Prescribing under Pressure: Parent-Physician Conversations and Antibiotics (Oxford Studies in Sociolinguistics)

232 Pages·2007·0.9 MB·English

by  Tanya Stivers

Prescribing under Pressure
OXFORD STUDIES IN SOCIOLINGUISTICS
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Edited by Carmen Fought
Prescribing under Pressure
Parent-Physician Conversations
and Antibiotics
Tanya Stivers
3
2007
3
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Library of Congress Cataloging-in-Publication Data
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. Antibiotics—Effectiveness. Physician and patient. I. Title
RM267.S75 2007
615'329—dc22 2006048256
9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
ACKNOWLEDGMENTS
A
lthough 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 fi eld-
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 infl uenced 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 time—many would not even remember participating; most
would surely be shocked to fi nd out that their few minutes would sum to provide me
with a career’s 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 fl oated 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 fi nally 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
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
infi nitely 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 or
another, 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 fi rst 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 in Health 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 in Health 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
ACKNOWLEDGMENTS vii
this book possible. The Language and Cognition Group, particularly Nick Enfi eld,
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 and
led 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 Infl uences Parent Negotiation Practices, 155
8. Conclusion, 185
Appendix: Transcript Symbols, 195
Notes, 199
References, 203
Index, 219