Why We Don’t Come: Patient Perceptions on No-Shows

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

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

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

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

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

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

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

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