Reimagining No-Shows as a Symptom and Not a Diagnosis: A Strength-Based, Trauma-Sensitive Approach

The words used to describe patients have the power to influence their care.¹  “No-show” is shorthand for a patient missing an appointment without alerting the health care team. This term has its contextual root in business, in which a customer’s failure to attend an appointment can be seen as inconsiderate because it translates to lost income and longer wait times. In an economic system that commodifies health care, the pressure to minimize loss drives solutions for patient no-shows such as penalization. The efficiency gained by reducing no-show rates in this manner comes at a cost paid by those who face the greatest healthcare inequities.

Punitive measures taken to limit “no-shows” can harm, discriminate against, or undermine the health of patients with the highest needs. The medical system's rejection of Dee based on her history of no-shows disregarded the underlying factors that Dee, a survivor of structural racism, poverty, and intergenerational trauma, must overcome to make it to an appointment. The medical community set unrealistic expectations for a young woman who was simultaneously navigating basic personal safety, food insecurity, unstable housing, and transportation, and worse yet, subjected her to further judgment and shame for not meeting them.

At times the same system we are working within can simultaneously be working against our patients, contributing to distrust. This lack of trust is associated with the underuse of health services and disparities in health outcomes. However, our health care system has not always behaved in ways that warrant trust. Medical mistrust is not just related to legacies of mistreatment but also stems from patients’ contemporary experiences of shame and discrimination in health care. We become less trustworthy when we automatically label patients as no-shows without pursuing a contextual understanding of their not coming to the visit.

This deficit-focused lens is further distorted for youth from racial and ethnic-marginalized groups (as defined by the US Office of Management and Budget and used by the National Institutes of Health) enduring systemic oppression.²  Structural racism inequitably limits opportunities for social, economic, and financial advancement, which results in a complex interplay between race, social determinants, and health that has negative consequences. Patients who experience racism report lower trust in health care, and subsequent lower satisfaction with and perceived quality of care.³  Marginalized racial and ethnic groups not only receive inadequate quality health care but are also viewed by some providers as “less desirable” or “difficult patients,” particularly because of a perceived lack of adherence to medical advice.⁴  As opposed to drawing attention to the social contexts that subject marginalized racial and ethnic groups to disproportionately greater health inequities, a significant proportion of patients with no-shows may be incorrectly labeled as disinvested in their health and blame them for their failure to benefit from treatment.

The problem is not the term “no-show” as a descriptor, but instead the conceptualization of and response to the patient labeled as a “no-show.” As clinicians in an adolescent shelter, we bear witness to the harm placed on youth when health care institutions do not provide the tailored support needed to convert a no-show into an impactful patient entry point to care. Supporting, rather than inadvertently shaming adolescents with multiple no-shows promotes more equitable health care access.

Institutional variations in their no-show policies may contribute to different degrees of age, sex, race, ethnicity, geography, and socioeconomic status bias that in turn may create, maintain, or exacerbate existing health inequities. The remedy is not to place blame on patients through punitive, consequence-oriented strategies.^5–7  Instead of having medicine subverted to serve the marketplace, it has to center on the needs of patients. Medicine must move beyond a transactional business model and honor patients as people.

To address no-shows, we draw from Svetaz and colleagues’ work, which added the theory of critical consciousness to trauma-sensitive models,⁸  an “empowering, strengths-based, non-expert directed approach that fosters insight and active engagement in solutions to challenge inequity.”⁹  Inequities in health care can be conceptualized in relation to the institutions and social conditions that determine health-related resources. Health care providers require training that helps them recognize how social and economic determinants, biases, and inequities shape health and illness long before the patient enters the clinical office.¹⁰  Developing structural humility is an evolving process that requires input from patients. Clinicians are therefore seen as collaborators in patient health care through active listening and shame-free support.

With the information gathered, we can replace the chart label no-show with “she no-showed because…,” which offers an invitation to action and obligates a next step (Table 1). After several no-shows, providers often rush through a lengthy checklist of tasks at the next patient appointment to make up for lost time. We offer an alternative: use that time to invest in building a trustworthy relationship early on to prevent future no-shows.

Although time-consuming, rapport building should be seen as a potentially life-saving measure. Providers are often cautious to discuss these no-shows to avoid inadvertently shaming the patient. However, by addressing this directly, we may be better able to understand the causes and together identify solutions such as connecting the patient to no-cost public health services (Table 1). If resources are available, investing in a social worker, patient navigator, and/or peer mentor who can engage with the patient beyond the appointment and address barriers to care can help reduce stigma and promote trauma sensitivity.

If patients are to engage in services, barriers must be removed within health care systems. When youth are blamed specifically for no-showing to a medical appointment, the opportunity is missed to support adolescent development and provide them with the tools needed to learn how to navigate their world.¹¹  Lowering expectations for any young person undermines their strengths. However, behaviors (eg, no-showing) need to be seen as a symptom of their interaction with their environment, not the mark of an apathetic person.

Our discussion focuses on youth who are facing structural and social barriers, but we believe these concepts are applicable to patients regardless of their age. By creating a process whereby more people are seen for who they truly are and not just the labels they carry, health care providers can better understand patient concerns and collaborate on a method to address no-shows over time.

We thank Dr Kenneth “Ken” R. Ginsburg for his thoughtful review of this manuscript.