Is there a better time of day to see your doctor?

WWhen it comes to the medical care you receive, it does not matter whether you see your doctor in the morning, in the middle of the day or late in the afternoon. But it can.

To study the effect of the time of day on cancer screening decisions, my unit team Penn Medicine Nudge and I recently reviewed the orders of primary care physicians for all-day screening tests. throughout the day. We focused on patient visits eligible for breast or colon cancer screening. We also followed patients for a year to see who had passed these tests and whether visit time counted or not.

As we report on Friday in JAMA Network Open, in almost every doctor's office we have seen the same pattern. Patients seen earlier in the day were more likely to ask their doctor to request cancer screening. At 8 am, for example, 64% of women eligible for breast cancer screening left their appointment with a mammography prescription. This decreased to 48% at 17 hours. We observed a similar trend with regard to colon cancer screening: at 8:00 in the morning, 37% of eligible people left with a colonoscopy prescription, compared to 23% at 17:00.

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The same trend is true in patients. A year later, those who had seen their doctor later in the day were much less likely to have been tested.

These gaps in preventive care are not limited to cancer screening. In another study, we found similar trends in influenza immunization. In addition to this, primary care appointments later in the day have higher rates of unnecessary prescription of antibiotics and higher rates of opioids for back pain. Hospitals have even proven that providers wash their hands less often towards the end of clinical changes.

Two main factors can play in the way doctors and patients make their decisions, especially at the end of the day.

The first is a phenomenon called decision fatigue. It's the tendency to make poorer choices after making a lot of decisions. Grocery stores take advantage by placing candies near the cash register. After making many decisions about which foods to buy, consumers may make less healthy choices toward the end of their purchases.

Decision fatigue probably affects physicians and patients in a similar way. While doctors make repeated decisions throughout the day, this fatigue can cause them to stop engaging patients in later discussions of the same decisions. Patients also make decisions throughout the day, whether at home, at work or elsewhere. Asked at the end of the day about their interest in cancer screening, patients are more likely to postpone their decision in the future.

Another factor stems from what happens with doctors' schedules. Suppose that a doctor has 15 minutes per patient throughout the day. At 8 o'clock, it has 15 minutes. But if she lags behind, she can be left with four patients to see in the last 30 minutes. This can lead to hasty visits in which discussions of health care decisions may not be discussed or deferred. Patients may also be in a hurry at the end of the day just because they want to go home.

Although these factors may seem impossible to resolve, our group found that simple changes in physician practice and electronic health record design can go a long way.

Repetitive decisions, such as asking each patient during the influenza season when he or she has received the flu shot, are an example. Rather than allowing doctors to remember to mention vaccination, the electronic medical record may prompt medical assistants to begin this discussion with patients before seeing the doctor, accepting or canceling a vaccine order based on the response. and put it in a queue. health record that the doctor can review. We tested this approach and found that it increased flu vaccination rates by 10%. In the clinics that used this boost, patients who had seen their doctor at the end of the day had vaccination rates similar to those of patients with appointments at 8 am in clinics that did not apply. this approach.

Some decisions do not have to be made when visiting a doctor. We have seen an improvement in colon cancer screening rates by offering to mail colon cancer screening tests to patients' homes. We also found that sending lists of doctors to their patients who, according to national guidelines, could benefit from cholesterol-lowering drugs, would have tripled the statin prescription rate.

The lesson from this work is that the medical decisions made later in the day may not be as good as those taken earlier, but that subtle changes in electronic health records and the adoption of New approaches to care delivery can make time useless.

Simple decisions can have long-term effects on health. Therefore, know what is important to you and make sure your doctor knows it too, regardless of the time of day.

Mitesh S. Patel, MD, is director of the Penn Medicine Nudge Unit, an assistant professor at the University of Pennsylvania and a staff physician at Cape. Michael J. Crescenz, Veterans Medical Center in Philadelphia.