Fear and loathing in the waiting room

Sick of getting stood up? No-shows say it's because
they need a little respect

By Owen Dyer

Research suggests that there's a somewhat lower rate of non-attendance in Canada than the 15-25% rates typical of US surveys. But the problem is still one that places strain on our healthcare system and is a source of frustration for Canadian doctors. How are we dealing with it? In clinics across Canada, charging no-shows a fine for cancellations made less than 24 hours before the appointment is becoming an increasingly common practice. "Our clinic charges patients for a no-show at the going rate that we bill Manitoba Health. If a patient has a good reason, then we will often waive that no-show fee," says Dr Gilles Pinette, a family physician from Winnipeg. At a clinic in Calgary no-shows are fined no less than $30.

"We usually allow three no- shows before sending the patient a standard letter explaining that they need to call 24 hours prior to their appointment to cancel," says Dr Wendy Graham, a family physician in North Bay, Ontario. "Charts may be flagged, and I've seen both two to three strikes before the patient is asked to see another physician," says a doctor from Alberta who preferred to remain anonymous. "It's certainly a shame when patients don't show up because it means the physician is not making money and other patients who are usually on long waiting lists could have been seen instead," he adds. "Many physicians just accept it, and use any free time to catch up on paperwork." So, what's a busy physician to do?

WAIT 'TIL AFTER LUNCH
A study in the Canadian Journal of Psychiatry last year found that in a short-term mental health unit in Victoria, first-time no-shows were 3.6 times more likely to skip a first appointment if it was scheduled before lunchtime. The authors recommended that new patients always be given a first appointment in the afternoon.

The biggest single factor leading to missed appointments, mentioned by 65% of patients in the American study, was fear of bad news and of uncomfortable procedures. "I just don't want to go to the doctor," said one. "I'm scared they might tell you something, some bad news... Come in with a headache and they say you've got a big brain tumour up there."

These patients made it clear that the longer they had to wait before their appointment, the more it would gnaw at their mind. Reminder calls, unless handled sensitively, may only increase the patient's negative feelings about the upcoming appointment. The authors suggest asking patients about their fears in an attempt to identify those who would benefit from targeted reminder messages explaining what to expect and why it will be important.

Long waits between scheduling and the appointment date have been repeatedly demonstrated to be a major contributing factor in no-shows. For one thing, delay often results in symptoms clearing up. "If it isn't a dire need to get into the doctor's office, then people forget about it," said one patient.

SOME R-E-S-P-E-C-T
This doesn't explain, however, why patients don't bother to inform clinics of their intention to skip appointments. Patients said they fail to call partly because they don't believe anyone at the clinic will be seriously inconvenienced. Dr Graham confirms this statement. "The frustration is the no-show patient, who is then seen in the after hours clinic or emergency because of the perceived convenience of clinic hours," she says. However, the primary reason patients didn't call to cancel is because they don't believe the health system treats them with respect, and are disinclined to show it any respect in return.

"There are so many appointments scheduled that it's just an assembly line thing," said one. "People want to be treated like human beings. They don't want to be cattle just running in the lounge." Overbooking appointments to match a clinic's no-show rate may only serve to widen the rift between patient and physician. Sure enough, a 2001 study in the British Medical Journal found that overbooking made the problem of non-attendance worse, not better. It's counterproductive because it increases waiting-room delays and makes patients even less inclined to feel they owe the clinic anything.

OPEN TO CHANGE?
The approach known as 'open-access' scheduling gets slightly higher marks from the authors. "My clinic has less no-shows than many because I run my practice with one to two days as open access," declares Dr Pinette. "This [system] allows patients to book when they want to and they know upfront that it's a 15-minute appointment or less if they need less time. They book these appointments the day before or same day," he explains. "I get fewer complaints of 'I can't get in to see my doctor when I'm really sick.'"

However, even this system isn't perfect. On the one hand, it reduces time between scheduling and appointment, thus addressing the problem of fear. On the other hand, it leads to longer waiting-room delays, which may backfire on the clinic when irritated patients take their revenge on future appointment dates.

Dr Mike Davies, a physician in the US Veterans Affairs system, says, "The answer here is to improve access to care — which will translate into less fear, more respect and simpler scheduling." Says Dr Davies, "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 will go down."