PAUL CLAY SORUM, MD, PHD JUNSEOP SHIM, MPA GÉRARD CHASSEIGNE, PHD ETIENNE MULLET, PHD MARIÍA TERESA MUÑOZ SASTRE, PHD THOMAS STEWART, PHD CLAUDIA GONZÁLEZ-VALLEJO, PHD Albany, New York; Tours, Bruxelles, and Toulouse, France; and Athens, Ohio Submitted, revised, May 29, 2001. From the departments of Medicine and Pediatrics, Albany Medical Center, Albany (P.C.S.); the Center for Policy Research, State University of New York-Albany (J.S., T.S.); the Département de Psychologie, Université François-Rabelais, Tours (G.C.); Ecole Pratique des Hautes Etudes (E.M.); the Département de Psychologie Clinique et Pathologique, Université du Mirail, Toulouse (M.T.M.S.); and the Department of Psychology, Ohio University, Athens (C.G.). Reprint requests should be addressed to Paul Clay Sorum, MD, Albany Med Primary Care Network, 724 Watervliet-Shaker Road, Latham, NY 12110. E-mail: sorump@mail.amc.edu.
Our study results should be reassuring to physicians. The most striking finding was the similarity between parents’ diagnostic judgments and treatment choices and those of physicians. The only difference in judgment policies was that the French parents placed greater stress than the French physicians on fever and gave a lower weight to bulging when deciding about treatment, which may be understandable given their unfamiliarity with the technical aspects of examining an ear.31 Indeed, contrary to our expectations, parents in both countries gave less weight to parent-sensitive cues than did physicians. Overall, parents did not diagnose AOM in the scenario children or recommend treating them with antibiotics more frequently than physicians.
The parents’ restraint concerning antibiotics is surprising given physicians’ perceptions and the results of a recent US survey52 in which 96% of parents said that “ear infections can affect a baby’s hearing,” and only 11% thought that “most ear infections get better by themselves.” Also, recent experts have stressed the high indirect costs of an episode of AOM and the value to parents of reducing the duration of the illness.53-56 One explanation may be the rising parental worry that antibiotic treatment may lessen their child’s ability to fight off future infections, in particular because of the spread of antibiotic-resistant bacteria.27 The parents in our study worried as much as the physicians about the adverse effects of antibiotics and agreed just as strongly as the physicians that the resistance of bacteria to antibiotics is the most important threat to the future health of the public. The parents’ ability to adopt the physician’s point of view should encourage physicians to undertake the patient and parent education efforts recently recommended25,28,57 as the best way to reduce the excessive prescription of antibiotics.
We had anticipated incorrectly that the decision to treat would be influenced by attitudes toward uncertainty, ambiguity, and risk.59,63 We had also expected, again incorrectly, that a greater belief in the usefulness of antibiotics and (for the parents alone) in the contagious nature of ear infections — and a lesser worry about antibiotic side effects and bacterial resistance — would identify physicians and parents who opted more frequently for antibiotics. The explanation may be that our questions were insensitive or that general attitudes are poor predictors of individual case-by-case choices and behavior. It may also be that physicians—and even parents who take the role of physicians—believe that diagnosis is the first and determining step in managing a possible ear infection.
Limitations
Our study has several limitations. First, generalization is limited by the small samples, the inequality of the sample sizes, and the convenience nature of the samples. Second, the patients were hypothetical, presented on paper in schematic form, with neither the richness nor the vividness of the real children brought by parents to physicians’ offices. Although the use of “paper patients” has been questioned,64,65 it is practical and has been supported in other studies of clinical decision making.66-69 Third, comparisons between the French and Americans may have been influenced by unappreciated differences in meaning of the French and English versions of the scenarios and questions.
Conclusions
It is encouraging that parents in our study were able to adopt the physician’s perspective and to focus on medical indications rather than on parental needs in their treatment decisions, that they did not choose to prescribe antibiotics more frequently than the physicians, and that they were as concerned as the physicians about the adverse effects of antibiotics and the threat from resistant bacteria. Patients and parents may, therefore, be more willing to forgo antibiotics than physicians realize.
Acknowledgments
We thank the following for their invaluable advice and assistance: Bernard Grenier, MD; Héléne Touchon, MD; Joél Cogneau, MD; Marie-Ange Lecomte, MD; Sabine Maciaszczyk-Jedeau, PhD; Appleton Mason, MD; the Association des Pédiatres de Ville en Touraine; the Latham Medical Group; the Albany Medical Center Department of Family Practice; Héma Sandanam; and Roberta Sandler, RN.
