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Time and communication are important aspects of the medical consultation.

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- Ethics takes time, but not that long

The study took place at the pediatric surgery outpatient clinic at a university hospital serving a population of 300,000 local residents and a region of 1.3 million for referred cases. Patients had been referred to the clinic by general practitioners, school health services or via emergency room for assessment of possible inguinal hernia. Patients were consecutively recruited at the time of their scheduled appointments. The attending nurse introduced the study and obtained consent from parents and assent from older children. All consultations were recorded on digital video disc (DVD).

Surgeons had been informed about the purpose of the study prior to its initiation. However, no details were provided regarding the behaviors that would be observed. All participants, patients and surgeons alike, were guaranteed confidentiality and that no one outside the research team would view the video discs. Because the study took place at a teaching hospital, medical students were present in some of the consultations. The study was approved by the regional ethics committee at Uppsala University Hospital.


We observed specific physician nonverbal behaviors directed towards the parent and positive behaviors occurring specifically during the physical examination directed towards the child. Behaviors selected for observation were chosen because they are considered to exemplify good doctor – patient communication reflecting empathy and listening skills [e.g. [25-27]]. Physician-initiated nonverbal behaviors directed towards the parent were recorded. We selected to concentrate on positive behaviors that reflect attentiveness or interest and consisted of looking at the parents during the consultation, paying full attention to parents while listening (e.g. not reading/writing in the medical record), waiting for the parents' attention before speaking, relaxed posture, having opened or approachable posture, speaking clearly, smiling or chuckling, physical contact with the parent during greeting or departure e.g. shaking hands, and being at eye level with the parent.

Positive behaviors occurring specifically during the physical examination directed towards the child included: interacting with the child before initiating the physical examination, approaching the child, being at eye level, making an effort to put the child at ease, showing responsiveness to child's mood, effectively dealing with child's mood, distracting, speaking softly, touching child softly, not being intrusive, inviting parents to stay close by, asking for permission to examine, informing what is/will be done during the examination, monitoring the child's state by asking how it is going, providing praise, and signaling that the child may re-dress.

Each behavioral occurrence was tallied and summed across both observers. After independent observations were made, observers watched the tapes together and agreed on the number and type of behaviors that were recorded.

We related behaviors to elements of ethical practice, i.e. the outcome variables. We defined ethical practice as consisting of informed consent (provision of information, understanding), respect for integrity (sensitivity, responsiveness, and respectfulness) and patient autonomy (decision-making). Global ratings of the aspects of ethical practice were made by the research team using five point scales. The global ratings were not meant to correspond to particular behaviors, but instead were general appraisals based on the entire consultation. Provision of information was rated as lacking, insufficient, only a few key points provided, several key points provided, and thorough. Parents' apparent understanding of the information provided by the surgeon was coded as lacking, very little, partial understanding, mostly, and completely. Respect for integrity was rated using three questions concerning general politeness, actively showing efforts to set the stage for a respectful encounter, and showing sensitivity in responding to parents' needs in a respectful manner. These three questions were also rated on a five-point scale (ranging from lacking to very much) and were pooled for analysis by taking the mean of the three questions per observer. Finally, we coded to what extent the surgeons actively involved parents in the decision making process. The ratings of the ethical aspects were averaged across raters for each consultation.

Observers rated child mood during the examination using a three point scale, (1 = calm, 2 = somewhat upset, 3 = very upset). The duration of the consultation was recorded in minutes.

Prior to the consultation parents were asked to provide demographic characteristics. Parents rated the perceived risk to their child's health of having an inguinal hernia as well as their own level of anxiety.


The consultations were coded in two steps. The first viewing was done independently by three of the authors, two ethicists (M.G.H., U.K.) and one psychologist (A.R.) who made global assessments of the ethical components. The second viewing of the consultations was done at least two months later when specific behaviors were tallied (U.K. and A.R.) and summed across raters.

We produced statistical analyses with SAS version 8.2 (SAS, Cary, NC, USA); all statistical tests of hypotheses were two sided at p

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