Our Doctoring Gets Worse as the Day Wears On
/A new study shows that ordering of mammograms and colon cancer screening tests occurs less frequently later in the day. Are docs too tired for this convo?
Imagine it’s 8 am. A 55-year old woman, otherwise healthy, comes into your primary care office for her annual checkup. Do you offer her screening mammography?
Now imagine that same women comes into your office at 430pm. Do you offer her screening mammography?
Of course, time of day should have no bearing on the care we deliver to patients, but a new study, appearing in JAMA Network Open adds to an expanding body of literature that suggests that in fact, our doctoring is not as good at the end of the day as it is in the beginning.
Association of Primary Care Clinic Appointment Time With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening
Researchers at the University of Pennsylvania analyzed data from primary care and family medicine practices from their own health system. Full disclosure – I did my residency in those very practices. Over a 2-year period, they identified 19,254 women eligible for breast cancer screening, and 33,468 individuals eligible for colon cancer screening according to standard guidelines.
They then asked a simple question – how often was screening mammography or colon cancer screening ordered during the clinic visit, and did that rate change as the day wore on?
Percent of patients who were ordered screening tests by time of day of that appointment.
A clear trend emerged. About 64% of eligible patients were ordered for mammography if their appointment was early in the day. That number declined to 48% as the day wore on. Colonoscopy screening orders started up at 37%, and ended the day at an anemic 23%
Why is this happening? One obvious explanation is that physicians fall behind over the course of the day – in their rush to see patients some elements of care are just going to be dropped – put off til the next visit.
Percent of patients who got screening tests in the year following a primary care appointment, by time of day of that appointment.
But it looks like the docs didn’t get around to it next time. Rates of completion of screening tests also showed that time-of-day dependence. Patients seen at the end of the day were not only less likely to have a screening test ordered, but also less likely to receive the test at any point in the following year.
In other words – even if physicians told themselves that they’d address screening the next time they saw the patient – that doesn’t end up happening.
Of course, other factors may be at play here as well. The authors argue that docs may be experiencing “decision fatigue” – after a day of wearying clinic conversations, it may be tempting to just go the easy route and not address screening. This is bolstered by other studies which have shown that, as the day wears on, physicians are more likely to prescribe opiates for low back pain, less likely to give flu vaccines, and more likely to give antibiotics for upper respiratory infections. This is path-of-least-resistance medicine.
And let’s not place all the blame on the docs, either – although measured patient characteristics didn’t differ too much throughout the day, it’s possible that those with later appointments simply wanted to get out of the office more than those who had their whole day ahead of them.
What’s the solution? Give docs more breaks? Sounds nice but I don’t see it happening.
Let me answer that question with a question. Why are we asking docs to order these tests anyway? Why spend incredibly valuable face-to-face clinician time talking about screening tests when we can deliver the same information in tons of other ways – through direct patient outreach or through physician extenders. In fact, insurance companies themselves should, in theory, have every incentive to ensure that their customers get these screenings. Maybe they should be charged with ensuring they happen.
In other words, docs are busy. Let’s let them be busy doing the things we need docs for.
This commentary first appeared on medscape.com.