Missed Appointments

O&P clinical care is a rewarding vocation. Most clinicians would agree that issues that impede the provision of O&P care, not the work itself, create the most frustration. Patients often bring challenging personal issues into encounters, and missed appointments are one of the most frequent causes of frustration. We may see these patient issues as unnecessary barriers to fulfilling our primary responsibilities. No-shows prevent us from performing most tasks essential for providing O&P care, create disruptions in our schedules, and take up appointment slots that could be used to provide care to other patients. Additionally, they can be interpreted as disrespectful and an indication of patients’ failure to accept responsibility for their own care.

In an interview published in the Winter 2021 issue of The Academy TODAY, Rebecca Herman, MSPO, CPO, a clinician with Shriners Hospitals for Children, described various aspects of this phenomenon. Figure 1 shows the reasons she described for missed appointments. According to Herman, research shows that “patients who are in the young-adult age category, lack personal transportation, have a low socioeconomic status, and are uninsured or insured by Medicaid are the most likely to chronically miss appointments.”¹ She points out that most Medicaid patients who can work do, and those who do not “cite having a disability, providing unpaid care for an ill family member, or being in school as reasons for not being employed.”¹ Most clinicians have predictable schedules that include paid time off for medical appointments and other reasons. Many entry-level jobs, the type that individuals with lower income are likely to have, do not include these advantages. Other factors that contribute to missed appointments are an inherent part of these patients’ life situations.

Professional Boundaries

Scheduling policies are a necessary part of most effectively and efficiently providing care, and they are a common way to address missed appointments. Some providers can bill for missed appointments, and policies allow for dismissal of patients after a certain number of no-shows. In O&P, we do not have the option of billing for missed appointments, requiring the implementation of nonfinancial consequences. In my case, rather than seeing a late patient as soon as they arrived, since this often would have required an on-time patient to wait, I have advised patients that I would see them at the next available time slot. This could occur when an appointment did not take the full time scheduled, another patient arrived late or did not show, or it could be scheduled for another day.

Providing care outside of the office setting can mitigate some of the factors that contribute to missed appointments, but it is not a solution in every case. A home care physical therapist I know reported that on average 20 percent of his patients were not available for a home visit at the scheduled time. One of the more egregious examples from my experience relates to a patient with quadriplegia. An insurance company referred the patient to our office on the condition that he be seen in his home. When I contacted him, he confirmed that he did not have transportation to come into the office. I made the 45-minute trip to his home, but no one answered the door. He later reported that he had left the house when an appointment opened up for a haircut. I notified him and the insurance company that he could schedule an appointment in our office at a time convenient for him.

O&P practitioners may deal with late and no-show appointments differently, but enforcing the policies is a professional necessity. Consistently seeing patients without an appointment or whenever they arrive communicates to them that an appointment is not necessary. Understanding the patient perspective on missed appointments can help clinicians develop strategies that go beyond the enforcement of an appropriate boundary.

Deeper Issues

It is easy to view appointment reliability simply as an issue of personal responsibility, but there are many factors that detract from a person’s ability to make and keep commitments. In interviews conducted by Chapman et al. with “32 US low-income adults in the rural Western US who regularly missed primary care appointments…the participants identified three barriers to attending appointments: appointment disinterest, competing demands, and insufficient systems.”² This research found that “participants also reported low overall health; moderate levels of medical mistrust, life chaos, and mastery; moderate to low resilience; and very a high number of adverse childhood experiences.”²

It may seem that none of these issues are ultimately the clinician’s responsibility, but understanding these contextual factors can help us avoid increasing barriers and develop strategies that mitigate them. Our enforcement of necessary professional boundaries, for instance, may unwittingly reinforce the habit of missing appointments. For example, in our efforts to accommodate as many patients as possible, we inadvertently may create long wait times in our offices, which patients report increases the likelihood that they will not show. Scheduling appointments well in advance may seem like a way to ensure that the time is reserved, but patients with irregular or frequently changing schedules may not be able to protect that time. Embarrassment or concerns that similar complications will arise before the next appointment are disincentives to calling to cancel or reschedule.

Viewing any appointment unreliability as an indication that patients do not care about their condition or treatment reflects an ignorance of the many complicating factors that contribute to patient choices and behavior. Most patients have many other obligations that interfere with their ability to prioritize their O&P care. Individuals with an amputation, for example, usually have multiple comorbidities that involve numerous complications and commitments to see other providers.

Disinterest in the Appointment

According to the patients interviewed by Chapman et al, the barrier of appointment disinterest involves mental health issues, perceived judgement by the provider, and the quality of the patient/provider relationship. “The process of attending a medical appointment was described as stress inducing, and for those with existing anxiety issues the encounter only worsened their mental health. Ultimately, missing, canceling, or delaying the appointment was considered the most logical path forward.”² A recent systematic review reported on “a Welsh study analyzing interviews of non-attending adults with type 1 diabetes….”³ Three groups of patients were identified, “based on their cognitive, emotional, and coping strategies…the ‘high fear’ group use coping strategies to minimize anxiety rather than reduce health threat.”³

This may not seem like a reasonable choice to us, but until we deal with similar issues in our lives, it is difficult to appreciate how they impact health decisions. It is not difficult to see how patients could view O&P treatment as secondary in importance to their mental health. At the very least, we can recognize that to the extent that avoiding appointments may be an unhealthy coping mechanism, it is one that they are likely to continue to adopt until the underlying mental health issues are resolved. In this context, missing appointments can in some cases be understood as a symptom of a medical condition that, while outside the scope of our expertise, directly impacts our care.

Judgement and Relationship

Participants in the Chapman et al. study “expressed some fears of confrontation related to lifestyle or health issues that they did not want to discuss with a provider. Individuals described a disinterest in being told to change lifestyle habits or having an illness-related appointment be dominated by conversations of weight, diet, and substance use…. Participants noted that this fear of confrontation adds to the anxiety of the appointment and results in either less motivation to attend an appointment or non-attendance.”² While these issues can be directly related to O&P care, clinicians must be mindful that the way they are discussed with patients may negatively affect adherence. A confrontational approach should be assumed to be as ineffective in medical care as it is in most issues of everyday life.

Comfort level with providers is an important factor in non-attendance. In Chapman et al.’s interviews “this relationship seems to be paramount to their interest or disinterest in attending the appointment” and “participants highlighted that trust, respect, and positive experiences made it less likely they would miss appointments.”² Most “described, at length, issues of that undermine their trust in providers.”² Patients may agree to an appointment but be reluctant to attend if trust has been violated, either through “perceived misdiagnosis or what they viewed as careless treatment plans.”² Patients may also avoid appointments if they believe the provider does not have the time to discuss their complicated case.² When a positive relationship has been established, patients may not attend an appointment because they “do not want to disappoint their doctors.”² This mindset is influenced by patients’ prior experiences.

“The experience of poverty and instability builds anxiety and undermines trust and confidence. Given these individuals have experienced numerous adverse experiences, the need for stability in medical encounters appears to be important for building interest or disinterest in attending appointments. In fact, when those relationships are built on trust and providers are accessible, the patients seem to have much more interest in the medical encounter.”²

 Adverse Childhood Experiences

The issues participants raised with Chapman et al. may indicate a history of trauma.² “Adverse childhood experiences were extremely prevalent with three-quarters of the group scoring four or more ACES [adverse childhood experiences] and over half scoring seven or more.”² Being aware of the impact of past trauma on current health behaviors can help clinicians address their effects, including how they impact reliability in appointments. Many of these patients may be experiencing ongoing trauma and “a strong patient-provider relationship is particularly crucial” in these cases, since these “individuals are more likely to report not being respected by or having quality communication with their primary care providers.”² Identification and treatment of symptoms related to traumatic experiences falls outside of our scope of practice, but awareness of their effects should inform our interactions with patients. “A tenet of trauma-informed care is empowerment, voice, and choice. Examples include explaining why the provider is doing something, asking permission before examining patients, and giving patients choices.”² A description of how ACES impact health choices can be found in “Everybody Hurts: ACE and Trauma-informed Care,” The O&P EDGE, April 2021, opedge.com/everybody-hurts-ace-and-trauma-informed-care.

Strategies for Schedule Disruptions

Many patients who miss appointments do so repeatedly, and in many cases, clinicians can anticipate a disruption in the schedule. An O&P colleague reports double-booking appointments for patients who routinely miss appointments, as well as scheduling them at a time in the day when non-attendance will be least disruptive. Missed appointments can also be an opportunity to perform work that does not require direct interaction with patients. With creative adjustments in our work habits, open slots in the schedule can be used to complete documentation, make phone calls, order supplies, and perform modification and fabrication. The question of whether these disruptions should occur is less important than how we choose to respond when they do.

 Closing Thoughts

The understandable frustration with personal issues of patients can escalate quickly. Obstetrician Erin Hoffman, DO, says that “the question of these no-shows and their capacity to change possesses devastating potential to embitter and discourage if left unchecked.”⁴ Frustration and a focus on barriers to providing care is less productive than empathy and finding solutions. Keeping appointments is a matter of personal responsibility, and it is helpful to remember that most patients who miss appointments “occupy a particularly difficult place in society.”² Our professional obligation is to apply our expertise to care for people, and device provision is only one aspect of that care. Patient issues are challenging, but they are a necessary part of clinical practice, and one that requires skills as important as the O&P interventions we provide. O&P EDGE

 John T. Brinkmann, MA, CPO/L, FAAOP(D), is an associate professor at Northwestern University Prosthetics-Orthotics Center (NUPOC). He has over 30 years of experience in patient care and education.