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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
The disrespect issue is deeper and more complex than doctors realize
Another Reason: Shaming/Hexing
USA/Mexico border no-shows in pediatrics
Why They Don't Show Up
Open Access Scheduling not equal to longer waiting room time
Small sample size limits any major conclusions
reverse no show
Timeliness and respect
Access
Delay
It's all about delay
"Why We Don't Come" and "How can I treat you if I can't see you?"
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C Reed, Lake Panasoffkee, FL USA Medical Research
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Re: "Why We Don't Come: Patient Perceptions on No Shows" The "disrespect" issue discussed in this article is deeper and more complex, and telling, than doctors realize or choose to acknowledge or choose to address. For 54 years, I have been in doctor's offices. Without exception, doctors have been to me cold, aloof, angry, indifferent, rushed, inconsiderate, uninformative, uninformed, lazy, sloppy, kept me waiting for excessive periods and never apologized, possessed the nerve to never once give me a full battery of endocrine or up-to-date thyroid & adrenal tests, yet dozens of doctors proceeded blindly and ignorantly to prescribe thyroid medication in dosages they GUESSED, none asked nor discussed the nutritional factors about my diet which is a highly contributory element in endocrine function, nor did they question or test for the existence of fungi, mold, parasites, yeast, allergies, chemicals, sugar, and other hormone disruptors or blockers. These people are not practicing "medicine", they are not "healers", they are incompetent, lazy losers who do not deserve a license to practice medicine. Each A.M.A. trained medical doctor ignored me as a person and as a potential friend. None ever sent me a holiday or birthday card, despite the fact that these could be deducted from business expenses, making them free, and go a long way towards cementing a physician-patient rapport and relationship. Not one doctor bothered to address the 100+ symptoms of hypothyroidism, notice them, acknowledge them, or care about how I was coping with them. They took no time to explain anything to me ever. They never went to a book or a computer to research any factor of my health. They never took time to explain side-effects of medicine they prescribed and generally they were rushing out the door when I had to call down the hallway prescription details, like should I take the meds on full or empty stomach, etc. How SAFE are doctors like this? It is 2005. In 1997, I saw an internist for natural (like, Armour Thyroid) thyroid medicine. She did the usual useless blood test and proceded to prescribe Synthyroid, an overpriced bit of garbage which contributes to osteoporosis, is entirely inadequate for correct hypothyroidism symptoms and which the manufacturer offers gifts and goodies to doctors who push this drug on patients. I refused it quietly and politely, she ordered me to sign-off the chart and not to be her patient anymore. She walked me to the waiting room where in front of patients and staff she broke ethical rules and God's by lying when she said to get revenge on me, "YOU HAVE ONLY 6 WEEKS TO LIVE!" in a loud, nasty, patronizing tone. I wasn't scared. I was obviously right. In 2000, a doctor claimed I had to have a certain medicine which I admitted I could not afford. A year's worth is on my credit card plus shipping since it was from out-of-state. It didn't help me and I'm still paying for it plus excessive interest. Does he care? Did he ever apologize? Was he even willing to discuss what went wrong? No, he blamed me. Allow me to add this: He insisted I purchase a specific fat medical book in medical terminology fit only for trained physicians to understand, and, this book involved a very complex protocol to follow. He did nothing except collect his chunky fee. He blamed...ME?! My current endocrinologist received a couple of calls from me asking for his secretary to call in a renewal on my Armour Thyroid. I added I was having car troubles, am only on S.S. Disability and can't afford parts and his office is 2 counties away without any bus service or anyone to drive me. He chose the cowardly route, not to return my phone calls personally but to send me a note dated Feb. 7th (it's April) TELLING me I must make an appointment. I already know it's for one of his usual 5- second "exams" which is no more than an excuse for him to send Medicare an excessively fat bill for doing nothing. He deserves respect for holding my prescription "hostage" to force me into his office despite no transportation? Where's his heart? In his safe deposit box? Instead of playing his cruel game, I've read 140 allopathic and naturopathic medical books and I'm eliminating the need for him and his damned prescription pad, I'm healing myself via the Lord & nutritional foods. I recommend it to all patients. The basic difference between allopathic and naturopathic is this: Allopathic treats symptoms of diseases only. Naturopathic seeks to heal the whole person and their diseases. A.M.A. doctors are taught ONLY allopathic medicine. N.D.'s are university educated naturopathic physicians who receive superior training. Regarding the endocrinologist: Last year, I addressed diet, fungal, & yeast issues. I proved to him via blood test, weight scale (down 15 lbs. in 1 mo.), and physical exam that I was correct and he wasn't. He was shocked. He finally admitted, "Your thyroid is active again! How did you do it?" I told him the book "The Fungus Link" by Dave Kaufmann and Dave Holland, M.D. (www.knowthecause.com) and followed that up with a note in case he forgot. Six months later I returned, I asked if he and his doctor wife had read it. I got an angry response, "We don't have time to read books!" And apparently you don't have time to HEAL PATIENTS. THE FACT IS THIS, MOST M.D.S DESPITE THEIR COCKER SPANIEL EXPRESSIONS OF CONCERN DON'T CHOOSE TO HEAL A SINGLE PATIENT. MERELY KEEP THEM SICK ENOUGH TO KEEP COMING BACK WITH THEIR FAT WALLETS IN HAND. AND PEOPLE WONDER WHY WE PATIENTS DON'T RESPECT THEM ENOUGH TO KEEP APPOINTMENTS? WHAT ABOUT THEM IS THERE WORTHY OF RESPECT? Let me tell you: I sent a note to the head doctor of the Allergy Department of the University of Florida in Gainesville asking a few simple medical questions and asking if I should make an appointment. THIS IS WORTHY OF RESPECT: He personally telephoned me at 8 p.m. answering my questions with enormous sensitivity and he added that I don't need an appointment. I sent him a thank you note. He phoned again to say hello. We've never met. THIS GENTLEMAN IS SIMPLY THE FINEST MEDICAL DOCTOR I HAVE EVER KNOWN AND THE ONLY ONE WHO HAS EARNED MY RESPECT BECAUSE...HE CARES MORE ABOUT ME AND MY HEALTH THAN MAKING A BUCK. PATIENTS: IF YOU CAN'T MAKE AN APPOINTMENT WITH A PHYSICIAN YOU HONESTLY RESPECT, DON'T BOTHER WITH ANY OF THEM. PRAY. READ BOOKS. LEARN HOW THOUSANDS OF YEARS OF HEALTHY PEOPLE AROUND THE WORLD HEALED THEMSELVES AND LIVED TO BE OVER 100. START WITH: "NOURISHING TRADITIONS" BY SALLY FALLON & MARY ENIG, PH.D, www.WestonAPrice.org, email: SAallon@aol.com. LEARN WHY DOCTORS STARVED PRIOR TO THE 1950'S. PEOPLE DIDN'T NEED THEM AND NOBODY RESPECTED THEM. THEY CAN READ THE BOOKS I READ TO HEAL PEOPLE, BUT ASK YOURSELF WHY THEY WON'T. C. Reed 4/28/05 Competing interests: None declared |
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k.c. dillon, usa diagnostic medical sonography candidate
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I came to a medical career late in life, but have been overweight since childhood. I cannot tell you exactly the percentage of medical problems that have been blamed on my weight, but I CAN verify that I have no comorbidities other than my obesity----BP good, lipids good, BG good, etc. I've been told that if I lost weight, I would get fewer sinus infections, fewer colds, have fewer migraines, my bronchitis would resolve faster,my pregnancy outcomes would be better (yet it's hard to know just how much better 9 out of 9 on the Apgar scale x 2 pregnancies could be), etc . I've also been told "If you don't lose weight, you will never make it to age 40." I'm 49 now and going VERY strong. My point is that the medical establishment needs education on the multifactorial causes of obesity, and more importantly, needs to focus on a "health at every size" paradigm. Differentiation also needs to be made between causation and correlation in the sequelae of obesity. And when you publish shameless and excoriating articles such as Dr. George Lundberg's recent screed, you demolish at least some of the progress made in encouraging overweight and obese patients to come for treatment. Since they don't come in, their conditions (including mobility problems) worsen. They need help, not a lecture. If the lectures (or the diets) worked, I would have weighed 130 pounds my whole life. Perhaps a scoring system including lipids, BG, HTN screening, nutrition (and nutrition education), cardiovascular fitness, exercise regimen, etc., would be a better tool to assess the health of all patients of every size. Thank you for listening. Kathleen Comalli Dillon Novato, CA Competing interests: None declared |
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Jamie F Jamison, El Paso, Texas, USA PNP
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Largest USA/Mexico border city:In our corner of the world our no- shows are followed up by phone. We have 2 full time pediatricians and one 1/2 time PNP (me). Most of our patients/families have medicaid. "Weather", lack of convenient private transportation and Fridays are the biggest problems. Interestingly we live in a desert climate so "weather" can mean a drizzle or temp below 50! The heat doesn't keep them away, nor does Monday. We do have public buses and the office is on the route. I was puzzled by the pattern I perceived SO I did an ad hoc survey of the no-shows in our practice (and also because I was hoping to make a case for switching my day off from to Monday). This community has a tradition of every other Friday payday for most hourly wage earners, BUT it is every Friday for the no-shows... it is also the traditional day for EVERYONE under 40 to party....as further noted by the increase in traffic and traffic accidents.....I am NOT a native of this area so the patterns are interesting.... Hmmmmm Competing interests: None declared |
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Anonymous Doe, WA USA physician
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I have an alternate explanation for the failure of these patients to show up for appointments. They do not value their medical care because they have it handed to them as a right rather than a service they purchase with their hard-earned dollars. I suspect that many or most of the patients who repeatedly miss appointments (minus those with transportation issues) have not worked a day in their lives, and the concept that others have to earn a living is as completely foreign to them as it is to a sheep that recieves it's food, shelter and medical care without active participation. I would venture to guess that most of them don't have much respect for themselves, so why on earth would they respect anyone else. I would suggest sending them a bill for missed appointments, just like those of us in the real world get, or charging them double to be seen next time. I bet some consistantly reinforced negative consequences for bad behaviour would alter that behaviour pretty darn quick. Competing interests: None declared |
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Nicholas J. Batley, Beirut, Lebanon Family Physician, University of Balamand
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As the authors point out, Open Access Scheduling, when implemented properly, should cut down appointment lead times significantly – clinics will be doing “today’s work today”. The authors, however, seem to be making the mistaken implication that because the patient will have access to an appointment on the same day or within twenty four hours, they will necessarily spend more time in the waiting room. Open Access does not equal, first come, first served; it simply reserves appointment times in the clinic’s schedule for patients who desire to be seen by their provider on the same day as the request for an appointment. For example; if a patient calls at 8am, the clinic will have protected appointment times in their schedule for just such a patient. The patient would then be given one of these specific appointments, say 11am or 2pm. Of course the patient could still no-show, but the concept behind Open Access is that they are profoundly less-likely to no-show than if they were given an appointment 5 days hence. How long the patient spends in the waiting room depends on other factors in the clinic’s work flow, and is actually likely to be better under Open Access because of the avoidance of over-booking and other techniques clinics employ to try to compensate for their no-show rate. Thank you for your time and consideration. Sincerely, Nicholas J. Batley, M.D. Competing interests: None declared |
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Michael V. Kline, West Hills, USA Emeritus Professor of Public Health; California State University, Northridge
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Interesting article but not too much new discovered related to voluminous studies in the field on this topic. I was also disappointed as to the large amount of space given to this article and its findings with regard to the very small N that was used and the tremendous difference in the N between sexes. Competing interests: None declared |
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sharon l johnson, annapolis md usa retired medical school professor
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As a patient, I've had doctors that cancelled my appt abruptly on the day of the appt, despite the fact that they were in their practice that day seeing patients, and reminder calls were made the previous day concerning that appt. I've never been a no show. I travel 50-60 mi for doctor appts. The driving is difficult and slow for me due to my narcolepsy. The impact on my health on those no shows was considerable in one case, annoying in the other. As a result of physician cancellation, the issue of a recent test to evaluate need for supplemental oxygen did not get discussed, and that test timed out in terms of qualification for O2. More delay, another mailed test prescription, etc etc, more money spent by patient for testing, etc., all of which was unneccesary. No real reason for abrupt cancellation given. This reverse no show, and the other with another physician, both practicing at one of the Best Hospitals, has left me distrustful of those two practitioners, one of whom is highly specialized. It is not easy to switch doctors in this situation, or to go elsewhere, because the scarcity of physicians nationwide specializing in the type of lung disease that includes my rapidly progressive fatal lung disease. The most likely solution for me is to fly many miles to the best respiratory care hospital in US, where patient care in this particular field has higher priority, and which showed much greater ability to communicate with patients during my second opinion visit there. Competing interests: None declared |
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Elaine H. Menard, Rochester, N.H. consumer
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As a consumer of medical services, I read this article with interest. I access primary care through my family physician. He is part of a medical practice that is affiliated with our local hospital. The hospital here has set up several primary-care/internal medicine and specialty-care practices. One of the things I like is the ability to access my physician for a visit when I'm acutely ill. My other health concerns are addressed on a regular basis with appointments in advance. In the rare case when my physician is off for the day and I need an appointment, I'm able to get in to see one of the other professionals. When I was with a different medical practice two moves ago, I can recall contacting the office because I was sick. I was too sick to work and I knew that what I had required antibiotics, but was told that I couldn't get an appointment for several days. I asked, incredulously, "Even though I'm sick?" and was told, as though it was a normal occurence, "Yes." Such an inefficient system encourages doctor-hopping within a practice as well as from practice to practice. One's physician who is aware of acute illness might also make the connections to other psychosocial influences in a person's life. Such connections also make a patient more likely to trust his/her doctor. It gives the patient an incentive to return to see the same physician over time. The doctor is also making an investment in the doctor-patient relationship which goes far beyond a single visit made for a sinus infection. Respect of the patient and timeliness in addressing both the acute and chronic illnesses of said patient are important and must be taught early in the education of doctors. Consider this...how would you feel if you called the local repair shop, one that you've used before, because your car is broken down and it isn't something you can fix at home? You call the shop and are told that it will be several days before they can even look at your car even though the sound coming from the car is an ominous clunking and you are blowing black smoke. You feel very scared about driving the car anywhere but you still need to get to work. You end up either hoping it will hold together until you bring it in to the shop or you call someone who can get you in right away. It turns out it's not anything too serious and you leave that shop relieved. In the future, you might be tempted to call the shop that could get you in right away, takes your concerns seriously, and does their best to help you. In the world of economics, better customer service wins over the consumers who pay for services. Car mechanics make good money and are worth every dollar paid. Doctors, in one sense, are body mechanics---concerned about regular mantainence as well as fixing the breakdowns to their best ability. It isn't all about mechanics however. It is also about good customer service. Competing interests: None declared |
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Michael L Davies, Whitewood, USA Physician - VA
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Audry, Yes. VA has taken on the whole issue of improving access in a big way. It can be a "journey" to change a practice to improve access, but it is a journey of improvement well worth it. IHI (Insitiute for Healthcare Improvement) also has (or can connect you with) expertise to improve access in practices. In my experience in VA, when access improves, no- show rates go down. In addition to waiting, one of the second biggest drivers of no-show (and cancel and reschedule rates) in VA is the scheduling system. When we create a system that schedules return appointments at a time closer to when they will actually occur (the "Dental Model", or "Recall Scheduling" system), no-show rates go down. In addition, as you mention, "closure of the visit" by the provider is critical to reducing no-shows. I think we need more research into the effects of all of these things. Thanks for doing it! Mike Davies Competing interests: None declared |
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Audrey Paulman, MD, MMM, Omaha Family Practice
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I agree that the delay is a large problem. One of the clinics in our system has gone to open access scheduling to prevent that increase in fear with increased wait time until appointment. It has reportedly decreased the no-show rate. Michael, I see you are at the VA system. Have they tried programs to decrease the wait? Competing interests: None declared |
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Michael L. Davies, Whitewood, SC, USA Physician/ VA
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I admire your willingness to study a common problem and look for the root causes. What I see in your report is not necessarily 3 "root causes" of delay (Emotional Barriers, Disrespect, and Lack of Understanding of Scheduling), but more like 1 main "root cause": DELAY. Delay is a common thread to each of the 3 you identified. Patients are upset when they feel urgency to schedule and are put off by the sytem; they feel disrespected by staff who "don't care" (enough to get me in soon), and have their "feelings" hurt when they have to wait. Finally, the lack of understanding of scheduling is at it's heart a triage system necessary because providers have to sort work (triage) anytime there is delay.... So, in my view, it's all about dealy and the answer here is to improve access to care - which will translate into less fear, more respect, and simpler scheduling. Mike Davies Competing interests: None declared |
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Audrey Paulman, Omaha, USA Family Medicine
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The research was performed in an inner city, university based clinic. This clinic population consists of many people in the lower socioeconomic group. Health disparities are well described in the literature. In the National Healthcare Disparities Report it is noted that "people of lower socioeconomic status and racial and ethnic minorities have in the past experienced poor health and challenges in accessing high quality health care." http://www.house.gov/reform/min/politicsandscience/pdfs/pdf_politics_and_science_disparities_rep_summ_final.pdf In this research, we have tried to give these patients a voice. In family medicine, we are uniquely qualified to help reduce the disparity through understanding access, providing compassionate care, and education. I would be interested in hearing about successes in helping patients successfully access care. Competing interests: None declared |
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