We have all been there… your last patient of the day is 20 minutes late to their appointment. All you can think about is how much more time do you give them, before telling the front desk to reschedule the appointment. With all those notes backed up, it would be nice to focus on finishing up, so you can get home before you miss another dinner. However, even after giving them an additional 15 minutes, they do not show up. During those times is not uncommon to hear or think things like, “they better have a good excuse”, “why can they not get here early like everyone else”, or “they have had no-shown 3 appointments, let’s fire them from the clinic.”
But in those moments, it is vital that we start to move away from the thought process of how this missed appointment affects us, to the thought of how does this missed appointment affect the patient and why could they not make it in today? Not only do missed appointments have negative effects on the patient, they can also impact the healthcare system as a whole [1,2]. While evidence suggests the majority of appointments are missed because of forgetfulness, other factors have been reported by families to affect their ability to attending clinic visits, such as: 
- Issues with transportation
- Schedule conflict (work, school, other appointments)
- Feeling appointments were unnecessary
- Child’s health improved
- Not feeling well
- Time commitment
- Insurance issues
Typical responses to a high volume of missed appointments in a clinic usually involve efforts to improve communication with families via reminder calls/text, open access scheduling to improve appointment wait times, and extended clinic hours to provide more flexible assess to care [2-4]. But none of these fully address issues with transportation, financial short falls, lack of insurance, or any of the countless other hardships families face while navigating a complex medical system. Each no-showed appointment is a unique problem that requires a unique solution, because the underlying factors can vary from day to day and patient to patient.
This is a perfect place to have the “social visit”: think of it as the well-child visit par excellence. These visits would be tailored to identify factors that act as barriers to receiving timely medical and preventive care. During these visits, referrals can be made to community resources, education can be provided on how preventative care is essential for maintaining health, and time can be dedicated for family-provider interactions to establish a robust therapeutic alliance.
In a perfect world, this would be done in the clinic so providers and families can personally come together and tackle their unique situation as a united team. However, if you cannot get patients into the clinic for regular visits, how effective is the “social visit” going to be if they do not show up for that either? Thankfully, it could also be completed by phone, which would allow for greater flexibility for families and hopefully lead to improved relationships and clinic attendance.
As pediatricians, we have the responsibility to make the effort to start changing the thought process and culture around missed appointments. These are perfect opportunities to reach out to families and provide assistance that they might not otherwise be willing to ask for. Additionally, we must advocate for our patients to make sure they have access to the “social visit”, regardless of billing/productivity constraints. We should push for protected time to make this happens, with the ultimate goal of changing the perspective, so we start to look at the causes of health disparities as medical diagnoses.
Aaron Pope, MD
1. Cameron E., et al. “Health care professional’s views of paediatric outpatient non-attendance; implications for general practice.” Fam Pract. 2014 Feb; 31(1): 111–117. Published online 2013 Nov 15. doi: 10.1093/fampra/cmt063
2. Samuels RC., et al. “Missed appointments: Factors Contributing to High No-Show Rates in an Urban Pediatrics Primary Care Clinic.” Clin Pediatr (Phila). 2015 Sep;54(10):976-82. doi: 10.1177/0009922815570613. Epub 2015 Feb 12.
3. O’Connor M., et al. “Effects of Open Access Scheduling on Missed Appointments, Immunizations, and Continuity of Care for infant Well-Child Care Visits.” Arch Pediatr Adolesc Med. 2006;160(9):889-893. doi:10.1001/archpedi.160.9.889
4. Aral L., et al. “‘Did not attends’ in children 0-10: a scoping review” Child Care Health Dev. 2014 Nov;40(6):797-805. doi: 10.1111/cch.12111. Epub 2013 Oct 18.