Table 3 Representative patient quotes for each insight

Patients’ schedules are not prioritized when making an appointment in clinic, leading to emotional distress and repeated non-attendance.

● Patients’ schedules are not prioritized when making an appointment in clinic...

 ○ “Maybe it’s MediCal but it took me a long time (1.5 years) to get surgery” (AN)

 ○ “I can’t schedule any appts around meals bc of my client” (AY)

 ○ “I called 6x to get this appt, call two different places -- struggled to get appt..I was told I’d get a call from 3 M to remove stitches and to call the clinic if I didn’t hear from them.” (BC)

 ○ “I had to fight to get this appointment to make a day that I could physically be in person to make this appointment” (AN)

 ○ “I try to make my doctors a priority but it’s hard when you have so many appts” (BD)

 ○ “I tried to call to reschedule my appointment, I couldn’t” (BF)

● ...leading to emotional distress and repeated non-attendance.

 ○ “my family already told me to sue because they’re playing with my health” (BH)

Patients struggle to find the support necessary to attend their appointment, leading to frequent non-attendance and increased socioeconomic stressors.

● Patients struggle to find the support necessary to attend their appointment…

 ○ “I’m retired, I take care of my grand babies, take my daughter to work…that’s why I have AM appts, so I can take everyone in the morning then come to my appt” (AQ)

 ○ “I’m the oldest in my family, I’m the person taking care of everything” (AZ)

 ○ “I’m a care provider through...my goal in life is to keep my clients alive and out of the hospital” (AY)

● ...leading to frequent non-attendance and increased socioeconomic stressors.

 ○ “My medical bills wipe me out...my friends keep telling me to move to Thailand or Germany, telling me it’s so much better here.” (AX)

 ○ “With housing, i feel more stable, I don’t worry about taking all my stuff with me to appointments” (BB)

Patients lack accessible transportation options that fit within their medical and socioeconomic constraints, leading to missed appointments and delays of care.

● Driving self

 ○ “I drove starting at 3 AM to get here today” (AL)

 ○ “I take the bus now...driving is challenging because of the parking…there’s only 1 hour parking around the hospital.” (AN)

 ○ “Once I had to wait for 45 minutes in a room, and got a $75 dollar parking ticket.” (BO)

● Getting a ride from friends and family

 ○ “My son drove me here and will pick me up. I have to be dropped off early in the morning before my son goes to work and wait for him to pick me up.” (BP)

● Calling a taxi or uber/lyft

 ○ “I gotta get better... I missed some appts...I try to make this a priority but every time I have to take a taxi over here, it’s expensive” (BD)

● Using public transport

 ○ “I like to get here ½ hr. before, today it was 10 min before because my bus was late and all the tech bus traffic.” (AY)

 ○ “I got lost from the bus stop, it’s a long walk, I had no idea where 3 M clinic was” (AV)

 ○ “I rely on the MUNI, I’ve been late a couple of times because of it.” (AX)

● Mobility issues

 ○ “[the clinic is] on the third floor. Even the check in place was pretty far from the elevator. All the way to this waiting room is not the shortest walk that I’ve done” (BJ) [has crutches]

● ...leading to missed appointments and delays of care

 ○ “They like us to be on time or else we miss our appointment” (BH)

Patients spend the majority of their visit in the clinic waiting to be seen by a provider, leading to anxiety and frustration.

● Patients spend the majority of their visit in the clinic waiting to be seen by a provider…

 ○ “You have to come half an hour and then wait another half hour or 45 minutes. I feel that’s too long”

 ○ “The procedure is not even 5 minutes but sometimes I have to sit in the room waiting for 45 minutes. I can’t do anything while I’m waiting.” (BN)

 ○ “Wait time is long but I can’t complain, there’s a reason why, but I’ve heard horror stories” (AG)

 ○ “The waits are too long..there’s a lot of patients overlapping in time” (BL)

● ...leading to anxiety and frustration.

 ○ “I’m here because it’s either be here or be in pain…I wouldn’t come if I had to wait this long and my leg didn’t hurt” (AU)

 ○ “Waiting is the worst part...but that’s just life” (BD)

 ○ “You wait a long time here...I got here early hoping they might be able to see me earlier” (AO)

 ○ “Lots of waiting here but I can’t complain...if you come earlier, they might see you earlier” (BE)

 ○ “The wait is too long…should be faster, I got things to do...what’s the point in scheduling if they’re always late? Sometimes I come late on purpose.” (AU)

Information opacity related to their clinic appointment makes patients feel disrespected and incapable of managing their medical conditions, leading to frustration and disempowerment.

● Information opacity related to their clinic appointment makes patients feel disrespected and incapable of managing their medical conditions…

 ○ “When I’ve come to clinic in the past, I’ve arrived only to find that my appt was cancelled or moved...they didn’t call me to notify me” (AY)

 ○ “I had to call beforehand to know where [the clinic] is. Otherwise, it was kinda unclear how to find the 3 M clinic.” (BJ)

 ○ “I called the clinic 6x, they didn’t pick up the phone, so I left a voicemail” (BB)

● ...leading to frustration and disempowerment.

 ○ “Is my doctor in? No? Well of course not. He is definitely going to be late.” (BM)

 ○ “I’ve been dealing with this hernia that I shouldn’t have... I don’t know if it was the method that was used, weakness in my stomach wall and that I overexerted...I followed all the directions but I still ended up injuring myself post surgery. I’m not happy with this, it was not explained, I wasn’t given adequate instruction to protect myself. (AK)

 ○ “Getting through to a person in clinic is challenging…patience is on my part to wait” (AK)

 ○ “I don’t like complaining…I’m so frustrated, I’m crying….What else can you do? I’m not going to go off on no body which I feel like doing, but I’m better than that. I have more patience… that’s all I can do. What else can you do?” (BH)

An uncomfortable physical clinical environment exacerbates patients’ anxieties related to waiting for their appointment and adversely impacts their mental and emotional states.

● An uncomfortable physical clinical environment exacerbates patients’ anxieties related to waiting for their appointment…

 ○ “Most of the people are dirty, filthy” (BL)

 ○ “it’s nice and it’s clean” (BG)

 ○ “[Waiting room is] not clean, there are so many types of people (AH)

 ○ “As long as it’s clean here [WR], I’m fine with it.” (AQ)

 ○ “Small room, gets pretty packed…I’d like a bigger WR or two.” (AC)

 ○ “First of all, it’s crowded.” (BJ)

 ○ “It’s a small waiting room. I don’t know if it gets packed this often, but maybe a larger waiting room closer to the elevators or something like that” (BJ, had crutches; in response to how to improve the waiting room)

 ○ “I like early morning appointments because it gets too crowded later” (AQ)

 ○ “when that man stands up, his seat will be wet” (BM)

● ...and adversely impacts their mental and emotional states.

 ○ “I cannot afford to have my conditions getting worse due to catching germs unnecessarily” (BL)

 ○ “I’m not hanging in there with this waiting room. I’m not doing too good at all” (BO)

 ○ “It needs something calming...not stuff that’s rousing of emotion” (AN)

● Preferred an environment that was calming

 ○ “[Emergency department] was much less crowded, quieter, we didn’t have the TV on that I don’t necessarily want to listen to” (BJ)

 ○ “We need one more central WR, people spend too much time walking around” (AX)

● Preferred an environment that included activities/amenities

 ○ “I liked that my other clinic has a computer” (AC)

 ○ “They should have a system where you they call you when you’re up next so you can step out and get a coffee” (AO)

 ○ “More comfortable chairs would nice...but you’re not going to be in here long” (AS)

 ○ “As long as I get care, this [WR] is fine. You can sit in places that have VR headsets but then you have to pay $1000” (AW)

 ○ “I’m on Medicare so I don’t feel like I have control of amenities” (AW)