By Diana Duong and Dr. Sharon Vorona
In a study published by JAMA Open last week, University of Pennsylvania researchers looked at the habits of 33 primary care practices to determine whether appointment times were associated with clinician ordering of cancer screening in eligible patients.
They found that patients who saw their doctors at 8 a.m. were most likely to have breast cancer screening tests ordered, with a rate of 63.7%. The rates of tests ordered decreased throughout the morning, dropping to 48.7% and increasing again at noon. By 5 p.m., only 47.8% of patients eligible for breast cancer screening had the tests ordered — a 15% difference. The ordering rates of colorectal cancer screening tests were similar, with the highest ordering rate occurring at 8 a.m. (36.5%), and the lowest occurring at 5 p.m. (23.4%). Similarly, patient completion rates at one year were lower if the patient’s clinic appointment time was later on in the day.
This prompted internist and Northwestern professor of medicine Dr. Jeffrey Linder to write that he too feels sharper during the morning and has a “three o’clock fade.” However, he says, this occurs in primary care because there is more work than time in the day, and physicians often run late or fall behind on their patient load.
Many healthcare professionals chimed in online about how long shifts are affecting both physicians and patients.
What causes decision fatigue? Sleep debt or time pressure?
Doctors ordered breast cancer screenings for 64% of eligible women at 8 am, but during 5 pm appointments, they ordered screening for ~48% of eligible patients. #Sleep folks: homeostatic? circadian? or both? https://t.co/q1pEyzxvda— Katie Sharkey MD PhD (@katie_sharkey) May 13, 2019
Dr. Katie Sharkey, the assistant dean for Women in Medicine & Science at Brown University’s medical school, asked her followers whether they felt this “three o’clock fade” was due to lack of sleep and whether their alertness was tied to their circadian rhythm. Several responded saying it was more likely to be the systemic issue of time constraints with patients and running late on appointments.
But it may also be all of the above
decision fatigue doesn’t absolve the system of fatiguing us with overwhelming decisions— Seth Trueger (@MDaware) May 14, 2019
Dr. Seth Trueger, an emergency physician at Northwestern and an editor at JAMA, said physicians’ decision fatigue may be a result of both time pressure and the effects of sleep deprivation. But ultimately, it’s the system that leaves physicians feeling depleted by the end of the day.
“Patients deserve a non-exhausted physician”
30 hour call. 7am to 12pm the following day: a day shift, night shift, and half a day shift. Twice I’ve hit a light pole with my car on the way home. This shit is not funny. I could have been taken or taken someone else from their family. For fucking nothing.— Dr. Intern (@DrIntern1) May 11, 2019
One intern tweeted the aftermath after working a 30-hour shift. Dr. Roxana Daneshjou, a dermatology resident, replied and said “I love how people recommend you take a cab/Uber but no one seems to think, ‘Hey, if it’s not safe to drive, maybe it’s not safe to be seeing patients after being awake so long.’”
Physicians have long felt time constraints with patients
NYT OpEd on competing pressures faced by primary care providers cites AJPH research that found the physician time required to provide all services recommended by the US Preventive Services Task Force would add up to 7.4 hours per day (Open Access): https://t.co/q1pfgOh1oU https://t.co/RMuv0xDTrg— AJPH (@AMJPublicHealth) May 16, 2019
This is not a new phenomenon. For decades, doctors have felt the pressures of time. The American Journal of Public Health revived a study from 2002 determining the physician time required to provide all the preventive services recommended by the U.S. Preventive Services Task Force at the recommended frequency. The study found that, to fully satisfy the recommendations, a physician would need to dedicate 1773 hours a year, or 7.4 hours each day.
The case of the week
A four-month-old presents with a three-day history of swelling of the occipital skull. The mass is bony, not mobile, and not tender. The swelling fluctuates then rapidly resolves. The child is otherwise healthy but has recently developed an eczematous rash on the face which has worsened following treatment with neomycin. The pediatrician has never seen anything like this, and is concerned. What are your thoughts? See the full case here.