Breast disease and the general surgeon. I. Referral of patients with breast problems.

OBJECTIVES--To determine the proportion of all new and follow-up patients referred to general surgical outpatient clinics with breast problems. To ascertain how long these patients wait for an appointment and how many require investigation or admission for operation. To review our management of patients with breast problems in the clinic and to determine the ratio of benign breast disease to malignancy. DESIGN--A 3-month prospective outpatient survey with patient details recorded on questionnaires completed by the medical staff. SETTING--The general surgical outpatient clinics of this firm at Battle Hospital, Reading, and Newbury District Hospital, Berkshire. PATIENTS--Those patients attending the above clinics during the 3-month period 1 October to 31 December 1989. RESULTS--In all, 693 new patients and 554 follow-up patients were seen. Of the new patients, 119, and of the follow-up patients 140 were seen for a breast complaint. At Battle Hospital 16% of all new patients presented with a breast problem, while at Newbury Hospital the figure was 24%. Of the follow-up patients at Battle Hospital, 23% were seen for a breast problem, and 41% at Newbury. The overall median waiting time for a new outpatient appointment was 21 days. No investigations were needed in 22% of the patients. The remaining 93 patients had investigations and a total of 70 mammograms and 53 fine needle aspirations for cytology were performed. The mean cost of investigations per patient investigated was estimated at 27 pounds. Of new patients, 58% were discharged from the clinic after a single consultation, and investigations as necessary. In 79% of the patients admitted for an operation, the decision to admit was made on the basis of the initial history and examination alone. Of new patients, 84% did not need admission and were managed in the clinic. In all, 14 breast carcinomas were diagnosed--12% of new patients with breast problems. CONCLUSIONS--The figures suggest that 24% of new patients and 41% of follow-up patients attending a general surgical clinic are seen for a breast problem. The waiting time for new appointments is unacceptably long. Most new patients do not require admission for an operation. Only 12% of new patients referred with a breast problem were found to have a carcinoma.     

Plastic surgery outpatient audit: principles and practice of "consultant only" clinics

The effect of instituting "consultant only" clinics on plastic surgery outpatient activity was to produce a 19% reduction in both clinic sessions and new patient bookings, but a 50% reduction in booked follow-up patients; non-attender rates reduced from 20% to 11% (Northern General Hospital, April 1986-March 1989). Mean clinic attendances reduced from 35 to 26 (Northern General Hospital) and from 33 to 27 (Barnsley District Hospital)--26% and 18%, respectively. Analysis of new referrals to such clinics in the 6 months January-June 1989 showed 41% of patients came from general practitioners, although 80% of "aesthetic" conditions came from this source. 31% of referrals were for malignancy, 51/72 (70%) being basal cell carcinomas. Malignancies waited on average 4 weeks, benign conditions 15 weeks, and "aesthetic" conditions 28 weeks from referral to consultation. Such clinic management has dramatically reduced follow-up episodes, but regulation of new patient attendances is associated with appreciable waiting times for non-malignant conditions. To reduce such waiting times and pursue a "consultant only" clinic policy nationally requires many more consultants.     

A one-stop vascular clinic: a practical proposition with non-invasive assessment.

One-stop clinics are becoming increasingly popular with both patients and their general practitioners. Traditionally, vascular patients have needed to attend hospital two or three times for clinical examination and investigations. We have introduced a one-stop clinic for patients with lower limb arterial disease (LLAD) and aortic aneurysms. In 92 clinics over 2 years, 1194 new patients and 1409 follow-up patients were seen, with LLAD being the largest single category comprising 40% of the patients seen, followed by varicose veins (25%), carotid disease (12%), and aortic aneurysms (8%). Overall, 57% of patients had non-invasive imaging performed, either in the clinic or on a separate visit. Performing all LLAD and aortic scans in the clinic requires 1.9 h of imaging time per clinic. Extending in-clinic scanning to patients with varicose veins and carotid disease would increase this to 3.9 h of scanning per clinic and require a duplex scanner and an additional technologist in the clinic.     

Reducing surgical outpatient waiting is not the solution to meeting the 2005 colorectal cancer target

OBJECTIVES: The majority of colorectal cancers (CRC) are not diagnosed through the Rapid access route (RAR) and follow-ups (FU) may prolong outpatient-waiting time for new referrals. The aim of this study was to assess the relative contributions of an efficient colorectal clinic and a stringent colonoscopy booking system on the total journey time for CRC. PATIENTS AND METHODS: We reduced the number of follow-up appointments with the introduction of 'Paper clinics'. The composition of the new clinic was determined by the known cancer yield through RAR and non-RAR route. A prospective analysis of clinics and CRC journey times was undertaken from November 2003 for 13 months, with the new outpatient clinic template introduced in December 2003. This coincided with a stringent policy on referral pattern for colonoscopy. RESULTS: In our hospital, only 4% of RAR yield CRC. Seventy-five percent of our CRC are referred through the non-RAR route. Eighty-one percent of follow-ups in a 'paper clinic' were discharged. A flexible template for the outpatient clinics, introduced a corresponding reduction in follow-up and increased urgent and routine slots. There was a progressive drop in the follow-up to new ratio and the waiting times for routine and urgent category decreased from a median of 15.9 and 3.4 weeks to 6.7 and 0.7 weeks, respectively (P < 0.001). Average waiting times for all categories fell from 13.35 weeks in November 2003 to 3.5 weeks in December 2004, while the number of patients waiting less than 4 weeks rose from 46% to 71%. This was associated with reduction in total journey times from 93 days to 62 days (P < 0.05). DNA rates remained unaffected. CONCLUSION: Modifying outpatient clinic composition with 'paper clinics' reduces the waiting time for all referrals to a surgical clinic with a modest effect on CRC clinic waiting time. Reduction in the total waiting time to first treatment (for CRC) is due to reducing the demand on colonoscopy in favour of barium enema. Redirecting the flow of patients towards barium enema is perhaps one way of improving the existing CRC journey time to first treatment, within existing resources. Achieving the 62 day target for cancer journey time will be difficult unless traditional surgical clinic habits are challenged.     

One-stop diagnosis for symptomatic breast disease.

A consultant-led one-stop diagnostic service has been available at a busy symptomatic breast clinic each week at St Bartholomew's Hospital for 18 months. Women can be investigated appropriately using mammography, ultrasonography and cytology with immediate reporting. The aim is to achieve a diagnosis and management plan for each patient at the initial outpatient visit. A prospective audit of four consecutive clinics was undertaken to assess the impact of this service on clinical practice. Fifty patients out of 134 new and 386 follow-up clinic attenders had one-stop investigations. As a result of immediate reporting, 48 (96%) patients had a management decision made at the first outpatient visit, 9 (18%) were offered surgery, and 18 (36%) were discharged with a benign diagnosis and no dominant mass. Four symptomatic cancers were detected and evaluated on a one-stop basis, constituting 8% of the workload of this clinic. The mean wait from designated appointment until surgical consultation was 37.7 min (range -68-171 min) and that for investigation until subsequent clinical review was 56.9 min (range -4-191 min). Thirty-six (72%) one-stop patients had a total wait of less than 2 h and 95% were seen in under 3 h. It is felt that the one-stop clinic allows optimum patient management, minimises anxiety associated with symptomatic breast disease, and maximises utilisation of hospital outpatient resources.     

The workload of a surgical unit in a district general hospital.

A 3-month prospective study of the workload of a surgical unit in a district general hospital was performed to identify the relationship between outpatient work, admissions to hospital, and scheduled operating lists. We have shown that under 60% of all new cases seen in the outpatient clinic had admissions arranged after initial consultation. Over two-thirds of inpatient admissions were for emergencies or urgent cases, and thus not able to be controlled by the surgical team. One-third of emergency admissions had an operation within 24 h of admission. One third of the total number of cases on scheduled lists were emergency or urgent cases (taking up approximately 50% of the operating time). Of all admissions, 32% were as day cases. Of all routine operations, 35% were performed at a community hospital taking only 18% of all our admissions.     

Resource implications of outpatient referrals to a general urological service.

The effects of new outpatient referrals on the dynamics of global provision in a surgical service has not previously been defined. Because of managerial pressure to reduce the time interval between general practitioner referral and first specialist assessment, many services are now faced with additional outpatient loads without any clear idea of the effect that this additional burden will have on overall practice. In an attempt to define the logistic implications of a new outpatient load, 293 patients, referred from primary care to a general urological service, were followed for a further two interactions with the secondary care team. 'One-stop' visits with in-clinic investigation and an active discharge policy were employed to assist with efficient patient management. Of the original patients, 28% required investigations not available in the clinic, with cost and logistic implications for support services. In all, 32% of the patients needed further follow-up appointments, despite the active discharge policy. This necessitated 95 people being seen in additional clinic time. Of the patients referred, 37% needed inpatient treatment; 46% being day case procedures, the remainder constituting a variable case mix. This work necessitated 7.1 operating sessions and an additional 75 inpatient bed days for every 100 new patients referred. A model for determining the resource requirements for a surgical outpatient load is proposed.     

Immediate cytodiagnosis and imaging in the clinical management of discrete benign breast lesions.

Benign breast disease accounts for the majority of referrals to a specialist breast clinic. Delayed investigation prolongs patient anxiety and increases outpatient waiting lists. Few centres offer the triple test of clinical examination, fine needle aspiration cytology (FNAC) and breast imaging by mammography and/or ultrasonography at initial presentation. We have analysed the practicality of such a service during the 12 months following its introduction in our district general hospital. We studied the cohort of 178 patients who presented with a discrete breast lump which was subsequently shown to be benign. A triple test was performed in 72% of all patients. In 100 patients (56%) this was performed at initial assessment. Of these, 87 had clinically benign disease confirmed by FNAC and breast imaging and they were informed of the results within 3 h. A triple assessment during the initial consultation allows the majority of patients with discrete benign breast disease to be given immediate reassurance.     

Role of pre-admission clinics in a general surgical unit: a 6-month audit.

We report a 6-month audit of the running of a pre-admission assessment clinic for routine general surgical admissions. An attendance rate of 91.4% of fit patients ready for surgery on the day of admission was achieved. Of all patients attending the pre-admission clinics, 79.5% underwent surgery as planned. Pre-admission clinics are recommended as a method of improving the efficiency of elective surgical admissions.     

The South Tyneside FASTRAK service: evaluation of a new model for day surgery

Objective: To evaluate a service (FASTRAK) offering general practitioners direct access to day surgery operative waiting lists, based on explicit guidelines regarding patient suitability for surgery and anaesthesia. Design: Notes abstraction for a cohort of patients referred via FASTRAK and a cohort referred via conventional day surgery routes; postal questionnaire survey of patient satisfaction amongst FASTRAK patients and matched controls referred via conventional routes; postal survey of professional satisfaction. Setting: One district general hospital in the north east of England, and all general practices in that district. Subjects: 1278 patients (1100 conventional day case patients; 178 FASTRAK patients) for notes abstraction; 70 patients for patient satisfaction survey 83 general practitioners for professional satisfaction survey. Main outcome measures: interval from referral to operation, and appropriateness of referral; patient experience and satisfaction with hospital and post-discharge care, especially with respect to information provision, for patient survey; overall rating of service, perceived benefits and disadvantages and future intentions for professional satisfaction survey. Results: The interval from referral to operation was significantly shorter for FASTRAK patients by a median of 91 days. Out of a total of 178 FASTRAK referrals, only seven (4%) were inappropriate whilst diagnosis was wrong in three (2%) cases. Patients referred via FASTRAK were much more likely to have received written information prior to admission (83 vs. 37%: χ²=12.25. P=0.0019). General practitioners (GPs) had positive views of the service; 94% rated it as ‘fair' to ‘very good'. GPs, 90%, perceived the main benefit to patients to be a shorter waiting time for operation; 40% felt that the availability of clear information for patients benefited doctors. Increased general practitioner workload was recognised as a disadvantage (61%) and the main barrier to use of the service was lack of eligible patients under the current guidelines (69%). Conclusions: When diagnosis, indication for surgery and fitness for anaesthesia are not in doubt, general practitioners, given appropriate guidance, are able to provide all the necessary pre-operative services that are usually provided in the general surgical outpatient clinic, without prejudicing the quality of care or decreasing patient satisfaction.     

Implications of sub-specialisation on the waiting times of general surgical clinics.

INTRODUCTION: Controversy around sub-specialisation in a district general hospital (DGH) has been ongoing for years. AIM: To study the effect of colorectal sub-specialisation on general surgical cases. METHODS: A retrospective audit between October 2002 and September 2003, including all referrals to the outpatient clinics of a single consultant surgeon in a DGH. RESULTS: 1,055 patients were seen in outpatient clinics, of which 53% (563) were seen in rapid access colorectal clinics. Overall, 87% (914) of patients were diagnosed to have colorectal pathology. The majority of the colorectal cases were referred using the designated referral forms. There were 427 urgent, 162 soon and 325 routine referrals with colorectal pathology, and 35 urgent, 22 soon and 84 routine referrals with non-colorectal pathology. Median waiting times for urgent, soon and routine referrals were 12, 61 and 91 days, respectively, for patients with colorectal pathology, in comparison with 44, 75 and 397 days for non-colorectal pathology. CONCLUSION: This audit confirms that colorectal sub-specialisation has resulted in a significant delay in the management of patients with non-colorectal diseases. This has major implications within a DGH setting.     

'Paper Clinics'- a model for improving delivery of outpatient colorectal services.

OBJECTIVES: The overburdening of colorectal out-patient clinics necessarily leads to delays in time from referral to consultation and subsequent clinic attendance. This study aimed to ascertain the feasibility of 'paper clinic' follow-up rather than all patients receiving a routine follow-up appointment following investigation. A more efficient outpatient follow-up process should reduce unnecessary follow-up, thereby facilitating the speedy investigation and diagnosis of patients through changes in clinic profiles. METHODS: From August 2001 all patients seen in the outpatient clinic of one (part time) Consultant colorectal surgeon, who required investigation, were prospectively recorded on a 'paper clinic' form. These patients were given the necessary test request forms but were not given a further outpatient appointment. The results of the investigations were reviewed, together with the patients' medical records at a formal fortnightly 'paper clinic' session carried out by the Consultant and Nurse Consultant, and a treatment plan derived. Patients then followed one of 5 follow-up pathways and were notified in writing with a copy to their GP. RESULTS: During a 24-month period a total of 897 patients were reviewed using the 'paper clinic' follow-up system. Of these, 285 (31.8%) patients were discharged without further follow-up. In a given 3-month period when the clinic was well established, 152 patients were reviewed, of whom 27% were discharged from follow-up, 17% received SOS appointments, 13% required further investigation (and consequently were returned to 'paper clinic' follow-up), and 7% received Nurse led follow-up. In this 3-month period 64% of patients reviewed by 'paper clinic' follow-up did not return to Surgical Outpatient's and 12% received a Surgical Outpatient appointment for review. CONCLUSION: 'Paper clinic' follow-up is an effective and feasible follow-up alternative, resulting in a major decrease in outpatient follow-up burden. This has allowed the redesign of the outpatient clinic profile allowing for an increase in new urgent slots, and more rapid clinic follow up review of those patients who need it. Re-design and rationalization of existing services can result in considerable service improvement. Expanding clinics should not be considered the only option when faced with capacity and demand issues.     

The two week referral for colorectal cancer: a retrospective analysis

Objective The two‐week referral (TWR) system was introduced in July 2000 to address the delays in referral, diagnosis and treatment of colorectal cancer (CRC) and lessen the associated psychological morbidity of prolonged waiting. General practitioners complete a proforma outlining ‘high‐risk’ criteria for CRC to ensure an urgent referral within 14 days. The aim of the study was to analyse the TWR process and the proforma criteria. Patients and methods One hundred and forty‐nine two‐week referral proforma were retrospectively reviewed between January and August 2001. The waiting times and proforma data, together with investigations performed and diagnoses made were gathered for 144 patients. Three did not attend clinic and two sets of notes were missing. Results Ninety‐six percent of patients (n = 144) were two week compliant and 14 CRC (10%) were diagnosed. The most common referral symptom was a recent change in bowel habit (36.6%) but specificity for all criteria was low. The highest diagnostic yield was a palpable abdominal or rectal mass where 16.7% had CRC and iron deficiency anaemia had high sensitivity (90%) for surgical pathology. Per rectum examination and haemoglobin analysis by general practitioners was infrequently performed. Discussion Our study has shown that CRC is difficult to diagnose by history and examination alone with a 10% detection rate. CRC incidence in TWR may be improved by primary care through routine rectal examinations, increased detection of iron deficiency anaemia and public education to reduce presentation via other referral routes. Further studies are needed to address these issues.     

The management of women with breast symptoms referred to secondary care clinics in Sheffield: implications for improving local services

Information was collected about 302 women referred for breast symptoms and seen in surgical outpatient or outreach clinics during one month at two hospitals in Sheffield. Three-quarters of the women (n = 244) were referred to specialist breast clinics, 22% (n = 70) were referred to general surgical clinics and 3% (n = 6) were referred to outreach clinics. The ages of the women ranged from 16 to 85 years with a mean and median age of 45 years. Some 200 women (66%) presented with a lump or lumpiness, 42 women (14%) presented with pain, 29 women (10%) had a skin and/or nipple problem, and the remaining 31 women (10%) were concerned about their family history or reported other symptoms. A total of 23 women (8%) were diagnosed as having cancer, 180 (60%) were diagnosed as having benign breast disease, and 99 (33%) were diagnosed as normal. Of the 23 women with cancer, 22 were over 40 years of age; 21 women presented with a lump, one presented with pain, and one presented with metastatic disease. The time required to reach a final clinical diagnosis varied from the same day as the clinic visit to 35 weeks, with a median time of 3 weeks. Surgeons assessed the appropriateness of GPs' referrals for 257 cases and judged that 122 (47%) could have been managed by a GP. The implications of the findings for the organisation of specialist outpatient clinics are discussed, and a categorisation of women as either urgent or routine cases is suggested.     

Day surgery for breast cancer

In Japan, day surgery for breast cancer usually means partial mastectomy without axillary dissection for small carcinoma under local anesthesia in the outpatient clinic. If histopathological examination of the specimens by serial section reveals that the cancer is noninvasive and completely resected with negative surgical margins, no additional surgery under general anesthesia is needed, and the patient does not require hospitalization. We call this procedure "probe lumpectomy". From 1991 to 1998, 169 patients underwent probe lumpectomy in our institution, and there were no major complications. Of these 169 patients, 64 did not require hospitalization. Ipsilateral breast cancer was observed in two patients, and these tumors were diagnosed not as recurrence but as second primary cancers. No distant metastases were observed. As sentinel node biopsy, which is not always easy under local anesthesia, becomes more common, the indications for day surgery or short-stay surgery will expand. As breast cancer is a malignant disease, informed consent and careful follow-up are needed if the treatment is completed only in the outpatient clinic.     

Improving patient throughput for oral day case surgery. The efficacy of a nurse-led pre-admission clinic

In an attempt to reduce patient failures and cancelled operations on the day of admission for oral day case surgery, and to improve pre-operative patient assessment and education, a nurse-led pre-admission clinic (PAC) was introduced in April 1996. Day case patients were selected in cohorts from the waiting list and invited to attend the pre-admission clinic prior to finalising their operation dates. Clinics were run by experienced staff nurses and patients screened for medical or surgical problems that might preclude day case surgery; access to experienced anaesthetic or surgical opinion was arranged as necessary. During a 2 year period 908 patients were sent clinic appointments, but only 727 (80%) attended; of these 629 (69%) progressed to surgery, but 98 (11%) were deemed unsuitable for day case treatment usually because of medical or socio-domestic complications and were managed more appropriately elsewhere. Of the 181 non-attenders, 140 were ultimately removed from the waiting list. Pre-admission screening thus filtered out 279 patients who were either unsuitable for day case surgery or no longer interested in receiving treatment. Waiting times for surgery were reduced from over 12 months to less than 3.     

Evaluation of occupational therapy–led advanced practice hand therapy clinics for patients on surgical outpatient waiting lists at eight Australian public hospitals

Study DesignThis is a prospective cohort study.IntroductionEvidence is emerging that advanced practice hand therapy clinics improve patient outcomes.Purpose of the StudyThe aim of this study was to evaluate an advanced practice hand therapy model of care for patients with chronic hand conditions on surgical outpatient waiting lists at eight Australian public hospitals.MethodsNonurgent and semiurgent patients were screened and treated, as required, by an advanced practice hand therapist and then discharged from the surgical outpatient waiting list as appropriate. Outcomes included patient safety, impact on the waiting list, patient satisfaction, and patients' perception of change as measured by Global Rating of Change (GROC). The GROC score was also compared across diagnoses. The relationship between the waiting time and need for surgical review during hand therapy treatment was also assessed. As appropriate, T-tests and analysis of variance were used for statistical analyses.ResultsA total of 37.2% of patients who commenced hand therapy were removed or discharged from the surgical outpatient waiting lists. Of the subset of patients who completed hand therapy (n = 1116), 28.4% were discharged without requiring surgical follow-up. A further 7.53% requested return to the waiting list despite discharge being recommended. The model of care was safe, and patient satisfaction was above 90%. The mean GROC score was +2.09 (±3.58) but varied across diagnoses with trigger finger or trigger thumb showing the greatest improvement (+4.21 ± 2.92, P < .01). Patients who did not require surgical consultation during hand therapy had a shorter wait time for their initial hand therapy appointment (P < .001).ConclusionsThe advanced practice hand therapy model of care was safe and effective in reducing hospital surgical outpatient waiting lists. Patients reported high satisfaction.     

Operative Therapie des Rektumkarzinoms

Aim

The present study aimed to analyze the satisfaction of referring general practitioners with the surgical departments concerned with further treatment of patients regarding cooperation and therapeutic results.

Patients and methods

A total of 442 general practitioners were interviewed about a total of 601 patients by a standardized questionnaire. The return rate was 63.1% and 73.4% of questionnaires could be analyzed. The study group (SG) comprised 265 patients with rectal carcinoma, who were treated by 204 general practitioners and in 17 different hospitals. The mean age at the time of surgery was 67.8 years.

Results

The oncological result represented the decisive the crucial criterion regarding therapeutic satisfaction of the general practitioners. Postoperative erectile function was the least satisfying parameter, although its priority was considerably more dispensable than the oncological result. Regarding cooperation with the hospital, the content of the epicrisis was the most satisfying parameter. The value of a sufficient and furthermore contemporarily forwarded epicrisis was categorized as very important.

Conclusion

Telephone availability, waiting period until in-patient admission and content of the epicrisis were assessed positively. The main point of criticism was the timely receipt of the epicrisis. The surgical expertise regarding the treatment of rectal carcinoma was assessed as the main quality parameter of the hospital.     

Reduction of preoperative investigations with the introduction of an anaesthetist-led preoperative assessment clinic.

Preoperative investigations, when used to screen for disease not clinically evident, have been shown to be unnecessary. The aim of this study was to rationalize the ordering of preoperative investigations by introducing guidelines and screening all investigations ordered at a new Day of Surgery Admissions clinic. Two hundred and one elective general and ear, nose and throat (ENT) patients attending this clinic at Sir Charles Gairdner Hospital from July to September 1997 were induced in a prospective study group. These were compared to a retrospective control group of 168 elective general and ENT surgical patients who had been admitted for surgery during May to July 1996. Patient demographics were similar for both groups. There were also similar proportions of each surgical subtype and degrees of surgical complexity in each group. There were significant reductions in most types of investigations (electrocardiogram, chest X-ray, liver function tests, urea and electrolytes, full blood examination, coagulation profile) ordered with the Day of Surgery Admissions clinic intervention. This resulted in an estimated reduction of preoperative investigation costs by 38%. It was concluded that the clinic intervention was associated with a reduction in indiscriminate preoperative investigation ordering patterns.     

Design of appointment systems for preanesthesia evaluation clinics to minimize patient waiting times: a review of computer simulation and patient survey studies.

Anesthesiologists can use the science of clinic scheduling to design appointment systems for preanesthesia evaluation clinics. The principal reasons reported for inappropriately [or arguably unethically] long patient waiting times are provider tardiness, lack of patient punctuality, patient no-shows, and improperly designed appointment systems. However, the fundamental reason why anesthesia clinics have such long patient waiting times is because of their relatively long mean (and consequently standard deviation) of consultation times. If commonly applied valuations of provider idle time to patient waiting time are used in anesthesia clinics, appointment intervals will be sufficiently brief that the mean patient waiting time will be at least the mean consultation time or half an hour. Patients will be dissatisfied with this level of service. Therefore, efforts to decrease the mean patient waiting time in anesthesia clinics should focus foremost on minimizing the mean consultation time and its variability, which can most likely be achieved by assuring that providers have rapid access to relevant clinical information, including external medical records, surgical dictations, etc. Anesthesiologists managing anesthesia clinics may find it valuable to apply other interventions to decrease patient waiting times. Scheduling of preanesthesia evaluation and surgical clinics should be coordinated to assure patient punctuality. Providers should be on time for the start of their sessions. If an add-on patient cannot be seen during a scheduled clinic session, because all appointment times have been assigned to other patients, the add-on patient should be seen by a different provider or at the end of the regularly scheduled clinic session. Mean consultation times should be measured accurately for each provider. Substantial provider idle time should be expected. Appropriate values for breaks, appointment intervals, and percentage no-shows should be determined by computer simulation, using parameters appropriate for each provider and anesthesia clinic. Finally, traditional efforts at making waiting for a consultation tolerable should be made.