Patient no-shows often have complicated reasons behind them [PODCAST]

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“I typed up a brief response to the no show memo, hit reply, and then deleted the original message. It’s not that I am a fan of wasting time and resources, but for now, I have a general personal policy to never dismiss pregnant patients. I’d have to try to address her barriers to care.  Again.  Our clinic tended to be a safety net for health care in the city, if I dismissed her, where would she go?  I do believe people can be changed.  Also, help me when I really don’t believe it.”

Erin Hoffman is a family physician.

She shares her story and discusses her KevinMD article, “The patient who no-shows.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Erin Hoffman. She’s a family physician, and she wrote the KevinMD article “The patient who no-shows.” Erin, welcome to the show.

Erin Hoffman: Thank you so much for having me.

Kevin Pho: So we’ll get into your article in a bit, but first off, tell me your story and your journey to where you are today.

Erin Hoffman: Yeah, thanks. So I’m just fresh out of residency. I’m a brand-new attending physician; I graduated a year ago, so I’m getting ready to start into my second year. I felt like God called me to medicine when I was young, in middle school, on a trip with my church group to Mexico. I just saw a lot of need, but I had no idea what it looked like to be a doctor. I don’t have anyone in my family in medicine, but I kind of chased that dream all the way through, and chased what I thought it was, which was serving internationally where there was great need. I always thought that I would be a doctor and I’d do full-time international medicine. I thought I would do family medicine; that would allow me to do the most for the most people.

And then when I went into residency in Wichita, Kansas, which I just completed, like I said, a year ago, I just discovered the crazy need that is in all of our cities, all of our towns, right here in our own backyard. Just like most residents, I served a mostly urban poor population, as far as a socioeconomic demographic, and a lot of Medicaid, a lot of uninsured, and I really fell in love with them and their stories. I found that I had severely underestimated their role in my teaching, and it’s redirected my trajectory, honestly.

So I am now planning to do international medicine part-time, and I’m working and practicing in northeastern Colorado with a mostly rural poor population now, and just trying to serve back in the community (I live just like an hour from where I grew up) that I was already equipped to serve, now with this new skill of medicine. I do full spectrum, and I do a lot of women’s health and obstetrics, and that’s probably my favorite part of my job.

Kevin Pho: So you mentioned that you’re going into your second year as an attending. What’s the number one thing that you learned during your first year that you didn’t learn as a resident?

Erin Hoffman: I think the number one thing I learned in my first year as an attending is that I still don’t know everything. I definitely underestimated the number of questions that I would still have, and the number of things I would still be looking up, and how regular that would be in my daily practice as a family physician.

Kevin Pho: No, I’m entering my 18th year as an attending, and I would still answer that question the same way. I’m still learning every single day. I still learn with every patient I see.

Erin Hoffman: Yeah, that’s good. That gives me hope, that gives me hope.

Kevin Pho: Now, how has the pandemic affected you and your practice?

Erin Hoffman: So it’s interesting. I practice in rural northeastern Colorado, and so per capita, we definitely don’t have the largest population by any means, but we have a large prison that sits within our county. So for most of this pandemic, it has looked like our county has the most cases in Colorado, because they tested basically the entirety of the prison population. Not a lot of those inmates were really sick enough to need our hospital care, but that’s been an interesting dynamic, working with and testing the prison population, and also the prison employees.

I would also say, as we’re a critical access hospital, we just have 25 beds, so we had prepared for this surge and just wanted everyone to be ready if it were to come. That includes everyone in the town that is a doctor, no matter what kind of doctor, being on call all the time. And I practice in an office that’s attached to the hospital, so our backup plan was for our clinic to be an extension of the hospital. So that’s been interesting, to just see how a small town and a small facility handles those things and tries their best to really prepare.

And initially, I think it also affected our patient volume. We did a lot of online and phone visits and that kind of thing as people were navigating. But now I would say we’re back up to speed, but our testing has increased overall.

Kevin Pho: Now, I want to talk about your KevinMD article, “The patient who no-shows.” You start with a policy that a lot of practices have: patients who miss a scheduled appointment without calling ahead to cancel or reschedule, three strikes and you’re out, find yourself another doctor. It’s a good policy overall, protection of provider time and office resources and all that, but oftentimes the story behind that cancellation is more complicated. Now, can you take my audience through that article and describe the reasons why you decided to write it?

Erin Hoffman: Yeah. So in residency, as I had said, we served a primarily lower socioeconomic demographic population. Resident clinics function as these safety-net clinics, as most people in medicine know, in the cities that they’re in. And so I saw a lot of pregnant patients in my residency training time, and resident clinics tend to have patients that are unreliable. So in an effort, I think, to really keep the doors open and keep things happening there, they do have to have these policies against patients that are going to repeatedly no-show, because there are so many of them.

There are so many of our patients that lack transportation, that lack resources, that lack any sort of regular functionality or organization in their lives. So an appointment, a regular doctor’s appointment, is kind of a big commitment for them, and so we end up with a lot of no-shows, as you can imagine. We can’t just have providers sitting around and missing all their day and not working, and the clinic needs to keep open too. But when you get to know the patients, and when they become your patients and you know their story, you sort of look to bend the rules, I guess, as a resident, a little bit.

In the article that I wrote, the particular patient I was talking about, I had followed for most of her first pregnancy. She had been in and out of jail. I was following her for her second pregnancy, and she dealt with substance abuse and unstable home situations and lots of things like that. And so, because I had that relationship with her, I could no longer view her as just anonymous, or as someone that didn’t have her own backstory. Sometimes it’s easy as physicians to walk into the room and not give any thought to what has brought that person there, what they’re going home to, and what their day-to-day looks like. But the longer you get to know them, the harder that becomes. And so I found that often, as I was experiencing clinic and hospital flow for the first time as a resident.

Kevin Pho: So from a policy or societal standpoint, what are some of the answers that we could do to fix these barriers to care that patients often have?

Erin Hoffman: In our residency clinic, one good thing that we did is we had a social worker right there with the clinic. Her only job was to work with our patients. Some OB floors and larger academic centers, such as the one that I trained at, have a social worker just dedicated, for example, to the obstetrics patients of that hospital. I think those are great ways to break down some of those barriers. Oftentimes in residency clinic, I would leave the patient and say, “I’m going to send the social worker in, if that’s OK with you, to talk to you about food resources, transportation resources, affording your medicine, affording your imaging, that kind of thing.” And so that more broad-spectrum approach to care, recognizing that they’re not just the sum of their body parts or their physiology and that they have all these other things going on, is very effective.

I don’t have that where I am now. We don’t have a social worker in-house, and I have found that to be very challenging. Rural areas are underserved in lots of ways as well. So one thing we do, in the case of obstetric patients, is work closely with our pregnancy resource center here, as well as our family resource center, for some of the more basic needs that our patients have, even including transportation. I’m able to connect them with an advocate through the pregnancy crisis center, and that advocate sometimes will function solely to encourage them and to bring them to their appointments. We always ask if the patient is willing, but that can be a really effective modality of compliance, I guess you could say, on their part, if you can just connect them with someone who’s going to be able to help them tie up some of those loose ends.

Kevin Pho: So you mentioned a little bit of a tension. On one hand, a lot of patients have these barriers to care that prevent them from going to a simple doctor’s appointment, but on the other, you worry about the no-shows, and you have doctors potentially sitting around as patients no-show. You mentioned social work being a solution, but what are some other options that you can think of to help with that tension?

Erin Hoffman: Yeah, so I definitely think that the patient and physician relationship is key for that as well. I try to call my patients, my personal patients, when they no-show, in particular my kids for well-child checks and my obstetric patients. I tend to think that if they know that I’m looking for them, if they know that they’re going to get a phone call from me if they miss their appointment, they have more accountability and incentive to come. They think someone really cares about them, they have a reminder, those kinds of things. So that’s something really small that I’ve tried to do in my own practice that I have found to decrease my own no-show rate.

From a systemic level, there are so many more things that we could talk about, definitely, as far as even just barriers to care and poverty, and urban areas versus rural areas. But from a clinic standpoint, I think that a really good thing that clinics can do, just at baseline, is try to keep patients with their own providers and not have them see other providers, because when you’re seeing another provider that you don’t know, you have less incentive to show up, just sort of at baseline. So I think that’s a way that we can improve it as well.

Kevin Pho: So as I mentioned earlier, I’m entering my 18th year of internal medicine primary care practice, and one of the things I really enjoy about talking to new attendings is that they bring a new perspective into medicine. So in your couple of years as an attending, is there something that you’ve seen, or something that you can teach some of the more established attendings?

Erin Hoffman: I think that’s a really good question, because I’m often trying to learn from them, so to turn it around is a good perspective to try to take. I have this burning desire to stay up to date. I think that residency is so good for keeping you up to date, in academic centers like that, and so you’re always learning the most up-to-date information. You’re changing policies as they should be changed, you’re changing protocols as they should change, and it’s easier to stay up to date because that’s your culture.

But I’m realizing, after just one year of practice, and we actually do have a small rural-track residency where I practice, but none of the attending physicians are full-time faculty. We all have our own practices and are working, and so it leaves less time for research, I think, at baseline. And I just am desperately wanting to not get behind, so I’m reaching out to my residency training program all the time to ask for updates and new things, and reading UpToDate online all the time, and listening to podcasts.

And I see the best attending physicians that have been in practice for a long time doing that same thing, because then they have the best of both worlds. They have the experience factor, which I’m still learning and growing into, which is invaluable, as we all know, but they also are able to change and be malleable with new things as they come out. I think that’s the kind of attending physician that I would want to grow into: someone who becomes more sure of my experience and what I know, but also to be flexible and to not be resisting change, especially when it’s positive change or updated information, and not to just practice the way I always have because it’s always worked. So the best attendings I see that have been in practice just a little longer, like yourself, do that.

Kevin Pho: So let’s take a step back. I was wondering if you could share with my audience something that you’ve been curious about, or something that you’ve been passionate about, recently.

Erin Hoffman: Sure. I’m always really curious and passionate about health maintenance, about preventative medicine, about how we can keep people from being on multiple drugs for preventable metabolic conditions. I always tell my patients I’m kind of a hippie at heart: “I don’t want to start medicines for you if you don’t need them. I want to take medicines away from you if you don’t need them.”

And so I have recently finished “The Obesity Code,” which is a wonderful book by a nephrologist regarding the complexity of obesity, and presenting some real, I think, simple solutions, which is excellent. So I do a lot of reading in that area. I also just finished a book called “Spark,” which is by a psychiatrist, basically about how exercise is the answer for lots of things in the arena of mental health. So I’m always trying to read and learn about those kinds of things, preventative medicine, too.

I feel like I’ve spent a lot of time memorizing drugs for diabetes and hypertension, and I think I should spend equal or more time not only being up to date on prevention, but knowing how to communicate with my patients effectively and to try to initiate change in their lives, which is a hard thing. So those are kind of my areas right now that I’m really passionate about.

Kevin Pho: We’re talking to Erin Hoffman. She’s a family physician, and she wrote the KevinMD article “The patient who no-shows.” Erin, my final question: What is your take-home message that you want to share with the KevinMD audience?

Erin Hoffman: I think the biggest thing that I want all physicians to think of, that I’m trying myself always to think of, is just to remember that our patients have a story, and that a lot of times they’re pretty voiceless. And so we often have a position to give them a voice, even if it’s just by listening to them, by taking the time, by thinking about how we can take them seriously, and sometimes at different levels. That’s why I really like to write, because I feel like it gives my patients a voice that they otherwise wouldn’t have. And we don’t recognize that voice if we don’t first recognize that they have a story, that they have some background that they walked into our office with, or our clinic with, or our hospital with. And I just want to know it more and more, essentially.

Kevin Pho: Well, thank you so much for sharing your insight and time, and thank you so much for being on the show.

Erin Hoffman: Yeah, thank you.

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