Your patient can get a reminder 24 hours before an appointment, another at 12 hours, and one more an hour out — and still never walk through the door. When that happens, you might reach for another message: tighter script, an extra text, a new policy. But Sarah Watters, PhD, thinks that instinct usually aims at the wrong target. 

Watters is a behavioral scientist trained at the London School of Economics and the founder of 50 West, a consultancy focused on engagement and behavior change. On a recent episode of the MGMA Insights Podcast Network, she told host and senior editor Daniel Williams that patients usually know what they should do; the work is figuring out why they don't do it.

Despite there being increasingly more way to reach patients, the numbers hint that the problem isn't going anywhere soon. In a recent MGMA Stat poll, 73% of practices reported that patient no-show rates had stayed the same since the previous year.

Knowing is not half the battle for patients

Many patient engagement strategies still assume an information problem: Explain the risk, send the handout, add the reminder, repeat. Watters pushes back on that idea. "Knowing, in my opinion, it's not half the battle," she told Williams. "We all walk around with a million things we know we should do, and here we are."

Watters' interest in behavioral science predated her PhD. She expected to go to medical school and got pulled instead toward the psychology underneath health decisions, becoming, in her words, "incessantly obsessed with why people make certain decisions" — especially the ones that look like no-brainers. 

"These things are almost inherently good for us," she said. "Why are we not ... exercising or eating well or taking our medication when we know these things are going to benefit us?"

This means a patient can fully understand why a follow-up, colonoscopy, mammogram, or refill is important and still skip it — because the real obstacle is fear, transportation, embarrassment, cost, confusion, or a day that simply got away from them.

More outreach becomes noise

Healthcare has never had more ways to reach a patient: texts, portals, robocalls, emails, apps, and automated reminders. Watters' warning is that volume can work against you. 

"We get so caught up in how we message people; send more reminders, and things like that," she said. "But [the impact of] every message you send [diminishes], and people start to tune you out more and more." 

She has a name for this tactic: "corporate nagging." If your patient doesn't have a ride, can't get time off, or aren't sure what the visit involves, your reminder never addresses the actual problem.

The alternative is to find the barrier first. "The moment we understand why, it flips the script, we can start to help them," Watters said. That, she argues, is what "meeting patients where they are" should mean in operational terms — understanding "not only what they need to do, but why aren't they doing it?" 

The no-show may start at scheduling

Most no-show tactics focus on the final hours before a visit. Watters says the risk is often baked in the moment the appointment is booked. "One thing that should be considered is how far in advance are we allowing patients to book appointments," she said. "The longer time horizon that emerges, the more likely something is going to come up."

Book a patient in June for an appointment in August, and you're asking a present-day self to make a promise on behalf of a future self whose work schedule, caregiving load, and stress level may all look different. By the time it arrives, "the appointment gets completely lost," Watters said.

One fix costs nothing and starts at the front desk: Change the question. 

Instead of asking when a patient is free, ask what days don't work. "When you force people to think in slightly different mental models," Watters said, "all of a sudden it forces them to think a little bit more critically about potential barriers and blockers."

She also pushes practices to treat no-shows as a pattern rather than bad luck. "There is some predictability there," she said. 

Patients avoid what they can't picture

Preventive screenings pose a different problem. A colonoscopy or mammogram is important and infrequent, which means it never becomes routine. "When you're trying to get someone to do something annually, I mean, that's even a much heavier lift," Watters said. "How do you get someone to do one rep per year?"

Patients can know the screening matters and still dodge it because they can't picture it. Watters points to the ostrich effect. "You can just picture the ostrich sticking its head in the sand saying, 'nope, not for me'." 

Faced with a blank, people tend to fill it with the worst version. "That hurts, it's uncomfortable, it's weird, it's embarrassing," she explained.

The usual response is more data — risk percentages, detection rates, intervals. Watters doesn't dismiss the numbers, but she's clear about their ceiling: "Stats sell, but stories stick," she said. 

Patients remember what an appointment actually involves: where they go, what prep looks like, how long it takes, what the discomfort is really like, and what someone like them went through. 

Build a streak before asking for transformation

Asked how to cut avoidable emergency visits and admissions, Watters moved upstream. The goal is to keep patients from ever reaching the point where the ED is the only option left. "How do we get people to even avoid approaching the decision where they need to use inpatient or they need to use the ED?"

Her starting point is the smallest repeatable action. For a patient with diabetes or hypertension, that might be taking a single blood pressure reading. "How do you practice very simply this kind of art of just showing up every single day?" The aim isn't transformation — it's a streak, proof to the patient that they can show up consistently, almost regardless of that day's numbers.

The same logic applies to medication, where forgetfulness is often the culprit. Her fix is to anchor the new behavior to an existing one: "I brush my teeth. I take my medication." She's candid about the struggle being universal. "I am a behavioral scientist and have been for many, many years now, and I still leave things in the middle of the floor if I know I need to pay attention to it later." 

The practice is full of humans, too

Watters' last point turns the lens back on the practice itself. "A lot of what we've talked about today is patient-facing," she said, "but many of these behaviors are human behaviors."

Front-desk scripts, care-gap conversations, rooming workflows, and medication counseling all come into play. Staff may know they should ask the transportation question or document the barrier and still skip it on a busy day. Her answer focuses on better design: "Planning for things that you know your future self should do."

Often that's as small as reframing the ask. Instead of telling a patient to take their medication, ask, "When are you going to take your medication?" Instead of telling them to monitor their blood pressure, ask, "When is a good time for you to measure your blood pressure every day?" The questions turn advice into a plan.

"Changing our own behavior as clinicians and professionals," Watters said, "should be looked at through the same lens as changing patient behavior."

Resources

• Connect with Sarah Waters, PhD, on LinkedIn
• 50 West Consulting
• MGMA Insights Podcast Network 
• "Patient no-shows in 2025: What’s changing and what to do about it" (MGMA Stat article)
• MGMA Events: Conferences and Webinars 
• Register for the MGMA Annual Conference (September 27-30, 2026 | San Antonio, TX)

Email us at dwilliams@mgma.com if you would like to appear on an episode. If you have a question about your practice that you would like us to answer, send an email to advisor@mgma.com. Don't forget to subscribe to our network wherever you get your podcasts!