The "Time of Day"Matka

Some years ago, a relative of mine with backache messaged me saying they had met the most awesome doctor, who saw them even though it was 2 AM in the morning, gave them adequate time (15 mins), examined them, discussed their problems, answered their questions and prescribed the appropriate medication.

I blanched. Unless it is an emergency like a stroke or a heart attack, there is no earthly reason to see any doctor at 2 AM for a regular office/OPD consult, however busy or famous that doctor may be.

The “time of day” can affect our health and outcomes in 3 different ways.

1. The advice we get from doctors and hence our outcomes can vary depending on the “time of day” when it comes to regular outpatient and/or non-emergency consults.

2. Our body’s response to stimuli can vary during different parts of the day, depending upon our circadian rhythm (e.g. better antibodies to influenza vaccinations, when given in the morning, as against the afternoon [1]).

3. The quality of services we get in emergency and acute situations may be variable at different times during a 24-hours period, though it shouldn’t.

Our focus today is on the first issue. The “time of day’ when we see a doctor for a non-emergency consult… is a controllable matka for most people…and it matters.

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Probably the most cited study on the “time of day” issue is a legal paper by Shai Danziger and colleagues [2] out of Israel, in 2011, which showed that parole judges would give a favorable decision on parole applications in the first hour of their session and/or immediately after a food break, with the rate of favorable decisions dropping every hour thereafter. The reason…“decision fatigue”.

As the session or day progresses, and as multiple decisions have to be constantly made regarding diagnosis and treatment, there is a strong likelihood of “decision fatigue” setting in. In simple terms, there is a limit to the number of complex decisions a person can make before it becomes more and more difficult. And when that happens, doctors (and everyone else) find it easier to stick to the status quo, to agree to what the patients want and avoid making complex decisions that involve a lot of explanations and answers.

This simple diagram by Tauseef Ali says it all.

Virtually all the medical studies I could find that have addressed the “time of day” phenomenon, date from 2014, likely inspired by the Danziger et al article from 2011.

The most recent article on this subject is by Allison Oakes and her colleagues [3]. It shows that as the day progresses, physicians prescribe fewer statins in patients with high ASCVD risk (Fig. 1).

Fig. 1: Time of day plotted against rate of statin prescription

A similar article by Esther Hsiang and her colleagues [4] showed reduced rates of breast and colorectal cancer screening orders by primary care physicians as the day progressed. Interestingly, they also showed that there was a reduction in the number of patients who eventually got the breast cancer screening done, likely reflecting the reduced time available for explanations that would convince the patients the need to get the screening done.

Fig. 2: From ref 4. Breast cancer screening orders and completion rates

Other studies have shown increasing opioid [5] and antibiotic [6] prescriptions as the day progresses, reduced orders for influenza vaccinations [7], reduced hand hygiene [8] and lower rates of indicated spine surgery among orthopedic surgeons [9] with similar curves as the one below from the spine surgery article.

Imagine a doctor, who starts the day fresh. As the day progresses and the patients keep coming in, two things happen. First, the doctor experiences “decision fatigue” from having to make multiple decisions, many complex, related to patient diagnosis and treatment and second, as the end of the day comes nearer, needs to rush through the patients to finish in time. This leads to reduced time for explanations and patient queries, which in turn leads to a suboptimal experience for the patient and sometimes suboptimal diagnosis and treatment.

Many doctors or practices that are aware of this issue institute hacks to combat this problem. I know of a chest physician, who when faced with a complex interstitial lung disease patient at the fag end of the day, will just keep everything for review and call the patient back another day, at a time when they are able to give their full, undivided attention to the patient and relatives. Others may use technology, or reduce the number of patients, or take naps in the middle of the day. Unfortunately, these options may not work for all doctors or hospital systems, may not be practical or worse, the awareness of the problem itself may be non-existent.

Funnily, the way many of our physicians work, especially in the smaller towns in India, may be related to an intuitive realization of this problem. Most doctors have two consulting sessions, the first in the morning from around 10 to 2, after which they go home, have lunch and sleep and then come back for a second session say from 6-10 PM, well-rested and fresh.

How does this affect us?

The “time of day” when we see a doctor, is a controllable matka for most of us. We should try and see our doctors either as the first patient or be among the first 2-3 patients of the day or the session. We should try hard not be the last patient and definitely not see the doctor at 2 AM in the morning, unless it is an acute emergency, in which case, all this becomes irrelevant.

This diagram summarizes it all.

Footnotes

1. Long JE, Drayson MT, Taylor AE, Toellner KM, Lord JM, Phillips AC. Morning vaccination enhances antibody response over afternoon vaccination: A cluster-randomised trial. Vaccine. 2016 May;34(24):2679–85.

2. Danziger S, Levav J, Avnaim-Pesso L. Extraneous factors in judicial decisions. Proceedings of the National Academy of Sciences. 2011 Apr 26;108(17):6889–92.

3.  Oakes AH, Adusumalli S, Snider CK, Rareshide CAL, Patel MS. Variation in Cardiologist Statin Prescribing by Clinic Appointment Time. Journal of the American College of Cardiology. 2021 Feb;77(5):661–2.

4. Hsiang EY, Mehta SJ, Small DS, Rareshide CAL, Snider CK, Day SC, et al. Association of Primary Care Clinic Appointment Time With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening. JAMA Netw Open. 2019 May 10;2(5):e193403.

5. Philpot LM, Khokhar BA, Roellinger DL, Ramar P, Ebbert JO. Time of Day is Associated with Opioid Prescribing for Low Back Pain in Primary Care. J GEN INTERN MED. 2018 Nov;33(11):1828–30.

6. Linder JA, Doctor JN, Friedberg MW, Reyes Nieva H, Birks C, Meeker D, et al. Time of Day and the Decision to Prescribe Antibiotics. JAMA Intern Med. 2014 Dec 1;174(12):2029.

7. Kim RH, Day SC, Small DS, Snider CK, Rareshide CAL, Patel MS. Variations in Influenza Vaccination by Clinic Appointment Time and an Active Choice Intervention in the Electronic Health Record to Increase Influenza Vaccination. JAMA Netw Open. 2018 Sep 14;1(5):e181770.

8. Dai H, Milkman KL, Hofmann DA, Staats BR. The Impact of Time at Work and Time Off From Work on Rule Compliance: The Case of Hand Hygiene in Health Care. J Applied Psychology 2015;100:846.

9. Persson E, Barrafrem K, Meunier A, Tinghög G. The effect of decision fatigue on surgeons’ clinical decision making. Health Economics. 2019 Oct;28(10):1194–203