I have a love-hate relationship with the no-show patient. Like most doctors, I’m a reasonably good multitasker, adept enough at charting while emailing while waiting on hold with insurance companies and planning what to prepare for dinner when I get home. But there are days, more than I’d like to admit, when I feel like I need just a little bit more time, and I find myself compulsively refreshing my schedule in the EMR, fingers crossed that the next patient’s name won’t light up as “arrived.”
The healer in me feels a bit ashamed about this. I went into medicine because I wanted to work with people, to sit in a room with someone who is suffering and do my best to make him feel better. Why on earth would I want to swap out face time with a patient for alone time with my computer? How often do I rant about the paperwork and the bureaucracy, lamenting that “I should be seeing patients right now!”? It’s a nonsequitur to crave time with patients and then hope for a no-show, isn’t it?
I suppose it has to do with feeling stretched too thin. There’s always more than enough to do in a busy clinic, so I rationalize my sense of relief about the no-show patient with self-assurances: It’s not like I’m using that extra chunk of time to play solitaire or catch up on Netflix; it’s not like the phone calls I make or prescriptions I write in that time aren’t helping some other patient; it’s not like that bonus bathroom break is going to pamper my kidneys or spoil my work ethic.
What’s more, I know that the extra time isn’t really extra time at all, that the patient who no-showed will have to be squished into my schedule sometime in the future and I’ll have to call in a refill or send home a letter such that less work today will almost certainly mean more work tomorrow. What inevitably follows is that my rationalizing morphs into frustration about the system and all its dysfunctions, and before I know it my love for the no-show patient transforms into indignation.
What about my productivity? The department doesn’t get paid for a no-show (academic center vs. private practice), so the take-home point financially is that a no-show is lost time, and I’m the one on record for having lost it. The phone calls and letter-writing and prescriptions are all part of the job, but they’re supposed to be squeezed in between patients or at the end of the day; those tasks aren’t billable time.
And then there’s the time that’s lost waiting to see if the no-show will no-show! I don’t want to start a phone call that could take fifteen minutes and get a page five minutes into it alerting me that my late patient is here and is now somehow waiting on me. By the time I’m sure that the patient is in fact not coming, there’s not enough time to make the call before my next appointment. It’s irritating that my no-show patient’s time seems to be more important than mine.
This is the point in my rant when I start to feel awfully self-centered, and I take a moment to consider the broader view. This is the job, this is what I signed up for, and no-shows are part of the deal; shouldn’t I just deal with it? Probably. The thing is, even as I set aside my own interests, the social justice aspect of the no-show really gets under my skin.
There is a growing shortage of physicians in the U.S. and my specialty, in particular, is one of the greatest in need. According to the American Academy of Child and Adolescent Psychiatry, “there are approximately 8,300 practicing child and adolescent psychiatrists in the U.S. and over 15 million children” in need of their specialized care. Kids can wait for months to get the first appointment with an appropriately trained specialist; during that time without care, they’re at risk for worsening emotional problems, more frequent suicidal thinking or attempts, destabilization requiring hospitalization, missed school, family disruption, etc. The point is, every spoken-for hour that goes unused by a patient is an hour that I could have been seeing someone else in need. No-shows are aggravating and, quite frankly, they’re unfair.
But I’d like to raise another point, one rooted in what’s arguably the most important tenet in medicine: empathy. If we treat a doctor’s appointment the same as any other appointment with a professional, then we’re missing something crucial. The very need for the appointment can sometimes get in the way of keeping it. I regularly see the lethargy of depression make hustling to the clinic nearly impossible; I see anxiety and the fear of stigma keep kids from getting out of the car in the parking lot; I see haggard parents take off a whole day of work from a minimum-wage job to drag an oppositional teenager and his four younger siblings onto three city buses with two transfers and a walk in the rain just to see me. It’s the same story for vomiting and back pain and headaches and dialysis. Imagine the disappointment and frustration patients must feel, even if only with themselves, upon waiting for months to see a doctor only to miss out, for whatever reason, on the chance to get help. Our patients’ time is not more important than our own, but it is almost certainly marked by more distress.
We should have policies about no-shows, and we should stress the importance of canceling with appropriate notice, for all the reasons listed above and for all the patients who go out of their way to arrive on time. But perhaps we should also take a moment to stifle our irritation about the once-no-show-now-rescheduled-patient and channel empathy instead, so that the next kept appointment starts out with a provider who comments, simply, “I’m so glad you’re here.”
Jessica M. Yeatermeyer is a psychiatrist.
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