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Are We Sending the Right Message?

Rita Mangione-Smith, MD, MPH; Marc N. Elliott, PhD; Tanya Stivers, PhD; Laurie L. McDonald, MS; John Heritage, PhD

Arch Pediatr Adolesc Med. 2006;160:945-952.

Objectives  To examine the relationships among physician-parent communication practices, physicians' perceptions of parental expectations for antibiotic treatment, and inappropriate antibiotic prescribing for viral upper respiratory tract infections.

Design  Cross-sectional study of pediatric encounters motivated by cold symptoms between October 1, 2000, and June 30, 2001. Each encounter was videotaped. Physicians completed a postvisit survey that measured whether they perceived the parent as expecting antibiotics. Coded communication variables were merged with survey variables. Multivariate analyses identified key predictors of parent-physician communication practices, physician perceptions of parents' expectations for antibiotics, and inappropriate antibiotic prescribing for viral conditions.

Setting  Twenty-seven pediatric practices in Los Angeles, Calif.

Participants  Thirty-eight pediatricians and 522 consecutively approached parents of children with cold symptoms.

Main Outcome Measures  Physicians' perceptions of parental expectations for antibiotics, inappropriate antibiotic prescribing, and parental questioning of nonantibiotic treatments.

Results  Physicians were 20.2% more likely to perceive parents as expecting antibiotics when they questioned the physician's treatment plan (P = .004; 95% confidence interval, 6.3%-34.0%). When physicians perceived parents as expecting antibiotics, they were 31.7% more likely to inappropriately prescribe them (P<.001; 95% confidence interval, 16.0%-47.3%). Parents were 24.0% more likely to question the treatment plan when the physician ruled out the need for antibiotics (P = .004; 95% confidence interval, 7.7%-40.3%).

Conclusions  Parental questioning of the treatment plan increases physicians' perceptions that antibiotics are expected and thus increases inappropriate antibiotic prescribing. Treatment plans that focus on what can be done to make a child feel better, rather than on what is not needed, ie, antibiotics, may decrease inappropriate antibiotic prescribing.

Author Affiliations: Departments of Pediatrics (Dr Mangione-Smith) and Sociology (Dr Heritage), University of California–Los Angeles; RAND Corporation, Santa Monica, Calif (Dr Elliott and Ms McDonald); and Max Planck Institute for Psycholinguistics, Nijmegen, the Netherlands (Dr Stivers). Dr Mangione-Smith is now with the Department of Pediatrics, University of Washington, Seattle.

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