AUTHOR: Tanya Stivers TITLE: Prescribing Under Pressure SUBTITLE: Parent-Physician Conversations and Antibiotics SERIES TITLE: Oxford Studies in Sociolinguistics PUBLISHER: Oxford University Press YEAR: 2011
M. Catherine Gruber, Chicago, IL, USA
“Prescribing Under Pressure” investigates the overprescription of antibiotics in the United States by looking at patient-child-physician encounters involving children with upper respiratory tract infection symptoms. Employing a conversation analytic approach, Stivers takes up the question of why doctors overprescribe antibiotics, given that antibiotics not only fail to cure viral infections, but also, infection-causing bacteria can fairly easily develop resistance to antibiotics, thereby making them ineffective against dangerous childhood diseases. As a case in point, Stivers notes that the U.S. has one of the highest rates of Streptococcus pneumoniae resistance to penicillin in the world. In this way, the micro-setting of doctor-patient visits has macro-level implications. Close attention to the details of these doctor-patient visits reveals that parents and physicians negotiate the diagnosis and treatment of children at a variety of points during the visit.
The crux of the problem is that in the process of determining that a child's symptoms are not consistent with a bacterial infection, doctors frequently refer to the child's illness by means of language that reflects a downgraded problem or no problem at all (e.g. “And usually that'll go along with this just being viral” (180) [N.B. I have stripped the quotations of paralinguistic elements of lengthening and use of quiet voice]). Parents, on the other hand, have been suffering at home with the sick child -- often for some time before they bring him/her in to see the doctor. Stivers writes, “... parents seeking medical help for these routine illnesses feel they have gone beyond the point where their own expertise is sufficient. 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” (17). From a parent’s perspective, the prospect of a “no problem” diagnosis and leaving the doctor's office without a prescription (or hope of some other cure) to face more of the same is a serious problem.
Most of the book follows the structure of an acute medical care visit. Stivers shows that each activity of the visit provides different resources for parents and physicians to negotiate the diagnosis of the illness and the treatment that is recommended. After the Introduction, Chapter 2, ‘Foregrounding the Relevance of Antibiotics in the Problem Presentation,’ takes up the first elements of parent-doctor negotiation during the establishment of the reason for the visit. For example, with the establishment of the reason for the visit, children’s problems are presented, either by means of an itemization of symptoms (e.g. “He has uh rash all over his body” (38)) or with a candidate diagnosis (e.g. “Uh- We’re thinking she might have an ear infection?” (28)). Both of these methods communicate the stance that the child has a doctorable condition; when parents offer a candidate diagnosis, however, physicians treat them as further embodying the stance that the condition is treatable and that the treatment that is desired is antibiotics. Interestingly, surveys of parents reveal that the offering of a candidate diagnosis does not invariably correlate with a desire for antibiotics. As Stivers points out, parents may be more concerned, for example, with emphasizing the legitimacy of their visit. From this perspective, the offering of a candidate diagnosis may merely signify that parents believe the child has a legitimate illness which is treatable with medicine.
Chapter 3, ‘Alternative Practices for Asking and Answering History-Taking Questions,’ looks at elements of negotiation during the physician's solicitation of the child's illness history. This phase is marked by questions posed by physicians. No question is neutral, however, and the questions physicians use can reveal whether they are heading toward a “no problem” diagnosis, which runs counter to the expectations that many parents have when they bring a sick child in for an urgent care appointment. Two resources that parents employ when doctors appear to be on a no-problem diagnostic and treatment trajectory are to: i. bring up additional problematic symptoms (e.g. “But thuh cough is wearing worse” (73)); and ii. mention an alternative possible diagnosis (e.g. “But his brother an’ his sister have ear infection” (69)). Stivers observes that mentioning additional symptoms tends to push doctors away from a particular trajectory while mentioning an alternative possible diagnosis tends to push doctors towards an alternative diagnosis.
Chapter 4, ‘No Problem (No Treatment) Diagnosis Resistance,’ examines the ways in which parents respond to and sometimes influence the doctor's diagnosis. The diagnosis stage is interesting because it does not make a response from the parent conditionally relevant. Typically, doctors pronounce the diagnosis and move directly to the subject of treatment. As a result of this default pattern, a response by the parent which does more than acknowledge receipt of the diagnosis, such as one which questions the diagnosis or introduces other elements, has the result of causing the doctor to revisit earlier elements of the visit and work through them again, often in a more elaborated way. This constitutes yet another point at which physicians and parents negotiate the diagnosis and treatment of the sick child.
Chapter 5, ‘Treatment Resistance,’ unpacks the resources for negotiation at the point at which doctors address the subject of treatment. Since doctors seek parent agreement with the treatment plan that they propose, parents’ withholding of agreement to the treatment provides another way in which they can exert influence. Stivers shows that when parents withhold agreement to the treatment suggested, physicians may “…offer a rationale for the treatment recommendation, offer[ ] evidence for the underlying diagnosis, return [ ] to the examination findings, and offer [ ] the parent a concessionary future action” (109).
After going through the negotiation sites of an acute care visit, Stivers takes up more macro-level features that pervade the visits. Chapter 6, ‘Overt Forms of Negotiation,’ looks at explicit requests and statements, which contrast with the covert forms that dominate the data set, but that occur at a variety of points during the visit. Chapter 7, ‘Physician Behavior that Influences Parent Negotiation Practices,’ sets the stage for the solutions that Stivers offers in the Conclusion. Among them, she suggests that physicians stop using downgraded language to talk about the symptoms of viral infections. Parents have learned that “minor symptoms” are associated with viral infections and severe symptoms are associated with bacterial infections, and as such, ''…parents who believe their child is “very sick” will pressure for antibiotics and will be unlikely to accept that their child has a viral illness because the child is sicker than they have been taught is associated with such illnesses'' (189). Another solution concerns the use of online commentary during a physical examination such as “Her ears are fine” (89). Comments about the child's symptoms are helpful because they can help prepare parents for a no-antibiotics treatment outcome while maintaining the legitimacy of the visit. As a result, Stivers recommends that physicians make use of this resource when possible. Further, non-minimized, affirmative, and specific diagnoses and treatment recommendations may help physicians manage parents who appear to be pressuring them for antibiotics. This means that “So I would say that this is that kind of viral stuff” (165) (positive diagnosis) is more effective than a negative “So with Clarissa right now she doesn't have any infection” (168), and that the suggestion of a specific over-the-counter medication, such as Robitussin PE, is better than “…whatever your favorite cough medicine is” (173).
The conversation-analytic approach has proved fruitful once again. “Prescribing Under Pressure” makes a valuable contribution to the discussion of what we as a society can do about the problem of the overprescription of antibiotics. Sociolinguists will appreciate Stivers' attention to detail and insightful discussion of the data. The solutions Stivers offers at the end of the book should be required reading for medical training programs.
Although the plan to organize the book around the medical visit makes sense, the macro- approach of the last three chapters means that many of the ''take away'' points of the book come at the end. Previewing them a bit more, earlier in the text, might better ensure that these important findings make their way to the medical community.
I found Stivers’ explication of the social context of the visit from parents’ perspective very compelling. If anything, I'd like to see more of this. However, some additional ethnographic information about the doctor-parent-patient encounter could be helpful for understanding the excerpts that were presented. For example, although we are told that the ages of the children in the data set ranged from newborn to 16 years of age, with most visits involving children from 6 months to 10 years old, I think it would be helpful to have the age of each child who is the focus of an interaction. My guess is that as a rule, the younger the child, the harder it is for parents when doctors downplay or minimize the illness.
Stivers' discussion of parents’ resources for negotiating their children’s diagnoses and treatments during the question-driven phase of history-taking challenges notions of control associated with asking questions. Although scholars have observed that questions range on a scale of coerciveness, even the least coercive form (broad wh-questions) imposes a frame of control that limits the answers that are relevant (Archer 2005). Institutional contexts such as doctors' offices and courtrooms (Burns 1999), in which the questioner occupies a position of authority, exemplify the use of controlling questions. Stivers follows Matoesian (2001) in the way that she unpacks the dynamics of negotiation and control amid questions and answers in an institutional setting. Close attention to the micro details of an interaction reveal time and time again the ways in which meaning actually is jointly constructed (cf. Silverstein 1998, Goffman 1974, Bauman 1986).
Stivers treats the sociology of parenting briefly and notes that, “…[c]oncern over a child's well-being is generally seen as the sign of a good, if slightly overanxious, parent” (18). On the following page she observes, “…a parent may hear a doctor's questions about her child's health as “testing her capabilities as a mother”” (19). These statements are consistent with the popular culture adage that parents more and more treat children as extensions of themselves (and a Google search indicates that there are multiple scholarly studies which support this view as well). When this lens is applied to the context of acute care visits for sick children, it casts new light on the true havoc that a sick child wreaks on the home; intense worry about a sick child translates into intense worry about oneself and the ways in which one is meeting or failing one's responsibilities as a parent. This is perhaps an interesting topic for future work.
Archer, Dawn. 2005. Questions and answers in the English courtroom (1640-1760). A sociopragmatic analysis. Amsterdam: John Benjamins Publishing Company.
Bauman, Richard. 1986. Story, performance, and event. Cambridge: Cambridge University Press.
Burns, Robert P. 1999. A theory of the trial. Princeton: Princeton University Press.
Matoesian, Gregory M. 2001. Law and the language of identity. Discourse in the William Kennedy Smith rape trial. Oxford: Oxford University Press.
Silverstein, Michael. 1998. The improvisational performance of culture in realtime discursive practice. In Creativity in Performance, edited by R. Keith Sawyer, 265-312. Greenwich, CT: Ablex Publishing Corporation.
ABOUT THE REVIEWER
ABOUT THE REVIEWER:
M. Catherine Gruber completed her Ph.D. in linguistics at the University of
Chicago in 2007 with a dissertation on the apologies produced by defendants
during allocution at sentencing. Her research interests center on the
intersection between role and individual identity, the ways in which the
ideologies at work in institutional settings both constrain and create
opportunities for meaning-making, and the communication of emotion.