In 1984, David Maister published the seminal article “The Psychology of Waiting Lines.” These days, many service businesses use its rules and observations to improve the experience of waiting.¹ Although I will argue that the emergency department is not a “business,” emergency physicians provide a service to patients. We provide intangible expertise to help our patients with a problem and create value for that person. That service inevitably includes the experience of waiting, which can lead to patient frustration and is associated with negative outcomes, such as emergency department staff burnout and violence against team members.²

Maister’s first law is: Satisfaction = Perception minus Expectation

Simply put, if one perceives a service to be better than their expectations, they are satisfied. In a perfect world, perceptions and expectations are matched with reality, but this is rarely true. For example, in a Canadian cross-sectional survey study of Calgary regional emergency departments (EDs), 67 percent of patients felt that the ED staff should update them at least every 30 minutes. More than half of patients expected to wait less than an hour for non-life-threatening problems, and to wait less than an hour from the time tests were taken to results were given.³

Unfortunately, the reality was that patients waited more than double their expected wait times. For further granularity, lab testing and CT imaging alone in the U.S. add an additional 70 and 60 minutes each to ED length-of-stay, respectively.^4,5 Patient expectations of ED waiting times are incongruent with reality—a setup for dissatisfaction. However, the two variables of perception and expectation can be adjusted.

One can adjust perceptions of the service, or manage expectation—that is, bring them closer to reality.

Managing expectations is often a strategy already performed in many EDs . EDs post wait times, and staff might provide an estimated wait time for lab testing and imaging, purposefully being on the more excessive end of wait times to manage expectations.

Perceptions can be adjusted, and that sometimes is the most important factor to focus on. We’ve had patients who have waited hours to be seen but are understanding. On the other hand, we’ve had patients who wait a few minutes to impatiently ask, “When will someone come by to see me?” The perception of waiting time described in a study by Thompson and colleagues of approximately 1,600 patient respondents in the ED was strongly associated with patient satisfaction, not actual waiting time.⁶ So, how do we address perceptions of waiting time?