Category: Medicine Hat News

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Missing Doctor’s Appointments and No Shows

Dave is angry. He forgets to keep a doctor’s appointment. He receives a bill for not showing up.

Susan is upset. She has to wait for an hour before her doctor sees her.

Doctors and their receptionists struggle all the time to book the right number of patients each day so everybody is seen on time. This helps patients, staff and doctors to get home to their families in time.

In reality, this never happens.

To physicians, the big problem is the “no shows”. Patients make appointments and some do not bother to show up. This happens inspite of being reminded by the physician’s office few days ahead of the scheduled time.

This costs the taxpayers dearly. In the United Kingdom, an estimated US$240 million worth of appointment time is lost each year because of the patients who fail to keep appointments with their GPs, according to a survey by the Doctor Patient Partnership (DPP).

In Alberta, the problem must be serious enough for the College of Physicians and Surgeons to provide directions on this subject. The College’s motto is “serving the public and guiding the medical profession”.

The College says: Although generally opposed, College recognizes that, under certain exceptions, physicians may bill patients for missed appointments.

Dr. Bill Taylor follows this policy. He is the only dermatologist in our region. His office gives out a pamphlet to the patients that says: If you miss an appointment without timely notification this becomes a “missed appointment”. This could result in you being billed for this and future missed appointments.

Dr. Stephen Cassar is the only plastic surgeon in our region. It takes a long time to get an appointment with him. Naturally, patients and physicians complain. We want instant service.

Last week, in sheer exasperation, he sent a letter to all the physicians indicating that in the last nine months he has had 80 “no shows”. This happens despite the fact that his office phones patients to remind them of their appointments.

This “no shows” do not include the ones who fail to attend due to inclement weather, family emergencies, or personal illness. Dr. Cassar says that if patients make their scheduled appointments as booked, then his waiting time would be cut be approximately 4-5 weeks!

An article in the Journal of the American Board of Family Practice says that missed appointments can affect patient health, disrupt schedules, and result in poor utilization of resources, and increased workload for staff and physicians.

Why do patients fail to keep clinic appointments? Asks a report in the International Journal of Clinical Practice. The answers are disappointingly predictable, says the BMJ. They forget the appointment, feel too ill to make it, or never receive details of it in the first pace.

Is there a solution to the problem? Like many things in life, it boils down to individual responsibility to use health services responsibly. Unfortunately, that message does not always get through to people who abuse the system.

The sad thing is, reasonable and responsible people pay the price for the delinquent ones.

DPP’s latest campaign – KEEP IT OR CANCEL IT!

This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems.

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Annual Physical Check-up

An apple a day keeps the doctor away? Is prevention better than cure? What about an annual physical examination? Is that the best way to stay healthy? Many people think so.

“The truth is that all of us are, to greater or lesser degrees, prisoners of ritual,” says Dr. Richard Goldbloom, MD, in an editorial in the Canadian Medical Association Journal (CMAJ). We perform these illogical practices to reduce our level of anxiety or, at least, to prevent it from rising.

Dr. Goldbloom is a Professor in the Department of Pediatrics, Dalhousie University, Halifax, NS.

In 1980, the Canadian Task Force on the Periodic Health Examination (now called the Canadian Task Force on Preventive Health Care) recommended that the routine annual physical examination should be discarded in favour of a selective plan for prevention to suite individual requirement.

Many physicians disagree with this recommendation.

Currently, physicians are inundated with clinical practice guidelines that are based on sound scientific evidence. But not many physicians buy into these guidelines as they conflict with the percieved needs and expectations of patients and physicians, Says Dr. Marie-Dominique Beaulieu and others in the same issue of the CMAJ.

Dr. Beaulieu is a Professor of Family Medicine at the University of Montreal, Montreal, Quebec.

The study conducted by Dr. Beaulieu and others, show that the majority of the physicians and patients find the annual check-up beneficial for variety of reasons. One important reason is that check-up permits a more thorough evaluation than regular medical visits. It also builds trust.

The authors say that tests play an important role for patients in their personal preventive routine. Patients considered test results more accurate than the history and physical examination.

Physicians value the history and physical examination much more than test results. Since there are very few truly effective screening tests, physicians feel the downgrading of the annual check-up unacceptable.

A screening test should have some effect on the disease process and offer gain in life expectancy to the majority of the people who under go such tests.

But there are many drawbacks to offering the public preventive therapy. It creates unnecessary anxiety. It exposes the public to procedural complications and the risks of false-positive and false-negative results; and it creates an unhealthy preoccupation with disease among the public.

It has a potential to induce fear.

Over use of diagnostic procedures for screening purposes creates long waiting lists. Thus the patients who would most gain from the test may be deprived of the benefit.

“Another attractive concept has been widely promoted is the belief that if more money were spent on prevention, less would have to be spent on treatment – a concept that, with a few exceptions, does not stand up to close scrutiny,” says Dr. Goldbloom.

For physicians and patients, annual check-up and tests relieve anxiety. To them, this is more important then worrying about clinical practice guidelines. For the preventive medicine experts, the biggest challenge is to bridge the gap between science and ritual.

Dr. Goldbloom says, “… physicians, like patients, are just plain folks after all, enslaved to ritual and tradition, reiterating beliefs and practices that both groups believe, logically or not, have served them well.”

So, don’t forget your apple today!

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Anti-inflammatory Agents (NSAID)

Wayne Gretzky seems to be suffering from arthritis. He is not alone. This disease afflicts 4 million Canadians. To stay comfortable, most arthritic patients are on anti-inflammatory agents.

These agents are steroids and/or nonsteroidal anti-inflammatory drugs (NSAID). Neither of them is completely safe.

Inflammation is body’s response to infection or injury. It is characterized by heat, redness, pain, swelling and, occasionally, loss of function.

If the inflammation is due to infection then antibiotic is required. To that one can add an anti-inflammatory agent to help reduce swelling and pain. If the inflammation is due to injury then an anti-inflammatory is enough. No antibiotic is required.

“Dr. B, I have arthritis and my doctor wants me to take an anti-inflammatory agent. I am scarred. My husband was on an anti-inflammatory and he almost bled to death. What are my chances of getting such a complication?”

This lady’s fears are shared by millions of people who are aware of the likely complications of anti-inflammatory agents. But there are millions more who are not aware of the risks.

It is estimated that 5 to 10 percent of patients will die from a bleeding ulcer as a result of NSAID use. The bleeding may start with no prior warning signs of an ulcer. This is true in 81 percent of cases, says a review article in the New England Journal of Medicine (NEJM).

Felix Hoffman, working at Bayer Industries, discovered the first NSAID (aspirin) 100 years ago. It was and is used for rheumatic diseases, menstrual pain, and fever. Since then numerous NSAIDs have been developed. These are one of the most widely used drugs – by prescription and off the counter.

It is estimated that 5 to 50 percent of patients will develop dyspepsia (upset stomach) due to NSAID use. But not necessarily develop an ulcer.

But the risk of developing an ulcer is high in patients who are advanced in age, have a previous history of ulcer, are on steroid (prednisone), are on blood thinner, have other medical problems, use more than one type of NSAID at a time, have bacterial infection of the stomach (H. Pylori), smoke, and use alcohol.

Most patients with osteoarthritis or rheumatoid arthritis have no choice but to take NSAID to stay comfortable. There are millions of people who take NSAID for other aches and pains. Therefore, it is important to make these medications safe.

Two strategies have been used to improve their safety, says the NEJM article. One is to prescribe concomitant medication to protect the lining of the stomach and duodenum and second is to develop safer anti-inflammatory agents.

Studies have shown that omeprazole (20 mg once a day), or misoprostol (200 mg three times a day) appear to be effective in preventing the recurrence of ulcers during continued use of NSAIDs.

Several newer NSAID agents are being studied (nabumetone, etodolac, meloxicam, celecoxib and rofecoxib). The authors of the review article say that the newer agents offer considerable promise in the treatment of inflammatory arthritis, but careful surveillance will be important to determine their ultimate benefit and safety profile.

In the meantime, vigilance on the part of physician and patient is required. Careful prescribing is important. Patients should follow directions properly. Especially, the individuals who consume regular off the counter anti-inflammatory agents.

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Recruiting doctors should always be ongoing.

The Medicine Hat News Friday, September 10, 1999

Letter to Editor

Recruiting doctors should always be ongoing

Recent media report on physician shortage has created considerable anxiety amongst the people of this Region. This naturally begs the question – what are we doing about it?

In the last two years, due to various reasons, we lost 12 physicians (7 family doctors and 5 specialists) but were able to gain 20 ( 8 family doctors and 12 specialists). A net gain of 8.

Current population to physician ratio in Canada is 550:1. In 1997, Prince Edward Island had a ratio of 830:1 compared to Alberta’s 640:1. In 1998, Alberta had a ratio of 620:1.

There are 100 physicians in our Region with a population of 85,000 ( ratio of 850:1). If my calculations are correct, then for our Region to achieve the national ratio of 550:1, we have to recruit about 75 doctors, or 50 doctors to achieve our provincial ratio of 620:1!

We know our Region does not need that many doctors. The national and provincial ratios do not take into consideration mal-distribution of physicians (rural vs. urban vs. metropolis). Two-thirds of Canada’s 56,000 physicians practice in Ontario!

Average age of our Region’s family physician is 44 and specialist is 45 (national average age 47 for all physicians).

Twenty seven percent of our doctors are under 40 (nationally 29 percent), 46 percent between 41-50, 22 percent between 51-60, and 5 percent are over the age of 60 (nationally 16 percent). In the next 5 to 10 years, we should expect 30 percent of our physicians slowing down or retiring.

Where are we going to find new doctors? At what price? Where is the funding going to come from? As we all know, there are no easy answers to these questions. Recruitment should be an ongoing process and our efforts will continue. Hopefully, we will be able to serve the people of our Region satisfactorily.

What are our current recruitment efforts? For Brooks, we are looking for 3 family physicians with special skills – anesthesia, obstetrics or other special interest. For Medicine Hat: 3 family physicians (hopefully with obstetrics), 1 internist, 1 anesthetist and a part-time pathologist.

Noorali Bharwani, FRCSC; FACS
Regional Chief of Staff
Palliser Health Authority

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