Acute Care Encounters Research Articles

Presenting the Problem in Pediatric Encounters: "Symptoms Only" Versus "Candidate Diagnosis" Presentations

This article examines 2 practices that are used to present children's problems to their pediatricians in acute care encounters. Using the methodology of conversation analysis, this article examines the alternative stances embodied by problem presentations, which offer "symptoms only" versus problem presentations, which also include a "candidate diagnosis." This article suggests that parents who offer only symptoms in their problem presentations are hearable as adopting a stance that they are primarily seeking medical evaluations of their children. By contrast, a parent who includes a candidate diagnosis of the problem is hearable as adopting a stance that he or she is seeking confirmation of the diagnosis and treatment for that illness condition. This communication practice may be treated by physicians as placing pressure on them to prescribe treatment-in particular antibiotic treatment. The implications of this are discussed.

From bench to bedside: the future is now. Presented at the 72nd Scientific Sessions of the American Heart Association, Atlanta, Georgia.

It is with great pleasure that I welcome you to the 72nd Annual Scientific Sessions of the American Heart Association. This year’s meeting provides an opportunity to look back with pride on the advances in science and medicine of the 20th century and an opportunity to look ahead with enthusiasm to the advances to come. But I want to talk to you today about another opportunity—a challenge, if you will—that is facing us right now, one that I believe we, as a worldwide medical community and as a global society, have not adequately met. A century ago, a male born in America in the year 1900 had an average life expectancy of 47 years. Today, a male born in this country has a life expectancy of 73 years, and for females, the average is almost 80 years. And although the numbers are not as high in the less-developed regions of the world, the increase in life expectancy has been equally dramatic worldwide. In the first half of this century, most of the factors that improved longevity, health, and well-being were related to advances in medicine, particularly in the isolation and eradication of infectious diseases, and the resulting decline in the infant death rate. We have witnessed, for example, the eradication of small pox, the control of polio, and the discovery and application of antibiotics such as sulfa and penicillin. It is only in the second half of the 20th century—recent history, really—that we have seen tremendous scientific advances in the understanding of the mechanisms underlying coronary artery disease, including stroke, and significant technological advances in the treatment of acute illness due to cardiovascular diseases. We have witnessed the essential eradication of rheumatic fever. We have identified the risk factors for atherosclerosis and enhanced our understanding of the role of risk …

Use of physician and acute care services by persons with and without Alzheimer's disease: a population-based comparison.

To estimate differences in use of acute care services between persons with and without Alzheimer's disease (AD). Population-based historical cohort study. All Rochester, Minnesota, residents with AD onset between January 1, 1980, and December 31, 1984 (n = 301), plus one age- and sex-matched nondemented control per case, were identified with a retrospective review of community-based medical records. Cases and controls were followed in their medical records for number of acute care encounters in the year before January 1 of the index year (year of onset for AD case and their matched control) and in the 4 years following December 31 of the index year. Encounters included clinician visits (office or nursing home), emergency room (ER) visits, hospitalizations (inpatient and outpatient), and inpatient days. Multivariate regression analyses were adjusted for age, sex, pre-index level of illness, and follow-up time. In the pre-index period, cases and controls were similar with respect to level of illness, number of office visits, ER visits, and hospitalizations. In the year before AD onset, 17 cases (7%) had a clinician visit in the nursing home compared with no controls. In the 4 years after the index year, mean length of follow-up was 3.4 years for both cases and controls. The numbers of ER visits, hospitalizations, and inpatient days were similar for cases and controls. Sixty-four percent of AD cases had a clinician visit in a nursing home versus 1% of controls. Controls experienced more office visits than cases (median = 16 vs 10, P < .001). The onset of AD is not associated with greater use of acute care services. However, neither is the high use of nursing home care offset by fewer ER or hospital encounters.