Docs Drop Screenings as the Day Wears On--Give 'em a Break?

F. Perry Wilson, MD, MSCE


May 15, 2019

Welcome to Impact Factor, your up-to-the-minute commentary on new medical studies. I'm Perry Wilson.

Imagine it's 8 AM. A healthy 55-year-old woman comes in to your primary care office for her annual checkup. Do you offer her screening mammography?

Now imagine that the same woman comes in to your office at 4:30 PM. Do you offer her screening mammography?

Of course, the time of day should have no bearing on the care we deliver to patients, but a new study[1] 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.

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?


A clear trend emerged. About 64% of eligible patients were ordered 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 until the next visit.

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 didn'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 that have shown that as the day wears on, physicians are more likely to prescribe opiates for low back pain,[2] less likely to give flu vaccines,[3] and more likely to give antibiotics for upper respiratory infections.[4] This is path-of-least-resistance medicine.

And let's not place all the blame on 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? That 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 that they happen.

In other words, docs are busy. Let's let them be busy doing the things we need docs for.


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