The inventory was scored by using a 5-point scale: 1 = definitely necessary, 2 = probably necessary, 3 = uncertain, 4 = probably unnecessary, and 5 = definitely unnecessary. Parents who reported a score of 1 or 2 were coded as expecting antibiotics, and parents who reported a score of 3, 4, or 5 were coded as not expecting antibiotics. Each encounter was then audiotaped.
Physicians’ perceptions of expectations
Physicians completed a postvisit checklist to indicate diagnosis, treatment, and their perceptions of what the parents expected. One item asked the doctor to agree or disagree with the statement: “This parent expected me to prescribe antibiotics.” Other items asked whether the physician thought that the parent expected other medications (eg, cough medicine). This measure is also described in detail elsewhere.13 These items were scored on a 5-point Likert scale: 1 = strongly agree, 2 = somewhat agree, 3 = uncertain, 4 = somewhat disagree, and 5 = strongly disagree. Scores of 1 and 2 were coded as the physician perceiving the parent as expecting antibiotics, and scores of 3, 4, and 5 were coded as the physician perceiving the parent as not expecting antibiotics.
Analysis of the doctor–parent interaction
Conversation analysis was used as a qualitative method for analyzing the audiotaped data.19 Conversation analysis looks for patterns in the interaction that form evidence of systematic usage such that they can be identified as “practices.” To be identified as a practice, a particular communication behavior must be recurrently used and attract responses that systematically discriminate it from similar or related practices. For example, when a physician asks, “How are you feeling?,” patients recurrently respond with information about an ongoing health condition (usually the problem they were treated for in a prior visit) even if there were new problems to report to the physician.20
By relying on conversation analysis as a methodology, for these data 6 primary communication practices were found to be related to antibiotics.15 Analyses of 3 of these practices have been published elsewhere.17,18 For the purposes of this study, 4 communication practices that seemed most robust given the relatively small sample size were identified and operationalized in a coding scheme to test the relations between these behaviors and survey-based variables. All encounters were coded by 1 coder (T.S.), and a 15% sample was recoded by the same coder for intrarater reliability. All κ values exceeded .8 reliability, indicating substantial agreement above chance.21 The communication behaviors that were coded are outlined in Table 1.
TABLE 1
Parent communication behaviors
| Communication behavior | Definition | Example | Frequency |
|---|---|---|---|
| Symptoms-only problem presentation | Parent presents child's problem by listing symptoms only | “He has a runny nose and a sore throat” | 51%* (n=151) |
| “Candidate” diagnosis problem presentation | Parent presents child's problem by suggesting or implying a diagnosis | “He's had a terrible sore throat so I thought maybe it was strep” or “He has green gunky nasal discharge,” implying sinusitis | 45%* (n=132) |
| Diagnosis resistance | Parent questions the diagnosis or suggests an opinion that conflicts with physician's diagnosis | After a diagnosis of no ear infection, the parent asks “He doesn’t?”; or, after a no-problem diagnosis, the parent remarks, “It's just that this has been going on for so long” | 17% (n=50) |
| Treatment resistance | Parent questions the treatment or states preference for a treatment different than physician's recommendation | After a suggestion to use over-the-counter cough medicine, a parent questions the treatment being recommended: “The Robitussin just isn’t working”; or, after a recommendation of an over-the-counter medication, the parent asks, “So, you don’t think he needs any antibiotics?” | 12% (n=35) |
| *These figures do not total 100% because in some cases physicians began the encounter with a question about the child's medical history and parents did not offer a presentation of their child's problem. | |||
Analytic methods
The survey data were merged with the coded audiotape data to examine the relations between (1) parents’ reports of their expectations for antibiotics, (2) parents’ communication practices, and (3) physicians’ perceptions of parents’ expectations for antibiotics. We tested bivariate relationships between the main outcome variables and several hypothesized predictors by using the χ2 test of independence and Fisher's exact test. Variables significant at the P=.05 level were included in a multivariate logistic regression predicting physicians’ perceptions of parents’ expectations for antibiotics. Whether the diagnosis was bacterial or viral was controlled for in the model. A similar multivariate logistic regression examining the relations between parental expectations and their communication behaviors was developed. Both included separate intercepts for each physician. All tests were 2-sided and conducted at the .05 level of significance. Results were then corrected for clustering with the Huber correction.22,23 Results of the logistic regression models are reported as odds ratios (ORs) with 95% confidence intervals (CIs).