When penicillin was first introduced to the public, it earned the nickname "the wonder drug" because it cured infections that had once been deadly. It ushered in the golden era of antibiotics, during which the bacteria-killing drugs entered widespread use, driving down rates of severe disease and death from infections.

Unfortunately, the sweeping adoption of these medicines also set the stage for their obsolescence. Once hailed as miracles, antibiotics are now losing their power as bacteria evolve strategies to evade them.

Today, the world is contending with a "silent pandemic" of antibiotic resistance, driven largely by the misuse and overuse of these critical medicines. Curbing resistance, then, means changing how doctors prescribe ‪—‬ and patients use ‪—‬ antibiotics.

I traveled to Japan because a government initiative aimed at correcting antibiotic misuse has helped slash unnecessary prescribing and I wondered if a similar approach could work in the U.S. The program offers "tips" of 800 yen (about $5) to the clinics of pediatricians and ear, nose and throat doctors (ENTs) who withhold antibiotics in cases when they're likely not needed.

My findings suggest that many of the factors that drive antibiotic misuse in outpatient clinics overlap in the U.S. and Japan. But the cultural, governmental and insurance landscape may differ too greatly between the two countries for America to copy-and-paste Japan's approach. Instead, here's what I think could work to close the gaps in antibiotic overprescription in the U.S., based on my conversations with doctors.

Similar pressures, different systems

In both Japan and the U.S., sick visits are mere minutes long, so doctors must determine quickly whether an antibiotic is needed. Few rapid tests exist for bacterial infections, introducing a degree of diagnostic uncertainty. Children's caregivers sometimes request antibiotics when they're not needed, and depending on the doctor, that social tension can be enough to prompt an unnecessary prescription, research has found.

I learned that children's caregivers value doctors who can answer questions and clearly explain their reasoning. They don't necessarily arrive at an appointment expecting a specific "solution," such as an antibiotic prescription — even if they sometimes request one. When faced with parents who request a prescription, doctors can often defuse the tension by explaining why antibiotics aren't necessary, my reporting found.

On paper, Japan's antibiotic incentive gets at both halves of this pediatrician-parent dynamic. It offers pediatricians and ENTs extra payment to avoid antibiotics for certain types of infections. To claim that cash for their clinics, the doctors must explain their reasoning for withholding antibiotics to the child's caregivers, to help educate them about appropriate antibiotic use.

Although the pressures that lead to overprescription are similar in the U.S., the countries have several big differences.

For one, Japan has a national insurance system in which children's healthcare is essentially free. People in Japan report a relatively high degree of trust in their national government overall, and they specifically report being very happy with their healthcare system, with satisfaction rates far exceeding those of similarly wealthy countries.

By contrast, the U.S. has a patchwork of private, subsidized and public insurance. About 27 million people — roughly 8% of the population — are uninsured, and those with insurance frequently face issues with using their coverage and major barriers to care, such as prior authorization and claim denials. Navigating these barriers can derail and delay medical care, spurring frustration. Meanwhile, the number of people able to cover medical care is falling as costs spike, and people worry that insurers hold too much sway over health policy.

These layers of complexity are baked into the U.S. healthcare system, whereas in Japan, the federal government can introduce an insurance policy and affect change across the whole system at once. That's how the 800-yen incentive for pediatric clinics was implemented.

Hesitations from U.S. doctors

Japanese doctors readily accepted the notion of "tips" for withholding unneeded antibiotics, in part because those types of small-scale incentives already exist in Japanese healthcare.

Clinics earn incentives by claiming an add-on fee when they seek insurance reimbursement for a given appointment. That reimbursement rate is dictated by Japan's federal government, which sets healthcare pricing, so it's simple to introduce such incentives at scale. Similar add-on fees have been used to encourage doctors to prescribe cheaper "biosimilars" over costlier drugs with the same effects and to adopt better treatment approaches for conditions like hip fractures and painful periods.

In contrast, reimbursement rates in the U.S. are set by a dizzying array of agencies and private companies, all with their own goals.

I asked U.S.-based doctors whether a similar incentive could work here. Their responses were mixed.

"I think a program like the Japanese one could work in the U.S.," Dr. Conor Blanco, a pediatric ENT based in New Jersey, told me in an email. He noted that many physicians' pay is determined partially by patient satisfaction scores, so there are existing financial incentives that steer their behavior. If you set up a similar incentive around proper antibiotic use, "maybe it makes a difference, it's tough to say," he said.

Dr. Dmitry Volfson ‪—‬ chief medical officer of CityMD, a large urgent care provider in New York and New Jersey ‪—‬ agreed that it might work. "But [it] may be difficult to implement" given America's multitude of insurance payers, Volfson told me in an email.

Other doctors were less open to the idea.

"On first pass, it feels very unethical to me," said Dr. Morgan Leafe, a pediatrician who worked in both inpatient and outpatient settings for 11 years. Children's caregivers might be upset to hear that clinics get paid more when they don't prescribe an antibiotic, given that some are already under the impression that U.S. doctors are overly motivated by money, she told me in a direct message.

Doctors already widely criticize insurers for denying what physicians deem necessary care. Dr. Jennifer Shu, a pediatrician with Children's Medical Group in the Atlanta metro area, worries that insurers might set up the incentive in a way that restricts doctors' prescribing patterns too aggressively or doesn't align with current scientific evidence.

"I do not believe that financial incentives should dictate clinical practice," said Dr. Erik Blutinger, an emergency medicine physician for the Mount Sinai Health System in New York who also works in its urgent care centers. "It should boil down to the patient's health and ultimate well-being over finances."

Dr. Ilan Shapiro, a community pediatrician at AltaMed Health Services in Southern California, said he could see an incentive driving down unnecessary antibiotic prescriptions, but he added that it could also overcorrect, encouraging doctors to hold back antibiotics that are actually needed.

"I'm not a believer in the carrot or the stick," Shapiro told me.

How incentives work in the U.S.

Notably, many U.S. doctors are already financially incentivized to improve antibiotic prescribing — but those incentives apply at a high level, rather than case by case.

For example, many American health insurance plans use a tool called the Healthcare Effectiveness Data and Information Set (HEDIS) to assess patients' quality of care at the medical centers they visit. The tool is used by many commercial insurers, as well as by private groups that manage Medicare and Medicaid plans.

Some insurers incentivize providers to achieve higher HEDIS scores by offering higher reimbursement in exchange, "but this is not universal," Volfson explained. There are HEDIS metrics that track how often antibiotics are used for ailments that are frequently viral, like upper respiratory infections, sore throat and bronchitis, he added.

These incentives fall under "value-based care," which aims to reward behaviors that tend to improve patient outcomes and lower healthcare costs. That's opposed to the more dominant "fee-for-service" model, which compensates practices for individual services provided.

Medicare has its own value-based care approach that includes metrics to track antibiotic use, including for upper respiratory infections. These metrics get factored into one composite score that can boost reimbursement (if the score is high) or lower it (if the score is low) for eligible clinicians and practices covered by the program.

Medicaid, which covers nearly half of U.S. children and is run at the state level, does not have an equivalent to this Medicare approach, but it has other ways of tying reimbursement rates to metrics like antibiotic use.

Medical practices' participation in value-based care is growing, but fee-for-service remains dominant. Some doctors are skeptical of the alternate approach, Leafe noted, because they feel it puts them on the hook for outcomes that are not completely within a healthcare team's control. But Shapiro, whose healthcare system uses value-based care, sees it as a way to encourage doctors to consider the long-term trajectory of a patient's health rather than only the acute ailment at hand.

"You have to have some sort of guardrail"

U.S. doctors were often put off by the idea of clinical decisions being steered by a potential bump in payment. "Patient-related outcomes are more important than financial incentives when it comes to shaping my clinical decision-making," Blutinger said.

Shapiro embraces value-based care but expressed doubts about the Japanese approach to incentives. My interviews suggested that incentives awarded for individual actions — such as offering $5 to not prescribe antibiotics for a given child's cold — might not be accepted as easily in the U.S. as they are in Japan.

As Shu expressed, that may partially come down to a lack of trust in insurance companies. There may also be a lack of trust in other doctors and practices; multiple doctors I spoke with expressed worries about underprescription.

"What if people become disincentivized to give antibiotics at all, even when they need them?" asked Dr. Shruti Gohil, an infectious-disease specialist with UCI Health who has designed antibiotic stewardship interventions for hospitals. "You have to have some sort of guardrail on that."

Gohil noted that, in Japan's case, the government incentive aims to promote a "culture of safety, whereas with an insurance company, it's just about finance." In other words, she worries that U.S. insurance companies mainly care about their bottom line, not public health. An insurer incentivizing doctors to provide less care struck her as "unsettling."

In contrast, the pediatricians I spoke with in Japan expressed concerns about other doctors overusing antibiotics, not underusing the drugs, and they argued that some doctors still don't take antibiotic resistance seriously. Their salaries are also lower than those of other medical specialties, and the doctors explicitly stated that they appreciate that the antibiotic add-on boosts their practices' profits.

Alternative approaches?

U.S. doctors may not accept a clone of Japan's incentive program, and given America's complex mix of insurance providers and systems, a similar incentive could be difficult to implement uniformly and at scale. But based on my research, I think that incentives that fit more comfortably within our existing infrastructure could still move the needle.

Doctors are already incentivized to record certain metrics, such as body mass index (BMI) and ongoing weight-management plans, in their notes, Shu said. For example, Medicare and HEDIS bake this documentation into quality measures that affect reimbursement, as well as other calculations that help dictate insurance payments.

Borrowing from Japan's approach, I propose that clinicians and health systems could be paid more when they document that they've explained key facts about appropriate antibiotic use to patients' caregivers. These facts might include that childhood illnesses are often viral and that symptoms like fever or green mucus don't necessarily mean bacteria are to blame. They could note that unnecessary antibiotics can cause side effects like diarrhea and make the medicines less effective over time. These talking points could be added to the electronic medical record, where clinicians could easily access them.

This parent-education requirement could incorporate follow-up plans for further learning. That might include providing parents with physical materials, like pamphlets, or links to vetted websites like the American Academy of Pediatrics' HealthyChildren.org.

Gohil's practice regularly uses those types of patient-directed materials. "Nothing beats the conversation," she said, "but they [the materials] give you talking points and then allow the patient to reference something."

Various trials suggest that educating parents about appropriate treatment for respiratory infections and uses of antibiotics can help shift their expectations around the drugs, in turn reducing how often they seek antibiotics. There's also data to suggest that doctors' providing parents both verbal and written information can help the knowledge stick. Some trials have found that the number of antibiotic prescriptions fell after such educational interventions.

Particularly effective trials combine parent education with efforts aimed at healthcare providers: in-office materials and presentations about antibiotics, guidelines within the electronic medical record that point doctors toward best practices, data on antibiotic resistance rates in the community, or "audit and feedback," where clinicians get report cards comparing their prescription rates with those of others in their practice.

This approach would not specifically incentivize nonprescribing over prescribing, but it would prompt clinicians to educate patients and caregivers about appropriate antibiotic use while providing them a simple script to follow. U.S. adults report placing more trust in health information from their own healthcare providers than from government entities, suggesting that these messages are more likely to stick when doctors deliver them.

Targeting caregivers

Incentives might also help by rewarding children's caregivers for educating themselves about antibiotics. That approach might be less ethically dubious than directly incentivizing doctors' prescribing habits, and the infrastructure for such incentives already exists, my reporting suggests.

Major U.S. health insurers — including private and public insurance — now offer their members cash, gift cards or reward points when they engage in certain "health promoting" behaviors. Even life insurers are getting in on the idea. Participants earn rewards by completing an annual well visit, getting a routine cancer screening, logging a certain number of steps per day, or completing courses on healthy eating or nicotine cessation.

The hope is that, by rewarding such healthy habits, insurers can reduce their members' medical costs. Evidence suggests that these programs can motivate people to change their behavior and improve related health measures, especially in the short term. Their long-term and systemic impacts are understudied, although some research — about quitting smoking, for example — demonstrate long-term behavioral changes.

This same infrastructure could be used to enhance patients' understanding of antibiotics, and thus relieve some of the pressure on doctors to explain why the drugs may not be necessary. Children's caregivers could earn rewards for engaging with short, interactive courses or informational pages about the basics of antibiotics — what the drugs treat, what they don't, what "watchful waiting" is, and why antibiotic resistance is a problem. Short quizzes and surveys could check parents' understanding and prompt further rewards from the insurer.

These resources could explain that many common childhood infections are viral and resolve on their own or, similar to an app about childhood illness created in Japan, lay out the recommended care for acute viral infections and describe the signs that a bug might actually be bacterial. The creator of the app, Dr. Masahiko Sakamoto of Saku Central Hospital, has found that the platform changes how parents understand childhood illness and interact with the health system.

Such information is already available to parents via trusted sources like the American Academy of Pediatrics; the difference in this scenario is that caregivers would be paid to use it. Gohil thinks that incentivizing this type of patient education would be a "boon," especially when combined with strategies aimed at improving providers' antibiotic use, such as audit and feedback.

"Presumably, with that kind of continuing education of patients, they would perhaps seek antibiotics less and less and understand when they're necessary," she said. "I think that [idea] is so compelling."

This approach could benefit insurers by averting unnecessary doctors' visits and prescription costs, and on a larger scale, potentially help lower the risk of resistant infections.

Beyond pediatrics

Japan's incentive program focuses on pediatricians and ENTs, because the government recognized a pattern of overprescription in those groups. In the U.S., pediatrics clinics aren't the main source of overprescription — but urgent care centers may be a significant one.

Compared with other outpatient medical settings, like doctor's offices, urgent care centers are more likely to write unnecessary antibiotic prescriptions, several studies suggest. One study of millions of urgent care visits found that prescriptions were written for 15% of bronchitis cases, for which antibiotics are nearly never needed.

Unlike primary care pediatricians, who see children's caregivers many times and have the opportunity to build trust, urgent care providers may see them only once. In a 2026 study of pediatric urgent care providers across the country, many reported feeling pressured to satisfy parental requests for antibiotics, and over 50% admitted to altering their care plans in response to such requests.

That said, 66% of those participants said parents are open to education about antibiotics, even when the provider's care plan didn't align with the caregiver's initial expectations. That suggests that prioritizing — and perhaps incentivizing — parent education in urgent care settings could help prevent unnecessary prescriptions.

"It does become challenging when you have a queue of patients waiting to be seen," Blutinger noted. Nonetheless, his practice aims to prioritize such education. He's found that parents are receptive to explanations about antibiotics, especially if he carefully listens to and addresses their concerns. "I've never found it helpful to make it a one-way, information-sharing conversation. It has to be two-way," he said.

The 2026 study included physicians, physician assistants (PAs) and nurse practitioners (NPs), with the latter two groups making up about half of the participants. (In Japan, only doctors can prescribe antibiotics, and there are no equivalent roles to NPs and PAs.)

Urgent care centers are often staffed largely by PAs and NPs, with one doctor on-site along with various medical assistants. That might be relevant to their antibiotic prescribing.

That's because some studies suggest that PAs and NPs are more likely to prescribe antibiotics than physicians are. In one study of acute respiratory tract infections, the providers were 30% more likely than doctors to write an antibiotic prescription for the same ailments, and that difference was more pronounced for visits with pediatric patients. In another study of outpatient providers, PAs and NPs had the highest likelihood of inappropriate prescriptions and pediatricians had the lowest.

The reasons for this difference aren't fully understood, although the study authors pointed out that efforts to improve antibiotic use have been aimed mostly at doctors. NP and PA education and training also tends to vary more widely than doctors' training, suggesting potential knowledge gaps.

These trends point to an opportunity to tailor interventions to NPs, PAs and urgent care providers. These might be easiest to implement in urgent care facilities affiliated with larger hospital systems, representing about 35% of U.S. urgent cares. These systems set the metrics that factor into bonuses that doctors, NPs and PAs frequently earn on top of their base salaries.

One metric that's already used widely is clinical documentation, which could be required to note when rationale for denying antibiotics was provided to patients. A large Utah urgent care network recently took a similar approach and gave their clinicians a goal to decrease antibiotic use for respiratory illnesses. They made a certain threshold of antibiotic use in a year a quality metric that clinicians could earn extra compensation for hitting.

That financial incentive didn't stand alone, though. It coincided with new educational materials for clinicians and patients about antibiotics, new guidance on antibiotics in the medical record, and the introduction of peer-to-peer comparisons of prescribing rates. Together, these strategies drove a substantial decrease in overall antibiotic use for respiratory ailments. Clinicians initially prescribed antibiotics for 48% of respiratory conditions; that fell to 33% within one year and to 26% the next.

It takes time for new antibiotic-use guidelines to filter down to individual providers, particularly when there's an existing culture of overprescription. Japan's experiment demonstrated that targeted incentives can reduce antibiotic misuse — at least in Japan. The exact same approach may not be acceptable or feasible in the U.S. But we can still take inspiration from the idea and explore it as one tool among many to fight this silent pandemic.

"Antimicrobial resistance is one of the world's most urgent public health threats," Dr. Sarah Kabbani, director of the Centers for Disease Control and Prevention's Office of Antibiotic Stewardship, told me in an email. "Because outpatient prescribing is so common, even small improvements can have a large impact on patient safety and population health."

This article is for informational purposes only and is not meant to offer medical advice.

One winter night in 2011, pediatrician Dr. Masahiko Sakamoto met two parents and a feverish infant who would shape the course of his career.

Sakamoto was working at a rural hospital in Japan's Fukushima prefecture, roughly 160 miles (260 kilometers) northeast of Tokyo. Around midnight, as a heavy snowfall coated the ground outside, two parents arrived with their young child. The infant had a mild fever but was otherwise in good shape, Sakamoto determined. There were no signs of an emergency that warranted a doctor's attention.

Then, Sakamoto learned that the parents had driven 1.5 hours from a small mountain village to reach the hospital.

"Driving a car, with such snow accumulated on the road ‪—‬ that's a very risky behavior," Sakamoto said. He told me he was shocked by the "imbalance" between the infant's mild case and the parents' decision to make a three-hour round trip on dangerous roads out of concern that their child might need emergency medical care.

The experience alerted Sakamoto to a broader pattern: Parents with a limited understanding of childhood illnesses can become especially anxious when their child gets sick and end up seeking unnecessary medical care. Pediatricians in both Japan and the U.S. have described a similar trend to me in the context of antibiotics; parents sometimes request antibiotics that aren't needed, in part because they believe the drugs will alleviate their child's suffering.

Many doctors make the effort to explain the basics of childhood illnesses and appropriate antibiotic use to children's caregivers. But given that they're pressed for time and those conversations can be tricky to navigate, doctors told me that it would be helpful if parents came to appointments equipped with that information. Since that snowy night, Sakamoto has made it his mission to help educate parents about childhood illnesses before they arrive at a medical facility.

"What I am currently most interested in as a pediatrician," he said, "is how to provide accurate medical information to the parents or guardians of the children."

Building a pocket-size doctor

By the time parents arrive at a doctor's office or hospital, the chance to avert an unnecessary visit has been missed, Sakamoto recognized. So he wanted to help give caregivers the information needed to weigh whether a visit is necessary. He hoped to relay which symptoms of serious disease should prompt medical intervention and teach them appropriate at-home care for mild symptoms.

He started giving public lectures on these topics. Later, he wrote manuals of childhood illness, featuring adorable illustrations and plain-language explanations. In 2016, those manuals went digital. The free "Oshiete! Doctor" app, whose name translates to "Teach me! Doctor," has been downloaded more than 500,000 times in Japan, with approximately 100,000 active users, Sakamoto told me.

"It's quite famous around here," Risa*, a mother of two in Saku, Japan, said of the app. Sakamoto now works at Saku Central Hospital, and the city provides funding for the app's operation and promotes its use at health centers and events aimed at children and their caregivers.

"As a parent, I'm really grateful to have something like that — a resource that makes it easy to access information — right at my fingertips," said Rie Shinohara, another mother of two in Saku.

The app's content gets updated annually and applies to children and teens up to about 15 years old. It provides information on hygiene, immunization schedules and disaster preparedness, such as how to care for kids' health while evacuating for a natural disaster. (The team translated the app's disaster preparedness content for caregivers affected by the war in Ukraine.)

The app also includes guidance on when children should visit a hospital and explanations of common childhood illnesses and injuries, such as what medications might reasonably be prescribed and how to manage mild symptoms at home.

For similar help with differentiating emergencies from minor ailments, parents in Japan can also look to online resources from The Japan Pediatric Society, or call #8000, a hotline that gives caregivers advice about whether to bring their child to a hospital. Japan's Ministry of Health, Labour and Welfare has recognized the "Oshiete! Doctor" app as a helpful complement to its national #8000 hotline and also awarded the app's developers for its design and impact.

Sakamoto and colleagues have studied the app's impact on caregivers. For instance, they've found evidence that app users utilize the emergency department more appropriately than nonusers do. In that study, 87% of users said the app made it easier to decide whether to visit the hospital, and 94% said they'd recommend it to others.

Challenges of educating parents

The team has also studied how the app's users feel about fever — the symptom that compelled the infant's parents to drive on snow-laden roads that night.

"The phenomenon known as 'fever phobia' among parents has long been recognized, and it is not unique to Japan," Sakamoto said. Notably, the American Academy of Pediatrics offers similar guidance to the "Oshiete! Doctor" app regarding fever, emphasizing that the symptom doesn't always require medical care and giving tips for when a doctor should be called.

Parents' worries about pediatric fever can be outsize compared with the threat it poses. Most fevers in kids are caused by viral infections that go away on their own, Sakamoto said, but caregivers can be compelled to seek care because they're concerned about fever triggering seizures or brain damage. This is especially true of first-time parents and parents with other children who'd had febrile seizures in the past, he added.

"With the first child, you just don't know. Why does he have a fever?" Shinohara noted. Of her firstborn, she added, "I probably took him to the doctor more often than necessary." But by her second, she felt she developed a better sense of when to seek medical care. Sakamoto's hope is that his app can help fill that information gap sooner.

In a survey-based study, Sakamoto and colleagues polled hundreds of caregivers in Saku about their understanding of fever, taking stock of which parents had downloaded "Oshiete! Doctor." Between 2017 and 2024, a greater proportion of parents understood that fever alone does not necessarily mean a child needs medical care. Plus, a lower percentage of parents thought that antibiotics are always needed to treat fever. On the latter point, users of the app were most likely to answer correctly, although nonusers also improved between the two survey years.

Sakamoto credits some of that improvement to the incentive offered to pediatricians to avoid unnecessary antibiotics, which requires that doctors explain appropriate antibiotic use to caregivers. He thinks the message is likely more powerful for parents when it comes from their pediatrician, rather than government information campaigns. That said, Sakamoto emphasized that it's important to have strong educational materials available to help support doctors' explanations to parents.

Despite these improvements, Sakamoto also observed that parental anxiety about fever complications increased between the two survey years — although, notably, the COVID-19 pandemic took place in that time frame, which could be a piece of the puzzle.

"Their knowledge about fever, how to manage fever, and also the appropriate use of antibiotics was enhanced, whereas the fear about the children's fevers worsened," Sakamoto said. "Even when knowledge improves, emotional anxiety does not easily disappear; this is one of the challenges of public education."

Other challenges include the rising use of AI chatbots among parents, Sakamoto noted. He's encountered parents whose anxiety was triggered by erroneous information from a chatbot that suggested their child's prognosis was worse than it was, for instance. "It is rather rare to see that the parents have holistically accurate information from AI," he told me.

If he can secure more funding for "Oshiete! Doctor," Sakamoto hopes to someday make the app multilingual. In the long run, he remains committed to providing parents with this vetted information to both alleviate their worries and optimize their use of the healthcare system.

"We have the responsibility to check how the information is delivered to the parents or guardians and how it leads to behavioral changes," Sakamoto said. "So it is not just us disseminating information but whether or not it is truly received."

Editor's note: Risa (marked with an asterisk) asked that only her first name be used for privacy.

This article is for informational purposes only and is not meant to offer medical advice.

It's a Tuesday morning, and you're getting your toddler ready for daycare. But as you brush her hair into a ponytail, you notice that her cheeks are flushed, her nose is runny and her breathing is phlegmy. Instead of daycare, you head to your pediatrician, who offers a solution: a prescription for antibiotics.

This scenario has played out many times in clinics around the world. The problem is that most common childhood infections are caused by viruses, which antibiotics don't treat. In the long term, unnecessary antibiotic prescriptions can foster resistance in bacteria, thereby reducing the drugs' potency and fueling the rise of dangerous superbugs.

That's why, in recent years, there's been a huge push in many countries to raise awareness of antibiotic misuse among doctors and to reduce the overprescription of these drugs. In Japan, the government noticed that the country's pediatricians were prescribing too many antibiotics, especially to young children, and offered them a financial incentive to break the habit.

It's been working remarkably well. Among young kids directly affected by the incentive, it slashed antibiotic prescriptions by 20%; it also contributed to a spillover effect in older kids and teens, as under-20s have seen a 50% reduction in prescriptions in recent years. I went to Japan to examine why the program has been so effective and to learn whether similar approaches could work in the U.S.

Understanding why a fairly modest incentive of 800 yen (about $5) a visit is so effective requires unpacking why Japanese doctors overused antibiotics in the first place. If doctors face similar pressures stateside, maybe the same strategy could work here too.

A culture of overprescription

Japan started out with a big problem of antibiotic misuse, especially among prescriptions for kids. From 2013 to 2016, over 30% of children with respiratory tract infections were given antibiotics, despite most of those infections being viral. (The U.S. started at a slightly better baseline regarding antibiotics given for respiratory conditions, with about 23% of outpatient prescriptions being unnecessary.)

For decades, it was common in Japan to routinely prescribe antibiotics for sniffles and tummy bugs, Dr. Takemi Murai, deputy head of the Infectious Diseases Division at Nagano Children's Hospital in Azumino, told me. That's in part because medical education there didn't emphasize the risk of "superbugs," meaning bacteria that can withstand many antibiotics.

"When I trained, antimicrobial stewardship wasn't yet a formalized part of the curriculum in the way it is now," said Murai, who finished medical school in 2006.

There also may be a generational divide, Dr. Tatsuki Ikuse, a pediatric infectious disease specialist at the National Center for Child Health and Development in Tokyo, told me. Ikuse, who finished medical school in 2013, suspects that older doctors "experienced many cases of bacterial infections when there was no vaccination."

Now that vaccines for whooping cough, diphtheria and pneumococcal disease are routine, children face a lower risk from the bacteria that cause those illnesses. But those early experiences treating children with serious bacterial infections may still be shaping doctors' prescribing patterns, even decades later, Ikuse thinks.

Surveys conducted in Japan suggest that doctors under 50 are more likely than doctors over 50 to see antimicrobial resistance as an urgent issue. Clinic doctors — those likeliest to see kids as outpatients for acute illnesses — also skew older than doctors in hospitals; in 2024, clinic doctors averaged about 60 years old, while those in academic and nonacademic hospitals averaged 40 and 48 years old, respectively.

Historically, Japanese doctors also had a strong bias toward prescribing antibiotics for "feverish" diseases, noted Dr. Norio Ohmagari, director of disease control and prevention at Japan's National Center for Global Health and Medicine.

Murai agreed with that sentiment. "If doctors saw a fever and a high CRP level [a sign of inflammation], they prescribed antibiotics," Murai said. "Doctors were following such a practice for a long time, so they didn't question it."

Concerns over secondary infections were also a big driver of unnecessary antibiotic use, said Dr. Masahiko Sakamoto, a hospital pediatrician in Saku, a highland city about an hour northwest of Tokyo by bullet train. Even if doctors suspected a viral infection, like the common cold, they worried that the illness could open the door for secondary bacterial infections, such as bacterial pneumonia. However, recent studies suggest this scenario is uncommon and shouldn't prompt doctors to use antibiotics preventatively.

Is antibiotic misuse still a problem in the U.S.?

Young children in the U.S. were once the most likely group to receive unneeded antibiotics, but now, those unnecessary prescriptions have "dropped dramatically," Dr. Sarah Kabbani, director of the U.S. Centers for Disease Control and Prevention's (CDC) Office of Antibiotic Stewardship, told me in an email.

Between 2011 and 2016, children's antibiotic prescriptions decreased 13% overall. "Overall declines in antibiotic use over the past decade have been driven in large part by reductions in prescribing for children," Kabbani noted.

Japan has also decreased its overall antibiotic use in younger populations, halving its outpatient prescription rates for patients under 20 between 2011 and 2022, Dr. Yusuke Okubo, division chief of clinical epidemiology and health services research at the National Center for Child Health and Development in Tokyo, told me.

The decrease in antibiotics overuse syncs with parents' lived experiences in both countries.

"I was taking antibiotics quite often" as a kid, Tatsuya Kanno, a software engineer and father of two in Tokyo, told me. "Nowadays, we don't get really prescribed those antibiotics easily."

"It has definitely been different from my childhood," said Gabby Brown, an apparel consultant and mother of two in Littleton, Colorado. "There was always a bottle of pink stuff in the fridge, you know? And now they're very hesitant to give it out."

Brown's pediatrician actually has an explicit policy on their website stating that they don't overprescribe antibiotics and instead follow evidence-based guidelines to determine when the drugs are truly necessary. I've found a number of other U.S. pediatric clinics that do the same.

One reason U.S. pediatricians have been able to improve several key metrics of antibiotic use is that the issue has been on their radar for a while.

"Antibiotic stewardship was a core tenet of my residency training 20 years ago," Dr. Morgan Leafe, a U.S.-based pediatrician who worked in inpatient and outpatient settings for 11 years after residency, told me in a direct message. "So I would say it's not new in pediatrics."

But there remains room for improvement.

Prescription rates vary widely among states and among different types of outpatient facilities, such as community practices versus those affiliated with academic medical centers. Rural communities often use antibiotics at higher rates and log more inappropriate use, compared with urban areas. These regional variations are "not explained by clinical factors," said Julia Szymczak, a medical sociologist and associate professor in the Division of Epidemiology at the University of Utah School of Medicine.

Nowadays in the U.S., urgent care clinics might be a hotspot for antibiotic misuse. These and other walk-in clinics serve an increasing number of pediatric patients, with an estimated 26% of children visiting one in the past 12 months. Urgent cares may prescribe antibiotics to children at a higher rate than other ambulatory settings do; in one study, 42% of the children seen at urgent cares were prescribed antibiotics at their visit, while the national average across all pediatric ambulatory visits is 21%.

It may be that urgent cares are more likely to prescribe antibiotics for conditions that they're explicitly not recommended for. One national analysis found that urgent cares prescribed antibiotics for 20% of allergy cases, 42% of viral upper respiratory infections and 52% of uncomplicated ear infections, while doctor's offices wrote far fewer of these inappropriate prescriptions. Other studies highlight similar patterns.

Among children, inappropriate prescriptions are less likely at urgent cares that specialize in pediatrics, highlighting doctors at general clinics as a potential population to target. Additionally, research has found that visits with nurses or physician assistants are more likely to end in an antibiotic prescription than those with doctors. (Only licensed doctors can write prescriptions in Japan, so this factor is more unique to the U.S.)

Different systems, similar pressures

Japan's nationalized healthcare provides a staggering degree of choice, because insurance coverage doesn't tie you to specific clinics or require you to get referrals to access certain care. Young children's care is virtually free thanks to national and local subsidies. So on paper, parents can easily shop around for a pediatrician that best suits their family's needs, as well as pop into any healthcare facility with flexibility should the need arise.

While this system is convenient, it has its downsides, some parents told me.

"In the U.S. and in Switzerland, they try to get to know you and know your child," said Reid, a fundraiser and father of two based in Okinawa, who recently moved to Japan with his sons and husband. "They don't at all in Japan."

In contrast, about 9 in 10 children in the U.S. have a primary care provider, although that percentage has fallen in recent years as the use of urgent care has increased. Primary care providers can be a go-to for sick visits as well as an ongoing monitor of kids' health via annual check-ups. (Annual check-ups in Japan are handled by local municipalities, not by children's regular doctors, Reid noted.)

In some ways, pediatric clinics in Japan can be considered more analogous to urgent care in the U.S., in that they're intended to address acute cases of illness as they emerge. For more serious illnesses, caregivers bring their children to hospitals, parents in Japan told me.

Diagnostic uncertainty

For a typical respiratory or tummy bug, doctors in both the U.S. and Japan make diagnoses based largely on a patient's symptoms and timeline of illness. In the U.S., most minor infections are "generally assumed to be viral unless certain criteria are present," Leafe said. These criteria are spelled out in manuals used by pediatricians.

The criteria enable doctors to "feel reassured" that they've correctly classified an infection as viral or bacterial, even in the absence of a highly sensitive diagnostic test, said Dr. Ilan Shapiro, a community pediatrician at AltaMed Health Services, a nonprofit health network in Southern California.

Rapid tests are available for only a handful of bacteria, including Streptococcus pyogenes (also called group A strep), a common culprit behind strep throat and scarlet fever. These tests are "definitely underutilized" by Japanese clinics, Ohmagari noted, while U.S. clinicians are encouraged to use them more widely.

"For strep throat, we never treat [give antibiotics], now, without a positive test," said Dr. Jennifer Shu, a pediatrician with Children's Medical Group, a group of pediatric offices in the Atlanta metropolitan area. (That said, electronic medical records suggest that not all doctors' offices use these tests before prescribing antibiotics, despite these recommendations.)

In both countries, doctors can use rapid tests to diagnose common viral infections, such as influenza and RSV. But those tests don't always catch every case. And even if they come back positive, they can't rule out the possibility of simultaneous infections with viruses and bacteria, Shu noted.

Shu's practice also uses a 20-minute test that looks for multiple viruses and bacteria in the nose and throat, including the bacteria behind whooping cough and Mycoplasma, which causes "walking pneumonia." Not all clinics use this type of test, though, because they require a special certification and equipment to run on-site, Shu said.

Such panel tests can be helpful but also tricky to interpret. Bacteria can sometimes be detected in a patient's nose without being the cause of their symptoms. "That's where clinical judgment comes in," Shu said, emphasizing that a doctor must combine test results with the timeline of a patient's symptoms.

Time crunches

The lack of quick, surefire diagnostic tests for bacterial infections can leave doctors with a degree of uncertainty, which can sometimes prompt unnecessary prescriptions, Szymczak said.

"Our number one motivation is to not harm somebody; that's the main thing," said Dr. Shruti Gohil, an infectious-disease specialist at UCI Health who designs interventions to improve doctors' antibiotics use. Worries about potential missed diagnoses can prompt doctors to reach for an antibiotic now "in exchange for a potential future, untoward consequence," such as a greater chance of resistant infections, she said.

In both countries, doctors must make diagnoses and treatment plans in a limited amount of time. "Pediatric outpatients in Japan are very busy and can only secure a few minutes for each patient," Ikuse told me.

Such time crunches are common in the U.S., too.

"I had a pediatrician who said they had — I can't remember the figure — but it was like 800 seconds for a sick visit," said Szymczak, who studies the factors that drive clinicians to misuse antibiotics. "They broke it down into seconds."

Given that antibiotics are generally very safe drugs, pediatricians can be tempted to prescribe them "just in case" in these situations, even if the need isn't certain, a 2019 review found. In these scenarios, patients end up taking courses of antibiotics they likely don't need.

Doctor shopping and bad reviews

One factor driving antibiotic misuse that might be unique to Japan is the competition between clinics and the customer service culture it motivates.

Japan's mandatory national health insurance makes it easy to "doctor shop." Depending on where a family is based, there may be a glut of pediatric specialists to choose from — as in metropolitan centers like Tokyo — or very few. For instance, in Okinawa, general family doctors are easier to come by than pediatricians, said Sandra Miller*, a researcher and mother of one based in the prefecture.

But across all settings, families can still flexibly choose which clinic they go to. Meanwhile, pediatricians in Japan, who make less than their peers who care for adults, can worry about losing clients to nearby practices.

Japanese clinicians used to worry that, after being denied antibiotics for their sick kids, dissatisfied parents would leave poor reviews online — particularly in Google Reviews — and thus drive away business, Okubo said. "They feared such clinic reviews."

Parents frequently used to demand antibiotics from their children's pediatricians, Okubo added. "Ten years ago, it was a common situation," he told me.

Among the clientele of Shu's Atlanta clinic, she's "seeing a trend where people aren't asking for antibiotics as much." But still, parents sometimes request the drugs when she's determined they're not needed. These requests often stem from the parents' past experiences.

"They'll say, 'Well, last time they took an antibiotic they got better faster, the next day,'" Shu said. Because mild viral infections often go away on their own in a few days, that timing could have just been a coincidence, but it leaves an impression on the caregiver nonetheless.

A parent in Japan told me about the other side of this conversation.

Kanno once brought his daughter into a clinic after she developed a bad cough after catching the flu. Their doctor prescribed antibiotics, and the cough resolved within days. Later, Kanno's son had similar symptoms, but the doctor didn't recommend an antibiotic in his case. When his son's coughing and wheezing persisted, "I asked him to prescribe that antibiotic, the same one that my daughter took," Kanno said.

The pediatrician said it likely wouldn't help but didn't explain why. The doctor said he would provide the antibiotic if the family wanted it. He ultimately prescribed it, and it didn't help. "He got my trust after that," Kanno said.

Szymczak's research has identified this "it-helped-last-time" bias as a common driver of patients' antibiotic requests that can be difficult for doctors to negotiate.

Parents' understanding of antibiotic resistance

In Japan, parents' awareness of antibiotic resistance has grown in recent years, Japanese doctors told me, but research suggests many still don't know much about it.

"I don't think parents generally understand that antibiotics don't work for colds, much less [understand] antibiotic resistance," said Dr. Yusuke Shibata of the Shibata Pediatric Clinic in Tokyo. "Explaining antibiotic resistance to parents is difficult," though he still tries to do so, he told me in an email after I visited his clinic.

Studies of U.S. parents suggest that many don't understand resistance or proper antibiotic use and that a misunderstanding of the purpose of antibiotics can drive requests for the drugs. In my interviews, I found that parents in both countries had some grasp of the concept of antibiotic resistance, but the depth of that understanding varied.

Tomomi Sato*, a New York City-based teacher and mother of two who lived in Japan as a child, said she'd heard that taking antibiotics too often could make it so your body didn't respond to them well in the future. She likened it to an urban legend about roaches that she heard from her mother and others from her hometown of Tokyo.

"You know how they talk about, in Japan, roaches are getting bigger and bigger?" she said. "They just build immunity … they don't respond to the old type of roach spray, so you have to get a new version."

Some parents are cautious about overusing medications in general but don't worry about antibiotic resistance, specifically.

"I want them to recover by trusting their own immunity, rather than relying on medication," said Risa, an HR representative and mother of two in Saku, Japan. But that said, "if it's something that's difficult to heal naturally, I think professional judgment and a prescription are necessary," she added.

Risa told me she thinks antibiotics may be medically appropriate when an illness is particularly severe or prolonged. She doesn't weigh whether the cause is likely viral or bacterial, even though antibiotics don't treat viral illnesses.

"I think that's probably the general mindset," said Fumie Kuchiba, a mother of one in Saitama, Japan, who previously worked as a registered pharmaceutical salesperson.

Other parents have a clear sense of the threat resistance poses.

"Resistance is a threat because if something is powerful enough to beat our current modern medicine, then it can wreak real havoc," said Malcolm, an editor and father of one in Atlanta. On the individual scale, he knows that resistance can emerge within an individual, potentially raising their personal risk of resistant infections. But on a global scale, he thinks of resistance as a threat as formidable as that posed by viral pandemics, such as COVID-19.

Difficult conversations

When parents seek an antibiotic that isn't medically needed, that can prompt difficult conversations with their children's doctors.

A Philadelphia-based doctor summed up the dynamic in an interview with researchers: "If patients feel like they need an antibiotic, it's very, very hard to talk them down from that. So, antibiotics are definitely overprescribed. And, you know, it's easier to say yes rather than taking time and, like, so much time to say no." This doctor and several other participants in that study felt they had "little autonomy to stand up to patient demand."

Some studies find that, when a pediatrician withholds antibiotics and a parent questions them, doctors can perceive that as negative pushback and give the drug against their initial judgment. But if a pediatrician denies antibiotics while also providing guidance for symptom relief, that conflict can be avoided and prescription becomes less likely.

Shapiro, the pediatrician in California, told me he handles such requests by walking parents through his diagnostic process and explaining the downsides of using unnecessary prescriptions. He also offers options for seeking further care — via phone, telehealth or an in-person visit — should the infection not improve as expected.

These conversations take time, and they can stir up conflict, which Shapiro said he's grown more comfortable navigating over his career. Early on, "you don't want conflict; you feel that conflict is bad, and you want everybody to be happy," he said. But ultimately, "the objective is for them to be healthy."

Multiple parents in Japan told me their doctors don't usually talk through their reasoning for checking for a given symptom or prescribing X drug over Y. "If we don't ask, he won't explain," Kanno said of their current pediatrician; but if prompted, their doctor provides good explanations, he said.

Similarly, Japanese parents told me their doctors don't often say whether or why they suspect an infection is viral or bacterial — a clarification that might help caregivers feel more comfortable forgoing an antibiotic.

Notably, Japan's antibiotic incentive program, which allows pediatricians to earn "tips" for withholding unnecessary antibiotics, provides the payment only if the doctors also explain responsible antibiotic use to children's caregivers. That requirement may be necessary to prompt that conversation.

Some doctors in Japan who claim the incentive provide verbal explanations about resistance or give parents a slip of paper that explains the basics and includes links to further information. Dr. Atsushi Miyahara of the Karugamo Clinic in Tokyo told me that, over time, his clients have become more knowledgeable about antibiotics, and insurance data related to the incentive also hints that this learning takes place. But it's unclear if these interactions can always move the needle.

Fielding parents' concerns

Shu, the Atlanta-based pediatrician, finds that some parents ask for antibiotics because they think the drugs will speed their child's recovery, without considering whether a bacterium is the culprit. Caregivers in both the U.S. and Japan also told me that they know parents who seek antibiotics as a quick remedy for illnesses.

Parents I spoke to who understood that antibiotics only treat bacterial infections added that it can be frustrating that there aren't many medicines available for viral ailments. Waiting for an infection to clear up can be stressful because you don't want your child to suffer, parents said, and the sickness also disrupts the family's normal routine of work, school or daycare.

"When your kid gets sick, things just kind of fall apart, and you need your life to get back to normal," said Katie, a journalist and mother of one in Jacksonville, Florida, who added that many parents may lack support that would help them take time off to care for their kids.

In both countries, pediatricians feel pressure to leave caregivers satisfied. While clinics in the U.S. aren't necessarily competing for patients in the same way Japanese clinics are, there is still a degree of customer service at play, Szymczak said. "That clinical encounter is very transactional, particularly in the United States," she said.

Doctors want to provide something of value — a diagnosis, medicine, reassurance — in exchange for the caregiver's time and money. Sometimes, pediatricians assume that what the caregiver wants is antibiotics, when really, they want a treatment plan to help their child, Szymczak said.

Could incentives motivate change?

While the U.S. has made progress in curbing antibiotic misuse, there's room for improvement. Could we close those gaps by using a similar approach to Japan's 800-yen incentive?

Similar dynamics are at play in both countries, with parents and pediatricians in both places dealing with similar issues. But while these pressures are similar in the clinic, a key difference sets America's situation apart: Our complex healthcare system, funded through a patchwork of insurers, can be difficult for patients and doctors to fully trust.

In the final installment, I'll talk with U.S. doctors to see what they think about Japan's approach and explain solutions that would suit our own fragmented healthcare system.

Editor's note: The names of some parents quoted in this story have been abbreviated or changed to protect their privacy. Altered names are marked with asterisks (*). This article was updated on Aug. 4, 2026, to note that the panel test used at Shu's practice takes about 20 minutes to run, not 45 minutes.

On paper, doctors should know better — antibiotics treat only bacterial infections, and yet, physicians sometimes give them to patients who have viral infections. For patients, an unnecessary antibiotic can mean short-term side effects, like diarrhea, or more-persistent impacts, like microbiome disruption. But on a grand scale, the overuse and misuse of antibiotics pressure bacteria to gain resistance, the ability to thwart the drugs intended to kill them.

That can fuel the evolution of "superbugs" that evade most, if not all, antibiotics. In the worst-case scenario, this could contribute to tens of millions of extra deaths over the next 15 years, caused by illnesses that were once easily treated.

Given that antibiotic resistance is one of the world's leading public health threats, earlier this year, I went to Japan to investigate a program that has been remarkably effective at curbing the overuse and misuse of the drugs. I wanted to understand why doctors sometimes prescribe antibiotics when they're not needed and what approaches have been shown to improve their prescribing habits.

To answer those questions, I took a deep dive into the research on the topic and found the work of Julia Szymczak, a medical sociologist at the University of Utah School of Medicine, whose studies shed light on why doctors prescribe these medicines when they're not needed. I spoke with Szymczak about the complex social dynamics behind this behavior and whether there are reliable strategies for reining in antibiotic misuse.

Nicoletta Lanese: Could you explain the focus of your work?

Julia Szymczak: All of my work is really focused on two things. One, understanding why it is difficult for clinicians in real-world practice to use antibiotics the way that medical guidelines or evidence suggests they should be used. And then, more recently in my career, it's focused on developing interventions or strategies to help clinicians apply evidence that's informed by all that work.

I think about the decision-making about how an antibiotic is used as not simply a decision that is about pathophysiology or microbiology — it's about social dynamics. Clinicians are sensitive to a lot of other features in the care delivery environment beyond what they know to be true about antibiotics, what they know to be true or apparent about the potential infection that a patient has.

NL: What are some factors that shape that dynamic?

JS: Diagnostic uncertainty is a major challenge for clinicians. Differentiating viral versus bacterial is not [straightforward] — you don't have a slam-dunk perfect test. There are attempts to develop things to help, but the diagnostic uncertainty piece is really challenging.

Then there's the organizational characteristics around clinician decision-making, which is that everybody is incredibly time pressured, and so decision-making about antibiotics happens very quickly.

In the ambulatory or the outpatient setting, where the vast majority of human antibiotic use occurs, one of the more common themes that you will hear when you talk to clinicians is that patients often want antibiotics that are not needed. That relationship is more complicated than it appears on its face, but that is a major pressure point for clinicians.

NL: Are there other pressures that are unique to the outpatient setting, where most antibiotics are used?

JS: The major one is time pressure. I had a pediatrician who said they had — I can't remember the figure, but it was like 800 seconds for a sick visit. They broke it down into seconds. Their experience of time in the outpatient setting is so intense. Certainly clinicians in the inpatient setting [hospitals] feel time pressure, but the decision-making is distributed over an admission, which still might only be two days, but two days is different than literally five minutes.

The other thing is your interaction with that patient. That clinical encounter is very transactional, particularly in the United States, particularly for those clinicians who work in, for example, telemedicine, which is a whole other context but has similar features to urgent care or sick visits. This idea that "I'm trying to provide you with something of value" [is a big factor]. That could be a proper diagnosis. That could be the provision of a prescription. It could be reassurance that you're going to be fine. In some scenarios, people are looking for information that they can share with their employer.

Someone is coming to you to get something for a problem. Oftentimes, your assumption is that what they're coming to you for is an antibiotic. The encounter is already shaped by the patient's expectation — or your [the doctor's] expectation of the patient's expectation. There's literature that shows that, in many scenarios, clinicians might perceive that a patient wants an antibiotic when the patient actually doesn't.

Oftentimes, clinicians will say that [when] somebody has what is very likely a viral infection and they don't need antibiotics, the act of explaining why they don't need antibiotics is very difficult, particularly if they seem to want them or if they've had multiple similar episodes and they've always gotten antibiotics in the past. That discussion, the literal conversation, is difficult. It takes time. It's draining.

Then, you're in an environment where there are competing priorities around how that patient is going to evaluate your care. If a patient is unhappy because you didn't give them an antibiotic and you're concerned about the patient-satisfaction score, which is being watched by your leadership, but no one's monitoring your antibiotic use, that could tip you into the prescription of an antibiotic that isn't needed.

Then, of course, there's also the fear of missing something. On the off chance the patient has an infection and it helps them, that staves off a whole bunch of other imagined or real bad scenarios down the line.

NL: You said it's often difficult for doctors to explain their reasoning around antibiotics. Do you think that's because the technicalities of resistance are hard to explain, or something else?

JS: I don't think it's necessarily that they aren't confident in the medical explanation. A paper of mine called "I Never Get Better Without an Antibiotic" goes through all the reasons why the discussion is difficult.

Briefly: The biomedical stuff is often not the hard part. What's difficult is countering a patient who you think has already made up their mind about what they need and convincing them that they don't need it. It involves not just the provision of microbiological facts but having to explain why their past diagnoses might not have been accurate or their previous clinicians didn't make a good decision. Or people might talk about their social network: "Well, so and so got antibiotics for that." And it's like, I'm not their doctor. I didn't see them. I'm making a decision about you.

There are social reasons why that discussion is just difficult, and then you throw that into the time pressure and potentially add in even the glimmer of antagonism or conflict, and people just don't want to go there because they're exhausted.

I don't think it's about the education, about the likelihood of this being viral and "antibiotics don't work for viral infections." It's a lot more countering beliefs that aren't necessarily accurate [such as antibiotics always being needed for certain symptoms] and dealing with social awkwardness.

NL: I feel like that breaks with the common stereotype of doctors being very cold, calculating and logical.

JS: In my life of explaining to people, mostly clinical and epidemiologic audiences, there is a bit of a professional pride about evidence-based practice. Clinicians are educated deeply, and they're experts; they should be applying this evidence to every patient every time. But I always start [by saying], "You guys are human too, right?"

With antibiotics, emotions play a large role in how people are using these drugs. I've had many clinicians describe antibiotics as some of the best anti-anxiolytics — so like it's an anti-anxiety medicine for the clinician.

This idea of the cold, logical, rational actor, I mean, doesn't apply anywhere in medicine. But in particular, I think this is a great [example of a] scenario where that perfect model of decision-making just gets completely upended by contextual and structural factors, as well as social and emotional factors.

NL: Are there additional factors to consider in the context of pediatrics?

JS: A lot of my portfolio is in pediatrics, and in fact, that's where I started my work. I was a postdoctoral fellow at the Children's Hospital of Philadelphia, so I have spent a lot of time doing pediatric research.

As pediatricians say, "We have two patients: there's the child and the caregiver, the parent or the guardian." Maybe two. And so you're navigating the patient and their parents, and the interactions have a lot of complexity. There's often the challenge where the patient can't communicate what's wrong; it's difficult to convey symptoms. It adds a layer to the diagnostic uncertainty.

Then, of course, the fragility of children [is a factor], and the concern of the illness going off the rails. That feels more fearful than it does for a middle-aged adult.

But I would say one thing with pediatrics is that parents are more open to the idea of not wanting to give their kids medication that they don't need. The origins of that may come from different places than what an antibiotic steward would necessarily think of as the main reason why you want to avoid antibiotics, because it's often just about avoiding any medication. But I think that parents can be a partner in stewardship, engaging with clinicians around whether or not an antibiotic is necessary or potentially being open to this "watch and wait" — this idea of holding off to see if the body fights off the infection on its own.

When you look nationally [in the U.S.], pediatricians have done the best at improving their prescribing. Some of the biggest leaps and bounds in outpatient stewardship, it started in pediatrics. So pediatricians tend to be on the cutting edge, I would say.

NL: In pediatric outpatient settings, are there any strategies that work really well?

JS: One of the most common ones is the use of "audit with feedback," this idea of prescribing report cards where you give clinicians information at regular intervals about how well they use antibiotics and then compare it to their colleagues in their practice or in their entire health system. That's been demonstrated to work, but not in isolation.

[Editor's note: Szymczak's research suggests that certain social factors make this approach more likely to work. For instance, clinicians who respond best trust that the data they're being given is accurate, feel supported by their leadership, don't feel overly stressed or surveilled by the feedback, and are comfortable fielding patients' demands for antibiotics.]

Another piece that has been demonstrated to work, if clinicians use it, is that many electronic health records have pathways or order sets or guidelines embedded. So, if a clinician's like, "I'm going to diagnose [urinary tract infection] UTI in this patient," there's a UTI pathway that they can click on that will give them evidence-based laboratory testing and management strategies. It takes them fewer clicks to get the stuff that they need.

So, it's multifactorial, but [effective stewardship] usually involves some combination of data, education and making the right choice the easy choice.

NL: When it comes to interventions for outpatient settings, are there strategies that just don't seem to work?

JS: Education on its own, targeting clinicians or patients, is not sufficient to move the needle on prescribing.

NL: Could you elaborate on why educating patients isn't the best approach?

JS: Patient education is important but has not been demonstrated to move the needle very much. I think partially that is because the approach we have taken to education has been connected to abstract concepts like antimicrobial resistance, which is important at the population level, of course, but can be difficult to understand for the lay public and can be less motivating [for them to change their personal behaviors].

I do think we are seeing more interest from the lay public in things like the microbiome and gut health and the role of antibiotics in potentially disrupting those things. I think education to the public that directly connects to individual-level harms is more motivating than population-level harms.

NL: When it comes to interventions, do you think the surrounding cultural context affects which strategies work best? I'm thinking of the U.S. versus Japan, for instance.

JS: I do think that the surrounding cultural context will always play a role, to some degree, in how interventions to improve clinical decision-making will fare. I have also written a bit about that in another commentary that delves into the observation in the United States that we have considerable regional variation in antibiotic use that is not explained by clinical factors.

I am cautious, though, about how we think about the concept of "culture" in relation to clinical decision-making. When it comes to antibiotic prescribing, I do think there are universal factors that shape how people respond to efforts to intervene, including the management of diagnostic uncertainty; fears of missing something, leading to "just in case" prescribing; a desire to offer patients something of value; and the difficulty explaining why antibiotics are needed or not.

NL: Regarding Japan's incentive program, which pays pediatricians "tips" for improving their antibiotic use, do you think a similar approach would be motivating for U.S. pediatricians? Would it be feasible to implement that kind of strategy here?

JS: I think it could be difficult to implement here, but the details of how the program is operationalized would be very important.

We know, in general, that financial incentives have [a] mixed impact on physician decision-making. You especially have to be careful about unintended consequences. For antibiotics, it would be very important to have a clear definition of the outcome that will be incentivized and how it would be measured. With antibiotics, there can be gray areas and you don't want to incentivize undertreatment, especially if it is individual-level financial incentives.

A better approach may be in aggregate and [to] reward health systems or clinics for improved antibiotic use for conditions in which antibiotics are never needed, for example.

Editor's note: This interview has been condensed and edited for clarity.

About a decade ago, the Japanese government spotted a worrying pattern: Pediatricians were doling out a ton of antibiotics, well beyond what should be needed to treat the bacterial infections coming through their doors.

Antibiotics treat bacterial infections, not those caused by viruses, fungi or parasites. Yet doctors were often sending young patients home with antibiotics for illnesses unlikely to be bacterial. Treating nonbacterial infections with antibiotics can fuel antimicrobial resistance (AMR) and the rise of superbugs by unnecessarily exposing bacteria to the drugs, pressuring those bacteria to evolve strategies to survive. Resistant bacteria can then spread their adaptations to others, thereby compounding the problem.

In the long run, resistance could make common infections impossible to treat with existing drugs, raising the risk of serious illness and death across the population.

When pediatricians in Japan did treat bacterial infections, they were overusing the antibiotics that are likely to fuel resistance — "broad-spectrum" drugs that target many bacteria at once. When compared against 35 other high-income countries in 2015, Japan ranked dead last in the appropriateness of antibiotic choices for kids under 5.

One way to slow the development of AMR is to get antibiotic prescriptions under control. So Japan focused on one of its biggest sources of problematic antibiotic use: pediatric outpatient clinics.

"The clinics are a particular problem," said Dr. Yusuke Okubo, chief of clinical epidemiology and health services research at the National Center for Child Health and Development, a research center and hospital in Tokyo. Looking at Japan's overall antibiotic use, "90% of prescriptions are [from] outpatient clinics, not hospitals," Okubo told me. (Outpatient practices account for a similar proportion of antibiotic prescriptions in the U.S.)

A large proportion of problematic prescriptions were being written for children under 3 years old, especially those with upper respiratory tract infections, which nine times out of 10 are caused by viruses, Okubo said. The stomach bug gastroenteritis was another biggie for overprescription, despite most often being caused by a virus.

Government officials hatched an idea: What if each time a pediatrician chose not to prescribe an antibiotic in these cases, they earned a small financial reward — a tip for making a better choice? Each tip would be small, amounting to about $5 per claim at today's exchange rate, but could translate to thousands of extra dollars of annual income for individual clinics. That's no small matter for Japanese pediatricians, who Okubo estimates earn roughly $90,000 to $100,000 a year.

This incentive program, rolled out in 2018, has proved a success, so much so that it's since been expanded to cover more patients, more clinics and a wider variety of diseases. But what made the program work? I went to Japan to find out what systemic and cultural factors contributed to the program's success. Ultimately, I wanted to see whether other countries, like the U.S., could learn from this nationwide experiment.

The quietly rising threat of resistance

With bacteria, as with animals, it's survival of the fittest. When exposed to antibiotics, a percentage of bacteria die, while others survive. That surviving population has traits that help them withstand the drug's effects, which are encoded in "resistance genes." Bacteria can transfer those genes to the next generation by multiplying, as well as physically pass those genes to nearby bacteria. Plus, they can pick up new resistance genes through random DNA mutations.

All antibiotics come with the risk of pressuring bacteria to evolve resistance — it's an inherent feature of the drugs. However, broad-spectrum drugs carry the greatest risk, because they place pressure on a wider variety of bacteria than narrow-spectrum drugs do. The 2015 cross-country comparison found that Japanese doctors prescribed antibiotics with the lowest risk of resistance only 35% of the time, meaning most antibiotic prescriptions were for broader-spectrum drugs.

It's sometimes necessary to use broad-spectrum drugs — such as when an infection is resistant to narrow-spectrum options — but using broad-spectrum antibiotics when they're not needed hastens the development of AMR. So does using antibiotics for nonbacterial infections. In both scenarios, you're introducing evolutionary pressure that could have otherwise been avoided.

Globally, resistance is rising among common disease-causing bacteria; it's far outpacing the development of alternatives to antibiotics. In 2021, resistant bacterial infections directly caused 1.14 million deaths worldwide and contributed to another 3.57 million deaths. Those numbers could climb dramatically by 2050 if swift action isn't taken now.

Common pathogens already show high rates of resistance in Japan, and resistant germs contribute to thousands of deaths each year, with most occurring among older adults. People over 65 make up about 30% of Japan's population. As that percentage grows in the coming years, AMR-related illness may also increase, health officials worry.

Japan's youngest residents are also at risk, though, as resistant bacteria can sometimes pass from mothers to newborns at birth and can cause serious complications, like sepsis. Resistance has also been detected among respiratory bugs that frequently infect kids, such as Mycoplasma pneumoniae, said Dr. Takemi Murai, deputy head of the Infectious Diseases Division at Nagano Children's Hospital in Azumino. "There have been outbreaks of Mycoplasma that are resistant to antibiotics," he said.

Yet not long ago, the unrestrained use of antibiotics was a mainstay of Japanese medicine. (I'll dig into the myriad reasons why in later installments of this series.)

National insurance data sampled from 2005 showed that 60% of patients in Japan with nonbacterial upper respiratory tract infections were prescribed antibiotics, mostly broad-spectrum ones like third-generation cephalosporins, macrolides and quinolones. Most of those prescriptions came from clinics.

Something had to shift.

Tips for appropriate treatment

In 2016, Japan got serious about reducing its antibiotic misuse, releasing its first National Action Plan on Antimicrobial Resistance. It aligned with a global plan from the World Health Organization, which aimed to raise awareness of AMR and optimize the use of antimicrobials, including antibiotics, among its member states.

Two of Japan's big goals were to slash overall antibiotic use by 33% and broad-spectrum antibiotic use by 50% by 2020. The country came very close to hitting those ambitious targets by the deadline, and doing so was no small feat. The tipping program was just one of a slew of initiatives introduced to improve AMR awareness and antibiotic use.

Prior to the incentive's introduction, Japan's Ministry of Health, Labour and Welfare (MHLW) — whose role is somewhat analogous to the U.S. Department of Health and Human Services — rolled out educational campaigns for doctors and patients and wrote a manual for antibiotic use, with the first edition directed primarily at outpatient doctors. It emphasized that most acute respiratory tract infections and acute diarrheal diseases don't require antibiotics.

Among kids, children under 5 saw the highest antibiotic prescription rates, often receiving the drugs for respiratory infections. Data showed this overprescription problem was the worst in children under 3 being assessed for upper respiratory infections or acute gastroenteritis. The government's solution? Pay doctors extra to withhold antibiotics when faced with cases that don't warrant them.

"If the clinicians provide more appropriate medical services, we add additional payment," said Dr. Takuma Kato, a counselor at the Permanent Mission of Japan to the United Nations who previously worked on the incentive program for MHLW. In this case, they pay "a little bit more" when doctors don't give patients antibiotics for illnesses that are likely viral, he said.

A "little bit more" is accurate. Each tip is 800 yen, equivalent to about $7.20 when the program launched in April 2018 and about $5 at today's exchange rate.

Here's how it works: A caregiver brings in their sick infant or toddler for an initial visit, and the pediatrician determines the child likely has an acute upper respiratory tract infection or gastroenteritis. These illnesses are typically caused by viruses, so the doctor decides not to provide an antibiotic. The doctor explains this rationale to the caregiver and provides guidance for home care. If the appointment checks those boxes, the clinic can claim an extra 800 yen when they seek reimbursement.

Because mild viral infections typically resolve on their own in a few days, a strategy called "watchful waiting" can help clarify if a bacterium is actually at fault. So if a doctor does prescribe an antibiotic at the first visit, they'll often encourage the caregiver to bring the child back if their condition remains the same or worsens within a few days. The incentive and this "waiting" strategy go hand in hand.

There are a few technicalities. For example, the children being assessed must have no underlying conditions that might complicate their case, such as a weakened immune system. If children test positive on a formal diagnostic test for influenza or COVID-19, the incentive cannot be claimed. To qualify for the incentive, clinics must specialize in pediatrics and use a "comprehensive" payment system, meaning patients pay a standardized amount for the whole appointment rather than the itemized "fee for service" that is ubiquitous in the U.S.

Despite this fine print, the perk is pretty appealing for the clinics that claim it. "I think pediatric doctor associations are really happy," Okubo said.

Doctors say "small incentives add up"

The Japanese government generally incentivizes doctors to adjust their behaviors, rather than penalizing them for poor practices, Okubo said.

"It's a constructive message from the government: 'You changed your behavior, so we'll pay something,'" Okubo said. "This constructive approach motivates physicians, especially pediatricians, to apply their common sense to their actual practice."

This system is readily accepted by Japanese doctors, who have historically held a lot of political power, Kato noted. Just like in the U.S., their professional groups, such as the Japan Medical Association, lobby the government and typically push against policy proposals that they view as potential threats to their bottom line.

By contrast, an incentivizing approach is "very, very welcome, especially by the doctors' associations," said Dr. Norio Ohmagari, director of disease control and prevention at the National Center for Global Health and Medicine, part of the Japan Institute for Health Security (JIHS) in Tokyo. Ohmagari also leads the AMR Clinical Reference Center, which collaborates with the WHO on AMR countermeasures.

Doctors I asked confirmed that they like the incentive, namely because it boosts their profits.

"I apply for the pediatric antibiotic appropriate use support premium each time" it's applicable, said Dr. Yusuke Shibata, who runs the Shibata Pediatric Clinic in Asakusa, a historic district in Tokyo's Taito ward. "I appreciate the premium, as pediatric clinics already have low profits" compared with clinics that care for adults, Shibata told me in an email after I visited his clinic.

For first visits with kids under 6, clinics are paid a base rate of 6,040 to 7,210 yen, or about $38 to $45 at current exchange rates. An extra 800 yen (about $5) increases that fee by more than 10% — "a huge amount," Okubo emphasized.

Shibata estimates that his clinic sees about 30 to 40 patients with an acute respiratory infection or diarrhea each week, depending on the season. He can potentially claim the incentive for the first visit with each of these patients, assuming they don't have any conditions that would disqualify the claim.

On the high end, Shibata estimates that he might claim the incentive 180 times in a single busy month, which would total 144,000 yen, or about $900.

Dr. Atsushi Miyahara, who runs the Karugamo Clinic in the Setagaya ward in Tokyo, said he was already conservative about using antibiotics so the incentive rewards him for sticking with his status quo.

Fifteen years ago, when Miyahara opened his clinic, he noticed that other physicians prescribed a lot of antibiotics, and he questioned the practice due to the potential to fuel resistance. He provides his patients with informational flyers that explain the risks of resistance and how avoiding unnecessary prescriptions can reduce that risk. When antibiotics are needed, he predominantly uses narrow-spectrum drugs that pose a relatively low risk of resistance.

Miyahara said the local government and medical associations announced the antibiotic incentive when it was launched, and he felt its introduction has been very positive. It's increased his revenue and encouraged him to continue his stewardship practices. He estimates that for every 50 of his first visits with patients, he claims the incentive 10 to 15 times, so it applies to at least 20% of those visits.

The incentive's impact

Because some pediatric clinics qualified and others didn't — due to fee-for-service clinics being excluded — Okubo and his colleagues could directly measure whether the policy worked.

To assess the incentive's effects in its first year, the researchers looked at insurance claims from over 10,000 medical facilities from just before and after the policy's introduction. About 3,000 of the facilities qualified and claimed the incentive 316,770 times, totaling 253 million yen ($2.29 million at the time). These eligible clinics saw a 17.8% reduction in their total antibiotic use over a year without any negative effects for patients, such as higher hospitalization rates.

To see if those effects lasted, the team drew years of data from over 165,000 young children who went to either eligible or ineligible clinics. Within the first month of the policy's implementation, the former group of children saw a nearly 45% reduction in total antibiotic prescriptions, compared with the other kids. Cumulatively over the next four years, their overall antibiotic use and broad-spectrum-antibiotic use was 20% and 24% lower, respectively.

The decrease in antibiotic prescriptions did not come with an uptick in hospitalizations or healthcare costs, although there was a slight increase in the total number of doctor's visits. But that's what you'd expect as doctors track an infection over time, Okubo explained, meaning they likely employed the watchful-waiting strategy and had parents bring their kids back in if they didn't improve quickly.

Okubo's team has continued to track pediatricians' antibiotic use, and he noted that they're seeing "spillover effects" among age groups not covered by the incentive. In the under-20 age group, outpatient antibiotic prescriptions fell by 50% between 2011 and 2022. He thinks the incentive is a key driver of this trend, directly reducing prescriptions for the youngest kids while also triggering ripple effects in older groups. (This research will soon be published in a peer-reviewed journal.)

That said, there's room to improve doctors' selection of antibiotics when they are used, as the ratio of broad- to narrow-spectrum drugs is still too high. "Total antibiotic use was reduced, but its quality should be improved further," Okubo said.

The incentive's evolution

While the 800-yen tip has proved significant to clinicians, the incentive represents a very small slice of overall government healthcare spending, which totaled 468 billion yen ($3.1 billion) in 2022.

"This program is not large compared to the whole budget," Dr. Kosuke Sasaki, who works in the MHLW's health insurance bureau, told me. The program's budget has no upper limit, so if the number of claims from clinics increased, there isn't a cap on how many could be paid out. "The number of doctors using this program has increased while the number of antibiotic prescriptions has decreased since the start," Sasaki's colleague Dr. Tomonori Aoki added, noting that the government isn't concerned about how to pay that rising bill.

The program's measurable impact and low price tag may explain its growth over the years.

Every two years, Japan's Ministry of Finance hands the MHLW its slice of the government budget, and MHLW then revises the pricing for drugs, medical devices and healthcare services. The antibiotic incentive falls under this revision process and has been expanded several times.

During its first revision in 2020, the incentive was extended to children under 6. In 2022, ear, nose and throat specialists (ENTs) newly qualified for the incentive; like pediatricians, they treat many acute infections in kids and tend to overuse antibiotics, insurance data suggested. That same year, doctors could start claiming the fee for ear infections and sinus infections.

"I see a tendency for pediatric clinics to avoid prescribing antibiotics, but I do see some ENT clinics prescribing antibiotics carelessly," Shibata, the clinic owner in Asakusa, Tokyo, told me. So ENTs seem to be a logical next target.

In 2024, a separate, facility-level incentive was introduced as a complement to the 800-yen incentive. It encourages clinics to submit data to a government database that tracks antibiotic use. If first-line, narrow-spectrum antibiotics make up a certain percentage of the clinic's overall prescriptions, that clinic earns extra money, Okubo explained.

Ultimately, the 800-yen incentive helped put AMR on the radar of doctors who didn't take it as seriously as experts like Kato, who told me "AMR is kind of my life's work." Kato and researchers like Okubo see the program as a success, although they pointed to room for improvement in antibiotic selection. Ministry officials like Sasaki and Aoki said the program is easy to implement and makes a difference. Clinic doctors like Shibata and Miyahara appreciate the incentive and use it consistently. All in all, at just $5 a claim, the incentive has been remarkably effective.

In speaking with experts in Japan and the U.S., I've learned that U.S. doctors have historically faced the same pressures and showed similar lapses in antibiotic use that Japanese doctors have. However, the U.S. does not have an incentive program like Japan's. Should it launch one?

In the next installment of this series, I'll explore a central feature of this problem: the motivations behind pediatricians' antibiotic misuse. What are they, and do those motivations differ between doctors in the U.S. and Japan? Answers to those questions will help determine whether a similar incentive might have the same impact in both places.