Your chances of having your primary care physician recommend that you undergo cancer screening may depend on the time of your appointment, according at team of University of Pennsylvania researchers.
Their study, published recently in JAMA Network Open, found that doctors were more likely to refer patients for breast and colorectal cancer screenings when they saw them first thing in the morning rather than late in the afternoon.
For the study, the researchers examined the health records of more than 50,000 patients who had visited 33 primary care practices in Pennsylvania and New Jersey between September 2014 and August 2016. All were visiting their doctor for a first or return check-up. None were “sick visits,” when the topic of screenings might reasonably be deferred. All the patients were also eligible for breast cancer or colorectal cancer screening under the guidelines of the U.S. Preventive Services Task Force guidelines.
The study found that doctors ordered screening tests for 64 percent of the eligible patients they saw at 8 a.m. That percentage fell as the morning progressed to 49 percent by 11 a.m., before rising at noon to 56 percent — most likely because of the start of a new shift at the clinics, say the researchers. During the afternoon, however, the order rate fell again, reaching its lowest level of the day — 48 percent — at 4 p.m. and 5 p.m.
Those early-morning screening discussions also seem to have made a stronger impression on the patients. Almost 37 percent of the patients in the study who saw their doctors at 8 a.m. underwent breast cancer or colorectal cancer screening within a year, compared to 23 percent of those who saw their doctors at 5 p.m.
“This indicates that decisions made during a single [primary care physician] visit may have a lasting effect on patient behavior,” the study’s authors write.
A matter of decision fatigue
The decline in the ordering of cancer screening tests observed in this study may have been the result of doctors running behind in their appointments and thus being more rushed during their interactions with patients later in the day, the researchers point out.
But it’s also quite likely that the study’s findings reflect a well-known psychological phenomenon known as decision fatigue.
“In other words, as the day goes on, clinicians may be less likely to discuss cancer screening with patients simply because they have already done this (and made other decisions) a number of times,” write the study’s authors. “As patients earlier in the day decline screening despite the clinician’s recommendation, it could influence how likely the clinician is to bring up the topic later in the day with a different patient.”
“These tendencies may lead to suboptimal care for patients with clinic appointment times later in the day,” the researchers conclude.
Fits with other findings
This is an observational study, so it can’t prove a direct causative link between time of appointment and ordering of screening tests. Other, unidentified factors having to do with the clinics or the patients might also explain the results (although the researchers note that their analysis found no observable differences between patients who visited their doctors early in the day and those who visited them later).
In addition, the study involved a single health system, and thus the findings might not be generalizable to all doctors.
Still, the findings are provocative, for this is not the first study to suggest that appointment times affect physician behaviors. Other research has found that as their workday progresses, physicians are less likely to recommend vaccinations and more likely to write out inappropriate prescriptions for antibiotics and opioid pain medications.
And, in hospitals, clinicians are less likely to engage in appropriate handwashing as they near the end of their shifts.
FMI: You can read the study in full on the JAMA Network Open website.
I’m not entirely convinced that there’s some nefarious force involved here. A 12% difference in screening suggestions borders on the “meh” level of concern for me – unless there’s a further study that shows ‘x’ level of confirmed cancer diagnoses among patients who chose not to follow their doctor’s recommendation to be screened. If that’s the case, it deserves further attention, but if not, this seems relatively minor.
It also occurs to me, as the relative of a GP, that primary care physicians are often under a variety of pressures – to see more patients per day / hour, to bring more money to the practice or clinic, to be more time-efficient when dealing with patients – that don’t allow for the leisurely consideration of adverse health possibilities. Being human – something we sometimes forget – perhaps a lot of primary physicians are simply tired at the end of the clinical day, and either forget the reminder or decide that the efficacy of screening for a particular patient doesn’t seem high enough to warrant the cost and anxiety for the patient.
Physicians don’t work traditional hours anymore. Someone may work 7 to 3. Others 1 to 8. Which one is tired at 2 pm?