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    "There is nothing like returning to a place that remains unchanged to find the ways in which you yourself have altered."
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David Baxter

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No Show
By Dinah

I hate it when patients don't show up for their scheduled appointments.

I have a solo private practice, it's just me-- no partners, no staff, no secretary. I run on time and I don't double book. Patients know that the time is theirs, I tell them this before the first appointment: The time is reserved for you, if for any reason you're not going to keep the appointment, please call and cancel. I tell patients on the first day that I bill for any appointment not cancelled at least 24 hours in advance, with the exception of weather emergencies or the sudden onset of an illness (in other words: I don't want to be infected or vomited on). Any appointment that is simply not kept is billed in full and the cost of a missed visit can't be passed on to an insurer. I've said it, and a few years ago I wrote it and handed it out on a sheet of Office Policies.

My first few years in practice, I was lax about enforcing the late cancellation/ no show policy. I hate charging people for a service they don't receive, especially since it seems that most of my patients struggle a bit financially. At some point, I realized my schedule was mayhem. People didn't show up, or they called asking for a different time-- I like to be accomodating and would shift when I could, but I started to feel like each day was a juggling routine, and the number of No Shows and Late Cancellations escalated, often for reasons such as conflicting Karate lessons, or I Forgot. I quickly figured out that if I value my time at Nothing, the patients do as well.

I still am a bit ambivalent about it and often debate with myself what to do. If I call and find the patient, we can develop a plan -- to reschedule or for him to come in for the remainder of the time-- and at least I can do something else with the time. If not, I am held hostage in my office, waiting to see if the patient is simply caught in traffic or enroute. I could rant about why is it that I have to repeatedly call patients on their mobile phones to ask if they're coming, only to be told at 15 minutes after the hour that they're almost there-- they couldn't phone first to let me know they're running late/? Another post for another day.

I still sometimes let the Late Cancellation folks slide, though my neighbor told me she still puts it on their statement with a notation "Fee forgiven due to..." and I've adopted this practice, even if it's just to write "Fee forgiven, one time only." The repeat offenders, I bill, even if I feel badly about it.

So yesterday, I left the clinic and went to my office. My first patient did not show up. He's done this before, several times, and I was unable to reach him on the phone and the bill is in the mail. The background is that in the past, I've spent the better part of a weekend worrying about him and ended up having someone go to his house when I could not reach him anywhere for days: he was busy and hadn't checked his messages in some time, but was alive and well. My next patient also didn't show up. This gentleman has been in treatment with me for years, and has only once or twice missed his weekly session. He always comes on time, and he called last night saying it was important that we meet and he came in today at a time that was convenient for me-- I let yesterday's missed visit slide with a One Time Only notation. Today, I had a late cancellation from someone who had switched work shifts to help a desperate colleague-- the catch: she'd switched shifts several days ago and had exhausted her One Time Only (which I believe was actually two or three times) pass several missed visits ago. Still, this patient works several jobs and struggles to keep up-- I feel badly charging for the missed visit.

In the public psychiatry clinics where I've worked, No Shows are always a problem. The clinics get the bulk of their revenues from Medicare and Medicaid and billing is not allowed if the service isn't rendered. In effect, the therapists' time is valued at Zero, there is little disincentive for patients to come, or even to call, if they can't come (or if they oversleep or if something better comes up or if they don't want to talk about the yucky things going on in their life). In some clinics, patients are discharged if they miss three appointments, but that's never been the case in the clinics I work in, and across the board, Community Mental Health Centers sport a 30% No Show rate (sorry, I should have a reference and a link, plus I think it was actually only 29%).

It comes up with Pro Bono patients as well, and when I've offered free care through Maryland's Pro Bono Counseling Project, I've taken to adopting a No Show fee-- if you show up, care is free, if you blow me off, there is a nominal fee meant to discourage people from abusing my time.

Do these measures work? Mostly, I think so-- it's much less of a problem than it used to be, though I did just write about 3 patients who didn't come in the last two days, and I didn't even mention one of the patients at the clinic who didn't show....
 

Daniel

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I have a solo private practice, it's just me-- no partners, no staff, no secretary.

I would think that the "no show" rate would be slightly less if the therapist had a person/service/computer call the patient the day before to remind the patient about the appointment.
 

David Baxter

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I would think that the "no show" rate would be slightly less if the therapist had a person/service/computer call the patient the day before to remind the patient about the appointment.

That's probably true.

But speaking as someone who is in the same position as the author, to do that, I'd have to hire someone or pay additional expenses. That would mean higher fees for my patients.
 

Cavi

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Just my 0.2 Why should a therapist be respondsible for reminding clients of their appts?...If I need to talk, I'll be there...A no show for me would mean I had nothing to say...I've never done a no-show...Rimh
 

AVC

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I had a dentist that canceled me as a patient because I missed an appointment, he called me indifferent, but that day there was a major rainstorm and my car would not start, so I had to cancel.

So it turned out that the Dentist was indifferent to the patient in this case and was thinking more about his cash flow than the human needs of his patients.

He mentioned to me that he could not run a professional practice with indifferent people like me as patients, showing he was a low class, self centered individual.

I had to get the state dental board on him just to get my records after that, this shows the kind of person he was by not having consideration for people.
 
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personally i find it a sign of disrespect if you don't show up, or show up late without calling, unless there are unforseen circumstances where you just can't make it.
 

Daniel

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Just my 0.2 Why should a therapist be respondsible for reminding clients of their appts?...If I need to talk, I'll be there...

I agree. Personally, I only "no showed" once out of maybe 100 therapy visits over the years, and that was because I simply forgot (when I was like 19 years old and not as organized).
 

Halo

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I can't ever recall ever being a no-show. I have always given notice that I was not going to be able to make one of my regularly scheduled appointments.

I agree that it is a sign of disrespect for a client to be a no-show or to be late without calling. However if I may flip the coin for a moment, I also find that it is just as disrespectful for a therapist to be a no-show or late as well. I believe that it is a two-way street and if that time has been set aside for me, I fully expect the therapist to be ready and available for my time barring any unforseen circumstances.

If I make the effort to show up for my appt and be on time then so should the therapist.

JMO.
 
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I agree, Nancy. I have never been a "no-show" either and I think the world of my therapist, but he is almost always at least 15 minutes late. I always show up on time just in case and sit and wait in agony. But then he takes extra time with me. At first it was upsetting, now it's just "the way it is."
 

Halo

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I can relate as mine is the same. I use to get all anxious and paranoid that he wasn't going to show up as sometimes I am his first appt of the day but then when he did and I realized that even if he was late starting with me he didn't cut my time short, I was okay. If he did cut my time short because of his delay, that is when I would be upset. I actually don't mind now because it gives me more time to debrief between work and my appts.
 
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I get anxious still, but I've just accepted it and he doesn't cut my time short or hasn't yet. Once, though, the front office people didn't tell him I was there and he came out to get his next patient and saw me sitting there and took me back for a few minutes. I was pretty upset and nervous. That hasn't happened again and it wasn't his fault.

I tell myself that if he doesn't call me back in half an hour I'll go ask at the front desk instead of sitting, waiting, for 45 minutes like I did that time. :eek: Heck, the whole thing is about anxiety for me anyway, what's a little more. :D :eek: And I think he can see how anxious I get and that helps him help me better. If that makes any sense. :)
 

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I missed an app't once because I was stuck in a parking lot that took 3 1/2 hours to get out of. I called my therapist 30 minutes ahead of time to tell her I wouldn't make it, and she said no problem. We had never really discussed her cancellation policy, but I was pretty sure it wasn't 30 minutes. At my next app't I gave her a cheque for the session I missed, and after she got over her shock, she said not to worry about it - and applied it to that day's session instead because our app't that week was originally Wednesday but she asked me to change days, which I did...so she said that because I changed for her, she wouldn't charge me for not being able to make it. I showed up once and she was still sleeping (we meet in her home) and she was horrified once she realized...my next session was free, so I asked her to do that a little more often as it's easier on my budget :D. When we first started meeting she was pretty unreliable and I was getting very frustrated but things have gotten a million times better...
 

Halo

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I showed up once and she was still sleeping (we meet in her home) and she was horrified once she realized...my next session was free, so I asked her to do that a little more often as it's easier on my budget

I can imagine how horrified she must have been but I just loved your comment about her doing it more often and being easier on your budget :lol: I really thought that was a good one :rofl:
 

ThatLady

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My doctor is late pretty often; however, I know why. He takes a lot of time with his patients. I appreciate that from him when it's my turn, and I'm sure others appreciate it when it's their turn. If a family has a loved one in dire shape in the hospital, I'd rather my doctor be there, with them, than looking over my lab reports and telling me I'm disgustingly healthy. I guess, in many ways, it's a matter of perspective.

As far as patients are concerned, they really need to be on time if there's any way they can be. No matter what kind of doctor it is, their time is subject to the needs of their patients. Some patients are just going to take a little longer than others. We're responsible to see that we're there when we're supposed to be and on time. I agree with RIMH. That's our responsibility as patients.
 

sunset

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My T works alone and has no secretary or partners.. If I cant make my appt I call and cancel. Its not hard to do, and it shows respect for your therapist. His time as well as your own is important, and when someone is a no-show, he could have gave someone else that time slot. He loses money also, and I can imagine if a lot of patients did this, it wouldnt be too good for him.

Its just common courtesy to call. I once got sick right before I was to see him. Not wanting to cancel last minute, I called him when my time was to start and talked to him from home. It worked out for both of us.

I like to treat people the way I would like to be treated. Seems like a good thing for all involved.
 

just mary

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I've always been on time for my appointments and I've never done a no-show, I guess I've been lucky with respect to illness and other emergencies.

However, my therapist was nearly, always late. Even for appointments first thing in the morning or right after lunch. I could never make an appointment during work hours because I couldn't take so much time away from work, a one hour appointment could end up being two, with most of that time spent waiting.

But I could never show up late for an appointment since it just isn't in me. I'm perpetually early, if I try to be late - I'll be there on time. And I did try to be late but I was always worried that if I was late, it would be the one appointment he was on time for and then I would be accused of not valuing his time.

To be honest it really frustrated me since I felt he didn't value my time. Since I've stopped seeing him however, I now understand that I was not the only one who experienced his chronic lateness. I feel better because after awhile I started to take it personally, I thought he didn't like me and that he was hoping I would just go away.

Sorry, I just had to vent. But I understand that the shoe can be on the other foot quite easily.

jm
 

Peanut

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My therapist is pretty strict about his cancellation and time policies. The first and only time I was late the appointment still ended on time. The other time I was really sick and I had to talk to him on the phone for the appointment to avoid the cancellation fee. He always starts on time or earlier and ends exactly on time. At first I thought it was a little off putting, but in the end I found it to be something that I really admire about him. When he talks about setting boundaries, it makes more sense because he practices what he preaches and provides a good model for boundary setting and I really like it.
 

healthbound

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I also appreciate the boundaries that my therapist sets and I use my appointments to try to work through my challenges with time and time organization.

I have huge problems with being late (I mean that I am often late) and I've also put my therapist through a few "no shows" over the last couple of years.

I get really stressed out about it (which makes the problem worse). I don't mean any disrespect and I have tried various ways to overcome this problem, but still can't "get it". And, of course, I also know how it feels to get stood up or am made to wait.

I have no idea why I've always struggled with time and sleep, but I have. I know it's extremely frustrating for people (friends, family and therapists) and it bothers me a lot.

I'm actually starting another medication for sleep (and pain) tonight. I'm supposed to stay on it for 6 weeks and if there's no improvement I have to get a sleep study done. I wish/hope/pray this medication works.

Our culture is very concerned with time and trying to get as much done as possible as quickly as possible. So, I realize my problems have a ripple effect on others. I am totally empathetic about the challenges I cause and I know it's my problem, but that still doesn't help the stress I feel and the frustration others experience. I think about it a lot and feel a lot of guilt about it (which again, might make the problem worse?)

On the other hand....in the author's line of work, there are going to be patients who struggle with organization or with life or with whatever. Sometimes people who are seeing a therapist are struggling to just stay alive or to just get out of bed and so getting to an appointment is a huge challenge and a major success.
 

David Baxter

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I've always had problems that way, too, Healthbound. It has nothing to do with disrespect in my case - I do know that much. It's primarily a problem of being a terrible judge of time - I think something is going to take 15 minutes and it almost always ends up taking longer, or else I just lose track of time altogether. Frankly, it's a bit of an embarrassment at times.

On the other hand, I'm never upset if someone else is late... empathy, perhaps. :eek:
 

healthbound

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On the other hand, I'm never upset if someone else is late... empathy, perhaps.

lol - Funny you should bring that up...Earlier, I was thinking about how I actually don't seem to care too much when people are late or no shows with me. I think it's because of my own challenges with time or because I just figure they probably owe me a few lates or no shows :)

I've been trying to get together with a new male friend for a few weeks now but both of us have either not showed up or not called when we said we'd call etc. etc. I was laughing at myself wondering if "no shows" or missed calls might normally be red flags when getting to know someone...but, in my case I just think the behavior is normal, lol.

I often lose track of time. My body and mind don't even seem to jive with night and day. I'm not sure what it is. I often won't realize how long I've been focusing on something until I realize my body hurts because it is hungry or tired. Maybe I get so distracted by what I'm working on or what's going on in my mind that I lose touch with the physical world? Geeze...that makes it sound like there's something really wrong with me.

I'm not good with calculating appropriate time for travel either. For some reason I think it will take me about 5 mins to get anywhere I want to go - even when it's way across the city.

Apparently, time is perpetually moving even though I think it is often still.

Anyway - here's a big shout out to everyone I've frustrated with being late - I'm sorry!

:flowers:
 

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