Why do physicians think parents expect antibiotics? What parents report vs what physicians believe

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Original Research

Why do physicians think parents expect antibiotics? What parents report vs what physicians believe

J Fam Pract. 2003 February;52(2):140-148

By

Tanya Stivers, PhD

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References

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Practice recommendations

Physicians are more likely to prescribe an antibiotic if they believe a parent expects one.
Parental pressure is not limited to verbal requests, but may include other behaviors, such as supplying a candidate diagnosis or resisting the physician's diagnosis and suggested treatment.
Recognizing these communication behaviors may help the physician more directly communicate with parents about their expectations and desires.

ABSTRACT

Objective: To examine the relation between parent expectations for antibiotics, parent communication behaviors, and physicians’ perceptions of parent expectations for antibiotics.

Study Design: A nested cross-sectional study with parallel measures of parents presenting children for acute respirator y infections (previsit) and physicians (postvisit) and audiotaping of the encounters.

Population: Ten physicians in 2 private pediatric practices (1 community-based and 1 university-based) and a consecutive sample of 306 eligible parents (response rate, 86%) who were attending sick visits for their children between October 1996 and March 1997.

Outcomes Measured: Communication behaviors used by parents expecting antibiotics and physicians’ perceptions of parents’ expectations.

Results: Parents’ use of “candidate diagnoses” during problem presentation increased the likelihood that physicians would perceive parents as expecting antibiotics (from 29% to 47%; P =.04), as did parents’ use of “resistance to the diagnosis” (an increase from 7% to 20%). In the multivariate model, parents’ use of candidate diagnoses increased the odds that a doctor would perceive a parental expectation for antibiotics by more than 5 times (odds ratio, 5.23; 95% confidence interval, 3.74–7.31; P <.001), and parents’ use of resistance to a viral diagnosis increased these odds by nearly 3 times (odds ratio, 2.73; 95% confidence interval, 1.97–3.79; P <.001).

Conclusions: Parents perceived as expecting antibiotics may be seeking reassurance that their child is not seriously ill or that they were correct to obtain medical care. Physicians were significantly more likely to perceive parents as expecting antibiotics if they used certain communication behaviors. This study revealed an incongruity between parents’ reported expectations, their communication behaviors, and physicians’ perceptions of parents’ expectations.

When physicians’ perceptions of patient expectations were examined as a predictor of prescribing, physicians were significantly more likely to provide a prescription if pre- or postvisit expectation for antibiotics was expressed by patients, even if antibiotics were inappropriate.^1-8 Patients who expected to receive a prescription were 30% to 45% more likely to receive one than patients who did not expect to receive one. Inappropriate prescribing of antibiotics for presumed viral infections is a serious problem,^9-11 particularly in the pediatric population.^12-14

Research in the pediatric context has shown similar results. Mangione-Smith et al found that physicians’ perceptions of parental expectations for antibiotics was the only significant predictor of prescribing when a viral diagnosis was assigned.¹³ When physicians thought parents expected antibiotic treatment for their child, they prescribed it 62% of the time vs 7% when they did not think antibiotics were expected (P=.02). In addition, when physicians thought parents expected antibiotics, they were significantly more likely to make a bacterial diagnosis (70% of the time vs 31% of the time; P=.04). Parents’ reports of their expectations were not significantly related to inappropriate prescribing. In all of these studies, physicians’ perceptions were stronger predictors of prescribing behavior than were patients’ reports of their expectations.

Missing from this line of research is an answer to the question: “How do physicians come to perceive that parents expect antibiotics?” Earlier work^15-18 identified and described several communication practices used by parents during acute pediatric encounters that may be related to physicians’ perceptions of parent expectations for antibiotics. This study examined the relations between 3 parent communication behaviors and parents’ reports of their expectations for anti-biotics the relations between these communication behaviors and physicians’ reports of their perceptions of parents’ expectations for antibiotics.

Methods

One community and 1 university pediatric practice were identified for possible inclusion in the study. Parents were eligible for study participation if they spoke and read English and their children were 2 to 10 years old, were being seen for upper respiratory tract infection symptoms (cough, rhinorrhea, throat pain, ear pain, or ear tugging), had not been taking antibiotics for the previous 2 weeks, and were seeing a participating physician. Approval for all study procedures was obtained from the UCLA human subjects’ protection committee.

Inventory of parents’ expectations

Before the encounter, parents completed a 15-item previsit expectations inventory that included 1 item about “how necessary” they thought it was for the physician to “prescribe antibiotics for your child (medicine for infection).” The other items in the inventory asked about previsit expectations for other medications (eg, cough medicine) and other tasks (eg, taking the child's temperature) and are described in detail elsewhere.¹³