Physicians should consider providing a contingency plan to parents who expect antibiotics for their children when there is no clinical indication. Further study is needed to determine how parents indirectly communicate their desire for antibiotics and what additional communication techniques physicians can use to resist the overprescribing of antibiotics.

ABSTRACT. Context. Widespread overuse and inappropriate use of antibiotics are a major public health concern. Little is known about racial/ethnic differences in parents seeking antibiotics for their children's upper respiratory illnesses.Objective. To examine racial/ethnic differences in parent expectations about the need for antibiotics and physician perceptions of those expectations.Design. We conducted a nested, cross-sectional survey of parents who were coming to see their child's pediatrician because of cold symptoms between October 2000 and June 2001. Parents completed a previsit survey that collected information on demographics, their child's illness, and a 15-item previsit expectations inventory that included an item asking how necessary it was for the physician to prescribe antibiotics. Physicians completed a postvisit survey that collected information on diagnosis, treatment, and whether the physician perceived the parent expected an antibiotic. The encounter was the unit of analysis. Multivariate logistic regression analyses were performed to evaluate predictors of dichotomized parental expectations for antibiotics, dichotomized physician perceptions of those expectations, diagnostic patterns, and antibiotic-prescribing patterns.Setting. Twenty-seven community pediatric practices in the Los Angeles, Calif, metropolitan area.Participants. A volunteer sample of 38 pediatricians (participation rate: 64%) and a consecutive sample of 543 parents (participation rate: 83%; ϳ15 participating for each enrolled pediatrician) seeking care for their children's respiratory illnesses. Pediatricians were eligible to participate if they worked in a community-based managed care practice in the Los Angeles area. Parents were eligible to participate if they could speak and read English and presented to participating pediatricians with a child 6 months to 10 years old who had cold symptoms but had not received antibiotics within 2 weeks.Main Outcome Measures. Parental beliefs about the necessity of antibiotics for their child's illness, physician perceptions of parental expectations for antibiotics, bacterial diagnosis rates, and antibiotic-prescribing rates.Results. Forty-three percent of parents believed that antibiotics were definitely necessary, and 27% believed that they were probably necessary for their child's illness. Latino and Asian parents were both 17% more likely to report that antibiotics were either definitely or probably necessary than non-Hispanic white parents. Physicians correctly perceived that Asian parents expected antibiotics more often than non-Hispanic white parents but underestimated the greater expectations of Latino parents for antibiotics. Physicians also correctly perceived that parents of children with ear pain or who were very worried about their child's condition were significantly more likely to expect antibiotics. Physicians were 7% more likely to make a bacterial diagnosis and 21% more likely to prescribe antibiotics when they perceived that antibiotics were expected.Conclusions. Paren...

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

Objectives. To assess whether prospective, observational study procedures, including questionnaires and audio recording, are associated with different patterns of physician diagnostic decision making and antibiotic prescribing. Data Sources/Setting. (1) Survey data from a prospective observational study of treatment patterns for children with acute upper respiratory illnesses (10/96-3/97) and (2) retrospective medical record abstraction data of nonobserved encounters for the same problems occurring during (10/96-3/97) and one year after (10/97-3/98) the observational study period. Ten pediatricians in two community practices were studied. Study Design. Patterns of diagnoses recorded in the medical record and antibiotics ordered for visits occurring outside of the observational study (same time period and one year later) were compared with the pattern of diagnoses and antibiotics ordered during the observational study. Data Collection/Extraction Methods. For the observational study (10/96-2/97), diagnosis and treatment choices were obtained from questionnaires completed by physicians immediately following the visit. For the nonstudy encounters (10/96-3/97 and 10/97-3/98), data were abstracted from medical records one year after the observational study was completed. Principal Findings. The proportion of viral cases in which an antibiotic was prescribed was 29 percentage points lower for the observational study compared to the retrospective analysis (po.05). In one of two study sites, the proportion of cases assigned a bacterial diagnosis was 29 percentage points lower in the observational study period compared to the retrospective study (po.05). Conclusions. Observational study procedures including questionnaires and audio recording can affect antibiotic prescribing behavior. Future observational studies aimed at examining the frequency of inappropriate antibiotic prescribing should measure and adjust for the Hawthorne effect; without such adjustments, the results will likely underestimate the true degree of the problem. Future interventions aimed at decreasing inappropriate antibiotic prescribing should consider ''harnessing'' the Hawthorne effect through performance feedback to participating physicians.Key Words. Antibiotic prescribing, Hawthorne effect, pediatrics 1603 THE HAWTHORNE EFFECTThe Hawthorne effect refers to a phenomenon where a study subject's behavior and/or study outcomes are altered as a result of the subject's awareness of being under observation. This phenomenon was originally identified at the Hawthorne Works Plant of the Western Electric Company in Chicago (Roethlisberger and Dickson 1939). Several studies were conducted at this plant between the years 1924 and 1932 in order to identify working conditions that would increase the productivity of the personnel employed by the plant. The investigators found that worker productivity increased regardless of working conditions when the workers knew they were under observation. For example, both more light and less light in the workroom resulte...

This article develops a system for analyzing the aggressiveness of journalists' questions to public figures and applies that system to a sample of presidential news conferences from Eisenhower through Clinton. The primary objective is to use the phenomenon of aggressive questioning as a window into the White House press corps and its evolving relationship to the presidency. Ten features of question design are examined as indicators of four basic dimensions of aggressiveness: (1) initiative, (2) directness, (3) assertiveness, and (4) adversarialness. The results reveal significant trends for all dimensions, all indicating a long‐term decline in deference to the president and the rise of a more vigorous and at times adversarial posture. While directness has increased gradually over time and is relatively insensitive to the immediate sociopolitical context, initiative, assertiveness, and adversarialness are more volatile and sensitive to local conditions. The volatile dimensions rose from the late 1960s through the early 1980s, declined from the mid‐1980s through the early 1990s, and rose again at century's end. Possible factors contributing to these trends, and their broader ramifications for the evolving relationship between the news media and the presidency, are also discussed.