Management of Acute Otitis Media by Primary Care Physicians: Trends Since

the Release of the 2004 American Academy of Pediatrics/American Academy of

Family Physicians Clinical Practice Guideline
Louis Vernacchio, Richard M. Vezina and Allen A. Mitchell
Pediatrics 2007;120;281-287
DOI: 10.1542/peds.2006-3601

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://www.pediatrics.org/cgi/content/full/120/2/281

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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ARTICLE

Management of Acute Otitis Media by Primary Care

Physicians: Trends Since the Release of the 2004
American Academy of Pediatrics/American Academy
of Family Physicians Clinical Practice Guideline
Louis Vernacchio, MD, MSc, Richard M. Vezina, MPH, Allen A. Mitchell, MD

Slone Epidemiology Center at Boston University, Boston, Massachusetts

The authors have indicated they have no financial relationships relevant to this article to disclose.

ABSTRACT
OBJECTIVES. In 2004, the American Academy of Pediatrics and the American Acad-
emy of Family Physicians released a clinical practice guideline on the management
www.pediatrics.org/cgi/doi/10.1542/
of acute otitis media that included endorsement of an observation option for peds.2006-3601
selected cases and recommendations of specific antibiotics. We sought to describe doi:10.1542/peds.2006-3601
primary care physicians’ current management of acute otitis media to compare it
Key Words
with the guideline’s recommendations and describe trends since 2004. otitis media, antibiotics, clinical practice
guidelines, primary care
DESIGN. We used a mail survey from March through June 2006 within the Slone Abbreviations
Center Office-Based Research Network, a national practice-based pediatric re- AOM—acute otitis media
search network. AAP—American Academy of Pediatrics
AAFP—American Academy of Family
Physicians
RESULTS. The response rate was 299 (62.7%) of 477. The observation option was
SCOR—Slone Center Office-Based
considered reasonable by 83.3%, compared with 88.0% in 2004, and was used in Research
a median of 15% of acute otitis media cases over the previous 3 months. The most Accepted for publication Mar 22, 2007
common physician-identified barriers to the use of the observation option were Address correspondence to Louis Vernacchio,
MD, MSc, Slone Epidemiology Center, 1010
parental reluctance (83.5%) and the cost and difficulty of follow-up of children Commonwealth Ave, Boston, MA 02215. E-
who do not improve (30.9%). In terms of antibiotic choices for acute otitis media, mail: lvernacchio@slone.bu.edu
agreement with the guideline’s antibiotic recommendation for 4 common clinical PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright © 2007 by the
scenarios was as follows: high-dose amoxicillin for acute otitis media with nonse- American Academy of Pediatrics
vere symptoms (57.2%), high-dose amoxicillin-clavulanate for acute otitis media
with severe symptoms (12.7%), high-dose amoxicillin-clavulanate for cases that
failed to respond to amoxicillin (42.8%), and intramuscular ceftriaxone for cases
that failed to respond to treatment with amoxicillin-clavulanate (16.7%). Each of
these proportions declined from 2004.
CONCLUSIONS. Most primary care physicians accept the concept of an observation
option for acute otitis media but use it only occasionally. Antibiotics prescribed for
acute otitis media differ markedly from the guideline’s recommendations, and the
difference has increased since 2004.

PEDIATRICS Volume 120, Number 2, August 2007 281

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D ESPITE BEING ONE of the most common illnesses for
which children are brought to physicians, acute
otitis media (AOM) remains a management challenge
for primary care providers. This is especially true given 2
important trends in AOM management. First, the con-
cept of initial observation without antibiotic treatment
has been adopted as standard practice in some parts of
the world1 and has begun to achieve acceptance in the
United States as well.2–6 Second, the widespread emer-
gence of antimicrobial resistance has increased the ur-
gency to reduce antibiotic use and, when antibiotic
treatment is chosen, has made the choice of antibiotic
more difficult.
In May 2004, in response to these issues, the Amer-
ican Academy of Pediatrics (AAP) and the American
Academy of Family Physicians (AAFP) jointly issued a
clinical practice guideline entitled “Diagnosis and Man-
agement of Acute Otitis Media.”7 The guideline endorsed
an observation option for selected children with AOM,
specifically considering it an option for those ⱖ2 years
old with nonsevere symptoms or an uncertain diagnosis
and for those 6 months to 2 years old with both nonse-
vere symptoms and an uncertain diagnosis. The guide-
line also made specific antibiotic recommendations for
various common AOM scenarios, including high-dose
amoxicillin as first-line treatment for most children,
high-dose amoxicillin-clavulanate as first-line treatment
for children with severe symptoms (moderate-to-severe
otalgia or fever of ⱖ39°C), and various specific antibiot-
ics for those whose conditions failed to respond to first-
line treatment.
In October 2004, we surveyed the physician-mem-
bers of the Slone Center Office-Based Research (SCOR)
Network to determine their familiarity with the guide-
line and to compare their practices with the guideline’s
recommendations in several key areas.8 We now de-
scribe follow-up survey data from the same group of
physicians collected ⬃2 years after the publication of the
guideline and 18 months after our initial survey.
METHODS
The SCOR Network is a national practice-based, primary
care pediatric research network coordinated by investi-
gators at the Slone Epidemiology Center at Boston Uni-
versity. In March 2006, we mailed surveys to all active
physician-members of the network inquiring about their
opinions and practices regarding the observation option
for AOM and about their preferred choices of antibiotics
for 4 common AOM scenarios. The AOM scenarios in-
cluded the following: AOM with nonsevere symptoms,
AOM with severe symptoms, AOM that failed treatment
with amoxicillin at 80 to 90 mg/kg per day, and AOM
that failed treatment with amoxicillin-clavulanate at 80
to 90 mg/kg per day. (The survey also contained a sec-
tion on screening practices for type 2 diabetes mellitus in
children, the results of which are not presented here.)
282 VERNACCHIO et al
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Approximately 6 weeks later, we sent a second survey to
nonresponders, half by mail and half by fax, determined
randomly. After another ⬃6 weeks, we called the office
of each nonresponder to verify the contact information
and faxed a third survey to the office.
To analyze open-ended responses about barriers to
the use of the observation option, 1 investigator (Dr
Vernacchio) reviewed the responses and created catego-
ries to which he assigned each response; a second inves-
tigator (Dr Mitchell) independently assigned each re-
sponse to a category. When the investigators did not
agree or when there were ⬍5 responses in a category,
the response was coded as “other.” Proportions were
calculated as the number of each given response divided
by the total number of valid responses. Comparisons of
proportions between groups were performed by ␹2 anal-
ysis or, when the analysis was limited to responders to
both the 2004 and 2006 surveys, by McNemar’s test for
paired observations. Comparison between 2004 and
2006 of the median proportion of cases in which physi-
cians used the observation option was performed by
using Wilcoxon signed ranks test. SAS 9 (SAS Institute,
Inc, Cary, NC) software was used for all analyses. The
study was approved by the Boston University Medical
Campus Institutional Review Board.
RESULTS
Four hundred eighty-nine surveys were mailed; 7 were
undeliverable because the physician had relocated and a
current address could not be determined, 3 physicians
were no longer practicing primary care, and 2 others had
retired. Two hundred ninety-nine completed surveys
were received, for a response rate of 62.7%. Among the
299 respondents, 207 also responded to our 2004 sur-
vey. Nonresponders did not differ significantly from re-
sponders by gender, practice setting, region, or specialty
(data not shown). The demographics of the responders
are shown in Table 1.
Overall, 249 (83.3%) believed the observation option
was reasonable for some children with AOM, whereas
50 (16.7%) did not. The proportion who accepted the
observation option did not differ significantly by the
physician’s gender, region, or membership in AAP
and/or AAFP, but it was higher among pediatricians
(compared with family physicians), suburban and urban
non–inner-city practices, and younger physicians (Table
2).
Compared with 2004, the overall proportion who
accepted the observation option among this group of
providers declined somewhat, from 88.0% in 2004 to
83.3% in 2006, although the difference was not statis-
tically significant (P ⫽ .1). Among the 204 physicians
who responded to this question on both the 2004 and
2006 surveys, the proportion declined from 90.2% to
84.3% (162 accepted the observation option at both
time points, 10 did not accept the observation option at
 TABLE 1 Characteristics of 299 Physicians Who Responded to the TABLE 2 Acceptance of the Observation Option According to
Survey Physician Characteristics
Characteristics No. (%) Factor n/N (%) P
Gender Gender
Male 215 (71.9) Male 180/215 (83.2) .7
Female 84 (28.1) Female 69/84 (82.1)
Specialty Specialtya
Pediatrics 230 (76.9) Pediatrics 199/230 (86.5) .003
Family practice 66 (22.1) Family practice 47/66 (71.2)
Other 3 (1.0) AAP and/or AAFP membership
Academy membership Yes 224/265 (84.5) .1
AAP 209 (69.9) No 25/34 (73.5)
AAFP 55 (18.4) Year of medical school graduation
Neither 34 (11.4) Before 1970 38/49 (77.6) .03b
Both 1 (0.3) 1970s 91/113 (80.5)
Year of medical school graduation 1980s 102/119 (85.7)
Before 1970 49 (16.4) 1990s 18/18 (100.0)
1970s 113 (37.8) Practice setting
1980s 119 (39.8) Suburban 138/155 (89.0) .0003
1990s 18 (6.0) Rural 48/68 (70.6)
Practice setting Urban, non-inner city 51/57 (89.5)
Suburban 155 (51.8) Urban, inner city 12/19 (63.2)
Rural 68 (22.7) Region
Urban, non-inner city 57 (19.1) Midwest 57/69 (82.6) .6
Urban, inner city 19 (6.4) South 51/63 (81.0)
Region Midatlantic 45/56 (80.4)
Midwest 69 (23.1) West 34/42 (81.0)
South 63 (21.1) Southwest 31/36 (86.1)
Midatlantic 56 (18.7) New England 31/33 (93.9)
West 42 (14.1) an ⫽ 3 with other specialties not included in this analysis.
Southwest 36 (12.0) b Test for trend.
New England 33 (11.0)

TABLE 3 Physicians’ Preferred Follow-up Strategies for Children

both time points, 10 did not accept the observation
option in 2004 but accepted it in 2006, and 22 accepted
the observation option in 2004 but did not accept it in
2006; P ⫽ .03).
During the 3 months before completing the survey,
the physicians reported by using the observation option
in a median of 15% of the AOM cases they diagnosed
(range: 0%–95%; 25th, 75th percentiles: 5%, 30%). For
those physicians responding to both surveys, the propor-
tion of cases in which they used the observation option
did not significantly change from 2004 to 2006 (median:
15% in both surveys; P ⫽ .4). In 2006, 10.7% of the
responding physicians used the observation option in
half or more of their recent AOM cases. Their prefer-
ences for follow-up strategies for children treated with
observation are shown in Table 3.
We asked 249 responding physicians who accepted
the observation option to identify in an open-ended
fashion up to 3 barriers to its use in their practices. A
total of 161 (64.7%) listed parents’ reluctance, demand
for antibiotics, and/or anxiety about observation as the
most important barrier, and 208 (83.5%) listed it as 1 of
the 3 most important barriers. Other reported barriers to
the use of the observation option are shown in Table 4.
For 4 common clinical AOM scenarios for which the
AAP/AAFP guideline makes specific antibiotic recom-
With AOM Treated With the Observation Option
Follow-up Strategy No. (%)
Back-up antibiotic prescription given at time of initial 170 (56.9)
diagnosis; parent to fill prescription if child not
improved in 48–72 h
Scheduled follow-up visit in 48–72 h 126 (42.1)
Parent to call for phone-in antibiotic prescription if child 102 (34.1)
not improved in 48–72 h
Parent to bring child back to office if child not improved 97 (32.4)
in 48–72 h
Column total adds up to ⬎100%, because multiple responses were allowed.
mendations, the surveyed physicians were asked which
antibiotic they would prescribe; the results, compared
with responses from 2004, are shown in the Figure 1.
From 2004 to 2006, physicians’ adherence with the rec-
ommended antibiotic choices declined for all 4 scenarios
presented.
DISCUSSION
This survey of a group of US pediatric primary care
physicians offers a portrait of the office-based manage-
ment of AOM in 2006 and relates it to the recommen-
dations of the 2004 AAP/AAFP AOM clinical practice
guideline. In addition, we compared the current survey’s
responses with those from a similar survey of the same

PEDIATRICS Volume 120, Number 2, August 2007 283

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 TABLE 4 Physician-Identified Barriers to the Use of the Observation Option for AOM
%
Most Important Second Most Third Most Total (Mentioned as
Barrier Important Barrier Important Barrier 1 of Top 3 Barriers)a
Parental expectations/demand for antibiotics 64.7 20.1 12.0 83.5
Cost/time/difficulty of follow-up visits 8.4 16.5 11.2 30.9
Physician’s concern about patient’s AOM-related symptoms 5.2 11.6 5.2 18.5
(eg, pain, fever)
Physician’s concern about parents’ reliability/adherence to 3.6 4.8 3.6 11.2
treatment plan
Legal liability 0.8 5.2 2.0 8.0
Young age of patient 2.8 2.8 1.2 6.8
Physician’s own habits/previous practices 1.6 3.6 2.0 6.8
Physician’s concern about AOM complications (eg, 0.8 2.4 3.6 6.4
tympanic membrane rupture, mastoiditis, meningitis)
Parent will find another doctor who will prescribe antibiotics 1.6 1.6 1.6 4.4
Patient with severe illness/ill appearance 1.2 1.6 0.8 3.6
Daycare/school regulations 0.4 0.8 2.0 3.2
Patient’s history of AOM/recurrent AOM 0.8 0.8 0.4 2.0
Other 7.2 11.2 9.2 25.7
a The total column does not always equal the sum of the first 3 columns, because some respondents listed multiple barriers that were placed in the same category.

A
100% B
9.7% Other 9.7% 100% Other 6.0%
6.6%
90%
2.4% 4.7%
90% 6.1% Amoxicillin-
Amoxicillin
80% 22.0% 33.1% clavulanate 10.4%
40–45 mg/kg per day 80% 40–45 mg/kg per day
70%
70%
60% Amoxicillin
60%
40–45 mg/kg per day
50%
50%
40% Amoxicillina Amoxicillin
40% 67.0% 66.2%
68.3% 57.2% 80–90 mg/kg per day
80–90 mg/kg per day
30% 30%

20% 20%
Amoxicillin-
10% 10% clavulanate a 12.7%
17.9%
80–90 mg/kg per day
0% 0%
2004 2006 2004 2006

C D
100% Other 100%
12.2% 11.4% 13.4% 10.4%
Amoxicillin- Other

Re Re
90% 90%
clavulanate 4.7%
6.3% 7.4%
40–45 mg/kg per day 8.0% Cefuroxime
80% 80%

70%
8.3%

vie Azithromycin
8.0%

70% vie
15.2%
axetil

Azithromycin
16.4%

60% 21.5%
w Cefdinir 30.4% 60% w
50% Co 50% Co
40%

30% 51.7%
Amoxicillin-
clavulanate a
py 42.8%
40%

30%
35.7%

py
Cefdinir 51.8%

80–90 mg /kg per day

20% 20%

10% 10% 27.7% Ceftriaxone IM a 16.7%

0% 0%
2004 2006 2004 2006

FIGURE 1
Antibiotic choices of physicians in 2004 and 2006 for 4 common AOM scenarios. A, AOM with nonsevere symptoms (a P ⫽ .01 for comparison of 2004 to 2006). B, AOM with severe
symptoms (a P ⫽ .1 for comparison of 2004 to 2006). C, AOM that failed treatment with amoxicillin at 80 to 90 mg/kg per day (a P ⫽ .05 for comparison of 2004 to 2006). D, AOM that
failed treatment with amoxicillin-clavulanate at 80 to 90 mg/kg per day (a P ⫽ .05 for comparison of 2004 to 2006). The antibiotics shown in bold type are recommended by the 2004
AAP/AAFP guideline on AOM.

284 VERNACCHIO et al
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group of providers fielded in late 2004, ⬃6 months after
the release of the AOM guideline.
The current survey, and the 2004 survey to which its
results are compared, were performed within the SCOR
Network, a national, practice-based, pediatric research
network consisting of nearly 500 pediatricians and fam-
ily physicians. Members of the SCOR Network may not
be representative of all US pediatric primary care pro-
viders in that they have chosen to be involved in re-
search. However, they do represent a diverse group of
office-based physicians from 42 US states and a variety
of practice and community settings, and thus can pro-
vide valuable insights into how the AOM guideline’s
recommendations are being implemented and which of
them are most problematic for primary care providers.
As for the possibility of response bias in the survey, the
fact that the demographics of responders did not differ
significantly from those of nonresponders is reassuring.
Yet, other unmeasured biases could have been associ-
ated with response. For example, we consider it likely
that physicians who are more familiar with the guideline
and/or more inclined to follow its recommendations
would also have been more likely to complete the sur-
vey. This possibility, combined with the fact that SCOR
Network physicians have all agreed to be involved in
practice-based research, suggests that our results likely
represent a “best case” scenario in terms of familiarity
with and adherence to the guideline’s recommenda-
tions.
In this survey, we found that most of these physicians
accept the concept of an observation option for selected
children with AOM, but the proportion who accept it
has not increased since 2004 and may have decreased
slightly. Those who are most accepting of the observa-
tion option include pediatricians (as opposed to family
physicians), younger physicians, and those practicing in
suburban and urban non–inner-city locations. Overall,
the responding physicians currently use the observation
option in ⬃15% of the AOM cases they diagnose, ap-
proximately the same proportion as in 2004, but just
over 1 in 10 of them are enthusiastic early adopters of
observation, using it with at least half of their diagnosed
AOM cases.
When questioned in an open-ended fashion about
barriers to the use of the observation option in their
practices, these physicians overwhelmingly pointed to
parental reluctance to accept this approach. There is,
however, growing evidence that many US parents will
accept observation when this option is presented in an
appropriate context,5,6,9–12 thus there is a disconnect be-
tween what studies show parents will accept and what
physicians think parents will accept. About one third of
physicians also cited the time, cost, and general difficulty
associated with follow-up for children managed initially
with observation who do not improve within an accept-
able time frame as an important barrier. This concern
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may be ameliorated somewhat by the use of a backup
antibiotic prescription given to the parent at the time
of initial AOM diagnosis, a follow-up strategy demon-
strated to be practical in several clinical trials6,9,13,14 and
favored by a majority of the responding physicians. This
strategy does, however, place more decision-making re-
sponsibility in the parent’s hands and may not be wel-
comed by or appropriate for all families.
This survey also demonstrates significant discrepan-
cies between the recommendations of the AAP/AAFP
guideline and physicians’ choices of antibiotics to treat
AOM. For AOM with nonsevere symptoms, slightly
more than half chose the recommended high-dose
amoxicillin. Nearly one third opt for standard-dose
amoxicillin, a significant increase from 2004. This trend
back to standard-dose amoxicillin for nonsevere disease
may represent an awareness of recent data that wide-
spread use of the heptavalent pneumococcal conjugate
vaccine has reduced the circulation of penicillin-resistant
Streptococcus pneumoniae in some communities.15,16
For AOM with severe symptoms, only 1 of 8 physi-
cians agreed with the recommendation for high-dose
amoxicillin-clavulanate, whereas a much larger number
chose high-dose amoxicillin. The widespread nonadher-
ence with this recommendation may reflect a feeling
that the guideline strayed from the evidence that AOM
with severe symptoms is more likely because of S pneu-
moniae (for which the addition of clavulanate is not
helpful) than nontypeable Haemophilus influenzae and
Moraxella catarrhalis.17,18 Alternatively, initially prescrib-
ing amoxicillin-clavulanate for children with AOM and
severe symptoms may leave physicians feeling that they
do not have a comfortable second-line option (ie,
switching to a different oral antibiotic with no better
microbiologic coverage for the likely organisms or giving
a painful and expensive daily intramuscular injection of
ceftriaxone for 3 consecutive days, as the guideline rec-
ommends).
For children whose treatment with amoxicillin failed,
just under half of the responding physicians chose the
recommended amoxicillin-clavulanate, with a substan-
tial and increasing number choosing cefdinir instead.
Cefdinir’s rise as a second-line agent at the expense of
amoxicillin-clavulanate may reflect heavy marketing of
the drug, more convenient dosing options, and/or a
lower risk of diarrhea.19
Finally, for children whose treatment with amoxicil-
lin-clavulanate failed, the majority chose an oral antibi-
otic alternative (primarily cefdinir or azithromycin,
which have inferior or at best equivalent microbiologic
coverage to amoxicillin-clavulanate for the likely organ-
isms), whereas only 1 in 6 chose the recommended
intramuscular ceftriaxone, suggesting a strong prefer-
ence for oral over intramuscular administration.
We did not ask the surveyed physicians to provide a
rationale for their antibiotic choices, thus we can only
PEDIATRICS Volume 120, Number 2, August 2007 285
speculate as to their reasons for not following the guide-
line’s recommendations. In addition to the possible rea-
sons cited above, one general possibility for nonadher-
ence is that the physicians are not familiar with the
guideline’s antibiotic recommendations. However, the
widespread dissemination of the AAP/AAFP guideline to
the pediatric primary care community after its publica-
tion, as well as data from our 2004 survey indicating that
⬎90% read the guideline or summaries of it, argue
against this conclusion.8 Nonetheless, previous research
demonstrated that casual familiarity with a clinical prac-
tice guideline does not necessarily result in putting its
specific recommendations into practice, and that may be
the case here.20 Also, other pressures, such as pharma-
ceutical company advertising, office stockpiling of free
antibiotic samples, and/or parental preferences, may
drive antibiotic choices as much or more than expert
guidelines, although there is little research to quantify
the effects of these influences.
Interestingly, we found that agreement with the
guideline on antibiotic choices declined from 2004 to
2006 for all 4 of the survey’s AOM scenarios. This fact,
combined with the lack of increase in acceptance and
use of the observation option from 2004 to 2006, sug-
gests that the impact of the AAP/AAFP guideline has
declined, at least among this group of providers. This
trend, if real, may reflect a waning of the intense pub-
licity (eg, review articles, news reports) that the AOM
guideline initially received. It may also represent “clini-
cal practice guideline fatigue” resulting from a poten-
tially overwhelming number of guidelines directed to
pediatric primary care providers in recent years.21,22 Fi-
nally, it may signal increasing disillusionment with the
recommendations themselves.
Based on the results of this survey, what might be
done to improve the quality of care for children with
AOM? First, for those who advocate increased use of the
observation option, the overwhelming perception
among physicians that parents are not willing to accept
this approach will have to be overcome. Recent success
in substantially reducing antibiotic use for uncompli-
cated upper respiratory infections suggests that such a
goal can be achieved through coordinated educational
efforts directed at both physicians and the public.23,24
Second, for those concerned about the appropriateness
of physicians’ antibiotic choices for AOM, additional re-
search will be needed to explain the large and increasing
gap between physicians’ choices and the guideline’s rec-
ommendations. Depending on the results of such re-
search, efforts should be undertaken either to more ef-
fectively educate practicing physicians or to modify the
guideline’s antibiotic recommendations to make them
more responsive to new data and to the realities of
primary care practice.
In the end, even the best evidence-based recommen-
dations serve to improve care only if the clinicians
286 VERNACCHIO et al
Downloaded from www.pediatrics.org by John C Kim on September 27, 2007
charged with their implementation find them both sci-
entifically convincing and clinically practical. In the case
of the 2004 AAP/AAFP AOM guideline, the experts still
face the substantial challenge of convincing pediatric
practitioners that the recommendations represent the
best interpretation of the data and of assisting those
practitioners in overcoming barriers to their implemen-
tation.
ACKNOWLEDGMENTS
We thank the physician-members of the SCOR Network
for participation in the survey.
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620 – 627

BEING A JUNIOR DOCTOR IN NATIONAL HEALTH SERVICE

“Lindsay Palling graduated with a medical degree from the University of

Cambridge in February 2005. Currently working in Nottingham City Hospi-
tal, she is waiting for the results of the MTAS job recruitment process— due
to be made public in June—to hear whether she still has a job. The form she
had to complete left no room for her qualifications or professional experience;
the only thing selectors judged her on were a series of 150-word answers to
nebulous questions. ‘The people who short-listed us didn’t see what we had
done or where we went to university, so none of our experience helped. No
one ever felt that they would do something like this,’ she says sadly. ‘They say
there are jobs for most of us, but they are talking about 6000 losing out. In the
old days it would have been people who failed their exams, but now that
doesn’t seem to count for anything anymore.’ Palling describes how the
MTSA debacle has drained her enthusiasm for the job. ‘I don’t feel the same
sort of dedication to it now,’ she says. ‘[This mess] has taken idealism about
the job away from all of us. It is now just a job. And not particularly well paid
for the hours. People die all the time. It is hard.’ Dealing with the uncertainty
of the recruitment process makes adjusting to other workplace problems ever
harder, says Palling. ‘We have had a really bad winter here. Quite a lot of
wards closed and we were parking patients in the corridor. There is nowhere
to do your job properly. You can’t do a proper examination.’ The insecurity
is affecting everyone in the hospital. ‘No one feels their job is safe,’ she says,
but it has also made her aware of how important it is to watch what is
happening on a political level. ‘We’ve always thought that we should have
been focusing on our patients and letting others look after the NHS. We are
all so caught up in our daily jobs but we should have been paying more
attention to the health reforms all the way through,’ she says. ‘I just feel so
helpless about it all. If I get a job in August I will try and become more
involved in politics. I think we all will. It has made us all feel that way.’”
Brown H. Lancet. May 18, 2007
Editor’s Note: A real disaster in England!
Noted by JFL, MD

PEDIATRICS Volume 120, Number 2, August 2007 287

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 Management of Acute Otitis Media by Primary Care Physicians: Trends Since
the Release of the 2004 American Academy of Pediatrics/American Academy of
Family Physicians Clinical Practice Guideline
Louis Vernacchio, Richard M. Vezina and Allen A. Mitchell
Pediatrics 2007;120;281-287
DOI: 10.1542/peds.2006-3601
Updated Information including high-resolution figures, can be found at:
& Services http://www.pediatrics.org/cgi/content/full/120/2/281
References This article cites 22 articles, 13 of which you can access for free
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