Missed Opportunities for Care — And What They Teach Us

Derick Alison
Derick Alison
9 Min Read

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    Fred Pelzman is an associate professor of medicine at Weill Cornell, and has been a practicing internist for nearly 30 years. He is medical director of Weill Cornell Internal Medicine Associates.

Today we missed another opportunity.

Actually, several opportunities — several opportunities to provide care to multiple different patients.

The No-Show — For a Good Reason

This morning, at the beginning of our practice session, there was a patient scheduled for a new patient visit with one of the residents on their ambulatory block rotation. It was a 1-hour appointment that, according to the scheduling system, had been made approximately 10 days ago.

Unfortunately, the patient was a no-show for their appointment, because it turns out they are currently an inpatient in the hospital — our hospital, same institution, right across the street, using the same electronic health record.

Looking back in the system, we can see that the appointment was made on the day that the patient, brand new to our hospital system, arrived in the emergency department with a series of systemic and constitutional symptoms. It appears that after several hours under their care there, one of the care navigators called the scheduling team at our practice and requested a new patient appointment for “follow-up from the emergency department.” However, just after this event occurred, it seems that new results came back which necessitated the patient being admitted to the hospital, where they have remained ever since, getting evaluated and treated.

No one bothered to cancel that appointment, and no one on the inpatient team taking care of them noticed that they were simultaneously scheduled for an outpatient initial visit appointment today in our practice, right across the street. No one bothered to follow up, no one bothered to call, probably because it didn’t come to anybody’s attention, or no one thought it was worth the effort.

The Question That Should Have Been Asked

But let’s go back to the very beginning, when the patient was being evaluated in the emergency department. At no point does it appear that anyone asked this patient, an elderly woman with a number of complex medical problems who was on a lot of outpatient medicines, whether she had a primary care provider in the community who had been taking care of her.

It literally took me 30 seconds to look into the electronic health record, under the system that connects similar users of the same EHR, to find that she has a primary care provider right in her neighborhood who manages most of her medical conditions and sees her regularly, most recently 2 months ago. So, in actuality, no one should have been making her a new patient appointment here, with a brand new set of doctors, more than 5 miles from where she lives, unless she somehow told somebody that she was firing her current doctor and wanted to continue all her care here after a brief emergency room visit.

I remember oh so many years ago, when I was an intern doing admissions in the hospital, the first question we asked patients was, “What brings you here today?” But the second question we were taught to ask was, “Do you have a primary care doctor?” And who is it? Do you know their phone number?

Without fail, the next morning on rounds, the attending would want to know who the patient’s primary care doctor was, and whether we had reached out to them to find any information that might be critically useful in the management of their current clinical reason for admission. What was their last EKG like? Do we know what their creatinine has been most recently? Are they compliant with their medications, according to their primary care provider? What’s their baseline mental status; who is their healthcare proxy; and do they have support at home?

Woe to the intern that came to morning rounds without all this information, or without at least having made the effort to reach out to the primary care physician in the community.

Several Missed Opportunities

In scheduling a patient for an appointment they probably aren’t going to attend, the folks who made it missed an opportunity for care — multiple opportunities, in fact. The patient in question should have had a follow-up appointment arranged with their primary care doctor, to make sure they got the appropriate care and follow-up from the emergency department interventions and treatments. And multiple patients were denied opportunities to get care from us, because that 1-hour appointment was scheduled for a patient who was definitely not going to show up for it. And the resident who was scheduled to see that patient sat around not learning, not taking care of a patient — definitely a missed opportunity.

No system is ever going to be perfect, but I think as we try and build a better healthcare system in this, the late early 21st century, you’d think we’d be able to design systems that would prevent bad appointments from being made, lower no-show rates, prevent late arrivals, and avoid the wrong care at the wrong time with the wrong provider.

We desperately want our patients to have access to healthcare and to come in and see us, and we want to engage them in their health and make sure we do everything we can to get them as healthy as they can be. But if we make appointments all wrong, if we can’t confirm they are coming, if we can’t get them transportation, if we can’t offer them telehealth visits, if we can’t get them onto the schedule because things are cluttered up with sometimes meaningless visits, then we’re doing a disservice to everyone.

Just the other day I saw a patient who told me he’d seen a specialist a couple of weeks earlier, who told him they were going to be arranging for him to undergo a particular test. But since then, he said, he hadn’t heard from anybody. He was enrolled in the patient portal, but he was not really sure how to use it. He reassured me that his contact information was all correct, his cell phone was the preferred number and was working, and that he had received no messages from their practice.

A quick outreach to the practice showed that they been trying to reach him but had been unable to, and with some gentle nudging we were able to make sure everything was connected and set up. But this stuff should happen by default. Loose ends should get tied, or shouldn’t exist in the first place.

Although there are so many things that need to be addressed in the healthcare system, including major issues such as institutional bias, lack of adequate insurance, low health literacy, and inequitable care, there also are still so many broken small parts of the huge machinery of healthcare, and fixing those could make a big difference in how things go.

For all of our patients, and for all of us.

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