Why do physicians think parents expect antibiotics? What parents report vs what physicians believe
Results
As previously reported, 8 of the 10 full-time physicians in 2 practices agreed to participate, and 306 of the 356 eligible parents agreed to participate (response rate, 86%). Eleven visits were excluded because of incomplete data. Thus, there were 295 complete encounters. Data were collected between October 1996 and March 1997. Parents in the sample were highly educated (mean years of education, 16), older (mean age, 38 years), and had high incomes (75% had household annual incomes greater than $50,000). Nonwhites comprised one third of the sample, and 60% were enrolled in managed care plans.13 Parents reported having an expectation for antibiotics in 49% (n=144) of cases. In contrast, physicians reported perceiving parents to expect antibiotics in 34% (n=100) of cases.
Qualitative analysis of the audiotaped data identified 4 primary communication behaviors associated with prescribing of antibiotics (see Table 1). When a parent presented the child's problem by offering a possible or “candidate” diagnosis (45% of cases), physicians responded as though the parent was seeking antibiotics as contrasted with a “symptoms only” presentation (51% of cases). The results of the qualitative analysis have been described in detail elsewhere.17 Candidate diagnoses (eg, ear infection, sinus infection, pneumonia, or strep throat) imply bacterial infections. In response physicians behave as though parents are seeking antibiotics. For example, they routinely confirm or deny the need for antibiotic treatment. Other qualitative research has associated these behaviors with inappropriate prescribing of antibiotics.24
When a physician announces a diagnosis (whether framed positively as a viral condition or negatively as not a bacterial condition), parents sometimes “resist” that diagnosis. This resistance typically involves questioning the physician's physical examination findings or questioning the actual diagnosis. As with candidate diagnoses, this behavior does not explicitly mention antibiotics, but physicians routinely respond to diagnosis resistance as having communicated that the parent is seeking antibiotics by confirming or denying a need for them. This behavior was found in 17% (n=50) of cases.
In response to physicians’ nonantibiotic treatment recommendations, parents may “resist” the recommended treatment. As with the other behaviors, this resistance usually does not involve an explicit request for antibiotics, but physicians nonetheless typically respond to treatment resistance as if parents are searching for antibiotics. This behavior was found in 12% of (n=35) cases.
After the qualitative analysis of these behaviors, each audiotaped encounter was coded for their presence so that these communication variables could be merged with survey data variables for quantitative analysis. Bivariate associations between each identified communication behavior and the 2 survey variables (parents’ reports of their expectations for antibiotics and physicians’ perceptions that parents expected antibiotics) were tested. The relation between candidate diagnoses and parents’ reports of their expectations trended toward, but did not reach, significance (n=295, 2 χ21=3.141, P=.08), and parents who reported an expectation for antibiotics were no more likely to resist a physician's treatment recommendation (eg, for an over-the-counter or nonantibiotic remedy) than parents who did not expect antibiotics (n=295, χ21=0.29, P=.59). The strongest trend shown in these data was that, when parents expected antibiotics, they were more likely to resist a viral diagnosis (n=259, χ21=3.71, P=.59, P=.05).
Although none of the identified parental communication behaviors were significantly associated with parents’ reports of their expectations for antibiotics, there were significant associations between 2 of the 4 communication behaviors and physicians’ perceptions that parents expected antibiotics: when parents offered candidate diagnoses, physicians were significantly more likely to perceive the parents as expecting antibiotics. If a parent offered a candidate diagnosis in the problem presentation, the physician was 62% more likely to think the parent expected antibiotics (an increase from 29% to 47%; P=.04).
“Symptoms only” problem presentations were more frequent than “candidate diagnosis” presentations. However, among the candidate diagnosis presentations (n=132), 82% were for conditions that could be treated appropriately with antibiotics.
In cases in which a viral diagnosis was assigned, a physician was more likely to perceive a parent to expect an antibiotic if the parent resisted the diagnosis. When parents offered resistance to the diagnosis, physicians perceived them to expect antibiotics 20% of the time vs 7% of the time when they did not offer resistance (Fisher exact test, P=.047).
Parent resistance to nonantibiotic treatment recommendations was not associated with physicians’ perceptions of parents’ expectations for antibiotics (Fisher exact test, P=.122).
Each communication behavior was included in a multivariate logistic regression model predicting physicians’ perceptions that parents expected antibiotics. For parallelism, all were also included in a model predicting parents’ reports of their expectations for antibiotics. The type of diagnosis (ie, bacterial or viral) was also controlled for.
