“Sorry for Holding You Up”: Surgeons’ Apologies for Lateness in Clinic Settings

ABSTRACT

Doctors running late may convey a lack of respect which can impair the therapeutic relationship. This study examines how surgeons address lateness in consultations with patients. We analyzed 52 consultation recordings from a range of surgical specialties in an Australian metropolitan setting. Conversation analysis was used to analyze interactional sequences where lateness was addressed. Six sequences were identified within four recordings. The two consultations with two apologies include a surgeon and registrar apologizing in a neurosurgical consultation and a surgeon apologizing twice within a colorectal consultation. Apologies were either accepted or responded to with an account for not accepting the apology. When these accounts were made, consultations could only progress when patients accepted an explanation for lateness or the degree of complainability about lateness was reduced. The infrequent occurrence of apologies for lateness, and the way in which these sequences unfolded when they did occur, suggest that there is greater acceptability of lateness for surgeons than in ordinary social situations.

Introduction

The doctor-patient interaction is a complex process that forms the foundation of a successful therapeutic relationship (Bredart et al., 2005; Duffy et al., 2004; Ha & Longnecker, 2010). Just as approaches to communication can demonstrate respect for the patient (Noble et al., 2018), so too can other professional behaviors, including punctuality (Royal College of Physicians and Surgeons of Canada, 2022). Being late is often out of the doctor’s control. Common reasons reported by doctors for lateness include requiring more time for complex patients, administrative factors such as inability to access a clinical room, or late patient arrivals (Eisenberg, 2018; Stevens, 2016; Zhu et al., 2012). For a doctor, lateness can reduce feelings of goal accomplishment (Mroz & Allen, 2017) and disrupt clinical flow with increased workload (Herndon & Pollick, 2002).

When doctors run late, patients can feel unimportant and perceive a lack of respect for their time (Reisman, 2010; Roberts, 2019), with a decrease in patient satisfaction correlated with increased waiting times (Anderson et al., 2007; Michael et al., 2013). Given the frequency of running late and the impact it has on both doctors and patients, being able to effectively communicate with patients about lateness is an important skill.

There has been a steady growth in analyses of recordings of consultations between doctors and patients (Barnes, 2019; Golembiewski et al., 2023). However, there is a paucity of research specific to the issue of lateness and its impact on the doctor-patient interaction, despite evidence that lateness to an appointment may alter the overall quality of the interaction (Alibeiki et al., 2021; Klassen & Yoogalingam, 2019).

Apologies serve as acts of expressing remorse, rapport building, and/or mediating future conflict (Cirillo et al., 2016; Drew & Hepburn, 2016; Fatigante et al., 2016; Pino et al., 2016). In most social interactions, violation of social norms around punctuality can cause offense (Robinson, 2006) and can warrant penalty from the recipient (Mroz & Allen, 2017; Robinson, 2006). Lateness that is uncontrollable by the perpetrator and delivered with an excuse and apology receives the most empathetic and favorable response from others (Mroz & Allen, 2017; Robinson, 2006). Addressing lateness in medical care, however, may adhere to modified social norms (Heritage & Clayman, 2010), with different expectations of how accountable participants are for being late.

Conversation analytic and linguistic research has identified several different formulations of apology sequences. Heritage and Raymond (2016) provide a taxonomy of different apology constructions: a simple sorry, an agent in I’m sorry, and extended apologies of sorry + named offense and/or account. They identify the format of the apology as relative to the nature of the offense. Fatigante et al. (2016) examine different uses of sorry and I’m sorry, with the former lending itself to maintain the progressivity of the ongoing conversation while the latter is designed, in some environments, to prioritize affiliation through connection between the apologizer, their trustworthiness, and the responder. Relevant here is also how people respond to complaints, which Schegloff formulates as complaint + response (e.g., apology, remedy, account, rejection) + acceptance/rejection of the response (Schegloff, 2005, p. 465).

While several studies have recommended solutions to combat the issue of lateness through the optimization of appointment systems (Cirillo et al., 2016), there is an absence of analysis of how doctors, specifically surgeons, interact with patients when they are late. This study aims to directly observe and analyze how surgeons address lateness within consultations. We explore how doctors and patients orient to a reduced accountability for lateness in medical settings through an examination of apology sequences where lateness is explicitly addressed.

Methods

Ethics and data

An existing database with recordings of clinical interactions was reviewed for the analysis. There were 52 surgeon-patient consultation recordings available for analysis. These were recorded between 2012 and 2017 and primarily consist of video recordings. Usability of the video recordings varies, with some consultations recorded with only the clinician visible. This was either due to patient preference or because of space limitations within the consultation room. The surgeons were from the subspecialties of Colorectal, Neurosurgery, Orthopedics, Urology, Plastics, and Breast. All consultations were recorded in metropolitan Australian surgical outpatient clinic settings and those who collected the data have confirmed that most patients had a wait time, though this was not formally measured. Both consultants and surgical trainees were involved in the consultations. The population of surgeons and patients included were male and female, all of whom were 18 years and older. All surgeons and patients spoke English fluently. Ethics approval was gained through Macquarie University Human Research Ethics Committee (ref no. 520211101335758).

Analytic approach

Conversation Analysis (CA) involves detailed and methodical microanalysis of talk-in-interaction. The primary goal of CA is to understand how people are co-creating a shared understanding through interaction (Sidnell & Stivers, 2012). The benefit of CA is its rigorousness in data collection and analysis (Clayman & Gill, 2004). This methodology is well suited to our aim to understand apology initiation and response, as well as construction, delivery, and action, in naturally occurring consultations between surgeons and patients.

All recordings were reviewed by two authors (KH, KM) trained in a linguistic ethnographic approach to data extraction (Copland & Creese, 2015; Seuren & Shaw, 2022) by a CA expert (SJW). A systematic analysis was used for the recordings where the authors focused specifically on identifying parts of the consultations that would answer the research question: how do surgeons address the issue of lateness with patients? Within the 52 recordings, four consultations were identified that answered the question, and within these four recordings, six distinct sequences were extracted for analysis. Given the surgeons within the 52 consultations were often running late, apologies for lateness occurred infrequently. Due to this infrequency, exploration of distribution is not possible (Stivers, 2015). Instead we can closely examine how and when apologies for lateness occur in such consultations with consideration of participant orientations to the activity in situ (Robinson, 2007) while also analyzing each case with reference to the others within the small collection (Clift & Raymond, 2018). As Glenn (2019, p. 229) states:

Turns that oppose, misalign, challenge, disaffiliate or complain invite inspection as islands of difference popping up in the waters of an interactional system built in various ways to encourage cooperation and agreement and minimise conflict.

The apologies occurred in two clinics: Neurosurgery and Colorectal. The Neurosurgery clinic involves surgical registrars working with consultants and the surgeons move between different consultation rooms and take their laptops with them. In consultations where the patient sees both the registrar and the consultant, the registrar usually sees the patient first and conducts history taking. The patient often waits in a consultation room between seeing the registrar and the consultant. The consultant and registrar then see the patient together. The registrar provides a brief handover to the consultant, sometimes outside the consultation room and sometimes in it, with the patient referred to in third person. The Colorectal surgery clinic involves only consultant surgeons. The surgeon in this data collects each patient from the waiting room and walks with them to the consultation room. The surgeon sometimes uses different consulting rooms in the clinic and so uses a laptop that is moved between rooms. The patients are sometimes asked to see a clinic nurse at the end of their consultation with the surgeon.

An interaction framework specific to surgeon-patient consultations was considered when approaching the analysis (White et al., 2013). This was used to help identify the activity in which each sequence occurs within the consultation (White et al., 2013, p. 309):

Activity 1: Establishing mutual understanding of the referral and achieving alignment;

Activity 2: Establishing the patient’s description (and perspective) of their problem;

Activity 3: Gathering further information through verbal and/or physical examination;

Activity 4: Reformulating the problem;

Activity 5: Proposing next steps;

Activity 6: Closing the consultation

The six sequences identified were transcribed using the Jeffersonian transcription system, which includes notations to indicate aspects of talk such as pitch movement and pause length (Hepburn & Bolden, 2012). Where possible, embodied actions are transcribed following the Mondada system (Mondada, 2018). The transcriptions were appropriately de-identified to ensure confidentiality.

Results

The following section involves an analysis of each of the six apology sequences, exploring how the surgeons and patients manage explicit talk about lateness. Two of the apologies were accepted directly while the other four were not. The analysis begins with immediately accepted apologies then moves to those that are, in some way, challenged.

Within the four recordings where participants explicitly talked about the doctor’s lateness, two consultations involved a neurosurgeon and a neurosurgical registrar and two involved a colorectal surgeon. There are six apologies as both the surgeon and registrar apologized in one of the neurosurgery consultations, and an apology was made twice in one of the colorectal consultations. The consultation codes are provided to identify the consultations in which two apologies occurred.

Five of the six sequences occurred prior to the opening activity (Activity 1: “establishing mutual understanding of the problem” (White et al., 2013, p. 309). The sixth sequence occurred in the preclosing activities (Activity 6: “closing the consultation” (White, 2015; White et al., 2013, p. 309) and occurred within the consultation that had two apologies from the same surgeon.

Apology + acceptance = progression

In the first two excerpts, the participants orient to minimizing accountability for the surgeon’s lateness. This is in the form of apology + acceptance = progression, where acceptance involves dismissal of or reduction in complainability, allowing the consultation to progress.

Excerpt 1: Consultation 1 (MQ-CARM12-10) – Sequence 1

This interaction is between a consultant neurosurgeon (DR1), a neurosurgical registrar (DR2), and a patient. The patient has been waiting for a total of 1.5 hours, much of which was recorded, both prior to seeing the registrar and between seeing the registrar and the consultant. In this video, the patient is only visible at times and is not visible during the opening sequence. This sequence occurs as the consultant enters the consultation room.

Excerpt 1. Apology prior to the start of the consultation

Greetings are exchanged as the consultant surgeon enters the room, with the registrar appearing to commence activity transition with a turn-initial so (Bolden, 2009, p. 979), however does not continue his turn. While we cannot see the patient at this point in the video, the surgeon is at this point still taking a seat and placing his laptop on the table.

The surgeon’s turn at line 9 is an apology, with his gaze moving to the patient at the end of his apology turn. The apology is produced with no accompanying excuse or justification for the lateness. Turns such as this can be considered complaint preemptions in that they recognize that something that has happened could be considered complainable (Schegloff, 2005, p. 460). Here the turn explicitly acknowledges the breach of a social expectation of running on time, with the surgeon specifying that the sorry is related to keeping you. The use of sorry rather than I’m sorry in this environment suggests that the surgeon is preferencing progressivity (Fatigante et al., 2016). The patient provides an accepting response to the apology (line 10), which begins with a no. This is not a rejection of the apology, but a denial of what Schegloff refers to as “the complainability of the conduct” (2005, p. 449). Part way through this, the registrar overlaps with the patient, disattending her laughter. The registrar begins transition to a new activity, which is to handover the patient to the surgeon, further truncating space to attend to the prior apology sequence.

As the patient denies that there was a complainable for which an apology would be warranted, she chooses not to further topicalise lateness. No further explanation or apology is then relevant. The progression of the consultation into the next activity, which is a modified Activity 1, demonstrates the participants’ orientation to the apology and the dismissal of its relevance as being unproblematic.

Excerpt 2: Consultation 2 (MQ-CARM12-4) – Sequence 1

This consultation is between a colorectal surgeon and a patient. The recording includes both surgeon and patient in the frame, however it is relatively close-up so body position is not always in view. Prior to commencing clinical business, the surgeon and patient organize themselves within the room, with the doctor showing the patient where to sit as the only preceding talk.

Excerpt 2. Apology prior to the start of the consultation

After closing the door to the room, the surgeon offers an apology for lateness as he makes his way to sit down (line 1). This is formulated similarly to another apology by the same surgeon (analyzed below in Excerpt 5), with the surgeon identifying himself as the cause of the lateness. The patient responds with both a dismissal of the complainability, oh no, and an acceptance, that’s alright (line 3).

Although the apology is promptly accepted by the patient, the surgeon initiates a non-minimal post-expansion of the apology-acceptance sequence in line 4 (Drew, 2012), pursuing reduction of complainability. The patient reassures the clinician, contesting the complainability of the lateness as she was minimally impacted due to her own lateness (Schegloff, 2005). The surgeon continues to provide an explanation for his lateness, with the patient acknowledging this (line 11). The surgeon commences clinical business with turn-initial so indicating the activity shift in line 13.

Apology + account for non-acceptance + explanation + acceptance = progression

Patients may choose to not accept an apology, which in this data set is achieved through provision of an account for non-acceptance. In order to progress the consultation, the surgeon works to either gain acceptance or reduce complainability. In Excerpt 3 the surgeon pursues acceptance of the apology by providing an explanation as to why they are running late.

Excerpt 3: Consultation 3 (MQ-CARM12-11) – Sequence 2

Following the consultation between the registrar and the patient, a consultant neurosurgeon joins. The registrar provides some handover to the consultant outside the consultation room, which is only very partially captured by the recording. The patient waits in the room alone for around five minutes during this time. Although the registrar has completed much of the consultation (Activities 1–4), the consultant re-starts the consultation. The surgeon walks in and shakes the patient’s hand and sits down. The patient is still off camera, with the video showing only the consultant. The registrar walked in with him and is in the consultation but off to the side.

Excerpt 3. Apology prior to the start of the consultation with second surgeon

The consultant enters the room, greets the patient, and provides an apology similar to that which he provides to the patient in Excerpt 1. The consultant begins with a complaint preemption, giving an apology, sorry, and then a reference to what the apology is for (lateness). While this is designed to preference progressivity, the patient self-selects to start speaking (line 6) resulting in a transitional overlap (Schegloff, 2007) and the excerpt unfolds into an extended apology sequence.

The consultant quickly abandons his turn, with the patient beginning with look i- i know (line 6). This is similar to i know in response to advice giving, as described by Mikesell et al. (2017, p. 272), with the patient acknowledging the need for an apology while also not accepting its action. The patient accounts for the non-acceptance of the apology by providing an explanation about his concern regarding the lateness, in which he assigns external parties as the reason for such concern. The patient designs this mostly in an objective way (Edwards, 2005; Pomerantz, 1986), focusing on the facts of the story. He includes only an elided reference to his subjective experience in line 17, where he comments on how the lateness has impacted his behavior. Given this is an interaction within a medical context where subjective experiences are not usually present within complaints (Edwards, 2005, p. 25), such an expression could be considered a deviant case. The past progressive tense used in this turn was just getting suggests the patient is referring to earlier action, so the account here is potentially regarding non-acceptance of the registrar’s earlier apology (see below, Excerpt 4) rather than his conduct within the current unfolding interaction.

The consultant offers a second apology in lines 18–19, using the same formulation as in lines 4–5, although this time it is in second position, meaning a response to the apology is not conditionally relevant (Robinson, 2004, p. 323). Again, the patient and consultant self-select at the transition relevance place after up, but this time the consultant continues and the patient abandons his turn. The consultant provides an account for the lateness, which places the onus on other patients needing more time. This implies a potential resolution in that this patient will also receive the time he will need. The patient quickly provides an affiliative response, i understand, to this account in line 23. The surgeon continues with his account by stating the importance of giving patients adequate time, and even provides a third apology (line 26). The third apology includes an agent in i apologise, which differentiates it from the previous apologies and makes forgiveness of the subject a more relevant next action (Fatigante et al., 2016). This is delivered in overlap with the patient due to a simultaneous start where the patient upgrades his affiliative response and dismisses the need for an explanation (lines 27–28). This is treated as acceptance by the consultant, who begins the transition to clinical business (and Activity 1) with turn-initial so (Bolden, 2009).

Apology + account for non-acceptance + reduced complainability = progression

Instead of pursuing acceptance, in the three remaining apology sequences, the participants work to reduce complainability of lateness sufficiently in order for the consultation to progress. This is achieved through provision of a solution.

Excerpt 4: Consultation 3 (MQ-CARM12-11) – Sequence 1

This excerpt is from the same consultation as Excerpt 3 and occurs earlier in the consultation, with only DR2 present. The recording captures the end of a conversation between the patient and their support person that occurs as the registrar fetches the patient from the waiting room and then as the patient and registrar they walk into the consultation room together. Once in the consultation room, the video only captures the registrar.

Excerpt 4. Apology prior to the start of the consultation

In Excerpt 4, the patient initiates a complaint sequence (lines 11–12), commenting to the registrar that he and his support person both have other appointments planned for the day. The patient starts this with unfortunately, indicating he has determined what is to follow is potentially problematic (Bonami & Godard, 2008). Rather than assigning blame to the registrar or the clinic, the patient comments on his own limitations regarding time.

The registrar’s response, initiated in overlap with the patient, begins with oh, followed by really produced with a questioning tone through the terminal upward intonation (line 13). While speaker transition between the registrar and patient is relevant following this, the patient does not respond and there is a short pause. The registrar then re-orients to this comment as being in the service of complaining given that lateness is something that can be complained about (Schegloff, 2005, p. 456). The registrar does this by offering an apology that includes a less negative characterization of the offense as a bit later (lines 13–14) while also including a sense of culpability of the team through the use of we are (Fatigante et al., 2016).

In lines 15–16, the patient gives a disaffiliative response; that is, one that takes a different stance to the registrar (Steensig & Drew, 2008, p. 9). This non-acceptance of the apology extends the complaint with greater specification as to the impact of lateness, while also shifting from the lateness itself to the reduced time now available for the consultation. This is responded to with a proposed resolution rather than an additional apology (line 17), which elicits no uptake from the patient. The registrar does not pursue acceptance, and, given that the proposed resolution occurs in a second pair part position, there is no interactional (or conditional) relevance for one (Robinson, 2004, p. 300; Schegloff, 2007, p. 20) and he moves on to the next part of the consultation, which brings the participants into the clinical business starting at Activity 1 (not shown).

Excerpt 5: Consultation 4 (MQ-CARM12-12) – Sequence 1

This consultation also includes two apology sequences, however this time they are delivered by the same surgeon. The recording includes both surgeon and patient in the frame, however it is relatively close-up, so body position is not always in view. The patient has been referred to a colorectal surgeon for discussion of a screening colonoscopy. Excerpt 5 occurs at the start of the interaction, prior to Activity 1, and is presented in two sections.

Excerpt 5a. Apology prior to the start of the consultation

The surgeon initiates an apology for being late on entering the room with the patient (line 1). In this he assigns fault to himself (rather than “we” or “the clinic”) as the cause for lateness, implicating the need for forgiveness for the offense (Fatigante et al., 2016). The surgeon makes relevant lateness as something that is complainable and the patient seemingly agrees with it being worthy of complaint with yes. The patient initiates a non-fitted resisting response that does not accept or reject the apology. This resistance calls into question the relevance of an apology as the patient offers a potentially acceptable explanation (or account) for lateness (bad day at surgery), which, if correct, could contest how complainable the surgeon’s lateness is and how warranted an apology would be (Schegloff, 2005). By doing so, the patient maintains the complainability of lateness without producing a disaffiliative turn (rejecting the apology).

At this stage, the surgeon has the option of accepting or denying the offered account. The turn by the patient, which ends in did you, is designed to receive acceptance in response. Such acceptance would reduce the complainability of the surgeon’s lateness and, thus, increase the likelihood of patient acceptance of his initial apology. However, the surgeon provides a disagreeing response (lines 4–6). Following this, the patient does not provide any additional acceptance or rejection to the apology.

Excerpt 5b. Apology prior to the start of the consultation

The surgeon initiates a new sequence with the turn initial so (line 10), which suggests he may have started to shift to a new activity (Bolden, 2006). Instead of moving into clinical business, however, he abandons this to comment on his lateness with i haven’t even looked to see how far behind i am. This comment implies that the surgeon has been too busy to even look at the time. The patient provides a literal response to the surgeon’s turn (line 12), which might be hearable as a complaint given the rhetorical nature of the surgeon’s comment (Drew & Holt, 1988). In the local context of the surgeon disagreeing with the patient’s earlier provision of what might have been considered an acceptable reason for lateness (Excerpt 5a), this complaint also serves as an account for the patient’s earlier non-fitted response to the apology as the surgeon’s lateness is still complainable. This is followed by laughter from the patient in line 14. Laughter can serve a variety of roles in interaction and in this context serves as a resource to manage a delicate action, which is her complaint (Edwards, 2005; Glenn & Holt, 2015). The patient offers an apology of her own in lines 14–15 and explains why the complaint was made (i’ve got kids).

Having maintained mutual gaze for much of the encounter so far, here the surgeon turns his gaze to the laptop and then to paper and pen and starts writing. The surgeon responds to the patient’s account for her non-response to the apology by pursuing more information (lines 16–17) but does so while looking away. This may mark the start of transition to a new activity (of taking notes while listening to problem presentation; Robinson, 1998), but again the surgeon abandons this and re-orients to the problem of lateness, looking at his watch then the patient while producing a gloss for confirmation about how far the patient needs to travel to get home on time (lines 21–22).

The patient responds by dismissing the lateness as a concern, which is produced with waving-away hand gestures, effectively reducing how complainable the surgeon’s lateness is (lines 23–25). The surgeon provides a solution in lines 26 and 29–30, and the patient attempts to collaboratively complete this with as it needs in line 31 (Local, 2005), demonstrating a shared orientation to a resolution of the issue of lateness as it pertains to the ongoing progressivity of the consultation. The surgeon uses a modified-repeat phrase of as i need to the patient’s as it needs, possibly to assert responsibility over that claim (Stivers, 2005). While the initial apology does not receive a response, the shared orientation to a resolution reestablishes intersubjectivity so that the participants can transition to clinical business, with the surgeon moving onto Activity 1 in line 33.

Excerpt 6: Consultation 4 (MQ-CARM12-12) – Sequence 2

Later in this same consultation the surgeon offers another apology. This occurs toward the end of the consultation, in which the surgeon has completed all other activities and is moving to pre-closing. Just prior to this the surgeon has suggested the patient see the clinic nurse directly following the consultation to organize a time for a procedure.

Excerpt 6. Apology in the pre-closing sequence

At the end of Activity 5, the surgeon comments that the procedure is non-urgent (line 1). Since the referred problem has been resolved and explanation and agreement have occurred just prior to this excerpt, closing the consultation is the next relevant activity. This sequence, then, could be a potential pre-closing, with the surgeon re-iterating the non-urgent nature of the planned procedure and the patient accepting this with yeah and then providing an enthusiastic assessment of fantastic (line 5). The bridge between the acceptance and the assessment, alright, indicates a shift toward closure (Filipi & Wales, 2003; Gardner, 2001) as it occurs in what is a closing relevant environment following the discussion of next steps with the patient (Robinson, 2001).

The surgeon initiates a new sequence in which he apologizes for being late (line 6), which occurs while he moves slightly away from his desk and starts to collect together the paper that is on it. The apology itself is this time designed with a more generalized cause for the lateness, we, directing complainability away from the surgeon and toward more systemic, yet unidentified, causes (Alibeiki et al., 2021). The patient begins to produce a response, which may have been designed to accept the apology (line 6), however the surgeon overlaps this, first with a statement that is abandoned and then with a question that is designed to elicit information about whether the patient has sufficient time to return home for the arrival of her children (line 8), attending to the impact of seeing the clinic nurse prior to leaving.

The patient confirms that there will be sufficient time with a minimal yeah. This is followed by a repeated that’ll be fine (line 10), dismissing the complainability of the lateness (Schegloff, 2005). While the apology is not accepted, it is rendered unnecessary due to this reduction in complainability which began at the start of the consultation and then ended in dismissal of complainability by the closure of the consultation. Given the apology was not accepted but the lateness was still complainable at the beginning of the consultation (Excerpt 5), it may be that the surgeon chose to use the apology in the pre-closing space to resolve the patient’s concern about his lateness.

Discussion

We found that apologies for lateness are infrequently provided by surgeons. Doctors frequently run late to appointment starting times for a multitude of reasons, yet there are so few apologies. We argue that this is because the standard social contract of punctuality is modified in medical consultations. The participants are orienting to different conversational norms in which doctor lateness is more acceptable and so there is less interactional need for them to apologize.¹

Participant orientation to reduced accountability of lateness for surgeons in consultations is demonstrated through infrequent occurrence of apologies as well as patient reference to their own time constraints and/or system-related reasons as to why lateness was a problem, provision by surgeons of explanations or solutions only when an apology was not accepted, and, progression to the next activity with reduced complainability rather than also requiring acceptance of the apology.

With a view to understanding the impact of lateness on both intersubjectivity and progressivity of the consultation (Raymond, 2016), we can see several different ways in which the participants (re-)establish intersubjectivity following an apology for or complaint about lateness and how this allows them to progress the consultation. There are three different ways this occurs in this data:

1. Apology + acceptance = progression

2. Apology + account for non-acceptance + explanation + acceptance = progression

3. Apology + account for non-acceptance + reduced complainability = progression

A patient’s response to an apology can indicate their orientation to the degree of complainability of the doctor’s lateness. Two of the five surgeon-initiated apologies for lateness were directly accepted by patients. These acceptances included contestation of the complainability of lateness and allowed the consultation to progress to the next activity. Although other survey-based studies found apology + excuse formats (Mroz & Allen, 2017, 2020) receive more favorable responses, in this data the initial apologies were offered simply without an attendant excuse, explanation, or resolution. These were only provided if the sequence was extended.

While there are few apologies across the data set, there are fewer complaints. One of these was patient-initiated and two others were within accounts for not accepting an apology for lateness. The low occurrence of complaints and the nonoccurrence of rejections of apologies may be due to the aforementioned modification of norms regarding acceptability of lateness as well as the power imbalance between a treating doctor and their patient (White, 2022). That is, there are differences in the interactional and institutional relevance of complaining about lateness in medical settings (Edwards, 2005).

The accounts here are designed not so much as to elicit an apology but to bring attention to the time limitations that are now placed on the consultation due, in part, to their lateness but also to the patient’s other commitments. The accounts focus not on the patient’s feelings or on the surgeon’s social transgression of lateness, but instead on facts (Edwards, 2005; Pomerantz, 1986); the practical implications of lateness.

In consultations where there is an account for not accepting an apology, the consultation seemingly cannot continue to the next activity without acceptance of an explanation or resolution by the patient. This is particularly evident in Consultation 3. In the first sequence (Excerpt 4), the patient initiates the complaint. When the registrar responds with an apology for lateness, the account for not accepting the apology is extended until a proposed resolution is provided. This is similar to the second sequence (Excerpt 3) in which the patient again extends his account following the consultant’s apology until an explanation and implied resolution is offered.

From these findings, surgeons can consider how they approach their own lateness within the consultation and how they might respond to patient complaints. The nature of medical work makes lateness a frequent occurrence. This lateness may be expected by both doctors and patients, however doctors have more institutional access to understanding the multitude of reasons why lateness occurs. Lateness impacts patient satisfaction (Eilers, 2004), though there is evidence to suggest that patient satisfaction is more greatly impacted by time spent within the consultation (Anderson et al., 2007), and as such a balance needs to be struck between spending time with patients and reducing patient wait times.

As patients are dependent on doctors for diagnosis and treatment, a power imbalance is generated (Robinson, 2006). This power imbalance in the surgical interaction may contribute to the lack of apologies (Landmark et al., 2015; Robinson, 2006; White, 2022). In addition to a clinical power imbalance, there may be greater expectation from participants that doctors have more control over the clinical interaction itself (Stevanovic, 2015; White, 2022). As such, while patients may desire an apology at the start of the consultation, if it is not provided there is likely less opportunity to pursue one in the face of the doctor commencing clinical business.

This is also reflected in how doctors’ lateness is often reframed in academic literature as “patient waiting times” (Anderson et al., 2007; Eilers, 2004; McIntyre & Chow, 2020). While there are both individual and systemic issues that impact punctuality, there is less emphasis on the doctor as an institutional representative to be accountable for lateness. Patients are the ones that wait rather than the doctors being late.

Structuring systems to support respectful care is one component of person-centered care (Santana et al., 2018). While lateness might be considered a natural part of such systems in practice, being late can negatively impact the therapeutic relationship. As apologies can facilitate the reestablishment of trust between the doctor and patient (Dahan et al., 2017), they contribute to a broader approach of person-centredness in the context of a dynamic and complex system. Apologies themselves can be designed in a way that further prompts person-centredness, with acknowledgment of responsibility (e.g., Excerpt 2) or accommodations to ameliorate the negative impact on the patient (e.g., Excerpt 6).

The major strengths of this study lie in the format of the dataset (recordings of naturally occurring consultations) and the application of conversation analysis. Recordings can help increase the accuracy of observation as they can be rewatched and reviewed an unlimited number of times. Recordings preserve the sequential organization of the interaction, with video providing access to embodied action, and so allowed us to observe not simply whether apologies were present, but how they were co-constructed by the participants, enabling observations regarding participant orientation to the normative acceptability of surgeon lateness and how it plays out interactionally.

As a secondary analysis there were limitations as additional data regarding patient waiting times, travel times, clinical urgency, and additional activities on that day were not collected. Similarly information about the surgeon’s competing demands and clinical experience was not captured.

Future research in this area can potentially identify or confirm whether certain characteristics can impact how lateness is managed interactionally. Designing studies with specific inclusion and exclusion criteria regarding demographic information as well as information about training and experience and whether there is an existing therapeutic relationship, may allow for greater understanding of why doctors infrequently apologize and why patients rarely complain about lateness. An intervention-evaluation study could be developed with training of surgeons to provide an apology plus explanation/resolution for their lateness and observation of how this impacts their consultations.

Conclusion

Apologies for lateness, although infrequent, bring patients and surgeons back to a more equal footing following a breach in the social contract of punctuality. They demonstrate a person-centered approach through an orientation to this breach and validate the impact of lateness on the patient. There are social obligations and expectations of a doctor, and these include competence and accountability (Cruess, 2006). When a doctor is running late, they can orient to the potential complainability of lateness by providing an apology. If this is met with resistance rather than acceptance, the doctor can then provide an explanation or propose a resolution. The offering of an apology with an explanation or resolution can be understood as the doctor accepting accountability for lateness, even if lateness for medical visits is considered less socially problematic than in everyday interactions.

Acknowledgement

We thank the participants for allowing us to record, store, and analyze their consultations. We also thank Antoinette Pavithra for collecting some of the data in this collection. Data is stored in the Clinical Communication Database at Macquarie University (approval # 520221087241397).

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The authors reported there is no funding associated with the work featured in this article.

Notes

1. As one anonymous reviewer commented: “the participant orientation to non-acceptance of doctors’ apologies for lateness point to quite marked normative pressure to absolve doctors of culpability in these contexts”.