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Pediatricians may feel pressured to prescribe antibiotics when parents imply a diagnosis that warrants them

Some parents only discuss their child's symptoms when they visit the pediatrician, while others directly or indirectly suggest a "candidate diagnosis." When parents offer symptoms only, for example, "he has a rash all over his body," pediatricians perceive that parents simply want a medical evaluation of their child. When parents offer a candidate diagnosis (for example, "I think she probably has an ear infection because she's been having pain"), pediatricians perceive that parents are looking for confirmation of the diagnosis and treatment for that illness, usually antibiotics. That's the conclusion of a study by Tanya Stivers, Ph.D., of the University of California at Los Angeles.

In a study supported by the Agency for Healthcare Research and Quality (HS10577), Dr. Stivers analyzed conversations between parents and pediatricians from 295 audiotaped acute care visits and 65 videotaped well-child and acute care visits involving a total of 14 physicians to examine how pediatricians responded to these two parental approaches. Parents mentioned symptoms only in 52 percent of total cases, parents directly mentioned a candidate diagnosis in 16 percent of cases, and they indirectly implied a diagnosis in 10 percent of cases by stating symptoms so specific as to imply a diagnosis (for example, citing green nasal discharge to indicate sinusitis or a "barky" cough to indicate croup).

In response to a symptoms-only presentation, pediatricians typically moved from it directly into an investigation of the child's problem, either by physical examination or history taking, and formulated their subsequent diagnoses as direct, positively formulated announcements. In contrast, doctors responded to articulated or implied candidate diagnoses by confirming or disconfirming the proposed diagnosis and discussing the relevance of antibiotic treatment during their final diagnosis and treatment recommendation. Of the total candidate diagnoses offered, 82 percent are typically treated with antibiotics, thus causing doctors to perceive parental pressure to prescribe antibiotics or defend why they won't prescribe antibiotics.

More details are in "Presenting the problem in pediatric encounters: 'Symptoms only' versus 'candidate diagnosis' presentations," by Dr. Stivers, in Health Communication 14(3), pp. 299-338, 2002.

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