Prescribing under Pressure: Parent-Physician Conversations and Antibiotics (Oxford Studies in Sociolinguistics)
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Antibiotics will soon no longer be able to cure common illnesses such as strep throat, sinusitis and middle ear infections as they have done for the last 60 years. Antibiotic-resistant bacteria are increasing at a much faster rate than new antibiotics to treat them are being developed. The prescription of antibiotics for viral illnesses is a key cause of increasing bacterial resistance. Despite this fact, many children continue to receive antibiotics unnecessarily for the treatment of viral upper respiratory tract infections. Why do American physicians continue to prescribe inappropriately given the high social stakes of this action? The answer appears to lie in the fundamentally social nature of medical practice: physicians do not prescribe as the result of a clinical algorithm but prescribe in the context of a conversation with a parent and a child. Thus, physicians have a classic social dilemma which pits individual parents and children against a greater social good.
This book examines parent-physician conversations in detail, showing how parents put pressure on doctors in largely covert ways, for instance in specific communication practices for explaining why they have brought their child to the doctor or answering a history-taking question. This book also shows how physicians yield to this seemingly subtle pressure evidencing that apparently small differences in wording have important consequences for diagnosis and treatment recommendations. Following parents use of these interactional practices, physicians are more likely to make concessions, alter their diagnosis or alter their treatment recommendation. This book also shows how small changes in the way physicians present their findings and recommendations can decrease parent pressure for antibiotics. This book carefully documents the important and observable link between micro social interaction and macro public health domains.
acute care visits can be seen as guided by the principles of optimization and problem attentiveness. This is an important component to our argument because through an orientation to these two principles, parents are able to ascertain the physician’s stance toward their child’s illness and can therefore negotiate treatment. The way a question is designed unavoidably conveys the physician’s stance toward the child’s condition (or some aspect of it) as problematic or nonproblematic. When questions
developing countries is more clearly a public health issue, the root of misuse in developed countries like the United States is at least equally a sociological issue.3 Misuse in the United States Earlier we discussed various determinants of misuse in developed countries. If we move more speciﬁcally to the United States, we can look more closely at this issue. One rather obvious contributor to inappropriate prescribing is whether physicians understand the relationship between viral infections and
“°Little bit re:d°,” and “I don’t see any drainage,” or (2) assessments of what is observed, such as “Your ears look goo:d” or “This one looks perfect.” In the report format, the physician does not overtly evaluate the signiﬁcance of the observation for the patient’s health status but leaves it to parents to draw their own conclusions about it. In the assessment format, the physician provides less insight into the examination but overtly draws evaluative conclusions. As an example, we can look at
interactional resource with which physicians can build a case for a no-problem diagnosis and thus a case for no treatment, while still reassuring patients of the rightness of their decision to seek medical assistance. Because parents are more likely to be satisﬁed when physicians make use of this resource, it appears to be an excellent means for diminishing resistance to no-problem, no-antibiotic treatment outcomes. 164 PRESCRIBING UNDER PRESSURE Presentation of No-Problem, No-Treatment
Physicians for Antibiotics Interactional Practice Candidate diagnosis presentation Primary Phase of Use Frequency of Use Reason for the visit 26% Mention of additional symptoms History taking Mention of alternative diagnoses History taking 9% 12% Diagnosis resistance Active treatment resistance Overt pressure 17% 19% 8% Diagnosis delivery Treatment recommendation Treatment recommendation We ﬁrst observed that during the problem presentation, parents can take a stance toward the child’s