Late to appointments

Whilst on prac in musculoskeletal outpatients earlier this semester I encountered a private (ie paying per session) patient who was always late for her appointments. Between the student before me and I we had diagnosed as a medial collateral ligament sprain and medial meniscal tear of her knee. Follow-up appointments were initially one hour in length, and the patient was 15, 20 and 35minutes late for her first three appointments with me. For two of those she also had to leave 5-10 minutes before the scheduled finish time, which she informed me of at the start of the sessions.

I was becoming increasingly annoyed and frustrated as it became evident that this was not a one-off, and that she clearly expected me to race through assessments and treatments, without any concern for the pressure that put me under as a student. She would say things like "Oh don't worry about measuring that again, it's basically the same again" when I was reassessing my asterisk signs to determine the brief treatments I would provide. It felt to me like she had very unrealistic expectations - that she could turn up when she was ready for 20 minutes after being told she needed to allow an hour for all sessions, and that I could just spend all that time treating the impairments that may or may not have been getting better without me knowing. In addition to this, I believe she was not resting her knee as I was recommending she do - with the limited treatment I had time to provide and constant exacerbation on her part, her knee was not going to get better for some time. This also seemed to frustrate her (understandably), even when I explained this to her.

When she turned up 35mins late to the third appointment I told her that I could not treat her, as it was unfair to me, her (in terms of responding to treatment) and patients I had after seeing her if we went overtime, which was quite likely. She was not pleased to hear this at all, however my supervisor backed me up and she seemed to understand after several minutes of discussion. I suggested other options, such as qualified outpatient clinics where 20mins is a much more realistic session length, however she would still need to be on time for them as they would have a similar policy. She did not like this idea either, however she did not come back to our clinic, so she may have followed this path.

This was the only time something like this happened on my 5 week placement, however I think it was a useful experience to be put in the position where I had to put my foot down about how I was being treated. It was difficult in that she was willing to pay for the treatments and have them rushed through, though I felt it was not as effective as it should be and that I was being put under additional pressure.

After the first session I assumed her lateness was a one-off and didn't make an issue of it as she apologised and blamed traffic. At the second visit I did mention that she needed to be on time, however in hindsight I think I should have made it clear how important this was for all parties. I think being clearer when addressing the patient's expectations and trying to make them more realistic earlier on would also help to prevent her lateness and frustration with her progress, gaining better compliance to education and treatment. Does anyone else have any other suggestions of how to deal with this sort of problem or better still, prevent it?