Your doctor obviously is no slouch in the brains department, since he/she got through the mental rigors of medical school and a residency program. However, as each long day of patient appointments wears on, he is likely to suffer a kind of “brain drain” associated with decision making that can leave you not getting the best care. Here’s what happens…and what you can do about it.

Making decisions, including critical, life-and-death ones about diagnoses, treatment, lab tests, surgery, etc., is part of the territory for doctors. But unrelenting hours of such decision making can have a cumulative negative effect called “decision fatigue”—where the quality of decisions deteriorates from the mental exhaustion of having to make so many. Decision fatigue is a well-known phenomenon in the medical profession (and in other professions as well).

The extent to which decision fatigue impacts patient care is still largely unclear. One study from the Penn Medicine Nudge Unit suggests that decision fatigue is the reason patients with appointments later in the day are less likely to be ordered routine flu vaccinations. Other studies have found that doctors are more likely to order inappropriate pain medications or unneeded antibiotics late in the day, which could be the result of decision fatigue.

Now a new study looks at whether the time of day of a doctor appointment affects another aspect of decision making—following guidelines for routine screening tests for breast cancer and colon cancer.

Study: Researchers from the Penn Medicine Nudge Unit followed about 20,000 women who were eligible for breast cancer screening and more than 30,000 men and women eligible for colon cancer screening at 33 primary care practices in Pennsylvania and New Jersey. The researchers looked at initial or annual routine visits over two years. Screening eligibility was determined by the US Preventive Services Task Force guideline recommendations—for breast cancer, that women ages 50 to 74 should have a mammogram every two years…and for colon cancer, that people ages 50 to 75 should be screened with tests including stool tests, sigmoidoscopy and colonoscopy.

Results: Women who had 8 am office visits had appropriate screening ordered at 64% of visits. By 5 pm, the percentage of appropriately ordered screening had dropped to 48%. For colon cancer, appropriate screening rates were 37% for patients with 8 am appointments…vs. 23% if their appointment was at 5 pm. While the rate of appropriate screening orders dropped as the day progressed, there was a slight improvement after the lunch period—suggesting that doctors taking a break helps.

The researchers also looked to see how time of day affected whether patients actually completed their ordered screening tests. After one year, 33% of patients who had had 8 am appointments had gotten their breast cancer screens…compared with 18% of patients who had had 5 pm appointments. For colon cancer, the completion of screening rates went from 28% (8 am appointments) to 18% (5 pm appointments).

The researchers suggest that as doctors fall behind schedule, doctors tend to have less time to spend discussing cancer screening with patients, including persuading patients of the importance of getting it done. Doctors may also tend to feel that they’ve already had the same discussion many times, albeit with earlier patients. Patients themselves are partly to blame—they’re more likely to be impatient to leave toward the end of the day and reluctant to stick around for a discussion, making them also more likely to not put a screening test high on their priority list.

This study also confirms a national trend—that many patients are falling through the cracks when it comes to cancer screening. Even for patients with early appointments, the guidelines still were not being followed as often as they should have been.

Help Your Doctor Help You

The most obvious way to avoid becoming a casualty of decision fatigue—yours and your doctor’s—is to book appointments for first thing in the morning or right after lunch. However, that isn’t always possible. Even if you do manage to get, say, a 9 am appointment, your doctor may already be running late from earlier hospital rounds…or have an emergency that bumps your appointment later. Nor does scheduling for right after lunch guarantee that your doctor actually took a lunch break. But there are some things you can do to help your doctor help you…

Be your own advocate: At routine checkups, if your doctor does not talk to you about screening tests such as for different types of cancer, kidney function or diabetes…or routine vaccinations…ask if you’re due for any. If your appointment is for a particular medical or health issue, it’s a good idea to do some research first so that you’ll know what tests, treatments, etc., are typically involved and will be able to ask informed questions.

Quell your impatience: If your doctor does want to talk to you about screening tests, don’t avoid the conversation or cut it short. Ask questions, especially if you think you need a test your doctor isn’t ordering…or if you think you don’t need a screening test he/she is suggesting. Also, make sure you get all the information you need to schedule the screening. Then follow through on getting it done!

And it wouldn’t hurt, if your appointment is late in the day or just before lunch, to stop on the way and get your doctor a coffee.

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