With the recent emphasis on decreasing the use of antibiotics, physicians must face parental expectations when caring for children diagnosed with upper respiratory tract infection (URI). Although antibiotics have no role in the treatment of the common cold, a significant number of patients receive antibiotic prescriptions. This inappropriate use of antibiotics increases the risk of developing drug-resistant strains of bacteria. It also substantially increases the cost of treating this common viral infection. Mangione-Smith and colleagues studied physician-parent communication behaviors to determine the following: (1) how parents communicate their desire for antibiotics to physicians; (2) which parent communication behaviors make physicians feel pressured to prescribe antibiotics; and (3) which physician communication behaviors enhance parent satisfaction with the visit.

Study participants were children with a history of symptoms consistent with URI and their parents who presented to two private pediatric practices. Parents of these children were given a 15-item previsit expectation survey, a postvisit expectation survey and a visit satisfaction questionnaire. Physicians completed a postvisit checklist to indicate diagnosis, treatment, and if they believed that the parents had expected antibiotics for the child. In addition, the office visits were audiotaped and analyzed.

Fifty percent of the parents expected an antibiotic prescription before the office visit, but only 1 percent of them made a direct verbal request for antibiotics to the physician. Physicians stated that they felt pressured to prescribe antibiotics 34 percent of the time, even though this perceived pressure did not correlate with any direct request by the parents. Parents who did not receive antibiotics for their children but were given a contingency plan were much more likely to voice satisfaction with the office visit than those who received no contingency plan. The contingency plan offered the possibility of an antibiotic prescription if the child did not get better.

The authors conclude that physicians should provide a contingency plan to parents who expect antibiotics for their children when there is no clinical indication for their use. This could reduce the number of parents who are dissatisfied with the physician for not prescribing antibiotics. It could also decrease the pressure to inappropriately prescribe antibiotics for children with viral URIs.

editor's note: One of the more common dilemmas that physicians face when treating a viral illness in children is how to meet parental expectations without using antibiotics inappropriately. Mangione-Smith and colleagues provide us with an alternative to writing that prescription. By giving parents of the ill child a contingency plan, we can improve the parents' satisfaction with the visit while reducing the use of antibiotics for viral URIs. This strategy is easy to implement and, over time, may reduce parental expectations for antibiotics to treat URIs.—k.e.m.