GAPS IN DOCTOR-PATIENT COMMUNICATION: I. Doctor-Patient Interaction and Patient Satisfaction Barbara M. Korsch, Ethel K.

Gozzi and Vida Francis Pediatrics 1968;42;855

The online version of this article, along with updated information and services, is located on the World Wide Web at:
http://pediatrics.aappublications.org/content/42/5/855

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1968 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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GAPS

IN DOCTOR-PATIENT
Interaction
Korsch, Vida M.D., Ethel Francis,

COMMUNICATION
and
K. P.H.N.,

I. Doctor-Patient
Barbara
Department

Patient
P.H.N., MS.

Satisfaction
M.S.,
and

M.

Gozzi,

of Pediatrics, Childrens Hospital of Los Angeles, University Southern California, School of Medicine, Los Angeles has been the care

of

T
are

HE

art

of

medicine

It
behavior

is generally and
are influenced

held their
by

that responses

patients to
social, their

health medical
eco-

topic of much discussion but been subjected to scientific Whereas other aspects of medical included in the to the physicians is expected approach patient

has never scrutiny. practice the to be on

nomic,

and

cultural

heritage,

as well

as by

training,

the basis of intuition, and it is traditionally learned only by precept and by experience. Until recently, long-standing, one-to-one
relationships between patient and physician

personality characteristics, ence, and knowledge. however, that the way cian
sponds ner

previous expeniIt is also assumed, in which the physipatient-how is, his bedside
feelings of is the

approaches
to )-affect The has been him the basic

the

he

re-

( that

patients hypothesis that doctor there

manand bepresent

were

the

rule

rather

than and and

have

the

exception.

In

havior. study between cation outcome sponse

that setting warmth standing could develop

terns dividual placed merous health daily community Most the eral dence, medical available of especially, lack of warmth care. as well medical of medical doctor-patient by short-term disparate workers. testimony with In care

mutual flourish.
changed,

underAs patthe inrenuother is the

the
between in

nature
terms

of the
and of advice.

a relationship verbal communipatient, and and the re-

relation encounters specialists addition,

is being with and there care

satisfaction

to medical

For
ited cation tified at extent has that reflected ceptions. been the to

technical
documentation only. since that This the this aimed present

reasons
of limitation teaching subject at

the

study
verbal also

was
communiseemed to at

limjusthe all,

to
the there

the

discontent
is criticism

of
offered. aimed in printed
to accept

the

medical and

of is

students, included

humanity there

the evi-

Finally as much
of patients

is gen-

relationship. of course,
in

the verbal aspect of the It is to this verbal interaction

study is directed, although,

awareness,

the
advice.

failure
This

the
the

non-verbal
patients

interaction
responses and

also
per-

is

constitutes

further

documentation
tor-patient study more important represents objective facet been

of

the
one

breakdown
The effort principles practice. to

of
introduce into

doc-

communication. scientific of medical

present

MATERIALS
this

AND

METHODS

Care

Research
The

Design
research design remained consistent

of
long

the

doctor-patient relation left to chance; because

to general practice it

has
of
must

for
its
now

too
imbe

throughout
Patient tape chart visits recording review,

the

substantive
were the and by studied medical

data
by

collection.
means interview.

portance

examined,
then can

defined,
it be practiced
12;

and

taught,
efficiently.

for

only

interview,

of by

follow-up

( Received
Supported

January

revision

accepted

May

29,

1968.)

b
Los

Computing
California,

Childrens assistance
Angeles, of

Bureau Grant was obtained

sponsored by

H-b. from

National

B.M.K.
Health. ADDRESS:

is recipient
(B.M.K.)

Career

Development
Hospital of

the Health Sciences Computing Institutes of Health Grant FR-3. Award #5-K3-HD-28, 297-03,
Los Angeles, 4614
PEDIATRICS,

Facility, National
Los No.

University Institutes Angeles, November

of of Cali1968

Childrens

Sunset

Boulevard, Vol. 42,

fornia

90027. 5,

855

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856

DOCTOR-PATIENT
TABLE
DATA COLLECTION

INTERACTION
I FOR GROUP I
Chart Chart Review Follow-up Semi-structuied Focused Interview interview Plus

PROCEDURES Interview Inter-

Patient

Visit

Post-visit Semi-structured
view

Data collection
method Data

Tape

Recording

Attributes
patient tion. independent

of

doctor-

Patients

perceptions

of

Demographic teristics of
diagnosis.

characpatient. recomniendavat iahle

Further
and other

demographic
background

coinmunicavariable

medical Independent

visit.
vai

iable

Doctors
tions,

data. Indepetident Statements compliance, ance, 1)ependent

satisfaction.

variable regarding reassurvariable

Independent

Figure defines variables. Study There All out

1 illustrates the

the

research and

design dependent

and

( including
and treated illnesses there
Catastrophic

acute

infections,

minor

injuries, cared for. are

independent

of

all

types but

)
those of

are

emergency

situations

also,

are this
usually records

few area
short, prac-

in for

Groups were three groups in the sample.

number.
study making tical; were

The

(
the in
there

advantages 1 ) visits
and

were

data collection procedures were carried on Group I cases as shown in Table I.

taping

analyzing

(2 )
result
making

visit specific
follow-up was nature

was

more

likely

than

not

In the thought that the post-visit interview itself might influence patient#{176} satisfaction and compliance, this procedure was omitted from Group II. Because of the general belief in the sicians
sponses,
Group

to
thus

advice to the on compliance

no patient of long-standing and the physician visit;

parent, feasirelato (4) and

ble;
tionship influence

(3 )

between the

that the presence of a tape recorder examining room might alter the phybehavior and the patients retape recording was omitted from

the
vice clinical study

child
for the was
a

most
ailment situation.

likely

had

no

previous
the the present unit

adfor
pediHospi-

to confound Therefore,

III. were

Upon assigned

arrival to the

in

the three

clinic, groups

pain

defined
patient clinic Angeles. the

as
and at

an
the

initial
Childrens group

encounter
in the

tients rotatation.

between atric tal

a doctor

walk-in of Los

The Clinical After

clinical

Setting investigation
the Emergency

Integrating

research

into

the

careful
settings,

of Angeles for the

various
Clinic at
AGE

TABLE
OF STUDY

II
SAMPLE

Childrens found to
Basically, where
In tients

Hospital be most
this unit common
this

of Los suitable
serves pediatric
more often

was study.
clinic
Age pa-

as a walk-in

Number Parienis
161 190 yr 250

of

many
pediatrics,

problems
refers to the

c
20 24 31

the
she.

parent, most commonly patient and parent will

and the parent

the be
will

changeably

mother. Hence, referred to interbe referred to as

Under
6-18 18 mo-S

6 too

mo yr

5-10

199

25

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SPECIAL
4POST

ARTICLES
-9FOLLOW-UP

857

MOThER INTERACTION

VISIT INTERVIEW

INTERVIEW (COMPLIANCE

MO. PERCEPTIONS
OF VISIT

OUTCOME

(REASSURANCE
(SATISFACTION

INDEPENDENT

VARIABLE
FIG.

DEPENDENT design.

VARIABLE

1. Research

clinical winning

setting, the

and support was one

informing, of of not the

wooing, medical,

and nurs-

rics staff patient another

who of the was

constitute emergency seen by staff

the

regularly

assigned occasional specialist

with longer

clinic.
a pediatric member

An

ing,
gency lenges study

and
to

administrative
the research did

staff
the team.

of

the

emerchalthe medical

or

clinic procedures

greatest Although delay

full-time

experience.
a sample l)y young,

The
well Lest the practices unlike This has

study
trained, it be

describes, practice
assumed and did on not full-time

therefore, as carried
hospital that their

of pediatric

out

care, a threat.

they

were Hence, of the

an the

encumbrance medical
having

as well staff had of the

hypotheses

as en-

to be

pediatricians.

persuaded
deavor-this

intrinsic the study

worth
the

more
that sional office, drastically study.

experienced
during venture the

colleagues,
pilot study

it can

be
an

said
occa-

despite

and them The

content lest the

of

withheld

from

into

a private
there

pediatricians
appear

findings

be contaminated.

those
not

documented adequately

in the stud-

Sample
of sampling the childrens hospi-

been
however.

Details

ied

on

a large

scale,

tal patient sultation

isticians. ple, view i.e., of It

population with
800

were
that visits,

planned
a large was

in conand
needed

a medical
was decided patient

sociologist

statsamin

Data
TAPE

Collection
RECORDING

Procedures
IN THE EMERGENCY

CLiNIc-Transcripts
actions recorder methods were in are obtained conjunction basically

of doctor-patient
by using with
different

intertape

the

many

variables
some of the from the was pediatric

affecting Tables
of study a larger the

docII
sample. one re-

a Uhert a Limpandert
from

tor-patient III and

graphic This cently

communication. Figure 2 list

characteristics sample studied differs in

and

demo-

their of reof

amplifier
cording speech.

to
of

make
frequencies

for

better
in

quality
the range

emergency

clinic
pital

at Los
in that

Angeles
there

County
less

General
unemployment

Hos-

an

The attractive from

equipment mobile
attached.

was cabinet and

Company,

incorporated in with a visible

was ob-

microphone tained

Permission

and social disorganization relatively fewer Negro families However, sample

Spanish
in

and

and more Hospital

there were Caucasian sample. Hospital more

than

all

patients

all

doctors
Melrose

to

in there

the even

Childrens in were
and the

the

Childrens
Negro families

f Magnetic Avenue, Los

Recorders

Angeles,

California

7120 90046.

proportionately population
in

surname

TABLE
ETII SIC BACKGROUND

III
OF STUDY
SAMPLE

the Table

Los
chief

Angeles
IV shows complaints

at large.4
of diagnospavarious

distribution

Number Ethnicity Patients

311 254

of /0

tients tic

categories.

The
patients were lows with

64
mostly

pediatricians
made the up the full-time

whose
substantive residents, experience

visits
or in

with
sample fel-

Caucasian

39
32

Negro

Spanish
Other,

surname
not reported

198 37

25 4

1 to 5 years

pediat-

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858
TABLE
PATIENTS CHIEF

DOCTOR-PATIENT
IV
COMPLAINT

INTERACTION points lowing view-and

istered visit. The
20
20
16

in the the
within interviews

study

period:

immediately post-visit interview

after designed the to the

folinteradminhospital obtain parents

interaction-the a follow-up
14 days were concerning

Vunrber

Chief

(omplaint

of

Patients Gastrointestinal Respiratory 222 221

information

(1)
childs
with this

perception
subjective

of

her

illness

and
illness;

her
(2)

Fever
Eye,

and/or
ear, nose,

convulsions
throat skeletal, behav-

174 155
69

experiences

14

I)evelopmental,

ioral
Trauma, Skin,

or psychological
injury rashes, allergies

her her the

expectations perception

from the medical of her interaction the

visit; with

(3) the

44 43 166

4 4 15

physician;

(4 )
and

visit;

(5 )

parents extent

satisfaction of follow

with through

Other

on medical advice. corded verbatim

Whenever possible

Responses during the

interviews were

were reinterview.
tape re-

have

their

consultations effort parents were

that,

recorded at improving children. that the

a period they

as part clinic Doctors records The

of

of

corded
the
greatly

to monitor
accuracy of

interview
verbatim

techniques
reporting.

and
A

a research services to and patients would

sicians dismay

aimed and told

after

shortened that contains

form the

of

the questions

interview which is

schedule

be
and

completely

confidential.

phyinitial tended

stated

self-consciousness,

proved most informative and reproduced in the Appendix. As many of the participating cians as could be located in

acceptable pediatriperson or

to deals
by

forget

the

presence
with from

of

Tim
interview

INTERVIEWS-The

the recorder. present report obtained

The inmothers.

by

primarily were
pretest.

information

patients are

mail were also interviewed to explore their perceptions and ideas in respect to the hypothesis and variables basic to the investigation. Preparation The
analysis

terviews
years

designed
They

after reporting-a the

more

than
and

semi-structured

designed mise and the follow-up unstructured itated

not

for between

verbatim obtaining

comprovalid data ones. The by a short, which facilinformation

of

Data task in

for

Analysis data the

I)

most

largest
was

preparing of
interviews

for
293 ex-

most reliably interview was focused inclusion

out by

ratable followed

the

coding
(Group

responses and
into mean-

from
post-visit

the

800

follow-up

interview of relevant
the

interviews

the
brought

ingful clusive coding making

categories but included

which all

were

mutually

semi-structured

possibilities. numerical, to computer

The thus pro-

form. Interviews

with

parents

were

held

at two

system was entirely the data amenable

I2

II
jll+8

Highest

Social

Class

Ill IV V
j21. 1230

Fic.

2.

Distribution

of

patients

in

social

classes.2

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SPECIAL
cessing. Intercoder reliability was of central

ARTICLES
TABLE
DISTal BUTION

859
V

concern.
coding

The
was

rate 95.2%. data,

of agreement Background and of the has coding This factual patient been the makes

for

the data visit

final conwere
highly

OF SATISFACTION

information,
.Vumber Satisfaction Patients
316

demographic cerning coded. The content established view interaction

(If

all aspects

40

satisfied

analyzed the follow-up possible categories

for interthe

by a method for responses.

utilizing

Moderately satisfied Moderately dissatisfied I-highly dissatisfied

Total

292
47

36
Ii

105 8(N)

13 lO()

comparison by computer content with the mothers

assessment pectations of and the degree perceptions

of the interaction perceptions, and

to which her childs exill-

bined that tient the

visit items

with indirectly satisfaction things

with yielded

responses address

to
what

other
were

questions to
some

of the

themselves not
.

paof

ness Other

are

responded including

to

by

the

physician. Bales in-

( e.g.,
you
doctor?) a more

methods

notably

that
the

did

like

about aggregate

your of any or
pro-

teraction process analysis will be described in subsequent reports. All data have been punched
onto

This

internally

consistent

on IBM
magnetic

cards

and
tape

then
for

transposed
processing

and other
tested. by

reliable
To experienced also found were

rating
give

of satisfaction that
a more

than devised

computer

combination responses,

was
representative

at the Health

University Sciences

of California, Computing RESULTS

Los Facility.

Angeles,

file of patient
were taken

the
account. two for all

global
in the

ratings
field

interviewers into these

Reassurance

Some
sults be intrinsic reported

of
emerging

the
here

descriptive
from since the they

qualitative
investigation are new and

rewill of

was ables analysis.

to correlate
that combined

so consistently
dependent aspects of

with
vanthe

satisfaction

interest. certain
features

In
of

addition, basic
the

the attributes
doctor-patient

results of

of the
in-

correlating
patients,

When isfaction,
asked. whether

all patients had been rated for certain basic questions could
First, any it was necessary to

satbe
see

teraction, sponses presented. physicians, tent analysis, ual cases relevant. General

and

the

follow-up satisfaction interviews

interview will with from when individthey

rebe the conare

with patient Results of findings and will be some

aspect that
different

of

the patient
in the

investigative satisfaction.
three

procedure Table
was of

influenced VI shows
way

patient

from included

preliminary data

in no patients.

satisfaction groups

Findings

on

Patient

Satisfaction visits satis-

The general
may

next basic concept be more closely

question related to the that patient satisfaction related to attributes of

Seventy-six percent of the patient studied resulted in high or moderate faction view. tributed shown The evolved questions themselves tion (e.g., as expressed The various themselves in Table final V. satisfaction ratings

by the mother on intersatisfaction ratings disover the sample were to those address satisfacgo?), com11 III

TABLE
STUDY (imu AND

VI
SATISFACTION

as
Study

Vumber

of #{182}; Satisfied

Group

Patients

carefully in the directly how did

from responses interview that to the your patients visit

293

72.6

294 213

76.1
76.3

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860
TABLE
SOCIAL CLASS AND

DOCTOR-PATIENT
VII
SATISFACTION

INTERACTION there would patient effective. the time minutes. found the It from
might

were enough automatically communication For No between IX). was also which
influence

be

time better would

patient and become patient from

care doctormore visits, 2 to 45 was and satisfied

Social

Class2

Number Patients 24 148 373 230 24

of

% Satisfied
79.2 74.3 75.7 76.6 62.5

the

recorded ranged

of interview

II
III IV V

significant the time of patients suggested visit

the

relationship of interaction who that clinic

of the

percent

were the

( Table

illness made
and visit

the

to the
length

was

the with
no

patient and the found VII VIII

himself, so forth physician. when

his In

background, to the the present

in

his experience

ed-

ucation,

than

that could
fying

certain kinds be handled the patient. of in good infection promptly; be illness

of patient quickly while For the the instance, skin physician communication and might

complaints still satisa be and simple diagmother about could

sample
satisfaction

significant

differences

local nosed would the

were

different
compared.

social educational Also, a significant attributes the

classes levels it was reof of

( Table ( Table
not

) )

or different
were

immediately,

therapy

possible

to demonstrate between any other and visits.

lationship

the population measured satisfaction with patient

degree

be instituted at once Table X shows, however, that in the patient visits studied there was no correlation between diagnosis and interaction time, or between diagnosis, time Patient of interaction, Expectations and satisfaction.

The next obvious query specific physicians personality to patient care and patient There
more

relates to the or approach satisfaction.

were 17 physicians who had seen than 15 patients in the study. Each of had some patients in each of the satisgroups. of Visit discussions
stated by
was

these faction Length In

is often

One of the hypotheses generally accepted and basic to the present investigation is that the extent to which the patients expectations cian are the visit met in from the clinic or the physiwill influence the outcome of terms of satisfaction and/or When looking at the total samvisits, this theory is validated responses of pediatric of their technical their and trouble the physician sympathetic for questions physicians in the study
and most

of optimal
pediatricians
determined

patient
that

care,
if only

it

compliance. ple of patient consistently. Interview proportion expectations scend his expects cemed, and Most of participated
selves as

Significance

square
correction.

tests

using 2 X In relationships

by means of chi 2 tables with contingency reported as significant,

indicate clinic physician competence. to be and and

that patients which This friendly, to take

a high have trangroup contime

0.01.

TABLE
EDUCATION AND

VIII
SATISFACTION

explanations. who of thempatients

Number

Grades

(ompleted

of

interviewed thought
of the

Patients
1-3 4 yr yr

Satisfied
74.8

friendly,

stated
high school school
159

that who more XI,

in

general Still, that

they there their

think were doctor be

doctors 193 seen pahad on of their

should tients been Table

be friendly. reported business-like. the patients

high

221 150
270

72.8
78.7 72.2

1-3yrcollege

Other

As can who thought

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SPECIAL
physician as

ARTICLES
TABLE
LF:NGTII

861
IX AND SATISFACTION

being

friendly

had of

signifi-

cantly

greater

proportion

satisfaction

OF INTERACTION

after doctor

the

visit,

as did their

those concern.

who

felt

their
Aumber Minutes of ratzents
.

understood day-pediatric
their them. Of singled expect with

Present
also well

patients apparently doctors to communicate

the patients studied, 244
Less

Satisfied

than

21

71

spontaneously

out

the

doctors of

comnote. he quesmore

3-5
6-1()

163 199 110 than 15

84

75 75 69
75

munication Those who

listened to

skills as being worthy commented favorably

me, satisfied he answered all

( e.g.,
my
were

il-IS
More

tions,
frequently

he and those skills XII. of

explained were

so

well others the

pie, than tion Table One

than dramatically

in the sammore satisfied communicaas shown consistently in

expectations that the

need parents

attention perceptions

is of

the

concept

who disparaged of their pediatricians tile striking

in all

the

illness to be used to
childs

and
taken
gave

anxieties into
parents

about account.
in

their child need The interview study that

concerning worried you

findings
phases of

the

an opportunity
about their

demonstrated

the

study

is

tell illness.

their

main Two were: information

worries

the for

patients information disease

patient

intense and
and
groups

concern
what with caused

with

and of

need their
analyz-

questions
What

yielded
almost the

highly
all most

explanation
it. In certain

relevant patients

childs
ing

expecta-

about
you?

Sibyls The
fears

illness? most
were

Why unexpected,
readily

did

that

worry
in re-

tions that causation

in common, for those and parents

there nature

is definite expecting of their childs

evidence to learn the illness

unrealistic,
expressed

dramatic sponse

the failure to have this leads to dissatisfaction larger number of visits der of the sample.
percentages

expectation fulfilled in a significantly than in the remainXIII in these shows patients. the

I
have

to these questions. thought she might heard when

her about illnesses. on neither where

Mothers choke to get

would

answered death, reI was

when apparently

that they
stomach

children have
children The

hopelessly
burst,

tarded
afraid (1ueried minor

a convulsion,
with

Table

of satisfaction Analysis analysis additional patient concerns.

presented patients who

highest
expectations

incidence
occurs in nor

of those
main

Content Content
throws

dissatisfaction

follow-up

of light on expectations Whereas

so far perceived

the the

interaction importance and dealing the interview

visits
worry

received

attention.

of meeting with their

material those

shows

only that

that their
DISTRIBUTION DIAGNOSTIC

TABLE OF SATISFIED
CATEGORIES BY

X PATIENTS
INTERACTION

IN CERTAIN
TIME

hopes filled
analysis whether

and were
an

expectations had more dissatisfied,

makes it expectation possible was

not been fulthe content to determine

actually han-

Mnu1es

Satisfied NiI7flber

D;agnosi.

dled deed.
measure

by the physician The content data

the findings

in word confirmed

and/or in in large
so far. The
G
.

<;;

.5-14

l5-4

#{149}5

of Patient.,

presented

I. (lisorder
infeetioti

as
47 31

.s7

69

Ear

failure increase the

Closely

to have expectations handled the probability of dissatisfaction

related

does in

Coid.
Skin Well

URI
disease chuII problem

4 I 4
4 0

iS
8

5
1

69
4

86
53

5
17
10 1

4
7
4 1

1
I
0 0

34 29
16 9

71 77
80 37

patient. to the idea that patients

Pneunmoiiia Behavior

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862
TABLE
MOTHERS PERCEPTIONS

DOCTOR-PATIENT
XI
OF DocToRs

INTERACTION

and only were

who 73 were visits

failed mothers but

to receive left did the who not clinic get

these, expected any;

there to only

were There receive 51% of Of 67 hoped

62% who

satisfied.

AND

SATISFACTION

medicine
Number Mothers Perception of Doctor of

Satisfied

Patients
Friendly 323
193 83 60 83 32

these clinic

satisfied with their visit. which the mothers vainly

would result in cure ness only 44% resulted one pected were figures of these visits told were to care were represent compared in Table number XIV. of made their for a to the satisfied. to have

for their childs illin satisfaction. Sixtyby child the mothers hospitalized child All these significant remaining mothers at home; satisfaction reduction sample who stated as who exbut 62%

Business-like
Did understand concern

625
80

Did

not understand

concern

Interaction

coding noting
were

for

content

also worries the too

alor

when shown that tion

lowed
expectations

for the

whether
mentioned

main
to

during tling
not

interaction.

It was

not

doctor star-

A small

to find verbalized not to were by the

that expectations to the physician mentioned find that specifically patient tended proportion
in more

were often ( 65% of ex-

they had hoped for physical of their child or reassurance were The not significantly only unmet for satisfaction This broad were may definition

examinafor themless likely expectations diminuexpectahave been of treatwas to

pectations impressive worries

doctor

),

but

it of

was main to the a sigand pa-

selves also be satisfied. which tion tion due ment of for used did

only 24% mentioned during the

make

significant

follow-up treatment. rather in coding.

medical

visit.
nificantly expectations

Pediatricians larger The whose

to handle of concerns educated true-among not high also were

to the

highly is were there finished

tients. those or more Other When pectations

converse concerns to, had not

mentioned significantly school.

Referred patients prone to dissatisfaction its than those who Hospital on due to unmet patient what would is usually

significantly more following their vissought out Childrens which since expect in the may also be a referred

responded who

their own expectations, tend to offered

Findings all other had

on Expectation patient not been groups met whose were excomto obthat

more than emergency

clinic. Miscellaneous
MEDICAL

pared to the rest of the sample in respect satisfaction, the following results were tained. Among 128 mothers who stated they had expected shots, tests, or

Findings
JARGON-An

outstanding

bar-

nier than

to communication half
use

encountered cases
technical

in more is the that pediathe

language.

x-rays,

the
of

recorded
difficult

tricians

One
TABLE
DOCTORS

mother

said

on

interview another requested he terms child had used

XII
SKILLS AND

COMMUNICATION
MOTHERS SATISFACTION

doctor during
pediatrician

talked medical, an interaction

repeat

mother that the said apply nares, in to

what of the

English.
Mentwned

The portions

technical

Communication
Skills

Number

of
Patients 244

(;

Satisfied

anatomic labia, (e.g., forth lumbar and to

(e.g.,

Liked

86

sphincter), to physiologic processes injection, edema, peristalsis, and so ) , often to laboratory procedures (e.g., puncture, the many Coombs other titre, subjects Tine dealt test), with

Disliked
Total Sample

53
800

25
76

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SPECIAL in medical were consultation. thought to Lulnbar drain the punclungs, located period time the effec-

ARTICLES
TABLE
EXPECTATIONS
I)IAGNOSIS

863
XIII CAUSE
NI)

tures

REGARDING
AND

meningitis in the throat, was interpreted for the patient use of medical tive
always

was understood to be and the incubation to be the prescribed to stay jargon in bed. Although tends to block it

SATISFACTION

Cause

and

Diagnosis

Number of Patients
73
given

Satisfied

/0

some
ently

communication of ideas, lead to dissatisfaction. mothers who, although

could not understand the

does not There are they apparexplanations

Expected

-not

told

51

Wanted Total

explanation--not

149 800

42 76

Sample

offered, and felt In and are the

were fancy

impressed nature to the examples instances

with thereof, foregoing

the and

quantity possibly technical

and tion

Inspection that
mothers guilt of seem cause,

of

individual to be more

cases with avid for

revealed self-blame explana-

flattered. addition complicated a great many

visits a Words are technical by context the in kind

preoccupied
as if to

of jargon, there in the recorded

stereotype shorthand, follow, and is

It
the

may
cause

be
and

relevant
physicians

vindicate in this ideas illnesses

themselves. context that concerning were inconSomething

Iatient language, used. history,

fancy

which routine of hospital workup, obscure terms, the and medical

one

mothers gruent
eaten

of childrens
in a number
causing

like as

of respects.

to

the
they staff,

patient
are often used

as
in

was

the
of 6 of the

childs
49

illness
patients

accorin

ding study, the 111

to

the and

mothers in only offer

the

ceaselessly crucial interviewer

these

patients explanation. their and this

seem

did In childs hazwas

in that

( e.g.,
doctor

mother
that they

told

the that

physician instances

same blamed chilled,

said

would

mothers exposure
as getting

admit
means

her

for

a work not

up-whatever clear to her of the child. and that

trouble
ards only mothers their might such 11 confirmed

on

to environmental
examining It would physician

meant

It was hospitalization

).

this

by of are the

the prone

ILLUSTRATIONS SYSTEMS-That

OF DIFFERENCES patient

IN VALUE

cases.

physician

op-

crate
systems

all too

often was one

findings

in widely disparate value of several observations

the as this present well impression. as study. more The Many formal moth-

immediate be thought

to incriminate known environment,

in invoke their own

factors in which
power to

which incidental results

prompted bear out illness

control,
while side

and
physicians

which factors. 65 of
they

are

familiar to more objective

them, out-

etiologic All but

what

ers
their almost

intense
childs

concern

with
may tendency

tile
be for

causation
related parents to

of
the

the
had

mothers
assumed

interviewed
to

specified

be

the

universal

to illness inthat
childs state-

blame

themselves

for

their

childs

diagnosis before they great many instances the

122

saw this

the was

doctor. In a the same as similar. One was that in the illness whereas only
in this

and other shortcomings. On follow-up terview 326 mothers openly verbalized

they illness. blamed Others themselves made were strong for their defensive

doctors
cases doctors

diagnosis difference,
the made

or highly

striking

was
47 gory.

gastrointestinal This the

however, mother thought in nature,

a diagnosis

ments
of guilt. stances

suggesting
There where

equally
only

definitive
a few

feelings
isolated explored inor

catesince, all

attempted
there diatrician although were

to
even she

the physicians relieve these

a few cases blamed

in

can be pediatric

readily patient

understood population,

feelings,
in which the

and the
mother

pe-

types of acute by gastrointestinal Mothers

protect their

illnesses manifest symptoms. seem to feel

and to

themselves need
them

specifically

also

greater
allow

to
to

had

not

incriminated

herself.

children

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864

DOCTOR-PATIENT invalided On doctor

activity

INTERACTION do peats just so you keep believe were her on that to ask counted a regular they it offer was

be that

with had
for

minor

illness 90 mothers

than stated

physicians. the
restricted

interview

recommended the child, kept

but the
OF

rest or 324 volchild

CONDUCT

schedule. Most pediatricians parents

yet when

ample

opportunity

questions, no quesonly one be where

unteered bed
OF
INCIDENTAL

they

had

indeed

in

questions

or at home.
OBSERVATIONS

found tions or two;

that 10% of mothers asked and an additional 27% asked and, one of these might

CONSULTATION-The

initial and of parent special that patterns.

encounter in the interest. and than More

between clinic There also

pediatrician office has been are certain certain individual pediatricians and some about this wear
some

do you go to get the appointment? or how do I find the bathroom?. This finding takes on additional stated liked lions. asked
quently gives

mores

prevail

importance that the showed

ignores

since they doctor that

these

193 mothers would more that not

the

on to by

half of the themselves complained that

greetings,

do not introduce mothers specifically in spite of the fact tags. After

proceed

interview have asked scrutiny mothers

the doctor answers,

have quesdo get infresubject.

Also,

of questions

doctors

name
pediatricians

brief
to

question,

vague

or changes

the situation at hand immediately, engage in a short period of irrelevant versation aspects cian and of the then visit. proceed to the the It is always

others conmedical physimother. doctorinstances effective

EXTRINSIC

COMMUNICATION

Btiuuims-

who calls In analyzing is a clear

the turns, never the the progress of the in cutoff which interview. certain point to

The study was not designed to illuminate the many barriers to doctor-patient communication that are extraneous to the verbal interaction. For the sake of completeness, however, it should be pointed out that indirectly the study did throw light on a great many external influences that seriously disrupted the medical consultation. Waiting time in the walk-in clinic extended from a few minutes to several hours. One out of four patients mentioned this long wait, but in many instances this apparently did not influence their feeling about other aspects of room, of the of the medical visit. Actual interruptions the consultation, other people in the practical preoccupations on the part

patient there

interaction,

communication in the mothers repeatedly basic pectations as evidenced comes answers to worry to or from by completely

is later documented If the doctor fails statement main she may that or hopes cease she and reduces of and either some cxbeher yeses. after perthe not to try

heed him, the

her

of her fact

mute hmms

toneless

Things said this critical ceived mother even what

trary.

and done by the doctor point may not even be

by the mother. In these instances will report that the doctor did examine was the
In

her or he matter when in the transcripts

didnt there

tell me is clear con-

TABLE
UNMET EXPECTATIONS

XIV
AND SATISFACTION

documentation gives
or

to the

up

other instances it is the doctor who in the face of a disturbed, verbose,

mother.

Number Unmet Expectation of Patients Shot, test, x-ray 128 73

.

c
-

Satisfied

unreasonable

This

is the

demonmother and less

In one Medicine Cure, Freatmeit
Examination

strated become
related

in that his decreasingly

to what the

answers to meaningful
mother

62 51
44

is saying.

make

well

67

such
tally

instance
chaotic

the
feeding

mother
and

is describing
sleeping

a topattern

Hospitalization

61
24

62
71

in her

infant

and whenever answer,

after the

the the

critical

moment seems simply to re-

14 11

50 36

has passed, require an

mother doctor

Reassurance

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SPECIAL mother with other children the at home or at

ARTICLES The The

has been tors53

865

Process process
studied but

school, pressures on noises, and underlying were among the many difficult corder

doctor, medical intrusions

outside problems that were tape reexaminwhile the Although dehow difA
be

of doctor-patient by a number
unfortunately,

interaction of investigausually not as

to ignore. On occasion, the was on and running in the the for had they did behavior presence
Negro

it applies to a regular medical \Iore recently Davis13 and

consultation. Adler et al.14

ing room during patient waited these liberately, some ferent

cheerful

long the not serve

periods doctor. been to

have applied the techniques of interaction Process Analysis of Bales#{176} to the documentation
effectively.

records patients in the

talkative

obtained reveal

and

analysis

of

medical

visits

most

was completely of the doctor.

family would

The

Content content doctor extensively

Everyone

The
between

of the

verbal

communication has been different

the

singing and and reduced

joking them

until the doctor to monosyllabic,

entered sullen,

nized
settings.

and patient in many

emphasizes

scruticlinical
need for

depressed-appearing respondents. One Negro couple speculated during their long wait whether the delay in their receiving service could be due to racial tion. These findings illustrate
some of the cultural barriers

the physician respond to situation. too too mented

also show

to listen to the patient the emotional overtones disadvantages or or

direct and

and to in the terms docustudies

com-

discniminadramatically
between

The

of using were These

between

technical hurried

too

ambiguous

or in being

docunrewhich in

perfunctory studies.155
relationship

tons lated

and to

certain patients which are the attitudes and behavior

in several

are shown attendance. BRIEF A

by

the

examining

physician

munication phasize cussed which

outcome. medical
the

Other topic patient

Balint2o for their of

studies should cooperation

stresses illness diagnosis

embe disvisit. to
that and has

during et
ai.10

doctor-patient

REVIEW of

OF

RELATED

LITERATURE information on

Mohler, emphasis patients points should stressed

relate
a name

wealth

published

on need out

treatment. that a

subjects ship is courage erature Some tor ful ic concepts

relevant available to venture as well work of the

to doctor-patient to those who into as into respective deals the with medical basic roles

relationhave the litjournals. sociologof docthe useinto intechni-

statement therapy.

non-medical

precede

Yudkin21

that

the

same

patient

may

have

of the

and patient; Parsons proposes division of the physicians acts ones

two diagnoses-one often more important, diagnostic skill to

needs Davis22 cussing certainty

overt and another one, which needs greater elicit and which also to during
emphasize the

to be
and

responded
Parsons23 reduces

the
that patients

visit.
disun-

strumental cal aspects sive ones and social lationship of the

which is

( dealing

with

the

of medical ( concerned aspects

care ) and expreswith the psychologic doctor-patient the the concept patient
to the

prognosis

and
or

anxiety.
threatening

The has
is finding

effect
patients

of raising
to make studied242O

of the also

re-

anxiety

He sick-role
.

elaborates played by
applicable

them
with thal

cooperate
somewhat more recently

better
confusing

been
results. that

Levenraising a

not

as

directly

pediatric described from

by

situation. Szasz the physicians to the patient

patient, depending

and role
on

Hollender8#{176} as ranging
the nature of

moderate
may

amount be helpful
reassuring

of anxiety in dieting
advice

in the cooperation,
is given.

patient if

doing
the

to participation

adequate

his illness Bloombo spective tients

and the emphasizes subcultures

phase of the relationship. the effects of the on the doctors and

Attributes Patients background,

of the attributes

Patient such as socioeconomic psychobackground,

repa-

cultural
communication.

functioning.

Personal

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on December 4, 2013

866 social have

fluencing

DOCTOR-PATIENT factors, education, been emphasized

communication

INTERACTION data are available at this time to demon-

by

and knowledge Blum27 as inthe doctor. advice has and

studies.2831

Failure
been tients

to follow
explained

up by in

on cultural

with medical factors of such

pa-

strate how and when patient correlates with follow-through advice. Here are a few of the patient satisfaction was chosen

satisfaction on medical reasons why as an impor-

beliefs physicians on

a number blame attributes and studies do not

Many failure
economic, ground.

communication as sociobackwith conthat been inthe and illness have Samora, commuracial dealing a very suggest

tant outcome variable: when the study was initiated, during the many long explorations and discussions of objectives of an doctor almost on the individand pauniversal pant of the ual consultation between tient, there seemed to be agreement that one aim physician was and to satisfy
disenchantment

patient
education,

Published vaniablesl2I4
picture. However,

these
sistent

yield they has

the
over

effect

of these have
of

factors Social and shown

probably to influence

to meet the patients needs the patient. The widespread with the medical community cane that to the at preswith concern in this
with ne-

estimated.

inter-personal

fluences
outcome may affect

been
medical doctor-patient

is being
ent also

offered

consultations3334 communication.

medical
investigation

highlights care needs

correlates

that dissatisfaction to be a central satisfaction

completely

The and been his

patients general by others, shown

understanding medical Seligmann, et

of his knowledge to affect

of physicians. assurance cepted

pediatricians

In addition, which is another

generally between
There parents.

ac.
is

et al.,#{176} and nication to medical The

goal some

of
and

communication
patients

with the physician and responses advice to a significant extent. Expectations expectations influence
at

also strong

quantitative on physicians the health behavior

evidence#{176} part and and of many the clinics

and that readi-

conviction to consult

Patients

long-term from the visit

have

Patients the
on

and
been

ness

for epwith apfor The sus-

strong

of mutual
relationships

expectations expecta-

doctor-patient

isodes of illness do reflect past medical care received. pear to constitute concentrating on
concept of patient

satisfaction This would justification satisfaction.

is a little

investigated

length.

Patients

tions role,
standing,

may relate to the i.e., they may look

emotional

doctors expressive for kindness, underSome pa-

another patient
satisfaction

support.3941

pect

among

many of the

legitimate profession are

and because

honorable quacks, for clienThis for, satismedical valid shun

tients tions ness.3943 they

or

emphasize about Other

relief

that the disease patients competence

for

they

expect and simply in their its

explanaseriousstate that

members

faith healers, and so forth producing high satisfaction tele, even though the service is of low quality seemed to the rather faction than in why

notorious in their that at times. a reason patient and

expect
symptom

is offered

themselves.

or dishonest research team studying to ethical

DISCUSSION Patient It Satisfaction seems appropriate many

documented effective

against, relation practices. ethical less the

to

point

out

first breaksatiswas

that, although downs were factory the

76%

communication in the study,

communication

top-level reason
good

There seems no physicians should

since

communication

it is the competition. concerning

stock-inpa-

and

rule and not of the patients visits. The wisdom tion as a yardstick ness of doctor-patient be questioned,

the exception. After all, were satisfied with their of using patient satisfacto measure the effectivecommunication may since insufficient

trade At tient those stated lation with

of their present

ethical findings

satisfaction are being correlated with on compliance. Even now it can be that there is no simple, direct correbetween satisfaction and compliance medical advice, and the dependent

especially

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on December 4, 2013

SPECIAL variables
arately as

ARTICLES septhis similar need relates not only in to the the the future basis, patients wish but to prevent also

867

will
well

have

to

be

looked

at

as together.

problems

to a

to

be

relieved here
pediatric

from illustrates often physician

feelings
the

of
investiga-

selfthe stateto be

Patient From the gation to the and ical and most

Expectations a practical relevant own is the patients documented ideas expectations been shown information point results of from need about view, this for the one investiattention illness of

blame.

Whatever

tion
parents

reported
of

amply
are

that
concerned

with ment
satisfied

causation from
and

and their
reassured.

need in
A question

a clear order

the familys visit. It has highly relevant

from the medthat important concerning is readily obinterview quesbe incorporated also been concerns docthe reof

raised uncertainty feelings mother. addition

parents,

as to the

harm

of allowing cause and

might be persistent unabated of the that, in of the part

illness be

concerning

patient tamable tioiis

fears and expectations with the simplest

which

of self-blame on the pant There is clinical evidence to

these

could medical that insufficient

consultations.

easily visits. currently attention

the

anxiety
feelings in handling

and
lead

distress
to the and

into regular demonstrated are corded than given

ton-patient

It has these
Some

overprotec-

tion
of the which avoided

and

inappropriate
may if be possible. harmful The

behavior

on the
childs should investiga-

during that, burden, to these visits. are met

Balint2 have can amenable

parents

patient adding to

visits the

suggest physicians given patient needs

and and need more plans. to they

rather attopOnce she to

has a name proceed.

present

tion

suggests

that

clear

discussion

of causa-

tention and recognition ics makes for shorter the

seems the for stressed their

tion of illness blame on the preventing

erprotective

and relief part of the parental behavior. Versus

of feelings of selfparents may aid in anxiety and ov-

mothers
more physicians the illness

urgent
attentive ideas patients before

undue

Expressive of the a
Some

Instrumental

Functions

Physician
of the findings presented can be re-

The failure ment often

present to was there

findings receive definitely

bear a clear associated

this

out with

in that statepatient that in addiwhich worries to repurgent the fit into

diag-

diagnostic
suggested

garded separation
functions

profitably of of
questioned the instrumental

in

the

light and Only study

of

Parsons,6 expressive 54 of the senipesix

dissatisfaction.

YudkinU

instrumental the physician. in

the

is a second

diagnosis

tion to the ostensive chief complaint needs attention. Some of the main mentioned in this report would seem resent such initially nonexpressed needs
physician

800
ously

respondents

the

group
competence

technical functions

( i.e.,
mothers of the

of the only

diatrician

whom felt child that left there

they

had

seen,

and

of the
to

patient elicit.
category

which These
of the

it behooves might
second

the pediatricians something to were a

handling be desired. profor and

the

Yudkins21 nosis.

However, portion
warmth, friendliness

considerable

of mothers who wished greater show of concern,

for themselves from

more more
physi-

Diagnosis
Previous tation patients had

and

Cause
on that, seek cause, in It
(lata.

explorations{ suggested often more to learn so forth

patient whereas

expecadult relief for

cian.
tients

A
who

different
have

sample
a longstanding

of might by
and

pediatric
relationship

paa and prodoes

pediatstudy

symptom what

with
higher

a particular
degree

doctor to judge medicine,

experience warmth, the public

impersonality

themselves,
a need on? and and

pediatric
the

patients
order be

parents
brought

have
it that

of friendliness, Still,
inhumanity one looks

sympathy. test exist over when

to feel
speculated

satisfied

the

reassured.
#{182} Unpul-)ljshed

can

of present-day nc care on

the
at medical

problem
and A recent

a broader

scale.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on December 4, 2013

868 by lates
vice.

DOCTOR-PATIENT Charney,
relation et a1.#{176}illustrates

INTERACTION longground; were made hence, no significant specific inferences physician at-

that

standing

with
Long-term

with follow-through

a pediatrician on medical cannot be

comeadesti-

concerning

compliance

mated tient lated

without

on the basis of the present study. Pasatisfaction, on the other hand, is meto the expressive role of the doctor
a question of a doubt.

tributes in relation to patient responses and satisfaction. As has been presented, every physician in the study had both satisfied and there clear tients that dissatisfied was from no their
no

patients, variation aspects needs expectations

and,

incidentally, It is paand all.

also all

in compliance. of the study that vary can are are

can

individual one patient

greatly meet such them so unrealistic

Patient The with study their

they

Attributes only higher is that fears

have

pediatrician problems

specific

attribute

of

patients in this to express and that

them

Some and
that

education demonstrated they are more prone and

to

of

a nature
them in a

pediatrician

fulfill

hopes
or

to the
chance

doctor
of having

short gested
recorder

encounter. that pediatrician unobserved best was This research not team the

It known do but

has

often presence
room

been of
would

suga tape
make

a better

responded

dealt support

with. the in of their the

However, view threat that of be

the paan ex-

in an examining

study tients
acute

does health illness

not can

the that ten. the came crease ance were

better. do know

This are how and not

assumes trying to do betto which hence it

behavior most
or findings,

pediatricians an assumption

frequently
educational

to do their

plained
ethnic, ground.

on the
religious, These

basis

socioeconomic, backthe recent reto contemcane

in

subscribed,

suits plate
offered

of Davis,13 at a time
increasingly

are when

like encouraging health

to groups

as no supnise that there was no inin patient satisfaction or in compliin the tape group of patients whose visits recorded. of Doctors that be must
effective as 5 minutes

is being the lower

educational findings physicians spend

tions to

and should who more

patients

also will time

economic be heeded readily and give

strata. These by all those admit more that they explanaintelligent out by Saphysi-

Utilization Evidence cation

as little

Time commumand
practical

a doctor-patient satisfactory
is of

can

effective
interest.

in with

who

and
mona,

more

educated. to them of vicious the

seem more As pointed

et

Inferences
reservations, already

be

drawn
It

from
is possible

this
that

et al.#{176}and

Seligmann,

however.

an doc-

cians tend understanding this

tion need

underestimate and medical in turn which circle in

from

the patients information and

less infonma-

consultation

between

ton
factory

and

patient
if more

might
time

be
were

even

more

satiseven

leads
to these of

to give

available

patients,

a kind apt

clearly which physician

leads most

to in are into

though
One is lost

more thing part

is of

time,

as

such,

is not that and that in

enough. time time same they seem acexespecially

is clear, of the and

lesser

however,
verbalization,

much the

education

their Taking

in ineffective

to receive

least.

all this

on the the
room

doctor, doctor
import

consideration, it seems important cians and other health workers patient the benefit of the doubt their medical enthusiasm,
manner, even

for physito give the and to give as much different

seem less

patient this that

spend time. spent

spend also quainted

period a few with the

of minutes

the than how It would in getting ideas and

explanations with albeit in a somewhat

with those who

patients

responsive Physician The ally

and

less

well

informed.

pectations later on doctor-patient

One

would save and make for

observation

the physician time a more satisfactory is hard from to describe the

lose

Attributes in the study in training were and generhack-

relationship. that examples

physicians homogeneous

without
ords

lengthy
is that many

case
time

recby

physicians

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SPECIAL
letting only themselves be described be trapped as into arguments what can and

ARTICLES
there and was patients dissatisfaction. A number of

869
com-

munication ute
notably the part

barriers
mother

between
were found and

pediatrician
to contribon

quarrels and will her

informs

with

the

patients. For she

These

take

time

are ridiculous. describe what baby. The

her that

instance, a mother calls vomiting by corrects her

is

significantly
lack of of

to
warmth

patient failure

dissatisfaction:
friendliness

physician for that

pass

and
the

the

doctor,

to take and lack

diagnosis

into

regurgitation

proper term She counters ing.

cious

what she she thought back, and while

likely and tell room he

has described. it was vomitmany

lectures

account the patients concerns tions from the medical visit,

cut explanation of illness, concerning and use causation

expectaof clearand jar-

He
attempts

argues

many, things
the the that

preand

of medical

minutes

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Acknowledgment to
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Grossman,

K. L., and in relation to

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for statistical counsel; to members of the pediatric and nursing staff of the Childrens Hospital of Los Angeles for their patience and cooperation; to the research team, Barbara Freemon, Marie Morris, and Elaine Aley, for their continued invaluable assistance; and to Anne Hinton, Myrene Smith, Irene Dalzell, Muriel Schuerman, and Leah Martin for past help in the project. Appreciation is expressed to Miss Coralee

Yale

for her

competence

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SPECIAL

ARTICLES APPENDIX

871

FOLLOW-U 1
2.
.

P INTERVIEW-(SHORT
things with

VERSION)
now?

How
Before

is he
you

now? saw

or How
the

are

___________
did

( or

whatever

opener

indicated).

3.
4.

Before
What

you
worried

came
you

doctor last to the hospital

most about

__________
what
his trouble?

what did you think you think brought it on?

s trouble

was?

did that worry you? 6. When you brought to the hospital on , what had you hoped would be done for him? 7. At that time, what sorts of things did you want a doctor to explain to you? A. And did you get a satisfactory explanation? Now lets talk about what youve been doing for him at home since your last visit here. (Regimen to be copied from chart)
. . .

5. Why

Medical

Diet Other 8. What 9. What 10. How 11. How

12. 13. What
What

medicines have you been giving? was the dose? often? long did you feel he needed the
other
about

medicine? been doing to help him get better?

sorts
changes

of things
in visit

have
feeding with

you
him?

Now
14.

lets What

talk did

about the

your

the the

doctor matter

on

___________
with

doctor

say

was

___________

15. 16.
17.

\Vhat What
Regarding What
\Vhat

did did
were

the the
your

doctor doctor
visit of of seem show it?

say caused say about

to the the to the things things understand

the trouble? what to expect?

in liked didnt how general, about like? concerned he your have wish more you were about or more friendly, s sickness? how since the visit, about your and/or you? visit here re-focus last on ? or? how your satisfied visit with were the you doctor? with it? you you

hospital,

18.
19.

some

were
the did he the
you

some

20.
21.

Did

doctor

22.
23. 24. 25. 26.

How How
How How Parents How

did
do well

doctor think was the blame

are

act, for example, was a doctor should act? doctor able to relieve themselves
you

l)USineSs-like about get been sick, going about

worries

often
satisfied
2

when
the way

their things they

children

with any

Clo$urc: some earlier

(Ask

if they

have when

comments

to add

response

necessary.

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GAPS IN DOCTOR-PATIENT COMMUNICATION: I. Doctor-Patient Interaction and Patient Satisfaction Barbara M. Korsch, Ethel K. Gozzi and Vida Francis Pediatrics 1968;42;855
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1968 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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