How do you work with patients who miss or cancel appointments, and then call needing help?

[SpongeBob DoctorPants]

Sorry, this ended up being longer than I expected; the last paragraph contains the main idea...

It seems to be a common scenario I run into. Here are a couple of recent examples:

1. A child's parents call 2 days before his next appointment to cancel it, but do not reschedule, and on the same day they call to cancel, they complain that he is not getting better and want to know what I can do for him. I make some recommendations for adjusting medications over the phone. They then call again two weeks later, saying there is still no improvement, and so I recommend further dose adjustments. There is still no future appointment scheduled, so I am expecting they will call again in a couple of weeks with the same concern.
   
   
2. Another child, who is being treated with a stimulant, gets a dose adjustment at his last visit with me, and I recommend follow up a month later. That appointment gets made, but is later canceled, and not rescheduled. Refills are requested each month for the next few months. I send those in to the pharmacy. After four months have gone by like this, I refill the medication once more, but with the instruction "must be seen for further refills", and I have the MA contact the patient's mother to explain that the child must be seen again before the next refill. Another month goes by, however, with no appointment being made, and another refill is requested. I decline the request and have the MA explain to the mother again that the child needs to be seen. The mother actually makes an appointment for Monday, but says her child will be out of medication on Friday, and because she has to work all weekend she worries that he will be a handful for the babysitter, so she requests the refill to be sent anyway and promises to attend the appointment on Monday.

There are countless other examples of patients who miss an appointment and then later that day request a refill of their medications. Generally I don't mind as long as they schedule another visit, but when they don't schedule and then continue to request another refill, month after month...

There are several other examples of patients who come in for a visit, but then leave without rescheduling, and a few weeks later call to complain of something not getting better, or something getting worse, or having trouble with sleep, or needing another refill, etc.... basically wanting some kind of help and not coming in to the clinic to receive it.

I don't mind making dose adjustments over the phone if it is something I plan on doing anyway. I often tell patients (or their parents) to call after a couple of weeks and if things are not improving as expected, we'll plan on raising the dose. I also don't mind making medication changes between visits if something gets worse within a short while after I see the patient, and they already have a follow up scheduled.

However, I do get annoyed by patients who miss or cancel appointments and then call in with concerns, and by those who request refills month after month with no future appointment being made, and by those who otherwise seem to want their medical care delivered over the phone so they don't have to come in to the clinic and pay for it. Yes, I understand that as physicians there is a certain amount of work we are expected to do for free, and I don't mind doing that, to an extent. I believe I am a compassionate physician, and I do my best to address my patients' concerns without requiring an appointment every time, but honestly, I think I may do so inappropriately sometimes.

So my question basically comes down to this: What is the difference between providing compassionate care by addressing concerns over the phone and adjusting/refilling meds without an appointment, and providing inappropriate care by doing the same thing? Or how do you decide when to tell your patient that they must come into the clinic to discuss a concern or get their medications renewed?

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[FlowRate]

1. "Let's discuss this during your next appointment."
2. "Dear XYZ, I am not able to provide appropriate medical care without seeing you on a regular basis. Please make an appointment to meet with me within the next 30 days. I will not be able to provide medication refills until I see you again in clinic." or something less awkwardly worded. The patient would have already been sent a couple of less ultimatum-y letters prior to that about how you were "sorry" that you "weren't able" to meet during their last scheduled appointment, then instructing them to make a new appt.

I wouldn't be making med changes on people who are repeatedly missing appointments/who I haven't seen in months. Also wouldn't be refilling controlled subs x months on patients who I feel I should be seeing monthly. IMO you've moved far past compassionate and deep into enabling.

 

[Old&InTheWay]

I've had some similar situations in my past professional life and I think it is really kind of you to recognize that life sometimes happens (especially for parents of kids with needs). But if you have repeat offenders who are essentially taking advantage of your compassion, I would make them come in before refilling the meds. If you don't feel like it's safe for the child go without his/her medication and the parent is not doing what they need to (i.e. coming to appointments) in order for their child to get the care they need, I would make a report of medical neglect to CPS.

 

[lyla]

Boundaries boundaries boundaries.

 

[TexasPhysician]

Examples are way too generous. I tell patients when I expect to see them back at each appointment. Patients that don’t follow through can have 1 refill after they schedule a follow-up within the next month for whatever times are available. Miss that and out of luck. Patients that feel too stable to regularly follow-up are referred back to pcp. Patients that expect phone calls are warned that I bill for calls too, at a higher rate usually. These policies are easily followed in my cash practice.

 

[VA Hopeful Dr]

If you no-show/cancel/reschedule an appointment, you get 1 refill to get another appointment. After that, you're SOL.

Do very little over the phone. You're doing work for free in that case which is bad for you and sets the patient up to expect to be able to do a lot over the phone.