Podcast Episode 3: Scheduling and Cancellations

Enlightened Practice Podcast

In this episode of the Enlightened Practice podcast, Dr. Ken Braslow and Kari Kagan continue their conversation on scheduling.

The duo discusses several scheduling scenarios, the administrative aspects, the psychology underneath the scheduling process, and finding balance through limitations. They also take time to look at scheduling from the perspective of seasoned practitioners versus new grads looking to start a private practice.

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Transcript of the podcast

Ken: Hi, Kari. Welcome back.

Kari: Hi Ken. Thanks, you too. 

Ken: So, today we’re going to be talking about scheduling and the joys of putting together a jigsaw puzzle. It feels like at times there’s about a million different ways that people approach scheduling. And, so I’m curious about how you do it. We could cover the whole gamut from how you start your day and how you end your day. Talk about the weekends. We could talk about. Are you a lumper or a splitter? Meaning, do you like to have all your clients bundled together or do you like to have that spaced out during the day? So those would be useful things for us to discuss. One of the things that I would like to know from you to start out with is how you handle cancellations. This is always challenging in my practice. What’s your thought process? What is your cancellation policy? And then we can talk about the nuts and bolts of daily scheduling.

Kari: Yeah. It’s important to think through what your cancellation policy is because it’s inevitable that it will happen many times in a week probably. Mine has changed over time. Right now my cancellation policy is 48 hours notice because it used to be 24 and I changed it before to 48 because realistically if I was going to try to be able to fill a slot from a cancellation, I would actually need more time than 24 hours. And my general policy is I do charge my full fee for cancellations that are not made before the 48 hour window, before the appointment. And there are exceptions in the case of sickness now more than ever. And of course emergencies and I do give people one free pass and that’s my general policy in how I handle it.

I will say in the time of Coronavirus it has become more flexible and just knowing that everyone’s schedules are so chaotic, but mostly if people are showing patterns of a lot of last minute cancellations that’s when I am pretty strict with it and I become less flexible, but I, these days I’m trying to actually be a little bit more flexible because I think the times call for it. So, my general thought on my cancellation policy is it’s constantly changing depending on what’s going on and like where I am at in my own life and what’s going on in the world, but it’s 48 hours. What about you?

Ken: So, mine is similar, but with a twist, it’s two business days. If you have a Monday appointment with me and you cancel on Saturday, that’s not helpful. So I put in the two business days. So that way I could have at least from Thursday and I really do try and fill that slot, even if somebody doesn’t give full notice, I try and fill in. But it’s just logistically really challenging when we’re running a practice too, and seeing patients and clients in real-time to then also be scheduling. I feel like most of my patients get that. But I am especially mindful of how the psychology and the people’s executive functioning, which they’re coming to see me for often affects our own scheduling. And so I use the cancellation policy when we’re talking about project management and psychology underneath it to talk about, one, to make it real for them. So they can internalize, you know, you really do need to follow my cancellation policy, but also we use that as a vehicle to launch into them showing up late for other things. So, no better way I feel to do therapy around those kinds of issues than to talk about how it affects our therapy itself in real-time. So, I think a cancellation policy is a nice way to bring the outside world into therapy. 

That said, I’ve got to run a practice. And while I do typically give people a one-time pass. So you’re more flexible, which is nice. I’m a little less flexible because now if the train isn’t running or there are other logistical issues, we’re meeting by video anyway. And so you’re the excuse pool I feel like has diminished. 

And if your wifi is not working or your video is not working, you can always pick up the phone and call me. And so, whereas in the past if I was just sitting in my office I felt like, well, you know, things happen in the world and I want to be mindful of that and be generous while also balancing that with running a practice. But I feel like now that everything’s remote, there’s a little less need for some of that. For example, when I’m working with kids, sometimes parents will say, well, my kid’s sick today. And I’ll say, okay then we’ll meet. Like it’s very challenging in the winter working with kids if every time a kid got a cold, they needed to cancel. We wouldn’t get very far. So try to think really of a scrappy kind of way about how we can make this appointment happen as scheduled. And then we can use that to broaden the discussion in general. 

Kari: Yeah. That makes a lot of sense. And it’s interesting to hear different perspectives on flexibility. It’s very personal. I think it’s an important thing to think through in advance for anyone who’s trying to start a private practice because it will definitely happen. And I do think it’s important to set a tone early on. Otherwise, it’s confusing for the therapist. It can be confusing for the client. So it’s definitely a really, really important issue to think through and to be really transparent about with your clients in the beginning.

Ken: Have you had anyone no-show for the initial intake or cancel at the last minute?

Kari: Yeah, I think I have and I consider those moments to be just one of those you have to cut your losses kind of thing in private practice because while oftentimes I actually do collect credit card information before we ever would meet for the first time. I don’t know why this is but it feels like before I even have a relationship with someone, I guess for me personally it feels a little off-putting or something like that. I can’t quite think of the word, to charge someone before I’ve ever even met them. I kind of just consider it apart, like one potential thing that could happen in private practice is you might get a no-show before you ever even meet the person. And for me, that’s just like, okay, that’s a place that I’m just going to have to cut my losses. Because it doesn’t happen that often, like maybe it’s happened two times over the course of six years or so. What about you?

Ken: And if they wanted to rebook, would you rebook them?

Kari: Yes, I would. You know, maybe we would have a conversation whether over the phone or email, just about the importance of keeping appointments or giving notice. And maybe at that point if we were having a conversation, I might at that point, remind them or inform them of my cancellation policy, because at that point before even meeting, they may or may not have read through the informed consent. So they might not even be aware of the cancellation policy yet. Has that happened to you?

Ken: So, when I first started out and maybe because I have a blend of meds patients and therapy patients. I take in a lot of new patients so I feel like it comes up a little bit more with the meds component. So I was very eager to fill my practice and I actually had one prospective patient, no show three times for an intake, and my colleagues were like, let it go, just cut your losses. And you know, it sounds really reasonable and I wanted to give them the benefit of the doubt. And then I slowly realized, yeah, you really can’t recoup your losses. You just have to kind of eat it and move on and better to move on. So, one of the things that I do when I’m in the intake process I don’t let anyone schedule until they’ve signed off on my policies. And that way there’s no confusion about what the cancellation policy is. So, I don’t feel like it comes up that often these days, but maybe that’s because I’m pretty clear about what the policies are. And I also do require credit card info to be entered and since that’s been done, and I don’t know if this is a coincidence or not but cancellations for no shows have almost stopped.

Kari: And one last thing I’ll say that I was just thinking about is one thing I do offer people is if we can reschedule later in that week then I don’t charge. And that’s just of course dependent on my schedule, but I think that’s part of my desire to be accommodating and flexible. But I will say that it’s more work on my end to try to figure that out. But again, it does depend on the context, but there are times that I do think this is more work for me, but there are times that the reason for the cancellation is something that’s outside of my client’s control, but not necessarily one of the reasons that I would not charge my cancellation fee. For example, a boss emailed and said, we need to pull you into a meeting last minute, which actually happens more now than it used to because of the video.

And so it’s not an emergency, but it’s something that’s outside of their control. And in those situations, I do want to try to be accommodating. Because I know that the client kind of feels stuck between a rock and a hard place. But I know a lot of therapists who are more strict if you’re canceling for whatever reason because you can just always make so many exceptions. And that’s something that I’ve played around within my own mind, am I too flexible or accommodating? Because it does end up being work on my end, but I think that’s also part of being like a growing therapist. I think it’s something that you get more comfortable with over time and you figure out for yourself, what am I willing to do and what am I not willing to do? Those are kind of the things I think through for now, because it doesn’t happen often. I feel willing to be more flexible, but I can see a day that that might change too.

Ken: Yeah, I think that’s really nice. And sometimes we’ll talk in session about the challenges that scheduling presents in people’s own lives in terms of having to set boundaries. And if you were meeting with me that means you’re not doing something else and being able to declare to others the value of this time and the conflict that might create and how to work through that conflict. So, it’s always good grist for the mill. I like your philosophy. I think it’s very reasonable. It’s hard for me to pull that off because my schedule is typically at a hundred percent capacity. And so there’s just not another slot to open up. But it is nice especially with clients or patients you’ve been working with for a long time who you and they know that it’s a one-off. If it’s more than once, then I’ll typically make that a high priority for us to discuss, do we need to find a new time slot? Is this working because I don’t want them to be in that position. I want them to resent therapy and feel frustrated with it to the point that they’re not able to let their guard down and get the most out of it.

Kari: Okay.

Ken: Okay. So I got one more question then I think we’re going to call it a day just because we had so much fun talking about cancellation policies and we’ll get to the other questions about scheduling next time. I’m curious how you approach a yearly number of cancellations or lifetime number of cancellations? So for example, there are some therapists who don’t have that big of a practice or their style is to work really closely with clients and patients and they need for that momentum to continue. And so they limit the number of cancellations patients or clients can have in general. So that way they can do the kind of work they think works best for what they’re offering. What’s your take on that?

Kari: Yeah. I had never thought of that until I think maybe when I was having a conversation with one of my colleagues who was making the transition to only allowing a certain number of cancellations per year. And after that conversation, I actually did add that into my policy because I think it makes sense that there is for the kind of work that I do with people which usually is weekly to biweekly. It is important to have consistency and because I only work limited days, limited hours. I want people in my practice who are willing, who are going to show up. Who wants to do the work and so I added in I think off the top of my head because they actually have not read my cancellation policy in a long time.

I think it’s six a year that I allow, up to six cancellations a year. And if we’re getting close to that then that’s a conversation I would bring up of course in advance to let a client know that’s where we’re headed. And I would try to work it out before we got to six, to understand what’s going on. Are there unique circumstances? There could always be some exceptions, but I do think that it also sets the tone again early on with a client that this is the work that we’re doing is important. And consistency is important to getting the benefits of therapy and also letting them know a little bit about the business side of it too, that like, there are limited slots and I want to be seeing people at the time that I’m scheduling them. So, that’s my take on it. Do you have that in your policy?

Ken: I don’t, although maybe I should, now that I hear you talk about it. I liked it as a benchmark. I’ve never really kept track of how many cancellations. I think I have the luxury of doing that because I see both meds patients and therapy patients. And if a therapy patient cancels typically the slot gets filled with the main check. And so I haven’t needed to implement that, but there are some therapy patients who are frequent cancellers and it’s very meaningful to talk about if that’s a reflection of their resistance to the work itself or if their lives are just super challenging and is therapy a good fit for them at this time? Maybe it’s a timing issue or maybe it’s a reflection of both and what would be reasonable going forward?

How do we make it work? They might be really committed but might have really demanding jobs. And so maybe you shift things to every other week. Although, then what happens if they cancel the other week and then now it’s once a month? So in general, I think those are really good things to be thinking about. I think the take-home here is even though cancellation policy could be not the world’s most exciting topic, there’s a lot of clinical implications for it -as well as business implications. And so those are always nice when you can feed that into the work itself and use that to grow your practice also. All right, Kari, well, it’s nice chatting and I’m sorry, we didn’t get to all the nuts and bolts of building one schedule, but we’ll do that next time. So thank you for your thoughts. I learned a lot today and we’ll see you next time.

Kari: It was nice talking about it. See you next time.

Ken: Bye.

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