Skip to content

My doctor’s practice is ignorant and wasteful

2010 October 2
by Malcolm Sleath

This is about the practical application of influencing skills.

Small changes can make a big difference to outcomes.

I try not to bother my GP too much, but I find myself getting irritated whenever I enter his surgery waiting room. The first irritant is a sign on the wall. It  draws attention to the waste of doctor’s time, and the inconvenience to other patients, which happens when people book appointments and don’t keep them.

I’ve tried pointing out that there are two simple remedies which would have an immediate impact on the problem, but it seems the practice manager does not want to know.

Remedy 1: Stop normalising the behaviour you don’t want. Normalise the behaviour you want.

To be fair, my doctor’s surgery is not alone in this. In the waiting room, prominently displayed, and regularly updated, is a sign that tells me exactly how much time is wasted in the previous month by patients not turning up.

What is the effect of this sign? It advertises to the occupants of the surgery that booking an appointment and then not turning up is something that a lot of people do. It normalises the behaviour, in the same way that when the press publicises that schoolchildren carry knives – more schoolchildren start carrying knives.

The notice allows people to think, “I know it’s wrong, but everyone does it don’t they?” So, when their symptoms have disappeared and they are rushing around preparing for work and trying to get the children off to school, looking up the doctor’s number and ringing the surgery to leave a message hardly figures in their list of priorities.

The remedy? Replace the sign with one that makes clear that the majority of patients who book appointments keep them – and says how much the surgery appreciates it.

Why am I so sure that changing the sign would make a difference? Professor Robert Cialdini is Regents’ Professor of Psychology and Marketing at Arizona State University. He is a leading authority on the small changes that can have a large impact on the behaviour of target populations. In January 2007 he gave a talk at the RSA in London where he spelled out the impact of social norms and other influences on behaviour in society (PDF) (Sound file opens in browser. Use ‘File/Save page as’ to save file).

During the talk, Cialdini showed that changing signs to emphasise the normality of responsible behaviour had a significant impact on the behaviour of people who saw them. Here is a particularly graphic example from the Petrified Forest in California.

We did a study. We went to several paths, three paths that wound through the Petrified Forest and we placed signs in front of those paths that on the one hand simulated the kind of sign that we saw at the entrance. It admonished people against stealing the wood and it showed a depiction of three individuals who were stealing the wood with a red circle and bar across them. Now we salted the path with marked pieces of petrified wood so we knew what the consequences of passing that sign and winding through the park would be in terms of theft.

Compare that to those same paths when there was no sign at the mouth of the path. Let me show you what happened in the first place when there was no sign there: about 3% or 2.96% of visitors stole a piece of wood. When the sign that depicted three individuals doing so with the warning – “Don’t do this because it undermines the integrity of the forest” – the sign tripled theft. So the sign didn’t produce crime reduction; it generated crime production by spurring people into action.

Now at the same time we included another type of sign. This one was designed not to normalise the undesirable behaviour but to marginalise it. To show a lone thief despoiling the environment with the claim that if even one person steals it undermines the integrity of the forest. It halved theft.

Remedy 2: Get people to commit to doing the right thing.

Cialdini points out that people feel the need to be consistent. He says that once people have said they will do something, they are much more likely to do it. In the following example you will see how by using two words the receptionists at my doctor’s surgery could make a significant impact on the problem of people not giving notice when cancelling their appointments.

There’s a particular restaurant owner in Chicago named Gordon Sinclair who has figured out a way to significantly reduce the percentage of no-shows at his restaurant by having his receptionist change two words in what she says when someone calls to book a table.

Previously she said “Please call if you have to change or cancel your reservation.” You’ve heard that kind of thing many times. Now she said, “Will you please call if you have to change or cancel your reservation?” and she is instructed to pause.

What if I said to you “Will you please call if you have to change or cancel your reservation?” What would you say in the moment after that pause. How would you fill that moment? “Yes of course glad to,” and that’s the commitment. No-shows at that restaurant have dropped from 30% to 10% as a consequence of those two words.

It’s not hard to imagine that a similar effect could be achieved if the receptionists at the surgery adopted this approach when booking appointments. At the moment they certainly do not.

When I visit my doctor, he expects me to take his advice because he is an expert on what he does. If his practice manager does not respect my expertise, I hope she is prepared to respect Professor Robert Cialdini’s. (Respect for authority is another driver highlighted by Cialdini.)

I don’t want to go to a surgery where the staff is prepared to waste public money by being wilfully ignorant of simple measures that would cost nothing to implement. In these difficult times, GPs need to be making intelligent use of limited resources.