prescribing under pressure parent physician conversations and antibiotics oxford studies in...

7/30/2019 Prescribing Under Pressure Parent Physician Conversations and Antibiotics Oxford Studies in Sociolinguistics

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Prescribing under Pressure


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OXFORD STUDIES IN SOCIOLINGUISTICS

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Nikolas Coupland

Adam Jaworski

Cardiff University

Recently Published in the Series:

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Maryann Overstreet

A Place to Stand: Politics and Persuasion in a Working-Class Bar

Julie Lindquist

Sociolinguistic Variation: Critical Reflections

Edited by Carmen Fought


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Parent-Physician Conversations

and Antibiotics

Tanya Stivers

32007


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Stivers, Tanya.

Prescribing under pressure: patient-physician conversations and antibiotics / Tanya Stivers.p. cm.(Oxford studies in sociolingistics)

Includes bibliographical references and index.

ISBN 978-0-19-531115-0

1. Antibiotics. 2. AntibioticsEffectiveness. Physician and patient. I. Title

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ACKNOWLEDGMENTS

Although only one name appears on the cover of this book, it represents the

thoughts, ideas, and contributions of many people. Some I formally acknowledge

here, some appear in the list of references, but many who appear in neither place

nonetheless helped me along the way by challenging me to consider yet another way

of approaching the set of problems that this book brings together.

I owe the biggest debt of gratitude to the people who let me study them: the

nearly 800 parents and physicians I videotaped over the course of 5 years of field-

work, much of which was used for the present book. Although the research discussed

here relies on videotapes of these interactions, many of these individuals (as well as

others) shaped my thinking in quite different ways: parent comments in physician

waiting rooms, physician comments or questions before or after parents arrived as

well as during ethnographic interviews, and medical assistant comments during the

course of a typical day all influenced my thinking about what happens when a parent

walks through the door with a sick child. Each of the subjects in my study granted

me just a small amount of timemany would not even remember participating; most

would surely be shocked to find out that their few minutes would sum to provide me

with a careers worth of data. Still, those minutes add up, and so I thank all of these

anonymous individuals for their generosity.My biggest supporter from beginning to end has been John Heritage. He believed

in the project from the moment I floated the idea by him, and his encouragement

materially, emotionally, and intellectually was invaluable. I shudder to think how

many versions of this material he has read over the years in the form of grant propos-

als, dissertation chapters, articles, and finally book chapters. Besides offering tireless

support, he taught me how to study social interaction without losing track of either

the structures through which interactants accomplish social actions or the fact that

interactants have feelings, concerns, and agendas. He challenged me each step of the


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vi ACKNOWLEDGMENTS

way to be more ambitious, to be more creative in my thinking, and to consider the

interplay between the microlevel interaction and the macrolevel social context. I am

infinitely grateful for the support, education, and contributions that he has provided.

Many others to whom I owe a substantial debt of thanks were, in one way oranother, connected to John. It was he who introduced me to Rita Mangione-Smith.

Rita provided both data and much support for the work after qualitative analyses

pointed me toward antibiotics. Rita had independently been investigating parent atti-

tudes toward, and expectations for, antibiotics and had been surveying physicians

on their perceptions. Thus, with our work combined, we could, for the first time, see

whether behaviors derived from conversation analysis could be linked with exog-

enous survey variables, and the merger was a success.

As a student of conversation analysis at the University of California at Los Ange-

les, I was mentored by both John Heritage and Manny Schegloff. Then and since,

Manny has consistently challenged me not to forget that whatever people are doing

in a medical encounter, they are doing it Turn Constructional Unit by Turn Construc-

tional Unit, turn by turn, sequence by sequence, as in all forms of social interaction.

And time and time again, the importance of understanding each level of orderliness

has proven critical to the analysis. To Manny I owe a thank-you for teaching and

modeling both rigor and enthusiasm in studying interaction. Both were contagious

early on, and have not waned.

This book is heavily based on my UCLA dissertation in applied linguistics:Negotiating Antibiotic Treatment in Pediatric Care: The Communication of Prefer-

ences in Physician-Parent Interaction (2000). Several of the chapters are based on

previously published articles. The ideas of chapter 2 previously appeared as Pre-

senting the Problem in Pediatric Encounters: Symptoms Only versus Candidate

Diagnosis Presentations, published inHealth Communication (2002b). The ideas

in chapter 5 previously appeared in Parent Resistance to Physicians Treatment

Recommendations: One Resource for Initiating a Negotiation of the Treatment

Decision, published inHealth Communication (2005c). Many of the ideas in chap-

ter 6 appeared in Participating in Decisions about Treatment: Overt Parent Pres-

sure for Antibiotic Medication in Pediatric Encounters, published in Social Science

and Medicine (2002a). Finally, chapter 7 is a compilation of work based partly

on Non-Antibiotic Treatment Recommendations: Delivery Formats and Implica-

tions for Parent Resistance in Social Science and Medicine (Stivers, 2005b) and

partly on Heritage and Stivers (1999), Online Commentary in Acute Medical Vis-

its: A Method of Shaping Patient Expectations in Social Science and Medicine. I

acknowledge Lawrence Erlbaum and Elsevier for allowing me to incorporate these

articles into the present book.Bringing together the previous ideas in the form of this book was most impor-

tantly prompted by a conversation with Steve Clayman. It was his timely prodding

and support that convinced me to revisit this work and draw it together. Besides

prompting the writing, he generously read drafts of the chapters and provided much

needed feedback, consistently pushing me to clarify my writing and, in turn, my

thinking.

I am also grateful to the Max Planck Institute for Psycholinguistics in Nijme-

gen, The Netherlands, and especially to Steve Levinson, for making the writing of


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ACKNOWLEDGMENTS vii

this book possible. The Language and Cognition Group, particularly Nick Enfield,

has through their own work, their way of approaching problems, and their questions,

pushed me to come to terms with disciplines and ways of thinking that I had previ-

ously been hopelessly ignorant of. This sentiment wove its way into this book andled me to attempt to situate the problem and discussions of it more broadly than I

otherwise would have.

Much appreciation is owed to my friends and family, who have been (and will

probably continue to be) subjected to ranting over the years about antibiotic over-

prescribing and the structures of social action. Instead of asking me to stop talking

about my work, they have engaged with my ideas and, through their own stories and

thoughts, prompted me to consider new analytic angles. Special thanks to Ignasi

Clemente, Amy Miller, Rob McClinton, Heidi and Luella Hood, Dr. Valentine, Kathi

and Milt Schmutz, Jim and Jean Stivers, and Julian and Riley Scaff.

Finally, thank you to Nik Coupland, Adam Jaworski, and Peter Ohlin for their

support of this book.


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CONTENTS

1. The Miracle Drug: The Context of Modern Antibiotic Usage, 3

2. Foregrounding the Relevance of Antibiotics in the Problem

Presentation, 23

3. Alternative Practices for Asking and Answering History-Taking

Questions, 51

4. No Problem (No Treatment) Diagnosis Resistance, 77

5. Treatment Resistance, 105

6. Overt Forms of Negotiation, 131

7. Physician Behavior That Influences Parent Negotiation Practices, 155

8. Conclusion, 185

Appendix: Transcript Symbols, 195

Notes, 199

References, 203

Index, 219


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1

The Miracle Drug

The Context of Modern Antibiotic Usage

The History of Medicine

2000 BCHere, eat this root.

1000 BCThat root is heathen. Here, say this prayer.

1850 ADThat prayer is superstition. Here, drink this potion.

1920 ADThat potion is snake oil. Here, swallow this pill.

1945 ADThat pill is ineffective. Here, take this penicillin.

1955 ADOops . . . bugs mutated. Here, take this tetracycline.

19601999 AD39 more oops . . . Here, take this more powerful antibiotic.

2000 ADThe bugs have won! Here, eat this root.

Anonymous

In 2000, primary care physicians in the United States handed out approximately 126million prescriptions for antimicrobials (McCaig, Besser, & Hughes, 2003). Basic

arithmetic shows this to be approximately 2.5 billion doses consumed by ambula-

tory care patients alone. Although in some respects rates of antimicrobial drug use

have fallen in the recent past, the annual population-based rate of prescribing in the

United States remains 461 prescriptions per 1,000 people (McCaig et al., 2003). In

pediatrics, the primary care specialty with the highest rate of prescribing, 235 ofevery 1,000 medical visits result in an antibiotic prescription (McCaig et al., 2003).

Unfortunately, many of these prescriptions are for the treatment of viral illnesses.

Because antibiotics are ineffective against viruses, such prescriptions are inappropri-

ate, and their prevalence threatens the effectiveness of antibiotics in treating bacteria

that cause pneumonia, strep throat, and ear infections (Streptococcus pneumoniae),

some of the most common childhood illnesses. This book asks why the problem of

inappropriate antibiotic prescribing persists and seeks answers by investigating the

3


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4 PRESCRIBING UNDER PRESSURE

details of interactions between pediatricians and parents in visits for children with

symptoms of an upper respiratory tract infection.

History of Antibiotics

The history of antibiotics is relatively short. By most accounts, penicillin was dis-

covered by British scientist Alexander Fleming in 1928, and initial results were pub-

lished less than a year later (Fleming, 1929). For various reasons, it was not until

1942 that the British and Americans began mass-producing the drug. Clinical use

became widespread during World War II, when penicillin was heavily marketed to

the public using what we now call direct to consumer advertising, such as Thanks

to penicillin, he [showing a picture of an American soldier on the ground] will come

home (Levy, 1992: 10). At this time, penicillin was widely heralded as a miracle

drug. People were astonished at the ability of antibiotics to cure illnesses overnight

that had previously been fatal.

But the golden era of antibiotics was to be short-lived. Fleming himself noted

early on that the drug required careful dosing and that bacteria mutate quickly in

response to exposure. When accepting his 1945 Nobel Prize, Fleming warned of bac-

terial resistance. Although his concerns were primarily with underdosing (a problem

that persists both through noncompliance and, primarily in developing countries,through lack of knowledge or proper antibiotic supplies), his illustration of the threat

of bacterial resistance is still relevant today:

Here is a hypothetical illustration. Mr. X has a sore throat. He buys some penicillin and

gives himself, not enough to kill the streptococci but enough to educate them to resist

penicillin. He then infects his wife. Mrs. X gets pneumonia and is treated with penicillin.

As the streptococci are now resistant to penicillin the treatment fails. Mrs. X dies. Who is

primarily responsible for Mrs. Xs death? Why Mr. X whose negligent use of penicillin

changed the nature of the microbe. (Fleming, 1945)

As it turns out, the resistance problem is actually worse than Fleming envisioned

in two ways. It turned out that even restrained use of antibiotics will generate bacte-

rial resistance over time. Moreover, the resistance problem emerged very quickly. As

early as 1946, just a few years after mass production began, when penicillin was still

available without a prescription in the United States, there were reports of penicil-

lin-resistant bacteria probably due in no small part to the misuse that Fleming had

been concerned about (Levy, 1992). But at that point, new antibiotics were quicklycoming onto the scene.

Fast forward just 30 years to the early 1970s, and antibiotic resistance had

already come to be considered a real public health threat. Strains of bacteria that

cause meningitis and ear infections in children and a strain that caused gonorrhea

once again proved fatal. Both had previously been treated successfully with penicil-

lin or a derivative (Levy, 1992).

At present, just over 60 years since the beginning of wide-scale antibiotic use,

the growing problem of bacterial resistance to antibiotics is widely recognized as one


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THE MIRACLE DRUG 5

of societys greatest health threats (Adam, 2002; Baquero, Baquero-Artigao, Can-

ton, & Garcia-Rey, 2002; Doern & Brown, 2004; Harbarth, Albrich, & Brun-Buis-

son, 2002; Jacobs, Felmingham, Appelbaum, Grneberg, & Group, 2003; McCaig &

Hughes, 1995; Neu, 1992; Reichler et al., 1992; Schwartz, 1999; Smolinski, Ham-burg, & Lederberg, 2003; Whitney et al., 2000; Wise et al., 1998). As discussed in a

brief introduction to a recent special issue ofEmerging Infectious Diseases devoted

to antimicrobial resistance, bacterial resistance promises to pose a still larger prob-

lem soon because the manufacture of new drugs is at a virtual standstill and has

been since 1968 (Weber & Courvalin, 2005). This means that we are on the brink of

returning to an era when common illnesses, long thought to have been conquered,

may once again prove fatal. At present, illnesses caused by such bacteria are already

more difficult to treat (Dagan, 2000; Friedland, 1995; Watanabe et al., 2000), more

expensive to treat (Gums, 2002; Holmberg, Solomon, & Blake, 1987), and result in

increased mortality (Feikin et al., 2000). For all of these reasons, the problem of bac-

terial resistance is a paramount public health concern worldwide.

Determinants of Bacterial Resistance

What lies behind the bacterial resistance problem? The answer is far from simple. A

2000 World Health Organization (WHO) report points to a number of issues, includ-ing the overuse of antibiotics in livestock (World Health Organization, 2000) and

international travel that spreads resistant bacteria (Fidler, 1998; Memish, Venkatesh,

& Shibl, 2003). But the biggest single factor across both developing and developed

nations appears to be the very problem of misuse that Fleming pointed to in 1945

(Albrich, Monnet, & Harbarth, 2004; Harbarth & Samore, 2005). Prescribing when

it is not clinically appropriate is still relatively common (Kaiser et al., 1996; Orr,

Scherer, MacDonald, & Moffatt, 1993; Todd, Todd, Damato, & Todd, 1984), and this

is a primary contributor to the generation of bacterial resistance (Albrich et al., 2004;

Cristino, 1999; Deeks et al., 1999; Gomez et al., 1995; Nava et al., 1994; Watanabe

et al., 2000). A second contributing form of misuse involves prescriptions for an

inappropriate type of antibiotic (e.g., using a second-line, stronger antibiotic rather

than a first-line one when clinical guidelines support the latter) (Hossain, Glass, &

Khan, 1982; Hui, Li, Zeng, Dai, & Foy, 1997), and this, too, has been shown to con-

tribute to bacterial resistance (Kozyrskyj et al., 2004; McCaig et al., 2003). Although

there is substantial overlap, misuse takes somewhat different forms in developing

versus developed nations.

Misuse in Developing Countries

In developing countries, the factors that lead to misuse revolve around problems of

supply and regulation. For instance, with respect to supply issues, developing coun-

tries often have difficulties in accessing the right medication or adequate doses of

medication (Guyon, Barman, Ahmen, Ahmen, & Alam, 1994; Uppal, Sarkar, Giriyap-

panavar, & Kacker, 1993). It is also not always possible to gain access to diagnostic

tests that would allow health practitioners important insight into the condition(s) that


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they are treating (e.g., Bosu & Ofori-Adjei, 1997; Horgerzeil et al., 1993; Mamun,

1991). Because of restricted access to information, developing countries may also

suffer from a lack of physician knowledge (Igun, 1994) and a corresponding lack of

patient knowledge (Braithwaite & Pechere, 1996).Regulation is also a serious problem in developing countries, where antibiotics

are often available directly from pharmacies, health care providers, or roadside stalls

without government restriction (Bartoloni et al., 1998). Evidence suggests that when

people can self-medicate, misuse is rampant in terms of both usage for inappropri-

ate conditions (Haak, 1988; Radyowijati & Haak, 2003; Vuckovic & Nichter, 1997)

and inappropriate dosing (Indalo, 1997; Kunin et al., 1987). To drive down the cost

of antibiotics, some patients purchase only one dose at a time, use insufficient dos-

ages, or truncate the course of antibiotics. Both a lack of understanding of how the

drug works and the implications of such practices, as well as economic issues, con-

tribute to this problem. These are practices that effectively educate bacteria to resist

antibiotics.

However, prescribing issues are quite a complex problem in developing coun-

tries because in spite of fewer antibiotic regulations, they do not necessarily have

higher rates of bacterial resistance. This is probably because many people, particu-

larly in rural areas, still have substantial barriers to access, including transportation,

cost, or lack of providers in the area. For instance, India has few regulations over

antibiotic prescribing but very low rates of resistance in the bacteria relevant to ourdiscussion here, at least in rural areas (Thomas, 1999). This means that there may

actually be less misuse of antibiotics in rural areas, despite the lack of regulations

in place (Quagliarello, Parry, Hien, & Farrar, 2003). But as a consequence, people

who should appropriately be treated with antibiotics may not receive them either.

Although it is difficult to fully assess the situation across developing nations, there is

substantial evidence that penicillin and erythromycin resistance is an emerging prob-

lem in community-acquired Streptococcus pneumoniae across many regions of the

world, even in more rural areas (see Okeke et al., 2005, for a review).

Misuse in Developed Countries

Developed countries generally have fewer problems with respect to physician knowl-

edge, access to high-quality drugs (barring problems with counterfeit drugs and the

like), and adequate amounts of medication. Moreover, developed countries typi-

cally regulate access to antibiotics, and many have public health campaigns in place

to educate patients about antibiotics. However, existing research shows that inap-

propriate prescribing of antibiotics for viral infections is nonetheless common inmany developed countries. In the United States, researchers and policy makers are

strongly advocating more judicious prescribing practices (e.g., Bell, 2002; Belongia

et al., 2001). But advocacy alone, even from national and international organizations

such as the Centers for Disease Control and the World Health Organization, has not

stopped doctors from inappropriately prescribing (Finkelstein et al., 2000; Gonza-

les, Malone, Maselli, & Sande, 2001; Gonzalez, Steiner, & Sande, 1997; Mainous,

Hueston, & Clark, 1996; Mangione-Smith et al., 2004; McCaig, Besser, & Hughes,

2002; Metlay, Shea, Crossette, & Asch, 2002; Pennie, 1998). For viral colds, the


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THE MIRACLE DRUG 7

prescribing rate across populations is estimated to be approximately 30%, and for

bronchitis and other illnesses typically of viral origin, it is estimated to be as high as

60% (Gonzales et al., 2001).

Cultural factors may also play a role. People with different cultural backgroundsmay be more or less likely to visit a physician for a particular condition (Pachter,

1994). People from particular cultural backgrounds may be more likely to expect that

a visit to a health care provider will result in a prescription for treatment (Radyowijati

& Haak, 2003). Such expectations may, in turn, affect prescribing rates among partic-

ular ethnic and cultural groups (Froom et al., 2001; Harbarth et al., 2002; Radyowijati

& Haak, 2003). Differences in cultural attitudes specifically toward antibiotics may

lead to another related issue: the transportation and sales of noncontrolled antibiotics

into developed countries where prescriptions are required (Mainous et al., 2005).

When physicians are asked why they prescribe against clinical evidence and

national guidelines, they commonly cite issues such as patient pressure (Avorn &

Solomon, 2000; Little et al., 2004; Stevenson, Greenfield, Jones, Nayak, & Bradley,

1999), lack of time (Little et al., 2004), and a concern with avoiding lawsuits over

missed bacterial infections (Sargent & Welch, 2001).

Whether in developing or developed nations, antibiotic misuse is unlike most

types of medical errors in that it is an error that has far greater social impact than

individual impact. As Avorn and Solomon observe, Antibiotics are the only drug

class whose use influences not just the patient being treated but the entire ecosys-tem in which he or she lives, with potentially profound consequences (2000: 128).

This was foreseen by Fleming, as noted earlier in the excerpt from his Nobel Prize

acceptance speech (1945). The social consequences of misuse may be at the level of

the community, as in the Fleming example, because bacteria can easily spread from

children to adults within the local community, but they can also be at the regional,

national, or even international level (McCormick et al., 2003). As Levy points out,

bacteria do not have respect for national borders (Levy, 1992). Thus, it is possible

for resistant bacteria to cross the world within 24 hours (Fidler, 1998). And travelers

definitely spread bacteria around: Approximately 1,500 of every 100,000 travelers

returning from developing countries bring with them an acute febrile respiratory tract

infection (Steffen & Lobel, 1996).

Misuse that does not result from lack of knowledge or supply problems typically

pits the individual against society and thus represents a social dilemma: situations in

which individual rationality leads to collective irrationality (Kollock, 1998).1 Anti-

biotic misuse by individuals is perhaps best understood as the type of social dilemma

Hardin made famous in his article in Science in 1968. Hardins example was that of

herders who collectively have access to common land for cattle grazing. Individualrationale would have it that each herder should put as many grazing cows as possible

onto the land, even though the commons will be damaged as a result. To make the

decision that would be collectively best would require all herders to act in a way that

is not in the interest of the individual (i.e., putting fewer cattle on the land) (Hardin,

1968). This type of social dilemmausing the land for individual gain even at the

cost of the collectiveHardin terms a commons dilemma.

Typically, patients and parents of child patients do not view their illnesses as

viral or bacterial but as minor or serious. A serious illness is one that they have tried


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to wait out or to treat but that has persisted or an illness that stands in the way of

some special event for which they do not want to be sick. At least among those who

believe that it is not good for human society to use antibiotics often, these cases are

much like the grazing situation described by Hardin.2

For parents, the desire to useantibiotics is rational at the individual level because of their belief that antibiotics

will help their children get better faster. For physicians, the desire to prescribe anti-

biotics is rational at the individual level because they believe that it will satisfy the

parent, enable the visit to be closed, and allow both parties to move on. The desire to

use antibiotics is irrational at the collective level because they expose bacteria to the

drug and thereby enable them to mutate and develop resistance to the drug. In gen-

eral, humans may be inclined to prioritize themselves as individuals or families over

the larger community. As noted by Humphrey in his important paper on social intel-

ligence, individuals have evolutionary reasons for prioritizing the survival of their

own genes over others and thus to do well for oneself whilst remaining within the

terms of the social contract on which the fitness of the whole community ultimately

depends calls for remarkable reasonableness (Humphrey, 1988). And solutions to

such problems are challenging, to say the least. (See Kollock, 1998, for a discussion

of strategic solutions to social dilemmas.) We will return to this in chapter 8.

Bacterial Resistance as a Global Problem

Ultimately, the community that stands to suffer because of individual-level decisions

is the global one. Even in countries where inappropriate prescribing is relatively low,

such as The Netherlands (Melker & Kuyvenhoven, 1994; Otters, van der Wouden,

Schellevis, van Suijlekom-Smit, & Koes, 2004), inappropriate prescribing does occur

(Otters et al., 2004). Still, national policies clearly do make a difference, as evidenced

by the broad range of rates of antimicrobial resistance and generally corresponding

rates of inappropriate antibiotic prescribing across countries. Europe is particularly

interesting in this respect because of the close proximity of so many countries.

According to reports from the Alexander Project 19982000 (a continuing sur-

veillance study that examines the susceptibility of bacteria involved in respiratory

tract infections), even countries that share a border can have dramatically different

rates of penicillin resistance to bacteria (Jacobs et al., 2003). Whereas Portugal has a

rate of 8.2% penicillin resistance, Spain has a rate of 26.4%. Whereas Germany has

a rate of 1.9%, Switzerland a rate of 8.6%, and Belgium a rate of 5.7%, France has a

staggeringly higher rate of 40.5%. The same goes for nearby countries as well. And

although relative to France, Belgiums rate of 5.7% is quite good, relative to its otherborder country, The Netherlands, it is quite poor. The Netherlands has the lowest rate

in the European Union, only 1.1%. Nearby UK has a rate of 10.9%, and growing still

worse, neighboring Ireland has a rate of 24.1%. In general, the data show a generally

consistent pattern between antimicrobial usage and resistance prevalence, and these

patterns also appear generally consistent with outpatient antibiotic sales (Cars, Ml-

stad, & Melander, 2001) and antibiotic usage (Albrich et al., 2004). France is again

the highest, Spain is also quite high, and Germany and The Netherlands are again

very low.


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THE MIRACLE DRUG 9

The Current Investigation

The problem of inappropriate prescribing is clearly large and amorphous. In this

book, we focus on one problem area: inappropriate prescribing of antibiotics forviral upper respiratory tract infections (URTIs) among children in the United States.

There are a variety of reasons for thinking this a useful population to study. First, 65

to 70% of URTIs are viral (Wald, Guerra, & Byers, 1991). Second, according to the

National Ambulatory Medical Care Survey, American pediatric patients receive two

to three times more antibiotic prescriptions than any other patient group, including

the elderly (Aronoff, 1996). Third, compared with adult populations, the pediatric

population has been particularly resistant to efforts to alter inappropriate prescribing

for viral URTIs (Belongia, Knobloch, & Kieke, 2005). Fourth, according to Alex-

ander Project data, the United States has one of the highest rates ofStreptococcus

pneumoniae resistance to penicillin worldwide. Its rate of 25% surpasses its neighbor

Mexico, a developing country with minimal antibiotics regulation, which has a rate

of 22%. Only Spain, Japan, Israel, France, and Hong Kong (with a whopping 69.9%

rate of bacterial resistance to penicillin) surpass the United States (Jacobs et al.,

2003). Thus, U.S. prescribing practices for children with URTI symptoms may yield

insight into the larger problems of misuse, both nationally and internationally.

This book demonstrates that pediatrician-parent interactions provide a critical

window into the macrolevel problem of bacterial resistance and antibiotic misusein the United States. Close examination of such encounters reveals the impact that

microlevel interactional phenomena have on diagnostic and treatment outcomes in

URTI visits. This investigation will argue that while the root of misuse in developing

countries is more clearly a public health issue, the root of misuse in developed coun-

tries 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 physi-

cians understand the relationship between viral infections and antibiotics. Because

research suggests that 89% to 97% of U.S. physicians do understand this relationship

(Schwartz, Freij, Ziai, & Sheridan, 1997; Watson et al., 1999), the question remains

as to why physicians continue to overprescribe antibiotics in the face of the antibiotic

resistance problem.

As mentioned earlier, physicians commonly cite patient and parent pressureas a reason for prescribing (Barden, Dowell, Schwartz, & Lackey, 1998; Palmer

& Bauchner, 1997; Schwartz, 1999; Schwartz et al., 1997; Watson et al., 1999).

In pediatrics, 50% to 70% of parents visiting report an expectation that their child

will be given antibiotics (Hamm, Hicks, & Bemben, 1996; Mangione-Smith et al.,

2004; Mangione-Smith, Elliott, Stivers, McDonald, & Heritage, 2006; Mangione-

Smith, McGlynn, Elliott, Krogstad, & Brook, 1999; Sanchez-Menegay & Stalder,

1994). However, parents reports of expectations are not necessarily associated with

inappropriate antibiotic prescribing (Mangione-Smith et al., 2006; Mangione-Smith


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et al., 1999). And physicians are not accurate predictors of which parents expect

antibiotics and which do not (Mangione-Smith et al., 2006; Mangione-Smith et al.,

1999).

Additionally, researchers in both adult and pediatric contexts have found thatdoctorsperceptions of patients expectations for antibiotics have a significant effect

on whether doctors prescribe antibiotics, even in cases where they judged them to be

not indicated (Britten & Ukoumunne, 1997; Cockburn & Pit, 1997; Gani et al., 1991;

Hamm et al., 1996; Mangione-Smith et al., 2006; Mangione-Smith et al., 1999; Man-

gione-Smith, Stivers, Elliott, McDonald, & Heritage, 2003; Vinson & Lutz, 1993).

Specifically, in one study there was a 25.5% increase in the probability that the phy-

sician would prescribe an antibiotic if he or she perceived the parent to expect it,

controlling for a range of other issues (Mangione-Smith et al., 2006). Additionally,

when physicians thought parents expected antibiotics, they diagnosed middle ear

infections and sinusitis more frequently (49% and 38% of the time, respectively)

than when they did not think antibiotics were expected (13% and 5%, respectively).

These figures are likely to be low because of improved behavior during the study

period (Mangione-Smith, Elliott, McDonald, & McGlynn, 2002).

This suggests a disconnect between what parents report and how physicians per-

ceive them. Because what physicians perceive appears to influence their behavior,

and they can access parents expectations only through parents behavior, it is this

that appears to be most consequential, which raises the issue of what parental behav-iors lead physicians to believe that parents are looking for antibiotics.

Overt parent requests for antibiotics might be expected to be the culprit, and

physicians typically cite and complain about this occurring (Schwartz et al., 1997;

Stevenson et al., 1999). Although overt requests and other forms of overt lobby-

ing for antibiotics do occur (discussed in chapter 6 primarily), they are quite rare

(Fischer, Fischer, Kochen, & Hummers-Pradier, 2005; Stivers, 2002a). On the other

hand, this book will argue that less direct interactional behaviors also communicate

pressure for antibiotic prescriptions, even if, at times, unintentionally. This book will

argue that in a variety of ways, parents actively participate in the visit in ways that

pressure physicians in the direction of bacterial diagnoses and antibiotic prescribing.

This book will also argue that parents, even when vying for antibiotics, are oriented

to this interactional work as in the physicians domain of expertise, and thus this

issue is something parents work to manage.

Pressure as Parent Participation

Patient participation is currently an important topic of discussion in health servicesresearch and health policy circles. Much of the emphasis from local to national lev-

els is to encourage physicians to involve patients or parents in treatment decisions.

According to the goals of Healthy People 2010, patients who participate actively in

decisions about their health care can have a positive impact on national health (U.S.

Department of Health and Human Services, 2000). Researchers assert that patients

should, whenever possible, be offered choices in their treatment decisions (Brody,

1980; Butler et al., 2001; Deber, 1994; Emanuel & Emanuel, 1992; Evans, Kiell-

erup, Stanley, Burrows, & Sweet, 1987; Fallowfield, Hall, Maguire, & Baum, 1990;


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THE MIRACLE DRUG 11

Kassirer, 1994; Levine, Gafni, Markham, & MacFarlane, 1992). Several American

medical associations now recommend that physicians overtly involve patients in

their decision making. For instance, the American Cancer Society, the American

Urological Association, the American Gastroenterological Association, the Ameri-can College of Physicians, and the National Institutes of Health (NIH) all recom-

mend shared decision making for decisions surrounding cancer screening (Frosch

& Kaplan, 1999).

Although there is recognition that not every patient wants to participate in

their health care, the primary rationale fueling these recommendations is, first, that

patients generally do have the desire and are entitled to participate in treatment

decisions (Blanchard, Labrecque, Ruckdeschel, & Blanchard, 1988; Cassileth, Zup-

kis, Sutton-Smith, & March, 1980; Emerson, 1983; Ende, Kazis, Ash, & Moskow-

itz, 1989; Faden, Becker, Lewis, Freeman, & Faden, 1981; Swenson et al., 2004;

Thompson, Pitts, & Schwankovsky, 1993) and, second, that patients have improved

outcomes when they participate in medical decision making, including satisfaction

(Brody, Miller, Lerman, Smith, & Caputo, 1989; Brody, Miller, Lerman, Smith,

Lazaro, et al., 1989; Evans et al., 1987), patient health (Brody, 1980; Greenfield,

Kaplan, Ware, Yano, & Frank, 1988; Kaplan, Greenfield, & Ware, 1989; Mendonca

& Brehm, 1983; Schulman, 1979), and patient mental well-being (Brody, Miller,

Lerman, Smith, & Caputo, 1989; Evans et al., 1987; Fallowfield et al., 1990; Green-

field et al., 1988).Although the movement toward shared decision making in health care has

certainly taken root in the care of chronic conditions, the issues have been far less

explored in acute care. But the social factors encouraging partnership in chronic care

may nonetheless also be affecting acute care encounters. First, because of the con-

sumerist movement in health care, patients can be seen to be moving away from the

guidance-cooperation models depicted as normative by Parsons in the 1950s (1951)

and documented empirically in the 1970s (Byrne & Long, 1976). Specifically, as

Haug and Lavin (1983) suggest, the consumer model refocuses the balance of power

on the patients rights (as purchaser) and on the physicians obligations (as seller)

rather than on the physicians rights (to direct) and patient obligations (to follow

directions) (p. 213). As summarized by Roter and Hall (1992), patients, particu-

larly younger and more highly educated ones, are becoming more likely to exhibit

consumerist behaviors (Ende et al., 1989; Hibbard & Weeks, 1985; Reeder, 1972),

which include having sophisticated medical knowledge, seeking information through

reading, and exercising independent judgment in following physicians recommen-

dations. Kravitz, Bell, and Franz (1999: 873) suggest that patients are more than the

passive recipients of doctors actions; they influence the clinical encounter throughuse of their own linguistic resources.

Second, as of 1985, drug companies have been allowed to market prescription

medication directly to consumers (DTC). Promotional strategies encourage patients

to act as consumers both in terms of product knowledge and with explicit sugges-

tions to ask your doctor if X is right for you. As summarized by Pinto, Pinto, and

Barber (1998), this shift was brought about because of pressure by drug companies

who felt that managed care companies restricted their access to physicians and to

patients in the sense that often only particular drugs would be covered by a given


23/232


company. Competitiveness in the drug market also added pressure. Additionally,

though, patients with the activist mindset of many . . . baby boomers (p. 93) also

gave the movement a needed push. Once in place, the DTC move fueled still more

patient activism: patients are active decision makers for their own health needs (orthe health needs of their babies) and . . . physicians are not the exclusive influencers

in brand selection (pp. 9192).

Research suggests that advertising is encouraging patients to ask about medica-

tion (Peyrot, Alperstein, van Doren, & Poli, 1998) and that physicians are likely to

prescribe or consider prescribing a drug requested by a patient (Borzo, 1997). With

respect to patients asking, Sleath, Svarstad, and Roter (1997) examine data involv-

ing patients receiving care for chronic conditions and who are prescribed a psycho-

tropic drug. They claim that patient-initiated talk showing that they wanted a new

prescription was associated with prescribing 20% of the time. More recently, Kravitz

and his colleagues have shown that requests do affect prescribing rates (Kravitz et

al., 2005). Moreover, there is additional evidence that patients are becoming more

consumer oriented: In a survey asking how people are likely to react to being denied

a requested prescription, Bell, Wilkes, and Kravitz (1999) found that 46% of respon-

dents reported being likely to be disappointed by a denied prescription request. Addi-

tionally, 25% of all respondents reported being likely to pressure physicians. Finally,

24% of all respondents who were denied a prescription said they would be likely to

seek a prescription from another physician.Related to DTC advertising is a third factor that may affect not only chronic but

also acute care: A vast amount of medical information is now readily accessible to

the public through the Internet (du Pr, 2000). Thus, patients are not only being influ-

enced to be more proactive in their own health care but also being given resources

with which to become more knowledgeable. Kravitz and colleagues (1999) found

that the most common information requests involved questions about medications

and that the most common action request was for medications. This has largely been

studied with respect to chronic or serious conditions, but these factors also affect

acute care. As du Pr points out, It is no longer enough (if it ever was) to simply

tell patients what to do. Empowered patients want information and the right to make

their own decisions (2000: 15). Thus, even in situations such as acute care, where

physicians may feel that a more medical or disease-based approach is appropriate,

there may be pressure from both patients and policy makers for patient participation

in the visit.

Treatment for an acute illness is typically conceptualized as something that the

patient is directed to do by the physician or that the physician recommends or advises

(e.g., Byrne & Long, 1976). And some research suggests that in the primary carecontext, doctors are much less likely to involve patients or parents in treatment deci-

sion making (Braddock, Edwards, Hasenberg, Laidley, & Levinson, 1999; Elwyn,

Edwards, & Kinnersley, 1999; Tuckett, Boulton, Olson, & Williams, 1985). Gen-

erally, the treatment phase of an acute medical encounter is thought of as doctor

driven (at least in the sense that doctors make recommendations and provide advice

for treating the patients medical problem), particularly in contexts where there is a

view that only one course of action is correct and thus decision making is basically

straightforward (Coulter, 1997; Szasz & Hollender, 1956). Additionally, patients


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THE MIRACLE DRUG 13

with acute problems are generally seeking a physicians treatment recommenda-

tion or advice, and the physicians recommended treatment is generally grounded

in his or her medical knowledge. Therefore, patients in the acute contexts might be

assumed to interact within the guidance modelnot disagreeing or querying thephysicians treatment recommendation (Szasz & Hollender, 1956). And if patients

were to influence acute visits at all, we might expect it to be done subtly, given the

general orientation of these visits.

For these reasons, only a method that examines interactions at a detailed level

would be able to identify such practices. This is the method adopted in this book.

Here what I show is that when we look carefully at the details of parent-physician

interaction, we see that parents and physicians frequently go through a subtle but

very much observable negotiation of the childs illness. Negotiation occurs at virtu-

ally every stage in the visit, from the opening statements to the doctor to the recep-

tion of the physicians treatment recommendation and a variety of places in between.

This book will step through each of the phases of the medical visit in order to show a

variety of different practices (mostly covert) that parents initiate and that can be seen

to affect the diagnostic and treatment outcome of their childs medical visit. Thus,

contrary to what would be deduced from the existing literature, this book shows that

even in rather doctor-centered visits, where the physician has made no real effort to

explicitly involve the parent in the treatment process, parents affect the diagnostic

and treatment outcomes of the visits through their interactions with the physician.

Methodology

Historically, there has been relatively little connection between large-scale social

or public health problems and microlevel studies. Rather, these problems have been

most typically investigated through large-scale surveys of either medical records or

of physicians and parents. [(As one example of a survey that has generated studies

relevant to this domain, see the National Ambulatory Medical Care Survey (CDC,

2004), which is a key survey in primary care for the Centers for Disease Control.)]

When provider-patient interactions are examined, this most commonly involves

process analysis methodology: a coding of the interaction, followed by an analy-

sis only of the coding rather than the interaction. Debra Roter has been the leading

figure in the development of this work since the pioneering research of Barbara

Korsch in the 1960s (e.g., Korsch, Gozzi, & Francis, 1968). Interactions in this and

similar types of approaches are coded on the basis of analyst- or literature-driven

constructs (a top-down approach), whether for issues of patient participation or phy-

sician behavior, rather than codes that have emerged from an understanding of howinteractions in the context of interest work. (See Roter & Hall, 1992, for a review of

one of the major coding schemes in interaction studies in public health, and Roter,

2002, for a full bibliography of studies using the Roter Interaction Analysis System

coding scheme.)

Microlevel analytic methods such as discourse and conversation analysis have

(but to a far lesser extent) taken root in the realm of health communication. These

studies have illuminated important dimensions of medical interaction but, with rare

exceptions (e.g., Waitzkin, 1991), the results are not generalized or are not generaliz-


25/232


able. For instance, using a microanalytic approach to discourse, Mishler shows that

physicians and patients commonly pursue very different (and, at times, conflicting)

agendas during medical visits: the medical agenda and the lifeworld agenda (Mish-

ler, 1984). West (1984) published the first conversation analytic book on medicalinteraction. She wanted to understand the role language played in structuring both

the social and the power relationships between physicians and patients. Todd and

Fisher published a collection of discourse analytic papers dealing with the organiza-

tion of medical communication (Todd & Fisher, 1993), and Heritage and Maynards

recent collection of conversation analytic studies examines each phase of the medical

visit and its organization (Heritage & Maynard, 2006).

Both discourse analysis (DA) and conversation analysis (CA) take the perspec-

tive that medical interaction is, at its most basic level, still basic social interaction

that is occurring in an institutional context (Drew & Heritage, 1992a). These meth-

odologies treat social interaction as a highly structured domain where the structural

underpinnings, like the structural underpinnings of a molecule, can be examined and

understood. For conversation analysts in particular, social interactants accomplish

social actions through language (See Heritage, 1984b, for summaries; Levinson,

1983). Thus, interactants greet each other, request things, and complain or invite

through language, and the doing of these social actions is itself highly structured.

One of the hallmarks of conversation analysis is that in analyzing any bit of

social interaction, analysts must validate their understandings of participants socialactions through an examination of interactants responses. This virtually necessitates

that analysts look at interaction through the lens of the sequence (e.g., an initiating

turn and a response) rather than restricting themselves to individual words, phrases,

or sentences, as linguists have historically done. This methodology was particularly

valuable in the present study because of the problem of understanding what parent

behaviors physicians were understanding as communicating pressure to prescribe,

regardless of parent intent.

In examining social interaction in sequence structural terms, CA looks for pat-

terns in the interaction that form evidence of systematic usage such that a particular

turn design, for instance, can be identified as a practice through which people

accomplish a particular social action either vocally or visibly. For example, from

ordinary interaction contexts, we see practices for opening telephone conversations

(Schegloff, 1968, 1972b, 1977), competing for epistemic rights over a claim (Heri-

tage, 1998; Heritage & Raymond, 2005), or inviting another interactant to complete

ones turn at talk (Lerner, 1996).

To be identified as a practice, a particular communication behavior must be seen

to be recurrent and to be routinely treated by a recipient in a particular way such thatit can be discriminated from related or similar practices. The significance of these

practices can be understood in terms of (1) the immediate sequences in which they

occur, (2) the larger activities in which they are embedded (Heritage & Sorjonen,

1994), and (3) the overall organization of the phases in the interaction. The latter two

levels of organization are particularly significant when CA is used to analyze inter-

action in institutional contexts, such as medical visits, because of the general goal

orientation of participants in these interactions (Drew & Heritage, 1992b).


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THE MIRACLE DRUG 15

A CA approach is highly structural in orientation. To this end, CA researchers in

medicine have been interested in practices of social interaction that reveal structure at

different levels: the visit (i.e., overall structure), the activity (e.g., the treatment activ-

ity/phase), the sequence (e.g., the opening question and its response), or the turn (e.g.,turn constructional practices). Some studies clearly fit into one level, such as studies

of the visits overall structure (for relevant work on phases, see Byrne & Long, 1976;

Robinson, 2003; Waitzkin, 1991) or studies of turn design within a phase, such as

Heritage and Stiverss examination of online comments offered during the physi-

cal examination (Heritage & Stivers, 1999). Other studies cross multiple levels. For

instance, Perkyl examines alternative ways of designing a diagnosis delivery. This

then is relevant both at the activity and the turn levels (Perkyl, 1998).

Very few conversation analytic studies have attempted to connect interactional

practices to large-scale exogenous issues, whether they are relational, socioeco-

nomic, demographic, or public health issues (but see Boyd, 1998; Clayman, Elliott,

Heritage, & McDonald, 2006; Clayman, Heritage, Elliott, & McDonald, in press;

Heritage, Boyd, & Kleinman, 2001; Kleinman, Boyd, & Heritage, 1997). This book

represents a conversation analytic investigation of how parents and physicians com-

municate about children with routine upper respiratory tract infection symptoms, and

it demonstrates that conversation analytic findings can offer results that bear on the

large-scale public health problem of inappropriate antibiotic prescribing.

Data

This book draws on three data sets. First, there is a corpus of 65 videotaped encoun-

ters involving 6 pediatricians from 5 practices collected as pilot data that I will refer

to as the Hillside data set. Then there is a corpus of 295 audiotaped encounters

involving 10 pediatricians from 2 practices that I will refer to as the Seaside data

set. Finally, there is a corpus of 522 videotaped encounters from 38 physicians in 27

practices that I will refer to as the Metro data set. All data were collected between

September 1996 and June 2001 in Southern California. Children ranged in age from

newborn through 16 years old, and all were accompanied by parents. Most visits

involve children from 6 months to 10 years of age. All visits involve children who

were being seen for routine illnesses, and approximately 98% of children had routine

upper respiratory tract infection symptoms. Informed written consent was obtained

from all participating parents and physicians in all samples. Only parents who could

conduct the visit in English were admitted into the studies. For purposes of anonym-

ity, in all transcripts pseudonyms replace any use of a subjects name or other identi-

fying information (e.g., school names).Demographic information was not collected for the Hillside data set, though I

expect it represents a midpoint (socioeconomically) between the Metro and Seaside

data. The Metro data involved parents who were 34 years old, on average, with a

median household income of $40,000. Most of the caregivers were mothers: 86%

were female. Fifty-three percent of the parents were Latino, with 28% white, 12%

African American, and 7% Asian. Sixty percent of parents were high school gradu-

ates but did not have a college degree. Twenty-four percent had at least an undergrad-


27/232


uate degree, whereas 16% had less than a high school degree. The Seaside data were,

on balance, somewhat wealthier, more likely to be white, slightly older, and more

likely to have a college education than the more diverse Metro sample. The demo-

graphic backgrounds of the Seaside and Metro data sets are described elsewhere ingreater detail (Mangione-Smith et al., 2006; Mangione-Smith et al., 1999). Statisti-

cal information that is mentioned throughout the book refers to either the Seaside or

Metro data. All data shown here were transcribed by the author according to the con-

ventions originally developed by Gail Jefferson (see Appendix for conventions).

The Role of Children in the Pediatric Visit

In earlier work (Stivers, 2001), I aligned myself with other researchers of pediatric

interactions against studies that fail to take into account the role of the child in the

interaction (e.g., Pantell, Steward, Dias, Wells, & Ross, 1982). Here, I appear vul-

nerable to this very criticism. However, in my analyses of these interactions, what

became clear is that children play quite a small role in the domain of treatment nego-

tiation. Interestingly, even when children are active participants in the visit, it is rare

that they perform the behaviors outlined in chapters 2 through 5 (but for a rare case,

see Extract 6.1). They typically do orient to the doctor as someone who can tell them

what is wrong and give medicine (see Extract 2.1 for an example). For this reason,

they can occasionally, without intention, make it difficult for a parent to perform abehavior that might have pushed for a bacterial diagnosis or antibiotic treatment.

For instance, if a child presents his or her own problem, parents are, at least in that

sequential location, blocked from presenting it in their own words: words that, as we

will see, can communicate a very particular stance toward the outcome of the visit.

For this reason, there will be relatively little discussion of the childs contributions,

despite the fact that in general interaction, their role is certainly important.

The Social Context of These Visits

Research on physician-patient interaction has been growing steadily, most signifi-

cantly since Barbara Korschs groundbreaking pediatric communication studies

(e.g., Korsch et al., 1968). I will not attempt to review that literature here (but see

Heritage & Maynard, 2006, for a comprehensive review). Instead, I will focus on

the issues that are most relevant to understanding what pediatricians and parents are

dealing with in their interactions involving children with routine childhood illnesses,

and specifically with upper respiratory illnesses.

Many American readers who have attempted to reach their primary care physi-cian during their lunch hour, after hours, or even when the phone lines are busy are

probably familiar with a common recording that physicians place on their voicemail

that instructs patients to call 911 emergency or to seek help in an emergency room if

their problem is life threatening. Virtually anything about which parents or patients

seek assistance from their primary care doctor is something that they do not perceive

as life threatening. But of course, many adults and children have health problems that

they live with or manage by themselves (Dunnell & Cartwright, 1972). In the case

of the visits with which we are dealing, it is likely that every child has had a similar


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THE MIRACLE DRUG 17

illness in the past, and it is virtually certain that every parent has experienced an ill-

ness similar to the one the child has several times, if not on an annual or semiannual

basis. Thus, parents in these visits have made a decision to seek medical care at this

time. Physicians, too, are aware that each visit was not a virtual certainty (as might beexpected with acute pain that results in a trip to the emergency room). Rather, visits

are understood to be the result of an active consideration of alternatives.

In general, this book will argue that parents seeking medical help for these rou-

tine illnesses feel they have gone beyond the point where their own expertise is suf-

ficient. Some parents may be coming specifically to get antibiotics; some may be

coming because they are getting no sleep, and their child is cranky, disturbing the

household, and they do not know what to do; others may want reassurance that what

they have been doing is right and that there is no more to be done. In all cases,

though, they have a problem that they no longer feel comfortable handling on their

own. Two issues seem to inhabit these interactions: (1) the legitimacy of the visit and

(2) the treatability of the child.

Legitimacy

In the way that adult patients present their reason for visiting the physician, they

often include statements that work to show they have not rushed to the doctor at the

first sign of a problem but have waited a reasonable length of time, have come forgood reason, and have attempted to manage their troubles prior to seeking medical

assistance (Heritage & Robinson, 2006a). Similarly, patients work to show that they

have not been overly attentive to their bodiesnoticing the slightest or most minimal

changebut rather are coming to the physician only with rather unusual noticings

or problems (Halkowski, 2006). Heritage and Robinson (2006a) argue that there are

three basic ways that patients in acute primary care encounters display their orien-

tations to their conditions as doctorable or worthy of evaluation as a potentially

significant medical condition, and worthy of counseling and, where necessary, medi-

cal treatment (p. 58):

1. Patients routinely include in their problem presentations attributions to third

parties in order to give support to their decision to seek medical assistance

(i.e., physicians, spouses, friends, or acquaintances said they should see a

doctor).

2. Patients routinely display troubles resistance both (a) in the report of their

decision to visit the doctor (e.g., stating that they have waited some length

of time, or that they tried over-the-counter medications) and (b) in theirdescription of their condition (e.g., they offer objective rather than subjec-

tive evidence of their difficulty as severe enough to warrant the visit). For

example, patients with shoulder pain will state that they cannot latch a seat

belt by way of indirectly indexing the severity and doctor worthiness of

their complaint, rather than describe the degree of their pain.

3. Patients rarely offer any diagnosis of their condition and furthermore orient

to this as a behavior to be avoided (Gill, 1998). In this way, they defer to the

physicians knowledge for solving their medical problem.


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The ways parents communicate about their childrens conditions appear to be

somewhat different. Whereas adult patients and parents share an orientation to the

doctorability of the medical conditions, the pediatric context appears to have char-

acteristics that are at variance with adult acute visits. First, parents more rarely for-mulate the reason for their childs visit as based on a third partys recommendation.

Rather, this is typically reserved as a justification for a concern either offered subse-

quent to the presentation or following indications by the physician that the child may

not have a problem (e.g., see Extract 7.24).

Second, parents typically report their decision to visit the doctor more straight-

forwardly and in less troubles-resistant ways than adults. For example, parents

appear more willing to go to the doctor quickly on behalf of their child than on their

own behalf, and they provide less justification for this behavior. Although as Parsons

(1951) pointed out, adults are normally obliged to resist the sick role and to make

light of their troubles, the sufferings of little children are another matter (Strong,

1979: 204). While troubles resistance may be invoked during pediatric encounters in

the form of showing, for example, that they did not rush to the doctor, the data in my

corpus also support Strongs suggestion that concerns to justify a visit to the doctor

may be somewhat relaxed in the pediatric context.

Third, parents orientations to bodily attentiveness appear to be markedly differ-

ent when they are acting as caregivers rather than patients. For instance, according

to Halkowski (2006), adults who are overly concerned about themselves risk beingthought to be seeing the doctor in a motivated way. Halkowski further suggests that

adult patients regularly show a balance between attentiveness and inattentiveness to

their bodies and emergent symptoms. By contrast, parents acting as an advocate for

their child appear to be more attentive. In this context, the balance normally seen in

adult primary care may be recalibrated. Concern over a childs well-being is gener-

ally seen as the sign of a good, if slightly overanxious, parent. This is supported

further by data involving British health visitors and first-time mothers (Heritage &

Lindstrm, 1998; Heritage & Sefi, 1992). For example, in this data extract, the health

visitor is illustrating the types of noticings and the level of detail at which noticings

should be made. The parents are instructed to notice when she smi:les (line 9),

when . . . shes holding her head up better (lines 910), and when she can see

(lines 1112).

(1.1) Extract from Heritage & Lindstrm, 1998: 404

1 HV: .hh These uhm (1.0) are the notes that I carry

2 arou(t) with me:,3 F: Mm hm,

4 HV: And I (0.2) I uh record your babys progress

5 on he:re.

6 (0.2)

7 HV: .hhh [So that uhm (.) I want to know when shes

8 M: [(Oh)

9 HV: doing new things when she smi:les and when she

10 (.) .hh uh:m you know shes holding her head up


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THE MIRACLE DRUG 19

11 better: .hh I want you to notice if she: (.) .hh

12 can see:_ ((datum continues with father volunteering

13 information about babys sight).

In contrast to an avoidance of overly self-attentive behavior in adults, with chil-

dren we see an orientation to both the acceptability and desirability of close bodily

monitoring.

Related to this argument, parents may be more sensitive to potential perceptions

of negligence when they are acting as their childs caregiver than when they are act-

ing on their own behalf. For example, a parent may hear a doctors questions about

her childs health as testing her capabilities as a mother (Bates, Bickley, & Hoekel-

man, 1995; Heritage & Sefi, 1992). Parents have some reason to be concerned about

their pediatricians perceptions of them. Sheridan (1994) surveyed pediatricians and

family practitioners about their perceptions of the accuracy of parents reports of

their childrens symptoms. She showed that while only 1% of parents were perceived

as actually falsely reporting or inducing their childs symptoms, 23% were perceived

to be in some way misrepresenting their childs symptoms (e.g., exaggerating them)

(Sheridan, 1994).

Fourth, parents appear markedly more likely to offer possible diagnoses in the

pediatric context. I will analyze this practice in detail in chapter 2, but for this discus-

sion it is important to recognize that this behavior may indicate that parents feel moreentitled to have expertise over, and to participate in, the diagnosis and treatment of

their child than in their own care. Specifically, a parent who is knowledgeable about

childhood illnesses, symptoms, remedies, and the like is displaying good parent-

ing. By contrast, an adult patient who is knowledgeable about acute illnesses may be

viewed, and treated, as an uncooperative or bossy patient (Papper, 1970).

Within the pediatric context, we have observed that parents, on the whole, are

less oriented to (1) diffusing responsibility for seeking medical care and (2) exhibit-

ing troubles resistance and are more willing to (3) diagnose their childs condition

and (4) be attentive to their childs body. That said, we observed earlier that with rou-

tine illnesses parents do make a decision that this illness at this point in time requires

medical attention, whereas similar illnesses at other times have not. So, although in

many ways parents are under fewer constraints to legitimize their visit, there none-

theless appears to be some underlying concern that their visit be legitimate, or at least

that its legitimacy be validated, and in various behaviors a concern with legitimating

their visit can be observed. However, to some extent it appears that the concern is less

to establish legitimacy than to have it validated. Whereas adults appear to frequently

treat their visits legitimacy as questionable from the outset, parents appear moreconcerned that the physician not undermine the inherent legitimacy of their visit.

This will be most clearly visible in chapter 3 on history-taking questions and chapters

4 and 5 on diagnosis delivery and treatment recommendations.

One reason for this might be that parents may demand and expect more doctor-

ing when they are acting as an advocate for their child rather than as a patient. Roter

and Hall (1992) suggest that parents are more likely to be assertive on anothers

behalf, especially a childs (p. 17). They provide an example of a father who, after

coming to an emergency room, announced that he would only see a doctor who


31/232


was a parent (p. 17). Researchers have also found that parents are more willing to

seek out information, ask questions, and voice concerns when speaking on behalf of

their child (Korsch et al., 1968). And parents may have a stronger concern than adult

patients about the cause of their childs illness (Korsch et al., 1968).

Treatability

These issues come together in a marked way with respect to treatment decisions.

Here, several key issues converge: First of all, parents have familiarity with these ill-

nesses both in their own experience and in observing their children. Therefore, they

may often feel that they know what the problem is and how it may need to be treated.

Just as parents and physicians orient to greater latitude across a range of behaviors

in the pediatric encounter, in contrast to the adult encounter, this may also affect

parents willingness to explicitly or implicitly seek out treatment for their child. That

is, in contrast to an adult patient, a parent may be more willing to (1) ask about treat-

ment, (2) pressure physicians for treatment, or (3) display expertise about treatment

options for their child.

Second, in contrast with adult care, parents may feel additional pressures to

cure their child. One pressure parents face in terms of sick children is the need

for a quick solution to their problem. As caregivers, parents are responsible for both

properly caring for a sick child in terms of keeping them at home and taking themto a doctor if needed and also in terms of getting medicine for them. In todays soci-

ety, the pressure to accomplish these things quickly has increased. As a pediatrician

quoted in a newspaper article put it, Years ago, parents might keep a child at home

and just sit out an infection. Now most dont have that luxury (Warren, 1998). In

a society where two working parents are increasingly common, a sick child poses a

problem for the family in terms of both nighttime sleep and daytime care. The pres-

sure parents feel to get their children well may understandably translate to pressure

on the doctor to make them well. Thus, for parents the pressures they feel may trans-

late to more latitude in terms of offering accounts of what they think is bothering

their child, pressing the physician to treat the child, and offering opinions on how to

treat the child.

Third, as was mentioned earlier, in the pediatric context, physicians may feel

more social pressure to cure a child patient than an adult patient. Insofar as chil-

dren are considered more of the societys responsibility than adults are (e.g., see

Strong, 1979), pediatricians may feel self-imposed pressure to do what they can to

help the child get well quickly. Furthermore, they may feel parental pressure to make

the child well. In this way, the physician may feel a greater obligation to proactivelyaddress the condition of a sick child than a sick adult. In sum, from both the parents

perspective and the doctors perspective, there is a pressure within the pediatric con-

text to cure the child of an illness.

As was mentioned earlier, for a variety of reasons parents come to the medical

visit seeking a solution for their childs problem. Throughout the visit, physicians

must balance two issues that are, at times, competing: maintaining the legitimacy of

the visit and communicating whether the child has a treatable problem or not. If the

childs problem is treatable, this is unproblematic: The legitimacy of the visit is quite


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THE MIRACLE DRUG 21

easily upheld through the prescription of medication. But if the childs illness is not

treatable, as in the case of most viral colds or other infections, then this becomes a

struggle. For parents, the issues are inverted: If a physician threatens the legitimacy

of the visit by indicating that the condition is either not treatable or not problematic,they may do work to reestablish the legitimacy of their visit and/or advocate for the

problematic and treatable nature of the childs problem.

Interestingly, what parents consider treatable is rooted in their folk model of

illness. Helman notes that prior to World War II and the mass production (and

availability) of antibiotics, the typical illness model viewed colds as something

triggered by external sorts of causes such as being in the cold air, drafts, or get-

ting chilled when not wearing shoes (Helman, 1978). With this model came home

remedies, so few physician visits were made. By contrast, postantibiotic patients

suddenly were more likely to visit physicians for colds. Arguably, this was because

all forms of illness were suddenly lumped together as caused by germs and there-

fore were considered treatable (Helman, 1978). Although we are nearly 30 years

past the time when Helman wrote about his suburban general practice, the basic

problem is the same.

A concern with treatability is different from a concern with legitimacy. A parent

can orient to the visit as legitimate and to their childs illness as treatable. Parents

can respond to a physicians recommendation against treatment as problematic either

because it delegitimates the visit (e.g., Yeah, it was my wife who called; I figuredthere wasnt much you could do) or because they feel that their child needs treat-

ment (e.g., Can I at least have thuh prescription an Ill decide whether or not to fill

it in a couple days?). However, it may not be entirely clear, to an analyst or to the

physician, whether a given physicians action is problematic because it deals a blow

to the legitimacy of the visit or to the treatability of the illness. Even with respect

to treatability, parents can want treatment without desiring antibiotics specifically,

as will be discussed further in chapter 6. Britten and her colleagues have shown

that adult patients do not always or simply want antibiotics (Britten, 1994; Brit-

ten, Jenkins, Barber Bradley, & Stevenson, 2003; Britten, Stevenson, Barry, Barber,

& Bradley, 2000). Moreover, other studies show that patients and parents alike are

not, across the board, less satisfied if they fail to get an antibiotic (Himmel, Lippert-

Urbanke, & Kochen, 1997; Mangione-Smith et al., 2001).

Much of this book will be concerned with interactional practices that are taken

by the physician to be solely concerned with treatability and, even more specifically,

taken to be directly indexing antibiotics. It is precisely because of this perception by

physicians that we will see that parents accomplish negotiation for antibiotics.

Overview of the Book

This book will examine the parent-pediatrician negotiation of legitimacy, treatability,

and antibiotics in particular, as these issues emerge throughout the visit. The book

is generally laid out in the order of the acute care medical visit (drawing on Byrne

& Long, 1976; Robinson, 2003; Waitzkin, 1991): (1) opening; (2) establishing the

reason for the visit; (3) history taking; (4) physical examination; (5) diagnosis; (6)


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treatment; and (7) closing. Chapter 2 will examine the beginning of the visit proper,

when parents are frequently offered an opportunity to explain their reason for seeking

medical help. This chapter will suggest that parents display rather different stances

toward their childrens illness and thus toward their preferences for the visit outcomethrough their formulation of their reason for visiting. Chapter 3 focuses on taking the

childs illness history, during which physicians primarily ask questions and parents

and children answer questions. Through the ways that physicians design their ques-

tions, they reveal their current diagnostic and treatment trajectories. We will see that

although in one sense parents are put in a relatively constrained and arguably power-

less position in this phase, they are nonetheless quite capable of working within these

sequential and structural constraints to encourage physicians away from one diag-

nostic trajectory and/or toward an alternative diagnostic and treatment trajectory.

Chapter 4 examines parent resistance as a response to no-problem diagnoses.

This chapter argues that through the use of three different types of responses and

because of the structural organization of the diagnosis, parents can take issue with

the physicians diagnosis and, at times, lead the physician to alter the diagnostic and/

or treatment trajectory from no problem and/or nontreatable to problematic and/or

treatable. Chapter 5 examines parent resistance in a second environment: follow-

ing a treatment recommendation. Taken together with chapter 4, this chapter shows

that resistance can take quite different forms, depending on the normative sequen-

tial organization of the action it is responding to. Still, as with diagnosis resistance,treatment resistance can be observed to be a powerful tool to negotiate in favor of

antibiotic treatment.

Chapter 6 examines the relatively rare behavior of parents overtly lobbying for

antibiotics. This chapter shows that this type of behavior can take several particular

formats that can be more or less direct (and more or less coercive). It also shows that

the practices, though more frequent during the treatment recommendation phase of

the visit, can be offered throughout the visit.

Chapter 7 shifts from the parent to the physician to explore several ways in which

physicians can, through the actions they perform and their design, shape whether par-

ents perform problematic behaviors such as diagnosis and treatment resistance. This

chapter focuses on three behaviors: online commentary, formulation of the diagno-

sis, and formulation of the treatment recommendation. Finally, chapter 8 concludes

by speculating about the issues underlying the problems of inappropriate antibiotic

prescribing, particularly in developed countries but also as it contributes to the global

problem of bacterial resistance to antibiotics.


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2

Foregrounding the Relevance

of Antibiotics in the Problem

Presentation

As discussed in chapter 1, medical visits are generally conducted in a way thatproceeds rather systematically through a series of activities, beginning with an open-

ing and progressing through to treatment discussion and closing. To understand the

variety of ways that parents influence the outcome of the visit, we will, in the course

of this book, look at a number of these activities in detail. This chapter is concerned

with an activity that generally occurs very early in the visit: when physicians and par-

ents establish why the child is visiting the physician. Depending on the scheme of the

medical encounters structural organization, this activity may be treated as the begin-

ning of the history taking or as initiating an activity in its own right. I follow Byrne

and Long (1976) in treating it as shifting to establish the reason for the visit.

The question that physicians generally ask parents (e.g., What can I do for you

today?) offers parents an opportunity to shape the course of the visit by describing

their childs problem in their own words and thus emphasize particular dimensions ofthe illness and de-emphasize others. With this question, physicians also provide par-

ents with an opportunity to formulate their worries (or not), to project and tell a story

about the problem (or not), and/or to offer their own speculations about the problems

cause, all in the course of their response. When physicians solicit the problem, this

represents the first and sometimes only sequentially provided foropportunity that

parents have to shape the physicians view of the problem and directly influence the

treatment decision.1 Thus, this is the obvious starting point for our study of parent-

physician negotiation of treatment.

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Parents generally respond to phy

prescribing under pressure parent physician conversations and antibiotics oxford studies in...

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