The Uncertainty Tax
Patients Experience What They Don't Know During the Wait.
Shorter wait times are an operational problem, while designing the information environment during the wait is a communication design issue. Community health organizations are addressing the first of these, leaving the second to build up over time.
You're in a waiting room and have been there for thirty minutes. Since the woman at the front desk asked you to sit down, no one has said anything. There's no screen showing a number. None of the people around seem able to give you any information. You don't know whether your turn comes next or whether there are twelve people in front of you. You also don't know whether the wait will be an additional ten minutes or forty-five.
You are not undergoing a waiting period of thirty minutes; rather, you are spending thirty minutes in uncertainty, together with the anxiety caused by the reason that led you to this place, since the environment has provided you with no means of judging where you are.
That is not the same experience. The clock fixed on the wall shows thirty minutes, but the experience doesn't match.
Time Passes Differently When It Contains Uncertainty
Psychological research into the experience of waiting has identified this difference with a certain degree of accuracy. Uncertain waits are perceived as longer than waits of the same length that are known to have a definite end. A patient who has been informed that their wait will be forty-five minutes has a different experience of that wait than a patient who waits forty-five minutes without an estimate. The second patient lacks a cognitive reference point; without such a point of reference, the mind tends to fill the uncertainty with something, and in a medical situation it generally fills it with anxiety regarding the purpose of the visit.
A qualitative study published in BMC Health Services Research examined patients' experiences across multiple clinic visits. One participant described having to wait at a pharmacy that used a random-number system: numbers were called out of order, making it impossible to tell how close one was to being called. The resulting uncertainty was not merely an inconvenience; it was said to take away hope. Because the patient did not know their position in the sequence, there was nothing to hold on to. Unlike a predictable long wait, the wait became open-ended.
The evidence consistently points to the same conclusion: knowing about delays reduces uncertainty and makes the waiting process more cognitively manageable. If patients know what is going on and have a general sense of when the situation will change, they can adjust their expectations and reevaluate. Waiting then becomes something they go through rather than something that happens to them without explanation. The feeling of control changes, even though the actual waiting time remains the same.
A patient will have a different experience of a forty-five-minute wait than someone who is waiting for the same forty-five minutes without any uncertainty. Although the clock remains the same, the experience does not.
The psychologist David Maister, who, in his early days, developed work on the management of waiting that became fundamental to service design, found that uncertainty is one of the main factors that heighten the sense of waiting, even when the actual waiting time remains the same. His rule was simple: waits that are uncertain are felt to last longer than those that are known to have a definite end. As a result, for any service organization, it is not always necessary to reduce the actual waiting time to reduce the perceived waiting time; sometimes it is enough to reduce the uncertainty during the wait.
What a Communication Intervention Actually Changed
A quality improvement study of 17,444 emergency department visits examined the effects of adding three simple communication interventions to the waiting environment—bilingual orientation materials, verbal information about the longest expected wait, and a bilingual display outlining the care process. The patients' Net Promoter Score rose from 33.5 at the start to 38.9, and staff responsiveness scores also increased.
It is reasonable for the researchers to note that wait times also decreased during the study period, so the communication intervention alone cannot account for the entire improvement. However, the key finding is the mechanism responsible for the directional change. The interventions did not shorten the time patients spent waiting. Instead, they reduced the uncertainty patients felt during that time. Patients who understood the process and had an estimate of how long they would have to wait clearly had a different experience from those with the same wait time who were not given that information.
What matters more than the extent of the NPS shift is what it indicates. An organization with 17,444 patient encounters improved the patient experience at scale without building a new wing, addressing its clinical throughput problems, or redesigning its triage process. It changed what patients knew while they waited. That constitutes a communication design intervention, not an operational one.
The Uncertainty Tax
In the field of community health, waiting extends beyond the waiting room; patients experience uncertainty at every stage of their relationship with a health center. At many of these times, the organization has not decided what the patient knows and what they do not know.
A patient awaiting test results has no way to know whether the lack of news is a positive sign or whether the results have not yet been reviewed. When a patient is waiting for a specialist referral, they don't know whether the referral has been sent or received, or how long the waiting list is. A patient going through Medicaid enrollment doesn't know whether their application is progressing or whether there has been a problem. A patient on a behavioral health waitlist doesn't know their position in the queue or when they can expect to be contacted.
In all these cases, the patient is waiting, but what they are mainly going through is the uncertainty during the wait. The length of time is what the clock shows. The Uncertainty Tax consists of all the costs they bear in addition to this: the anxiety of not knowing, the mental effort of looking for signs, and the general fear that silence means something has gone wrong.
The Uncertainty Tax is the amount patients pay in addition to the waiting time itself; the clock does not keep track of it, but it is determined by what the patient does not know while the clock is running.
Certain portions of the tax are unavoidable because it takes time for results to be reviewed and for referrals to move as quickly as the receiving organizations can process them. The waitlists are genuine and lengthy, and no communication-based intervention can alter the fundamental capacity constraints faced by a community health center operating under constant staffing and funding pressure.
However, a large part of the Uncertainty Tax borne by patients in community health settings cannot be explained by those unavoidable limitations. This situation arises because there is no deliberately created information environment for them. No one determined what information the patient should receive, when they should receive it, or which channel should be used to transmit it. As a result, the patient has to wait in silence, and this silence builds into anxiety that no eventual explanation can completely alleviate.
The Moments Nobody Has Designed
In most community health organizations, the periods between services are not regarded as communication moments, even though the appointment itself is one, the interaction at the front desk is another, and the time spent in the examination room is also a communication moment. The various phases that occur between these points—such as the patient sitting in the waiting room after check-in, the days that elapse between the appointment and the receipt of the test results, and the weeks that pass between the referral and contact with the specialist—are handled operationally but not managed as communication moments.
It is common for patients to interpret silence as meaningful, and they are not mistaken in doing so. If an organization says nothing to a patient while they are waiting for their referral status, it is, in effect, conveying that the referral is not important enough to mention, that the patient is not part of a system that records their experiences between appointments, and that waiting is simply the way things are done here, with the patient expected to deal with it themselves.
The way communication was handled was unplanned; it was simply the result of no decision being made about what to tell the patient while waiting for the next event.
Designing the information environment during waiting times is not primarily a matter of technology or staffing but of organizational responsibility—that is, deciding who is accountable for what the patient learns between visits. Has anyone actually been given the authority to make these decisions systematically, rather than allowing them to accumulate by default?
What This Asks of a Community Health Organization
The communication design the research suggests is not complicated. In the emergency department study, the effects were achieved through bilingual orientation materials, a verbal approximation, and a display. The patient in the BMC study required nothing more than a queue system that indicated position. The mechanism is not technology; it is the choice to treat the information environment associated with waiting as a deliberately designed experience rather than an afterthought of operations.
For a community health center, this involves examining each of the major waiting periods in the patient's relationship and posing two questions: what the patient currently knows and what they would need to know to regard the wait as manageable rather than open-ended. The response to the first question is generally less than people had thought, while the answer to the second is usually simpler than people anticipated.
A message confirming the referral was sent, along with an approximate timetable for when contact would be made; a brief description of the next step and who will carry it out; and a follow-up at a predetermined interval for patients on the behavioral health waitlist. These actions do not constitute technology deployments but rather decisions about whether the organization accepts responsibility for the patient's experience between services.
The concept of the Uncertainty Tax is one that most community health organizations have neither named nor measured; it is included in patient satisfaction scores as a general factor contributing to dissatisfaction and is attributed to waiting times rather than to the uncertainty present during those times. Some of the Uncertainty Tax can be reduced by shortening wait times, while adjusting the information environment for patients during waiting periods will reduce another part of it, and in certain cases a bigger part, all without making any changes to clinical throughput.
The next question is not primarily about communication strategies; it is about organizational responsibility. At present, no one at most community health centers takes ownership of patients' experiences of not knowing. That gap is not an operational one; it is the result of a design decision that has never been made.
Some ideas are worth discussing in the context of your organization.
