Doctor – patient communication during the medical consultation is central for effective care; however, it has been known for some time that a sizable number of patients in hospital (41%) and general practice (28%) settings are dissatisfied with communication . Dissatisfaction often stems from inadequate explanations and feelings of being devalued or rushed . Patient understanding and respect for integrity are not just elements of good communication, but also are the cornerstone of ethical exchange.
The requirement to obtain informed consent is universal within medicine today, even though information and consent procedures vary [3-7]. It is further clear that most patients want to be informed and that many also want to participate in medical decision-making [8-10]. Accordingly, there is a strong emphasis on patients' understanding of procedures, risks, benefits and alternative therapies whether participating in medical treatment or in clinical trials [11-13].
The same ethical focal points are emphasized when children are treated or are research participants [14-17]. It is essential that the consultation be allocated enough time so that both parents and children can have an opportunity to ask questions , thus augmenting the exchange of information, understanding, and issues of voluntariness and consent. From this perspective, child age is crucial, because children's capability to assent depends on their level of maturation and development . The age limit for soliciting assent in addition to parental consent is set at 7 years (e.g. according to Swedish Regional Ethics Boards), however one study found that children younger than 9 years understood poorly or not at all . In contrast, young children and even infants have an understanding of basic emotions conveyed by others' expressions and speech quality, i.e. nonverbal behavior .
The current study sought to explore elements of communication in pediatrics between doctors and patients/parents in relation to ethical practice that can guide future clinical training. According to a recent review , studies examining physician verbal and nonverbal behaviors during actual consultations are few and there is a great need to further empirically study such behaviors particularly for educational purposes . Because our interest was in finding "good examples" we focused only on positive behaviors. This study is the first to record physician nonverbal behaviors in relation to ethical practice.
We observed behavior during a routine consultation for inguinal hernia in a pediatric surgery outpatient clinic. We selected this procedure because it is routine in that it is easy to treat and relatively common. However, successful treatment requires surgery which necessitates the need for clear information and decision-making, thus highlighting ethical practice. Further, suspected inguinal hernia entails a brief physical examination of the child's intimate areas that requires particular sensitivity on the part of the physician to insure respect for children's integrity. The term respect for integrity is vague and is often used in different ways. Here, we follow one main understanding that reflects respect to the patient by the physician in terms of sensitivity to patients' mental sphere (e.g. beliefs, desires, and decisions) and corporal sphere (e.g. unwanted physical contact). We were also interested in the amount of time spent on the consultation. A recent study shows that time spent in the consultation is not a top priority , however, we hypothesized that time would be important in pediatric cases. Time may be thought to be important for the ethical quality of a consultation based on the fact that giving information as well as ensuring patient understanding are time consuming processes. It may also take time to create an atmosphere in which patients feel secure, particularly children who may be unfamiliar with the situation. Thus, our aims were to measure the occurrence of positive behaviors by physicians and the length of time spent on the consultation and to determine if these were related to ethical practice as appraised by observers.