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May 24, 2019

Do doctors provide worse care at the end of the day?

Daily Briefing

    A patient's chance of being screened for cancer increases when the patient sees his or her primary care provider (PCP) in the morning, according to a recent study in JAMA Network Open.

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    Study details

    For the study, researchers sought to examine whether the time of day a patient visits his or her PCP affects the doctor's likelihood of ordering a cancer screening. The researchers also examined whether the time of day affected a patient's chance of receiving the ordered screening.

    The study involved data on about 53,000 PCPs. The researchers examined the records of patients who had primary care visits with physicians in the University of Pennsylvania health system between 2014 and 2016. Among the patients, a total of 19,000 were eligible for breast cancer screenings and more than 33,000 were eligible for colon cancer screenings.


    The researchers found that, during 8 a.m. visits, PCPs ordered breast-cancer screenings for 64% of eligible patients and colon-cancer screenings for 37% of eligible patients. In comparison, PCPs during 5 p.m. visits ordered breast-cancer screenings for 48% of eligible patients and colon-cancer screenings for 23% of eligible patients.

    The researchers suggested the decline in the number of screenings ordered during 5 p.m. visits could be tied to "decision fatigue," which refers to the difficulty individuals have making decisions because of the mental exhaustion they experience as they progress toward the end of the day. The researchers wrote, "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."

    The researchers also acknowledged that the decrease could be a result of physicians running late on appointments or "patients who see their clinician later in the day want[ing] to leave sooner and declin[ing] a discussion about cancer screening."

    When the researchers looked at follow-up data, they found that, one year later, patients who saw their PCPs later in the day were less likely to complete their cancer screenings when compared with those who saw their PCPs earlier in the day, STAT News reports.


    Jeffrey Linder, a professor of medicine at Northwestern University's Feinberg School of Medicine who wrote an editorial accompanying the study, said the study serves as "a reminder that doctors are human, too." He said, "They're laboring under the same psychological and fatigue constraints as everyone else."

    Linder said physicians should be aware of how the time of day affects the care they provide patients.

    Mitesh Patel, an assistant professor of medicine at the University of Pennsylvania and one of the study's authors, in a STAT News opinion piece wrote that there is an opportunity for [EHRs] to help remind physicians to order screenings or to use other approaches to offer screenings to patients. For example, Patel wrote, "We've found improvements in colon cancer screening rates by offering to mail colon cancer tests to patients' homes. We've also found that sending doctors lists of their patients who, based on national guidelines, could benefit from cholesterol-lowering medications tripled the rate of statin prescribing."

    Patel wrote, "The take-home lesson from this work is that medical decisions made later in the day may not be as good as those made earlier, but that subtle changes to [EHRs] and taking new approaches to delivering care can make time irrelevant" (Norton, HealthDay/WebMD, 5/10 Patel, STAT News, 5/10; Keshner, MarketWatch, 5/11).

    Next, learn how to get the word out about lung cancer screening

    Ten million individuals nationwide are eligible for lung screening every year—but the average program only screens about 25. Given its potential to increase survival and volumes, lung cancer screening is one of the best opportunities to achieve program cost, quality, and growth goals.

    Early adopters, however, are finding it challenging to market the program to patients and primary care providers. Download this infographic to learn how to reach them—and grow your screening program.

    Download the Infographic

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