Fatigue matters, even when it comes to doctors. Especially when it comes to doctors--we've got data. This is Healthcare Triage News.

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This first story is a few months old, but I was recently reminded of it on Twitter. It was published in JAMA Internal Medicine and it's entitled, "Time of day and the decision to prescribe antibiotics."

Doctors have to make many decisions every day. Doctors also often work pretty long hours. They can be tiring. I'm not saying this to complain, but when I was a resident, I'd often have to work 36 hours straight, usually more than once a week.

There's every reason to believe that this would have some sort of impact on patient care. But we'd rather have some data to confirm or refute that, rather than rely on our guesses. This study tried to do that.

As many of you might know from watching previous episodes of Healthcare Triage, antibiotics are of no use in treating acute respiratory infections. So their use is considered inappropriate. This study wanted to look at whether physician fatigue might have any impact on how a doctor might prescribe an inappropriate antibiotic.

Researchers looked at billing and electronic health record data for 23 different primary care practices over about a year and a half, in 2011 and 2012. They specifically looked at visits by adults age 18-64 years who were otherwise healthy, but were being seen for acute respiratory infections. Then they looked at whether the patients got a prescription for antibiotics.

Over the study period, there were almost 22,000 visits for acute respiratory infections, and about 44% of those resulted in a prescription for antibiotics. But they saw something interesting: prescriptions for antibiotics became more common later in the day.

This happened on pretty much every weekday. When docs started working in the morning, their rates of antibiotic prescriptions were at their lowest. This was true for things where antibiotics were sometimes indicated, and for things where antibiotics were never indicated, and even overall.

Prescription rates peaked three hours later, before lunch. Then, when the doctors came back from lunch, hopefully refreshed, their rates of antibiotic use had dropped. But still not to 8AM levels. And over the course of the afternoon, rates increased again, with overall and inappropriate use peaking at the end of the day.

Now let's acknowledge some limitations to this kind of research. What we're seeing is a correlation, not any proof of causation. It's possible, but sort of unlikely, that the patients that come in at 11AM are different than the patients that come in at 8AM. And same for those at 4PM and 1PM. But that wouldn't account for the use of inappropriate antibiotics. 

It's also possible that some other confounding factor's responsible for the differences. But I'm having a hard time thinking of one.

This looks like a fatigue issue. We know from other areas of research that people make worse decisions as they grow tired. This looks like that. We need to be aware of it. We need to devise ways of compensating for it.

That could mean better decision support. Or ways to flag the use of antibiotics for docs to tell them when they might not be doing something right. It could mean smarter schedules, more breaks, or fewer continuous work hours.

But we shouldn't ignore it. Fatigue matters, especially for those with whom we're trusting our health and our safety.

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