The doctor will see you now, or will she?

My friend breathed a sigh of relief as she finished her last clinic visit for the day and headed down the hall to the physician workroom.  It was only 5pm.  She still had notes to write and labs to check, and as a senior resident she needed to make it back to the hospital wards to check on her team’s interns, to get updates on the afternoon’s events and help them finish any of the work that remained for the day.  But still.  Most of her patients had shown up and she had been able to give all of them thoughtful, thorough care.

The resident clinic at our program has a relatively high no-show rate.  The majority of our patients belong to an extremely underprivileged, underserved population, and oftentimes their resources are so limited that even making an annual trip to the doctor’s office is a nearly insurmountable task. If patients’ parents have jobs, they often have trouble securing time off in order to attend appointments.  Most don’t have cars, and wrangling several children through several transfers on the city bus can prove not only logistically but financially challenging.

Winters in New England don’t render the task any easier.  As a result, out of the six patients booked for each resident’s morning clinic sessions and the eight for each of our afternoon sessions, we may seen anywhere from two or three patients to the entire scheduled panel.  Or even more, as parents often show up with a sibling of the scheduled patient, requesting that he or she been squeezed in for a sick visit or vaccines or because his or her asthma has been acting up.

Of course, as Murphy’s Law would have it, the days on which every patient shows up are also the days on which every patient has a laundry list of problems and at least half require an interpreter, further slowing the process of attending to each patient’s needs.

As my friend entered some last labs and prescriptions, the front desk called to alert her that one of the patients on her schedule — one she had never met before, whose entire medical history would need to be explored and reviewed — had been in the clinic waiting room for over an hour but had never checked in; would she still be able to see him today?

Late patients represent a huge source of frustration among physicians practicing outpatient medicine.  They disrupt the flow of an already tightly packed schedule, making it impossible to dedicate the amount of time, energy, and focus to each visit that every patient deserves.  They also present a conundrum to which there is no clear answer: Should physicians patients who arrive late, despite the inconvenience to the provider and the other waiting patients; or should they ask tardy patients to reschedule, thus risking that they do not keep the new appointment and get the care that they need?

During medical school I worked with a physician who had a ten-minute rule: Patients who showed up more than ten minutes after their appointment time would need to reschedule.  It sounded harsh, but she was very open about the rule and the reasoning behind it. When she was a medical student, she had once been late to an appointment for a haircut because she had been studying.  The hairdresser had refused to accommodate her that day, explaining that her time was not more valuable than the hairdresser’s own.    The doctor agreed, and felt the same way now: Her time and her patients’ time were equally valuable.  Each should be held responsible for adhering to the obligations of their schedule.

And yet.  When your patients are not middle- and upper-class car-owners who are able to make accommodations to take time off from work, and who, if they are late and need to reschedule, will do so and almost assuredly attend the subsequent appointment, do — should the rules change?  When children miss three appointments for well-child checks in a row, leaving them behind on vaccinations and screenings for developmental delay, and sacrificing opportunities to provide education and anticipatory guidance to the parents who are raising them, is it inappropriate to try to — and incorrect to believe that we will –“teach them a lesson,” in a manner of speaking, by holding fast to such a rule?  Should we gratefully seize any opportunity to see them, no matter how late they arrive and how many other patients, both in our clinic and back up on the hospital wards, we may be neglecting in order to accommodate them?  Or does such lenience only exacerbate the problem by sending the message that it is not necessary to arrive on time for an appointment, that patients are free to come and go at their own convenience?

And in my friend’s case, does it make a difference that her patient had been present since the appointed time but lacked either the knowledge or experience to know how to check in appropriately?  At the same time, isn’t it fair to expect people to take some amount of responsibility in the process of obtaining care, including asking for help if they are unsure how to proceed?

I don’t have a good answer to these questions, and I find that my own leanings change according to the day and the nuances of the situation.  But I’m interested to hear others’ own thoughts and the practices they adhere to or have encountered.  And most of all, I’m striving to figure out: Is there some happy middle ground?

Rebecca E. MacDonell-Yilmaz is a pediatrics resident who blogs at The Growth Curve.

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  • buzzkillerjsmith

    The answer is that there is no answer.

    That said, most docs pull the plug on this sort of practice as soon as they are able–usually the last day of residency.

  • NewMexicoRam

    15 minute rule for me.
    They reschedule, or if really ill, have to wait for another open slot in the day, or until the end of the day.
    I only have one chance in this life with my kids, and I’m not going to miss it if I can help it.

    • Dr. Cap

      Amen, NMR. No shows drive me crazier though, since a patient running 15 minutes late is usually on time for me. But the patients who don’t show and don’t call is wasting the patients time who is waiting weeks for an appointment. And somehow the patient who gets screwed almost assuredly has cancer.

  • Dr. Drake Ramoray

    Why is your front desk allowing people to wait over an hour without checking in? Sounds like you need a PCMH so you can have a morning huddle or even better hire a “waiting room coordinator” to manage your wait times. Wouldn’t want those satisfaction scores to go down. /s

    • Patient Kit

      Front desk should notice if a patient has arrived and failed to register/check-in. But I can see how that can get missed in a large busy clinic, especially if a lot of patients bring non-patient family members with them. Of course, the patient himself has responsibility to ask if he doesn’t know what the procedure is — ask the front desk staff or ask other patients. When I’ve been in a waiting room as a patient and I see someone come in who truly looks lost and confused and sometimes even frightened, I will ask if they are here to see a doctor and tell them that they have to check-in at the desk. Other patients can step up and help a fellow patient.

    • Lisa

      The physical design of most medical offices I go to takes you by the front desk. Pretty hard to walk by without having the front desk person greet you and have you check in.

      • Suzi Q 38

        i disagree.
        Sometimes they are busy with phone calls and other interruptions. Sometimes they are too tired or busy to even say “hello.”

        • Lisa

          That really hasen’t been my experience.

          • Suzi Q 38

            Agreed that we have had different experiences and expectations.
            If a doctor wouldn’t see my 89 year old mother because she forgot to sign in, then I would try to find her another doctor.

          • Lisa

            :-)

            I agree with about your 89 your old mother. But I do think the doctor needs to have serious talk with the front desk person.

    • Suzi Q 38

      The receptionist at my neurosurgeons office was the “key” to my getting an appointment with the neurosurgeon. She happened to have a high school education.
      It took a lot of haggling and persuasiveness on my part in order to convince her that I needed a much needed appointment than the initial appointment, 3 months later that she gave me.
      I was asked after my surgery what improvements could have been made to make my treatment before during and after my surgery better. I was also asked “Would you return if you needed another surgery?”
      I told them I would if I could have seen the doctor sooner.
      I asked them how is it that they put a person in charge to schedule the appointments who does not have a science or medical related degree?
      I said, here I have a cervical spine injury and she decides if and when I get to see the doctor.

      I told them that the physician assistant or NP should make the decision. Not the receptionist with the high school diploma who is not familiar or knowledgable with the fact that I was worsening day by day.

  • guest

    In residency we are indoctrinated to disregard everything else in our lives in order to help the patient. I think this attitude makes sense only in an emergency or a war zone. This guy is going to live, let him go home, next time he will learn. You cannot do everything for everyone. He is probably a new imigrant, does not know he needs to check in. It makes me sick just thinking how long it would take to actually see him, would your staff stay until 7 pm. There is always the ER if it is urgent.

  • southerndoc1

    Late patients don’t bother me: I’ll work them in as I can.

    No shows are completely unacceptable: after the second no-show, they pay a fee before rescheduling, or get the boot.

    • Patient Kit

      That seems totally reasonable to me.

      • southerndoc1

        You’d be surprised at how many people don’t think it’s reasonable. Better to just weed them out asap.

  • EmilyAnon

    I take my doctor appointments seriously too. I’ve never been a no-show, but I have a couple times got my dates mixed up. Both times came a day early which they kindly fit me in. Hopefully I filled a no-show spot.

  • Patient Kit

    I’ve been on Medicaid for the last year, after many years of being covered by Blue Cross. (It’s a long story how I came to fall through those cracks that I’ve told elsewhere on this board. The short version: I was diagnosed with ovarian cancer after I got laid off from a longtime job and lost my health insurance.)

    Anyway, I have seen the healthcare system through a Medicaid patient’s eyes for the first time this year. I think some accommodations should be made for the working poor who truly do have trouble getting time off from work without threat of losing their jobs. But for unemployed no shows who just don’t feel like coming, there should be a penalty for no shows.

    I’ve received most of my treatment from a NYC teaching hospital this year. Initially, I was always called a day or two before my appointments to remind me about my appointment. But since I always show up, they stopped calling to remind me.

    Really, absent a truly good reason, showing up for appointments is an uncomplicated matter of simple respect for and consideration of others. That is not a matter of economic class.

  • Suzi Q 38

    “””’As my friend entered some last labs and prescriptions, the front desk called to alert her that one of the patients on her schedule — one she had never met before, whose entire medical history would need to be explored and reviewed — had been in the clinic waiting room for over an hour but had never checked in; would she still be able to see him today?…..”

    I think the receptionist needs to make it a habit to call out each name, regardless if the patient signed in or not. Some don’t remember to sign in, still others may be older and forgetful. Cut the patient who was waiting an hour for the doctor without signing in a break.
    H/she should be next on the list to see the doctor. A sharp receptionist or office manager would have discovered the patient was there.

  • Lisa

    I’ve never missed a doctor appointment, in part because many doctor’s offices in my area make reminder calls. It helps.

    I have no showed for an appointment with my lymphedema therapist; I paid her no show fee. It seemed quite fair to me as I totally screwed up – I thought my appoinment was on the next day.