Should you really say, “You’re fired,” to your patients?

Recently, an elderly patient presented for the first time to one of our health system’s outpatient practice sites.

When asked what prompted her to seek care with us she related that she was fired from her prior physician’s practice because of three missed appointments. The first miss she had a different date on her appointment book. The second miss was because she lives alone and relies on others to provide transportation, and the cab she called for didn’t show up in time for her to make her appointment at the scheduled time. Her third miss was because inclement weather prevented her from leaving her home.

So although the diabetes, hypertension and high cholesterol can easily be imported from her medical records, along with the medications and all the lab and radiology tests that comprise her medical history, the tacit knowledge her previous physician gained can’t be easily obtained from the medical record and will have to be reconstructed.  What if her previous practice examined not just the biological markers it uses to construct a treatment plan, but looked at data that predicts why patients miss appointments?

Why do patients miss appointments?

David A Ellis and colleagues published a study in the December 2017 issue of Lancet Public Health that presciently fit the demographic profile of patients who miss appointments-older, female and lower socioeconomic status. Furthermore, health care professionals might be able to see how their practice might contribute to missed appointments, since practice factors have a greater factor on missed appointments than patient factors.  

Unfortunately, missed healthcare appointment can lead to a greater risk of patient mortality in a recent study published by Ross McQueenie and colleague in a 2019 article from BMC Medicine. As a result, patients may find that their new provider may warily enter into the relationship thinking that she is not engaged in her health care, while her old practice has terminated the relationship without asking whether there is anything they could have done to minimize missed appointments. Trust has to be reestablished within a new patient-physician relationship, which may not have needed to occur in the first place.

Who benefits in this situation? Physician practices may mistakenly chalk up the patient dismissal as another example of patient non-adherence, which contributes to physician frustration and burnout, and a patient who carries the stigma of being ‘fired’ from a practice that might have been prevented and could ultimately lead to a poor health outcome.

What are the reasons patient get fired?                                                                                  

Ann O’Malley and colleagues in a July 2017 article from JAMA Internal Medicine listed several reasons practices dismiss patients. These include disruptive behavior towards clinicians or staff, violations of controlled substance policies for chronic pain, missing appointments, failure to adhere to treatment and/or lifestyle recommendations and failure to pay bills. 

An uncomfortable question that has to be asked is whether practices that “fire” patients because of no-show policies are considering how value-based reimbursement may impact their finances or quality scores that may negatively impact their reputation. Often health care providers can’t control autonomous patient decisions as it relates to decisions patients make in accessing healthcare or adhering to treatment recommendation, but they can be instrumental in minimizing office-related factors to non-adherence.

Practical tips in helping patients overcome non-adherence to patient visits

1.     Is the story you are telling yourself about patient no-shows accurate?  Asking this question minimizes confirmation bias, or the tendency to remember information in a way that confirms one’s preconception. For example, the patient didn’t show up for her appointment because she doesn’t care about her health.

2.     Ask patients, “What barriers exist that prevent you from attending your appointment?” Rather than preconceived ideas about non-adherence, you are framing the question in a way that promotes a constructive dialogue aimed at problem solving. Being cognizant of challenging social determinants of health like transportation difficulties may lead to not only understanding but practical solutions where community resources can be engaged to assist with transportation.

3.     Ask patients, “How can our office assist in ensuring you don’t miss your appointment?” Flexibility in scheduling and how your office reminds patients of their appointments can potentially assist patients who rely on public transportation or other individuals to come to your office.

4.     Take a page out of cognitive behavioral therapy and retrain your thoughts about the efforts patients have to go through to seek care. One patient I am aware of had to make six bus connections in order to get to her appointment. Instead of lamenting that she was 30 minutes late for her appointment, I commented on her herculean effort to better her health by enduring such a complex journey. Instead of being personally frustrated, I was inspired by her efforts.

5.     Ensure no dismissal letter gets sent without your personal consent. Do you really want to fire your patient? Obviously, belligerent or disrespectful behavior to providers and staff should not be tolerated. For patients who do not show or do not adhere to recommendations, there might be social determinants of health that prevent them from achieving all they can from the patient-provider relationship. Your ability to be curious and empathetic may uncover a potential solution that empowers the relationship rather than ending it.

Joseph M Geskey is the Vice President of Medical Affairs at OhioHealth Doctors Hospital in Columbus, OH. He is currently working on a book about the health care experiences of patients with limited health literacy and challenging social determinants of health in the digital and technological era medicine is embracing.