The current study provides preliminary information on the importance of time in the consultation and positive behaviors by physicians that can guide future research and is immediately beneficial to clinicians, researchers, and health-care policy makers. All of the consultations we studied took less than 20 minutes, the majority consisting of 10 minutes or less. Despite this narrow time frame, we found strong and consistent association between increasing time and higher ratings on all components of ethical practice we studied, especially respect for integrity.
Examination and diagnosis of inguinal hernia is usually quite brief for an experienced surgeon. The positive signs are easy to detect either physically or through the patient history. Therefore, the amount of time spent on consultations in this study is not unusual and compatible with the time allocated for appointments at the study site. The patients in this study were all healthy children and did not demand further work-up for other complications.
There is disagreement amongst ethicists about the necessity for empirical investigations and their impact on normative medical ethics [28,29]. Our view is that empirical investigations such as this one are necessary to identify the non-ethical factors that underlie sound ethical praxis in clinical settings. Empirical studies are important because they are part of the process in which open-ended concepts can be tested, revised, or challenged. Previously, doctors' behaviors related to friendliness, courtesy, and the like have been shown to be related to patient satisfaction [30]. We offer evidence that doctors' behavior, including nonverbal behavior, is important from an ethical perspective and that these behavioral subtleties are instrumental in setting the stage for a respectful encounter.
Physical examination was stressful for the children. Our study indicates that a positive response to these situations will draw not so much on verbal as on nonverbal behavior that put the child at ease. Physicians who could serve as role models expressed relaxed concern and respect for the child and his/her parent. The video-recorded observations captured aspects of communication that relate to ethical practice, which would otherwise be difficult to assess using pencil-and-paper assessments. However, our study is limited by the small sample size that did not permit the analysis of individual behaviors. Our aim was not to offer a recipe of specific behaviors. Such would stifle the doctors' individuality and responsiveness to the particular situation at hand. The nonverbal behaviors we studied in the consultation all reflect genuine attentiveness and interest. Specific behaviors may very well vary, but the message is clear that the physician should not "act" interested, but convey interest via posture and in nonverbal quality of speech. Some of these behaviors may be culturally sensitive so that interest and openness is conveyed or perceived differently according to cultural background.
Our findings show robust relations between time and positive nonverbal behaviors in relation to ethical practice, therefore, it is unlikely that our results were due to chance. On the other hand, statistical power to detect true relations among the variables was limited due to our small sample size. Lack of statistical significance points to uncertainty, even though relations were in the expected direction, replication in future studies is required.
The generalizability of our study is somewhat limited because we examined only one type of medical case. However, we made this choice from a statistical standpoint to limit variability associated with examining a variety of medical cases. We also made the choice to focus on inguinal hernia because it is particularly related to issues of respect for integrity and because it is surgically treated; issues on informed consent are highlighted.
Despite the limitations, this study provides support for the importance of physician behaviors and the time spent on the consultation for the ethical exchange, which have not previously received much research attention. The insights provided by the present research should serve as an impetus for more detailed analysis of physician behaviors. Physicians and policymakers strive for efficiency in healthcare, which sometimes can translate into less time being allocated to the medical consultation. Consequently, some doctors may feel rushed or pressured and perhaps cut off the consultation prematurely. This may show in their nonverbal behavior. Time in itself, however, may not be key, but rather the behaviors that fill the time. More time gives the opportunity for more positive behaviors, as we found. Further studies should investigate whether time may be related to a greater opportunity for parents and patients to ask questions or perhaps just for pauses in which an opportunity to think about the message is provided. Our results show that just a little bit of time and physicians imparting relaxed interest make a big difference for ethical practice. The price for a few minutes of physician time may be far lower than the price of ethical transgressions.
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