In the model predicting parents’ expectations, none of the communication behaviors reached significance as predictors. The results are shown in Table 2. After controlling for diagnosis and other communication behaviors, the odds that a physician would perceive a parent as expecting antibiotics were more than 5 times higher if the parent used a candidate diagnosis problem presentation. Similarly, the odds that a physician would perceive a parent as expecting antibiotics were nearly 3 times higher if the parent resisted a viral diagnosis.
The CIs for the associations of these 2 measures with physicians’ perceptions of expectations did not overlap with the corresponding CIs for parent-reported expectations, suggesting significantly stronger associations with physicians’ perceptions than with parents’ expectations. Neither treatment resistance nor resistance to a bacterial diagnosis reached significance as a predictor of physicians’ perceptions that parents expected antibiotics within the multivariate model.
TABLE 2
Multivariate logistic regression model predicting physicians’ perceptions that parents expected antibiotics and parents’ reports of their expectations*
| Independent variables | Prediction that physician perceived that parent expected antibiotics OR (95% CI) | Prediction that parent reported expectations for antibiotics OR (95% CI) |
|---|---|---|
| Parent suggests “candidate” diagnosis | 5.23† (3.74–7.31) | 1.48 (0.94–2.32) |
| Parent resists viral diagnosis | 2.73‡ (1.97–3.79) | 0.69 (0.46–1.02) |
| Parent resists bacterial diagnosis) | 0.36 (0.10–1.27) | 0.96 (0.33–2.80) |
| Parent resists treatment recommendation for viral diagnosis | 3.18 (0.15–68.82) | 1.14 (0.96–1.36) |
| Parent resists treatment recommendation for bacterial diagnosis | 0.87 (0.06–12.44) | 2.54 (0.50–12.90) |
| * Controlling for listed behaviors, bacterial diagnosis, and allowing independent physician intercepts. Data are presented as odds ratio (95% CI). | ||
| † P<.05. | ||
| ‡ P<.0001. | ||
| OR, odds ratio; CI, confidence interval | ||
Discussion
Prior research has suggested that parents commonly pressure physicians for antibiotics by overtly requesting antibiotics.6,7,25,26 In this study this overt parent behavior was quite rare (for further discussion of these cases, see work by Mangione-Smith et al16 and Stivers18). This study suggests that physicians form their perceptions of parents’ expectations for antibiotics from far less direct communication behaviors such as parents’ candidate diagnoses or diagnosis resistance. Given the association between a physician's perception of a patient's or parent's expectation for antibiotics with increased rates of inappropriate antibiotic prescribing,1-3,13 it appears that when a parent exhibits one of these behaviors, physicians may feel pressure to prescribe. Qualitative analyses of these data support this analysis.17,24 Physicians appear to treat parents who use these communication practices as indicating an expectation and a desire for antibiotic treatment. However, parents may not always be intending to communicate pressure or even an expectation for antibiotics. This study found no association between the communication behaviors described and parents’ reports of their expectations for antibiotics.
This finding suggests 2 possible interpretations. Parents may not be accurate reporters of their expectations; they may be unwilling to admit to an expectation for antibiotics before the visit. Possibly, parents may accurately report their expectations before their medical encounters, but physicians misunderstand their behaviors as indicating such an expectation. Some parents may offer a candidate diagnosis because they feel that antibiotics are necessary; others may offer a candidate diagnosis to show competent parenting, or as a reflection of their concern that their child has a more serious illness, or of their concern that their visit may have been premature or unjustified. In the latter cases parents may be seeking reassurance from the physician, and they may not realize that they may be understood by physicians as pressuring for antibiotics.
However, as this study suggests, physicians do not differentiate between these alternative motivations and may tend to understand these behaviors as pressure to prescribe. The problem of mismatched parental expectations and physicians’ perceptions of those expectations is further exacerbated because it is rare for parents to explicitly state their desire for, or opposition to, antibiotic treatment.
Limitations
Because the data for this study were from 2 practices in the same geographic area and with a relatively homogeneous group of parents and physicians, we do not know whether the findings will generalize to other settings involving participants from more diverse backgrounds. In addition, we may have failed to detect associations that could exist between treatment resistance or diagnosis resistance and physicians’ perceptions of parents’ expectations or parent-reported expectations due to the relatively small sample size, the rarity of some of the behaviors, and the association of parental communication behaviors with one another. For these behaviors, we had 80% power to detect only true multivariate odds ratios that were relatively large.1,11-14 Further research on these behaviors with larger sample sizes is indicated.
We may have introduced measurement error through reliance on parent and physician self-reports of 2 of the variables we studied. In relying on a single-item measurement of parents’ expectations for antibiotics, there may be some unreliability in the assessment of parents’ expectations.