Monday, June 12, 2006

The No-Show Show

The urban community health center where I work has a 30-40% no-show rate for scheduled appointments. There are many theories about why this may be, including that if impoverished people feel undervalued in the healthcare setting, they will also learn not to value their health, healthcare or medical providers. This same theory has also been used to describe the reason for the amount of trash littering poor urban neighborhoods: if people do not feel valued and live in areas which are neglected by the powers that be, polluted with industrial waste, and suffering from infrastructural neglect, what would cause pride of place to be engendered? These are all good theories which, for me, hold a great deal of water.

That said, when a community health center's funding from its parent hospital organization is based upon productivity, and a 30% overall no-show rate plagues that facility, the patients will eventually suffer due to decreases in staffing, fewer available appointments, and a decreased standard of care delivered by overworked staff. The picture becomes more gloomy as the cycle expands.

This chronic lack of motivation or value effects many providers on a variety of levels. In terms of mental health, we refer our vulnerable populations to community mental health centers for management of mental illness and psychotropic medications. Due to the economic constraints placed upon the mental health agencies, their providers are generally paid on a fee-for-service basis. Thus, when our patients are referred and subsequently miss two or three appointments, they are automatically discharged from the practice and placed back on a waiting list which can be as long as six to eight months. Without a psychiatric provider, the patients decompensate, and return in crisis to the clinic, where the overworked staff and providers struggle to provide mental health care and psychotropic medication management which they are inadequately prepared and staffed to deliver. Suicidality and psychiatric crisis visits to the ER abound, but the local Psych Crisis unit is under pressure from the state, so the client is generally screened out of an inpatient stay and sent back out into the community, back to the six-month waiting list for mental health care and a primary doctor who would rather discuss their diabetes or HIV rather than their schizophrenia or bipolar disorder. You can see where this could lead.

For myself, today was a typical example. I had a tightly booked day, no home visits planned, but a number of clinic visits and a great deal of paperwork to do, let alone telephone calls, faxes, and a few urgent walk-ins who I attended promptly. I even squeezed in a 90-minute visit to the hospital to help organize a dying patient's discharge to home and a 75-minute lunchtime conference at a local restaurant. Amidst this controlled chaos, two of my patients no-show'd as I waited for them by filling my time with other tasks. While a no-show frees up time unexpectedly, it often wreaks havoc with a carefully planned schedule and precludes my ability to see a patient who would have gladly filled that spot. I did indeed turn down a few calls for visits today which I may have squeezed in without the patients who simply ignored (or forgot) their appointments with me.

But the piece de resistance today came with a 1pm telephone call from the surgical office. To explain, a patient called me last Thursday after an ER visit during which she had received a diagnosis of cholelithiasis and cholecystitis. After she pleaded for expedited attention, I pulled all of the strings at my disposal, landing her an appointment with one of the best surgeons in the area for the following day, Friday. She went to this appointment, and much to her pleasure (and my surprise) was scheduled for surgery today (Monday) at 11am with the same surgeon. I was extremely grateful to my colleagues for making this process so seamless, and I gave my patient explicit instructions for weekend symptom managment.

The 1pm call came from the surgical nurse, informing me that the patient did not show for surgery. The OR was prepped, the surgeon was ready, the team prepared for a cholecystectomy and simultaneous liver biopsy which we had requested at the last minute due to the patient's underlying untreated Hepatitis C. Understandably, the surgeon was peeved, having lost thousands of dollars of surgical income, and the incredibly busy OR whose schedule and waiting list are bursting at the seams was also negatively effected.

And the patient? MIA. I left a message on her machine, stern but not harsh. Is she OK? Did she have an emergency over the weekend? Did she realize the ramifications of not showing for the surgery? Did she realize that this surgeon may never agree to see her again, along with all of the surgeons in his practice? (And, I thought, is she dead? The best excuse for a no-show.)

So what do we make of this scenario and that which is described earlier in this post? How do we correct this insidious problem? How do we stem the tide and decrease the deleterious effects of such dynamics on both our patients and our medical practices and staff? Is there an answer to our dilemma when we actively choose to serve the poor, vulnerable and disenfranchised with quality medical care? There are no easy answers. This was not the first time one of our charges failed to arrive for a scheduled surgery, and it will not be the last. There are truly few answers, and each question or potential response only begs a host of other considerations. For all of our efforts, the show must go on, and the No-Show Show will no doubt be a popular attraction for many years to come.
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