Online commentary during the physical examination: a communication tool for avoiding inappropriate antibiotic prescribing?

A previously identified communication behavior, online commentary, is physician talk that describes what he/she is seeing, feeling, or hearing during the physical examination of the patient. The investigators who identified this communication behavior hypothesized that its use may be associated with successful physician resistance to perceived or actual patient expectations for inappropriate antibiotic medication. This paper examines the relationship between actual and perceived parental expectations for antibiotics and physician use of online commentary as well as the relationship between online commentary use and the physician's prescribing decision. We conducted a prospective observational study in two private pediatric practices. Study procedures included a pre-visit parent survey, audiotaping of study consultations, and post-visit surveys of the participating physicians. Ten pediatricians participated (participation rate=77%) and 306 eligible parents participated (participation rate=86%) who were attending sick visits for their children with upper respiratory tract infections between October 1996 and March 1997. The main outcomes measured were the proportion of consultations with online commentary and the proportion of consultations where antibiotics were prescribed. Two primary types of online commentaries were observed: (1) online commentary suggestive of a problematic finding on physical examination that might require antibiotic treatment ('problem' online commentary), e.g., "That cough sounds very chesty"; and (2) online commentary that indicated the physical examination findings were not problematic and antibiotics were probably not necessary ('no problem' online commentary), e.g., "Her throat is only slightly red". For presumed viral cases where the physician thought the parent expected to receive antibiotics, if the physician used at least some 'problem' online commentary, he/she prescribed antibiotics in 91% (10/11) of cases. Conversely, when the physician exclusively employed 'no problem' online commentary, antibiotics were prescribed 27% (4/15) of the time (p = 0.07). Use of 'no problem' online commentary did not add significantly to visit length. 'No problem' online commentary is a communication technique that may provide an effective and efficient method for resisting perceived expectations to prescribe antibiotics.