White Coat, Black Art·Dr. Brian's BLOG

Early appointments mean better care from your GP

If your doctor doesn't screen you for cancer, you may be booking the wrong appointment time slot.
In comedy, they say timing is everything. In scheduling health-care appointments, timing may also be an important factor. (Andreas Gebert/EPA)

If your family doctor or nurse practitioner doesn't screen you for cancer, you might be tempted to choose a new health professional. Or, you might just want to change the time of your appointment. That timely bit of wisdom comes from a recent study published recently in JAMA Network Open. 

Time of day may be critical to whether or not patients get screening for cancer by their primary care physician. That's the main conclusion of a study by Dr. Mitesh Patel and colleagues at the University of Pennsylvania, and Johns Hopkins in Baltimore. The researchers looked at 33 primary care practices in Pennsylvania and New Jersey.

During the study period, there were 19,254 patients who met U.S. eligibility requirements for breast cancer screening.  At 8 a.m., 63.7 per cent of eligible patients got screened for breast cancer. At 11 a.m., just 48.7 per cent got screened. At noon, the number screened went back up to 56.2 per cent. At 5 p.m., just 47.8 per cent of patients got screened for breast cancer, which was the lowest percentage of the entire day.

In other words, women eligible for breast cancer screening were most likely to get the scans within a year if they booked an 8 a.m. appointment and were least likely to get screened if they came at 5 p.m. 

To see whether there was something unique about breast cancer screening that made the time of day a factor, the researchers also looked at screening for colorectal cancer. Just over 33,000 patients in the study were eligible for colorectal cancer screening. Essentially, they saw the same phenomenon. At 8 a.m., 36.5 per cent of eligible patients got screened. That figure decreased to 31.3 per cent at 11 a.m. before increasing to 34.4 per cent at noon. At 5 p.m., just 23.4 per cent got screening. The daily variation was similar to that seen with breast cancer screening.

Patients were most likely to get screening for colorectal cancer if they booked an 8 a.m. appointment and far less likely to get screened if they booked a 5 p.m. appointment.

Women eligible for breast cancer screening were most likely to get the scans as recommended if they booked an 8 a.m. appointment than if their appointment was later in the day. (Jean-Paul Pelissier/Reuters)

The researchers wondered why the time of day of the appointment influenced whether or not patients got screened for cancer. In the paper, they speculated that as the day progresses, clinicians might typically spend less and less time with patients as they get behind schedule. A decision might be made to defer screening to another appointment.

Or, the clinician might experience something called decision fatigue. At the beginning of the day, he or she eagerly brings up the subject of cancer screening with patients. As the hours tick by, the physician has recommended screening so often that he or she is tired of doing so.

Hurry up and wait

Patients themselves might be a factor in timing-of-appointment healthcare. The later the appointment, the longer the patient might be waiting to see the clinician. By the time they've arrived in the examining room, patients might be sending signals that they would rather leave in a hurry, prompting the doctor to put off talking about screening.

This unusual bit of research is important. Other studies have shown a similar effect. Doctors are more likely to prescribe opioid pain relievers at appointments later in the day. They are also more likely to prescribe antibiotics when they aren't necessary if it's late in the day.

I have found that I am more likely to prescribe an antibiotic quicker at the end of my shift when I'm tired than at the beginning when I'm well rested.

Another study found that you are also less likely to get a flu shot at an end-of-day appointment.

Benefits of a rested health-care team

The study just published is one of the first to show that appointment time has an effect on the likelihood of cancer screening. Not only were patients seen at 8 a.m. most likely to get cancer screening tests, but those screening tests were also most likely to be completed within one year.

As the authors emphasized, it means that a decision made during a single visit to a GP or nurse practitioner may have a lasting effect on patients. It could even have a measurable impact on cancer survival.

Understandably, the authors of the study wrote that more research is needed to understand why time of day seems to affect care. However, in the meantime, I have long recommended that patients try to book appointments first thing in the morning. At that time, they are more likely to have an on-time appointment, and the doctor or nurse practitioner is more likely to be more rested and less distracted by daily crises and decision fatigue.

And if you don't manage to score that early appointment, be extra vigilant for the inappropriate care you might receive and for the good things you might be apt to miss.

In comedy, they say timing is everything. When it comes to scheduling health-care appointments, timing may not be everything. But it appears to be a factor that should not be ignored.

About the Author

Dr. Brian Goldman is a veteran ER physician and an award-winning medical reporter. As host of CBC Radio’s White Coat, Black Art, he uses his proven knack for making sense of medical bafflegab to show listeners what really goes on at hospitals and clinics. He is the author of The Night Shift and The Power of Kindness: Why Empathy is Essential in Everyday Life.

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