My friend breathed a sigh of relief as she finished her last clinic visit for the day and headed down the hall to the physician workroom.  It was only 5pm.  She still had notes to write and labs to check, and as a senior resident she needed to make it back to the hospital wards to check on her team’s interns, to get updates on the afternoon’s events and help them finish any of the work that remained for the day.  But still.  Most of her patients had shown up and she had been able to give all of them thoughtful, thorough care.

The resident clinic at our program has a relatively high no-show rate.  The majority of our patients belong to an extremely underprivileged, underserved population, and oftentimes their resources are so limited that even making an annual trip to the doctor’s office is a nearly insurmountable task. If patients’ parents have jobs, they often have trouble securing time off in order to attend appointments.  Most don’t have cars, and wrangling several children through several transfers on the city bus can prove not only logistically but financially challenging.

Winters in New England don’t render the task any easier.  As a result, out of the six patients booked for each resident’s morning clinic sessions and the eight for each of our afternoon sessions, we may seen anywhere from two or three patients to the entire scheduled panel.  Or even more, as parents often show up with a sibling of the scheduled patient, requesting that he or she been squeezed in for a sick visit or vaccines or because his or her asthma has been acting up.

Of course, as Murphy’s Law would have it, the days on which every patient shows up are also the days on which every patient has a laundry list of problems and at least half require an interpreter, further slowing the process of attending to each patient’s needs.

As my friend entered some last labs and prescriptions, the front desk called to alert her that one of the patients on her schedule — one she had never met before, whose entire medical history would need to be explored and reviewed — had been in the clinic waiting room for over an hour but had never checked in; would she still be able to see him today?

Late patients represent a huge source of frustration among physicians practicing outpatient medicine.  They disrupt the flow of an already tightly packed schedule, making it impossible to dedicate the amount of time, energy, and focus to each visit that every patient deserves.  They also present a conundrum to which there is no clear answer: Should physicians patients who arrive late, despite the inconvenience to the provider and the other waiting patients; or should they ask tardy patients to reschedule, thus risking that they do not keep the new appointment and get the care that they need?

During medical school I worked with a physician who had a ten-minute rule: Patients who showed up more than ten minutes after their appointment time would need to reschedule.  It sounded harsh, but she was very open about the rule and the reasoning behind it. When she was a medical student, she had once been late to an appointment for a haircut because she had been studying.  The hairdresser had refused to accommodate her that day, explaining that her time was not more valuable than the hairdresser’s own.    The doctor agreed, and felt the same way now: Her time and her patients’ time were equally valuable.  Each should be held responsible for adhering to the obligations of their schedule.

And yet.  When your patients are not middle- and upper-class car-owners who are able to make accommodations to take time off from work, and who, if they are late and need to reschedule, will do so and almost assuredly attend the subsequent appointment, do — should the rules change?  When children miss three appointments for well-child checks in a row, leaving them behind on vaccinations and screenings for developmental delay, and sacrificing opportunities to provide education and anticipatory guidance to the parents who are raising them, is it inappropriate to try to — and incorrect to believe that we will –“teach them a lesson,” in a manner of speaking, by holding fast to such a rule?  Should we gratefully seize any opportunity to see them, no matter how late they arrive and how many other patients, both in our clinic and back up on the hospital wards, we may be neglecting in order to accommodate them?  Or does such lenience only exacerbate the problem by sending the message that it is not necessary to arrive on time for an appointment, that patients are free to come and go at their own convenience?

And in my friend’s case, does it make a difference that her patient had been present since the appointed time but lacked either the knowledge or experience to know how to check in appropriately?  At the same time, isn’t it fair to expect people to take some amount of responsibility in the process of obtaining care, including asking for help if they are unsure how to proceed?

I don’t have a good answer to these questions, and I find that my own leanings change according to the day and the nuances of the situation.  But I’m interested to hear others’ own thoughts and the practices they adhere to or have encountered.  And most of all, I’m striving to figure out: Is there some happy middle ground?

Rebecca E. MacDonell-Yilmaz is a pediatric resident who blogs at The Growth Curve.