Prescribing under Pressure: Parent-Physician Conversations and Antibiotics

Prescribing under Pressure: Parent-Physician Conversations and Antibiotics

Prescribing under Pressure: Parent-Physician Conversations and Antibiotics

Prescribing under Pressure: Parent-Physician Conversations and Antibiotics


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.


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.

1960–1999 AD39 more “oops” … Here, take this more powerful antibiotic.

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


In 2000, primary care physicians in the United States handed out approximately 126 million prescriptions for antimicrobials (McCaig, Besser, & Hughes, 2003). Basic arithmetic shows this to be approximately 2.5 billion doses consumed by ambulatory 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 of every 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 inappropriate, 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 . . .

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