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Therefore, direct scheduling enhances patient autonomy, improves patient access, and reduces costs to providers associated with no-shows.1Ganguli I. Orav E.J. Lupo C. Metlay J.P. Sequist T.D. Patient and visit characteristics associated with use of direct scheduling in primary care practices.JAMA Netw Open. 2020; 3e209637https://doi.org/10.1001/jamanetworkopen.2020.9637Crossref Scopus (16) Google Scholar,2Yanovsky R.L. Das S. Patient-initiated online appointment scheduling: pilot program at an urban academic dermatology practice.J Am Acad Dermatol. 2020; 83: 1479-1481https://doi.org/10.1016/j.jaad.2020.03.035Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Stream scheduling, a popular form of direct scheduling, allocates fixed blocks of times for different visit types.3Matulis J.C. McCoy R. Patient-centered appointment scheduling: a call for autonomy, continuity, and creativity.J Gen Intern Med. 2021; 36: 511-514https://doi.org/10.1007/s11606-020-06058-9Crossref PubMed Scopus (12) Google Scholar These slots are predictable and accommodate well-defined patient concerns, such as suture removal. At these visits, patients plan to address a single clinical concern, which may mitigate unrealistic appointment expectations and improve appointment efficiency for straightforward clinical concerns. Conversely, direct scheduling may compromise access for underrepresented patients, have mixed effects on physician autonomy, and obfuscate appointment expectations. A cross-sectional study of primary care practices showed that patients who used direct scheduling were more often young, White, and commercially insured.1Ganguli I. Orav E.J. Lupo C. Metlay J.P. Sequist T.D. Patient and visit characteristics associated with use of direct scheduling in primary care practices.JAMA Netw Open. 2020; 3e209637https://doi.org/10.1001/jamanetworkopen.2020.9637Crossref Scopus (16) Google Scholar Given the limited supply of appointments, direct scheduling thus compromises access for older, non-White, or underinsured patients who may lack resources or prefer not to schedule through an online portal. This inequity, with respect to advances in technology, dubbed the “digital divide,” may be exacerbated in a direct scheduling system.4Hadeler E. Prose N. Floyd L.P. Teledermatology: how it is impacting the underserved.Pediatr Dermatol. 2021; 38: 1597-1600https://doi.org/10.1111/pde.14838Crossref PubMed Scopus (7) Google Scholar Direct scheduling, like other scheduling methods that are traditionally managed by administrative staff, may also reduce the ability to regulate appointments. For example, if a patient were to unknowingly schedule a routine medical follow-up when a longer-duration appointment would be warranted, the dermatologist may not be able to satisfy the patient’s expectation in the given appointment duration. This dissatisfaction can be encapsulated by the term “adequate time,” which describes the patient’s subjective judgment of time needed to address a concern as opposed to what is actually required.5Braddock III, C.H. Snyder L. The doctor will see you shortly. The ethical significance of time for the patient-physician relationship.J Gen Intern Med. 2005; 20: 1057-1062https://doi.org/10.1111/j.1525-1497.2005.00217.xCrossref PubMed Scopus (81) Google Scholar Although this drawback is not entirely unique to direct scheduling, it does erode the patient-physician relationship.5Braddock III, C.H. Snyder L. The doctor will see you shortly. The ethical significance of time for the patient-physician relationship.J Gen Intern Med. 2005; 20: 1057-1062https://doi.org/10.1111/j.1525-1497.2005.00217.xCrossref PubMed Scopus (81) Google Scholar Direct scheduling is a useful tool to enhance provider efficiency and patient autonomy. However, it has mixed ethical implications for physician autonomy and may compromise justice for patients with limited access to direct scheduling. We suggest that dermatologists consider direct scheduling for follow-up appointments and low-complexity clinical concerns to satisfy patient preference and practice efficiency. We also recommend that providers retain traditional (phone or in-person) scheduling methods to minimize the injustice to patients with preferences against or limited access to a direct scheduling system.2Yanovsky R.L. Das S. Patient-initiated online appointment scheduling: pilot program at an urban academic dermatology practice.J Am Acad Dermatol. 2020; 83: 1479-1481https://doi.org/10.1016/j.jaad.2020.03.035Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar None disclosed.