Doctors more likely to prescribe antibiotics later in the day

Study suggests cumulative fatigue plays a role in doctors writing more prescriptions for antibiotics towards the end of the working day.

A study involving Boston-based doctors in practices affiliated to the Massachusetts General Hospital shows that doctors are more likely to prescribe antibiotics for acute respiratory infections (ARI) in the afternoon

Doctors are more likely to write prescriptions for antibiotics to treat acute respiratory infections (ARI) towards the end of the day, suggesting they are worn down during the course of seeing patients, say researchers in a study published in JAMA Internal Medicine[1]

“This is the first study we’re aware of where we see healthcare professionals making different decisions about prescribing based on time of day,” says Jeffrey A Linder, a physician and researcher in the division of general medicine and primary care at Brigham and Women’s Hospital (BWH) in Boston, Massachusetts, and lead author of the study. “Even something routine, such as prescribing an antibiotic, is influenced not by particularly dramatic degrees of sleep deprivation but by physicians just getting tired over a period of time.”

The 17-month study, which began in May 2011, involved 204 Boston-based doctors in 23 practices affiliated with BWH and Massachusetts General Hospital. Linder’s team used billing and electronic health record data to identify patient visits and diagnoses. The researchers analysed more than 21,000 ARI visits by adult patients during both 8am-12pm and 1pm-5pm clinics. The rate of antibiotic-prescribing climbed steadily through both late morning and afternoon sessions.

Although antibiotics are not indicated for some ARI conditions, such as colds, influenza and acute bronchitis, researchers found that doctors wrote antibiotics prescriptions for these conditions later in the day. “This corresponds to about 5% more patients receiving antibiotics at the end of a clinic session compared with the beginning,” he says.

Linder did not find huge spikes in antibiotic-prescribing just before the end of each clinic, which might have been expected if doctors were trying to speed up the appointment. Instead, he saw a steady increase. “We suspect that physicians are more willing to have detailed conversations with patients earlier in the clinic session,” he says. “Most doctors know they shouldn’t prescribe antibiotics for certain respiratory conditions but, as they fatigue, they’re more prone to succumb to patient pressure or to want to end the visit. The easiest way to do that is to give patients what they want, even though antibiotics can cause adverse reactions, such as rashes, diarrhoea, and the increase of antibiotic-resistant bacteria.”

Linder concedes that the study leaves the door open for patients to time their healthcare visits later in the session to improve their chances of extracting “a prescription for antibiotics your doctor doesn’t think you really need”.

The catalyst for the research was Linder’s fascination with a legal study involving judges who were more inclined to grant parole early in the day, when they were more apt to review paperwork and take other factors into consideration. Before lunch and right before the end of day, however, judges were less inclined to grant parole. Linder wondered whether physicians’ decision-making would also be influenced by the clock.



[1] Linder JA, Doctor JN, Friedberg MW, et al., Time of day and the decision to prescribe antibiotics. JAMA Internal Medicine. Published online 6 October 2014. doi:10.1001/jamainternmed.2014.5225

Last updated
The Pharmaceutical Journal, PJ, 18 October 2014, Vol 293, No 7832;293(7832):DOI:10.1211/PJ.2014.20066737

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