Reduction and Management of No-Shows by Family Medicine Residency Practice Exemplars

Bradley J. Johnson; James W. Mold; J. Michael Pontious

doi:10.1370/afm.752

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Ideal number of patients per resident per session = ?
Andreas Cohrssen

Published on: 13 February 2008
Re: Asking the patients
James Mold

Published on: 26 November 2007
Our Strategy for Reducing No-Shows
Bradford T. Winslow

Published on: 26 November 2007
When in doubt, ask the patients
Paul A. Lazar

Published on: 22 November 2007

Published on: (13 February 2008)
Page navigation anchor for Ideal number of patients per resident per session = ?
Ideal number of patients per resident per session = ?
Andreas Cohrssen, New York, NY
Other Contributors:
On a different note- We want to take issue with the assertion that the educationally ideal number of patients for the entire residency practice should be 8-10 patients per session.
We could not find evidence to support an ideal number of patient visits to support an educationally excellent environment.
From our experience we calculated a lower number.
Our assumptions:
Session length...
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On a different note- We want to take issue with the assertion that the educationally ideal number of patients for the entire residency practice should be 8-10 patients per session.
We could not find evidence to support an ideal number of patient visits to support an educationally excellent environment.
From our experience we calculated a lower number.
Our assumptions:
Session length 4 hours (though many residencies have sessions of 3 or 3.5 hours).
Suggested encounter duration: 20 minutes for attendings. (Kaiser has looked at provision of high quality care and is supposedly benchmarking this number to meet their quality goals).
Time for education: 25% of encounter time, varies by resident year.
Minimum number to be seen by PGY-1: 4 patients per session, PGY-2: 6 patients per session, PGY-3: 8 patients per session.
Our goal is to have residents start at the minimum number and get to minimum plus 2 by the end of the PG- year.
The calculation:
Number of sessions: PGY-1: one session (sees between four and six patients per session), PGY-2: two sessions (sees on average 7 patients), PGY-3 three to four sessions = 3.5 sessions (sees on average 9 patients).
The sum of all visits divided by the 6 ½ sessions =
(1x5 + 2x7 + 3.5x9)/6.5= 7.77
This is lower than the 8-10, even though the assumptions were generous (full 4-hour session, exceeding the minimum requirements).
We suggest that increasing the expected per session visit numbers may lead either to a reduction of the education time and/or may impact the quality of care provided.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (26 November 2007)
Page navigation anchor for Re: Asking the patients
Re: Asking the patients
James Mold, OKC, OK
I couldn't agree more that we should try our best to understand no- shows from the patients' perspectives though this was not a strategy mentioned by the exemplars. In my experience, a simple questionnaire wouldn't be sufficient to get to the real issues. A great deal of very fascinating work has been done in this area with patients visiting EDs for non-emergent conditions. After reading that literature a few years ago,...
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I couldn't agree more that we should try our best to understand no- shows from the patients' perspectives though this was not a strategy mentioned by the exemplars. In my experience, a simple questionnaire wouldn't be sufficient to get to the real issues. A great deal of very fascinating work has been done in this area with patients visiting EDs for non-emergent conditions. After reading that literature a few years ago, I came away reminded that most people really do tend to make choices that look entirely rational once you understand their circumstances.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (26 November 2007)
Page navigation anchor for Our Strategy for Reducing No-Shows
Our Strategy for Reducing No-Shows
Bradford T. Winslow, Denver, CO, USA
Drs. Johnson, Mold and Pontious have written a useful article about a common problem in primary care. Our residency practice was able to decrease our no-show rate from approximately 18% to 10% using most of the practice strategies mentioned in Table 2. We created a No-show Committee, which developed a plan and then met monthly to track results. We found that an automated reminder calling system for all appointments and...
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Drs. Johnson, Mold and Pontious have written a useful article about a common problem in primary care. Our residency practice was able to decrease our no-show rate from approximately 18% to 10% using most of the practice strategies mentioned in Table 2. We created a No-show Committee, which developed a plan and then met monthly to track results. We found that an automated reminder calling system for all appointments and a personal reminder call for longer appointments, including well-child visits, complete physical examinations and procedures, was particularly effective. The concept of the negotiated follow-up interval is intriguing, and we may explore that option in the future.
Bradford Winslow, MD
Competing interests: None declared
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Competing Interests: None declared.
Published on: (22 November 2007)
Page navigation anchor for When in doubt, ask the patients
When in doubt, ask the patients
Paul A. Lazar, Flint, MI, USA
This is a fascinating look at an age-old problem in Family Medicine education.
As a resident, I practiced in two different FPC's, one community based (close to the residences of most patients) and one located on the campus of the hospital. Like all the residents who practiced at both sites, I noticed a huge difference in no-shows. The residents had all kinds of theories about why this was. Both practices served...
Show More

This is a fascinating look at an age-old problem in Family Medicine education.
As a resident, I practiced in two different FPC's, one community based (close to the residences of most patients) and one located on the campus of the hospital. Like all the residents who practiced at both sites, I noticed a huge difference in no-shows. The residents had all kinds of theories about why this was. Both practices served mostly low-income people, but one was free while the other charged a low flat fee, and had a lower no show rate, which many attributed to the theory that "people value what they pay for." There was a difference in the ethnic background of the majority of patients served at the two sites, unfortunately a source of many comments which must have been later regretted.
For me, the issue became clearer one day when I heard shouting from the area of the front desk. Thinking I recognized the voice of one of my favorite patients, I went out to the front. The patient showed me his twice-stamped and much crumpled transfer slip from the transit authority. It provided clear proof of the three frustrating hours he had spent trying to get to his appointment, for which he was now an hour and a half late. I agreed to skip lunch yet another time and see him.
In the ecology of the underserved, transportation is only one of many barriers to access. Staff have a lot of information about the no show rate, but the patients have the most information about the causes. If all else fails, ask the patients.
Competing interests: None declared
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Competing Interests: None declared.