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How Much Information About Adverse Effects of Medication Do Patients Want From Physicians?
Dewey K. Ziegler, MD;
Michael C. Mosier, PhD;
Maritza Buenaver, BS;
Kola Okuyemi, MD
Arch Intern Med. 2001;161:706-713.
ABSTRACT
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Background Little information exists concerning the amount of information patients
expect from physicians as to the risk for an adverse medication reaction.
The present study was designed to determine such opinions in a population
sample; to correlate results with sex, age, educational level, and previous
experience with adverse effects; and to determine whether patients believe
physicians should use discretion in the amount of such information given.
Methods Two thousand five hundred sequential adults visiting outpatient clinics
filled out a 12-item questionnaire. Percentages of subjects desiring information
about varying degrees of risk and those believing physicians should and should
not use discretion in the amount of such information provided were recorded.
Results were correlated with demographic variables and previous experience
of adverse effects.
Results Among the respondents, 76.2% desired to be told of all possible adverse
effects; 13.3% only if an adverse effect occurred 1 in 100 000 times;
and 10.2% only if such occurrence was 1 in 100 times; 0.4% were not interested
in any information. (Percentages have been rounded and do not total 100.)
Percentages were closely similar to those for the same question that restricted
opinion to serious adverse effects. Desire for maximum information was significantly
correlated with lower educational level (P<.00l)
and previous frequent experience with adverse effects (P<.001) and in older women (P<.001).
The opinion that the physician should give the same information to all patients
was given by 67.6% of the sample, and 73.4% opined that physicians were never
justified in withholding any information.
Conclusion Most individuals desire from physicians all information concerning possible
adverse effects of prescribed medication and do not favor physician discretion
in these decisions.
INTRODUCTION
PRACTICING physicians face continually the problem of how much detail
concerning risk for adverse effects of prescribed medication they should provide
patients. The prevalence of adverse side effects of medication has received
increasing attention in recent years.1-2
To explain to patients, for each medication prescribed, every possible adverse
effect would clearly be a task of unacceptable time consumption and questionable
advisability. How, then, is the physician to choose which facts to give?
Two basic ethical principles are involved in this decision. The first
is the ancient one embodied in the Hippocratic Oath: to do what is best for
the patient. The second is the more recent concept of patient autonomy: the
right of the patient to have full control over anything done to his or her
body. One translation of the latter principle into practical decision making
has been embodied in the concept of informed consent, a medicolegal term for
a contract by which a patient acknowledges that he or she has been informed
as to the nature and the risks of any prospective treatment and gives consent
to that treatment. Written consent is currently used almost exclusively for
research studies or invasive procedures. Acceptance by a patient for any treatment,
however, implies informed consent.3
This problem of the adequacy of the amount of information as to risk
provided to patients by physicians has often been before the courts. The following
3 legal concepts have been used by the courts in various jurisdictions to
define how much information physicians must give patients to supply criteria
of informed consent: (1) the professional practice standard in which "the
physicians are expected to disclose the type and amount of information that
another physician in the same specialty and location would disclose"; (2)
the reasonable-person or lay standard, which states that the practitioner
must provide information of a type and amount that a reasonable man or woman
in the patient's situation would have wanted to make an educated decision
about the recommended medical intervention; and (3) an expansion of the lay
standard to one that includes needs of a specific patient with regard to "unique
concerns or lack of familiarity with medical procedures."3-4
These standards, derived from legal proceedings, clearly differ markedly
and provide only vague guidance for the physician in the common clinical situations.
Two specialists, for example, often differ in opinions as to the appropriate
amount of information to be given. Similarly, the determination of how much
information a "reasonable person" in the patient's situation would want is
extremely difficult. The autonomy principle alluded to above dictates that
patients have a major role in decisions about medical procedures performed
on their behalf; such decisions obviously imply transmission of information.
The autonomy principle therefore would seem to indicate the importance of
determining patients' desires as to information on risks of treatment. It
is interesting that, despite the growing emphasis on the principle of patient
autonomy, there are few data on this specific subject, although abundant literature
exists on physician behavior and on the overall desire of patients for information.
The present project was designed to determine, in a large population
sample, the amount of information about the risk for adverse effects of medication
that patients want from physicians and the frequency of the patient opinion
that the physician should be allowed to use discretion and judgment about
the amount of such information given.
SUBJECTS AND METHODS
SUBJECTS
The population was a convenience sample consisting of subjects 18 years
or older attending outpatient clinics of the University of Kansas Medical
Center, Kansas City; family members accompanying such patients; medical students;
or nonprofessional employees of the medical center. For 2 weeks, all individuals
of these categories in the outpatient clinic areas of the departments of family
medicine, internal medicine, neurology, otolaryngology, and ophthalmology
present in waiting areas were approached daily by a physician or research
assistant (M.B.).
DATA OBTAINED
Subjects were individually handed a 1-page questionnaire, its purpose
and nature were read to them from the questionnaire, and their consent to
complete it was requested. The first part of the questionnaire consisted of
7 questions, with the first 3 defining demographic variables (age, sex, and
years of school completed).
Two subsequent questions asked subjects to select the one answer that
best reflected their opinion as to the information they would want from their
physician about risk for adverse effects of medication. The first question
(question 4) was preceded by the statement that some adverse effects (described
as side effects in the questionnaire) of drugs were
common and some rare, and noted that opinion on the following statements in
this question concerned all adverse effects. The choices were as follows:
- I want to hear of any side effects from the doctor
no matter how rare.
- I want to be told if a side effect has occurred
in 1 in 100 000 patients.
- I want to be told if a side effect has occurred
in 1 in 100 patients.
- I am not interested in being informed as to side
effects.
The second question (question 5) was preceded by the statement that
some adverse effects are mild and some serious (defined as causing prolonged
discomfort, disability, or death). Subjects were asked their opinion about
information desired from the physician concerning such serious adverse effects,
and given the same choices as in the previous question.
Subjects were then asked to what extent they thought the prescribing
physician "should use his/her judgment as to how much detailed information
to give the individual patient concerning possible side effects of medication"
(question 6). The choices were as follows:
- The doctor should give the same detailed information
to all individuals as to frequent and rare, mild and serious side effects.
- The doctor should give as much information concerning
side effects as he or she thinks best for the individual patient.
Subjects were then asked for a yes or no answer to the question "Do
you think there are occasions when a doctor is justified in withholding information
about side effects?" (question 7).
Two additional questions asked the individual's experience with adverse
effects of medication in the past year. One question asked about the frequency
(none, occasionally, or frequently) of adverse effects experienced, the other,
if adverse effects had occurred, their severity (mild, moderate, or severe).
Since a first answer in a series can be preferentially chosen by nonobservant
subjects, regardless of subject matter, we tested an additional 143 subjects,
reversing in all questions the order of answers.
STATISTICAL ANALYSIS
Results of the questionnaire were tabulated as the proportion of respondents
choosing each multiple-choice answer. Responses were then statistically compared
for differences among subgroups defined by age, sex, years of education completed,
and the frequency and severity of any previous adverse effects experienced.
We performed  2 tests for association and multiple logistic
regression for determination of adjusted odds ratios (ORs) for choosing a
particular option for each of the questions. Variable selection for the regression
model was performed using stepwise selection.
RESULTS
Surveys were completed by a total of 2500 subjects. One hundred fifty-two
individuals of those approached refused to participate (5.7%). Table 1 provides a summary of the demographic data in the population
sample. As shown, 61.2% of the responders were women, the average number of
years of education was 14.2, and the average age was 47.2 years.
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Table 1. Demographic Summary*
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OVERALL DESIRE FOR INFORMATION
Most subjects (76.2%) responded that they would want to hear of any
adverse effects, no matter how rare. A greater percentage, 83.1%, responded
that they would want to hear of any serious adverse effect, no matter how
rare. Figure 1 depicts the percentage
of subjects giving each of the 4 possible answers to these questions.
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Responses to questions 4 and 5. Response 1 indicates no matter how
rare; 2, only if more than 1 in 100 000 times; 3, only if more than 1
in 100 times; and 4, not interested. For differences among categories of answers, P<.001 on questions 4 and 5. Because of rounding, percentages may
not total 100.
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Of the 143 subjects who answered the questionnaire in which order of
answers was reversed, 80.4% chose to know of all adverse effects and 83.9%
to know of all serious adverse effects.
DESIRE FOR INFORMATION BY DEMOGRAPHIC FACTORS
Table 2 presents the percentage
of responders who indicated they wished to be told about all adverse effects,
no matter how rare, according to the demographic characteristics of sex, age
category, and education level, and past experiences of adverse effects. Included
in Table 2 are univariate analyses
of percentages using individual 2 tests and the results of
a multivariate logistic regression model.
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Table 2. Respondents Desiring to Hear of All Adverse Effects by Demographic
Factors
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The univariate analyses indicated that sex, overall, was not associated
with choosing this option. Respondents were grouped by age into categories
of 18 to 35, 36 to 55, 56 to 65, and 66 years and older; the percentages of
respondents choosing this option within each category were analyzed. In the
univariate analysis, P = .01 indicated there is at
least 1 age category that differs significantly in response from the other
categories. It appears that individuals in the youngest category were slightly
less likely to wish for complete information. The logistic regression analysis
revealed a significant interaction between age and sex, with no difference
across ages in men, but in women a highly significant increase in desire for
information was associated with increased age.
Although more than 50% of respondents at all educational levels asked
to hear about all adverse effects, there was a significant difference between
the different educational groups with increasing desire to know all adverse
effects in the less well-educated group (P<.001).
Also correlated with this option was the previous experience of frequent adverse
effects (P = .002) and of severe adverse effects
(P = .004).
Because of collinearity of the main effects of age and sex with the
interaction, 2 separate models were used. The first was a main-effects model
with sex, age, education, experience with frequent adverse effects, and experience
with severe adverse effects, and the second model contained the interaction
of age and sex without the main effects. This is interpreted as the effect
of age among women, since men were used as the reference group.
As seen in Table 2, educational
level and whether respondents had experienced frequent adverse effects in
the past were again the most important predictors of electing to hear of all
adverse effects. Previous experience in both models of severe adverse effects
was statistically significant in the univariate analysis (P = .01) but not in the multivariate analysis, since after adjustment
for affirmative responses to frequent adverse effects, the responses to severe
adverse effects provide no additional information (collinearity).
The analyses of answers to the question concerning risk for serious
adverse effects closely paralleled those concerning all adverse effects. A
larger difference between the sexes was observed, however, with the univariate
and the logistic regression analyses, indicating that women were significantly
more likely to desire information about any risk (P
= .003; adjusted OR, 1.36; 95% confidence interval [CI], 1.09-1.69). Age was
not statistically significant (P = .12) but was similar
to answers concerning all adverse effects; the youngest and oldest subjects
were slightly less likely to desire hearing about all risks. Unlike responses
to the questions concerning all adverse effects, there was no significant
interaction between age and sex in this response (P
= .45).
For education, the same striking trend across levels as seen for the
question concerning all adverse effects was found for that concerning serious
adverse effects, with lower educational-level groups desiring to know all
risk (P<.001; adjusted OR, 0.61; 95% CI, 0.53-0.71).
Also found to be predictive of this response was previous experience of frequent
adverse effects (P = .002). As in the analysis of
responses concerning all adverse effects, past experience of severe adverse
effects was significant in the univariate analyses (P
= .04), but after adjustment for positive response to frequent adverse effects
in the multivariate analyses, it was no longer informative.
Two questions were designed to complement each other in discovering
opinions regarding how much discretion physicians should be allowed in tailoring
the amount of information given to the individual patient. Shown in Table 3 are the results of the univariate
and logistic regression analyses for the first of these (question 6). Approximately
two thirds of the respondents (67.6%) thought physicians should give the same
information to all patients (answer 1) as opposed to giving "as much information
as he/she thinks best for the individual patient." Women were significantly
more likely to respond with the first answer (P =
.003). The youngest and oldest respondents were slightly less likely to give
this answer, but after adjustment for other factors in the logistic regression,
the differences were not statistically significant. Educational level again
was the strongest predictor of response (P<.001),
with higher percentages of individuals with lower levels of education responding
that physicians should give the same information to all individuals.
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Table 3. Respondents Favoring Physicians Giving the Same Detailed Information
to All Patients, Overall and by Demographic Factors
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The frequency and severity of past adverse effects, as seen in Table 3, were both important in the univariate
analyses of answers to this question, but, as in the previous questions (4
and 5), because of collinearity both were not needed in the multiple regression.
In this analysis, it was presence of severe adverse effects that was selected
for inclusion in the model instead of frequent adverse effects.
When asked whether a physician is ever justified in withholding information
about adverse effects, 73.4% of all individuals answered no. There was no
significant difference between the sexes in this response. The youngest group
(aged 18-35 years) gave the lowest such response (68.5%), with all other age
categories being significantly greater and similar to each other (75.4%, 76.8%,
and 74.4% in the groups aged 36-55, 56-65, and  66 years, respectively; P = .004).
Educational level again proved the strongest predictor of this response,
with more individuals with lower levels of education responding no (P<.001; adjusted OR, 0.67; 95% CI, 0.59-0.76). The presence
of severe past adverse effects was also an important predictor of the answer
no (P = .006; adjusted OR, 1.58; 95% CI, 1.01-2.48).
High correlations were expected between the opinions that equal information
should be given to all patients (question 6) and that the physician is never
justified in withholding information (question 7). A similar high correlation
was expected between the opinions that physicians can be justified in withholding
information and that the physician may use judgment on the amount of information
given. A summary of the responses to question 7, categorized by the responses
to question 6, is given in Table 4.
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Table 4. Cross-tabulation of Responses to Question 6 With Responses
to Question 7*
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These expected strong associations were detected (P<.001). As to inconsistent responses, only 10.9% of respondents
gave responses favoring physicians giving the same information to all but
also allowing physicians to withhold information. However, of the 794 respondents
who indicated that the physician may use his or her judgment in determining
how much information to give, 40.7% gave the seemingly inconsistent opinion
that the physician is never justified in withholding any information.
COMMENT
The Council on Ethical and Judicial Affairs of the American Medical
Association in its code of medical ethics states that "the patient has the
right to receive information from physicians and to discuss the benefits,
risks, and costs of appropriate treatment alternatives."5
How comprehensive this information as to risks should be has been a topic
of considerable dispute. Do these words obligate the physician to discuss
all risks of treatment?
The most striking finding of the present study is the high percentage
of subjects desiring information from physicians concerning risk for adverse
effects of medication, "no matter how rare." This was the opinion expressed
most frequently by all age groups, both sexes, and all educational-level groups
and for all adverse effects and for serious adverse effects only. The close
similarity of results to the questions concerning all adverse effects and
serious adverse effects was somewhat surprising. Does this mean that most
individuals do not discriminate between the two?
Although, to our knowledge, no previous study has documented patients'
desires about this specific information, there have been many relevant studies
concerning patients' desires for participation in medical decisions. Controversy
exists concerning the degree to which patients wish such participation, but
there is agreement that a large percentage of patients desire the information
relevant to such decisions.6-10
There are also data on patient dissatisfaction with information received from
physicians on this subject. Enlund et al,11
in a community sample of 623 patients taking antihypertensive medication,
found that only 31% were satisfied concerning information received about possible
adverse effects of the drugs. Other studies have found that 50% to 90% of
patients have expressed the desire to have more information about adverse
effects of medication.12-13
These studies form an interesting supplement to studies documenting
the frequent omission by physicians in providing this information. Wynne and
Long,14 for example, found, in a group of patients
taking a nonsteroidal anti-inflammatory agent, that only 41% of those without
subsequent gastrointestinal tract pain remembered having been warned of this
potential side effect. Katz et al,15 in taped
encounters between rheumatologists and adult outpatients taking such medication,
found that adverse effects apart from epigastric discomfort were mentioned
in 15% or fewer of such encounters. Two other studies report that large percentages
of patients were not aware of possible adverse effects of medication they
were taking.12, 16
Patients expressed the desire for all information about risk for adverse
effects, no matter how rare, which seems unrealistic to professional personnel.
Do patients really want to be briefed on the one-in-a-million adverse response
as documented in the fine print? Probably, many did not realize the magnitude
of the mass of information involved and gave a stereotyped response on the
order of "more knowledge is good." Subjects who feel uncertain when dealing
with numbers in estimating risk and who prefer qualitative to quantitative
terms might also tend to choose this alternative. We elected to use a partially
quantitative scale to describe risk, rather than a qualitative one using terms
such as probable and rare.
There is controversy as to which type is preferable,17-18
and it would be of interest to repeat the present study, using all qualitative
terms. Patient interpretation of risk expressed quantitatively has rarely
been investigated. More attention has been paid to variables affecting interpretation
of qualitative terms.17, 19
Artifactual results of preferential choice of the first alternative
on the list were ruled out by the finding of similar results when the order
of alternatives was reversed.
Of the variables studied, increased educational level and, to a lesser
degree, youth correlated with what might be called tolerance
of flexibility on the part of the physician in providing information
as to the risk for adverse effects. The higher educational-level and the younger
age groups desired less information about risk. The opinion that physicians
should use judgment as to the amount of information provided was also found
to be more prevalent in these groups. Related data are those of Busson and
Dunn,12 who correlated knowledge of adverse
effects of prescribed drugs with socioeconomic class. They found (on the basis
of admittedly incomplete data) that knowledge of adverse effects of drugs
was markedly less in the lower compared with the higher socioeconomic groups.12 The socioeconomic variable was not included in this
study and may be a more important one than education.
There would seem to be several possible reasons for our results concerning
educational level. The better-educated group may in general be better informed
so that they realize the impracticality of being told of all adverse effects.
Conversely, the less well-educated group may be more insecure in their relationship
with the physician and therefore less tolerant of flexibility. They also may
feel more confident with qualitative answers than with quantitative ones.
Of the other variables, there was a trend for women more than men to
opt for information about all adverse effects. The more elderly women significantly
expressed this desire for maximum information. The finding in the present
study that youth was correlated with lessened demand for information about
risk seems to conflict with that of Enlund et al,11
who reported in their series of hypertensive patients an increased need for
information among those younger than 49 years. As these authors point out,
however, their finding may be an artifact of the increased number in their
study who gave the answer "uncertain" rather than yes or no to the question
of need for further information. Ende et al7
found that the older groups, similar to the less well-educated groups, desire
less participation in medical decision making. Our finding that a history
of previous severe adverse effects increases the desire for full information
about risk is in accord with that of Enlund et al.11
Both questions concerning the amount of discretion desired from physicians
in discussing adverse effects were designed to amplify the information obtained
from the questions concerning information about risk. Most subjects opted
for a restricted role of physicians' judgment concerning the amount of information
given. Even more believed that no information should ever be withheld. These
replies are consistent with the large percentage expressing the opinion that
information on all adverse effects should be given. Particularly of interest,
however, is the quite large number of subjects who answered that physicians
should use judgment in the amount of information given but also that no information
should be withheld, which were seemingly inconsistent responses. The questions,
of course, forced simplistic answers in very complex issues, and many patients
stated in written comments their reservations about answers. Many individuals,
however, undoubtedly did not realize that using judgment in this area must
involve withholding information on occasion.
The responses to these questions concerning physician discretion when
studied in conjunction with the variables of age, sex, and educational level
gave results similar to those found for the first 2 questions. Women and respondents
with less education were, to a significant degree, less tolerant of a physician
varying the amount of risk information given. Similarly, less education correlated
with the opinion that no information should be withheld. The latter opinion
was also more prevalent in the elderly. These findings, as noted previously,
are somewhat at variance with those of other studies, in which elderly respondents
desired less information than younger respondents.11
The factors determining desire for complete knowledge clearly are related
to overall trust in a physician. The latter may involve variables such as
personality qualities of the patient that would be of interest to study.
There are many limitations of this study. The population sample is not
community based. Many respondents were in the process of receiving medical
care, and the presence of illness may create bias in favor of receiving maximum
information. Because of the necessary brevity of our questionnaire, important
variables such as severity of illness for which the hypothetical treatment
is being prescribed were not sampled. Furthermore, these opinions were asked
for in isolation, and not as a part of a risk-benefit discussion, ie, a highly
artificial situation. Others have shown, as noted previously, that although
patients wish physicians to take a major role in the therapeutic aspect of
decisions, they strongly desire being well informed about variables involved
in these decisions.9-10
Other important population variables that we did not study are socioeconomic
class and ethnicity. It has recently been pointed out that certain ethnic
and cultural groups do not favor complete disclosure to the patient of all
medical facts, particularly negative ones.20-21
It is possible that other parochial factors influence results found in this
population. It would be of interest to repeat the study with a large community-based
sample from different sections of the country. Results of such surveys would
clarify the possible role of variables such as geographical area or urban-rural
site of residence in subjects' opinions.
The number of subjects who did not completely understand the questions
is unknown, although care was taken to give the questionnaire individually
and only to alert individuals who gave consent.
As noted, both questions concerning physician behavior in delivering
information forced simplified opinions in a very difficult area. The questions
were designed to provide a crude measure of the degree of discretion patients
were willing to allow physicians. It is of interest that most patients expressed
desire for stereotyped behavior on the part of physicians in this area (same
information to all patients). It would be of interest to determine whether
these individuals believe their physicians behave this way. Of equal interest
is that most respondents expressed the opinion that no information about adverse
effects should ever be withheld. This opinion clearly is also a highly unrealistic
expectation. For many respondents, the answer may have been a stereotyped
response to the word withheld being considered a
synonym for concealed.
The results suggest the value of follow-up studies to explore in more
detail the areas where patients are willing to trust physicians' judgment
and the variables that may affect such attitudes. Deber et al,10
for example, found that patients have a high desire for information, overall
do not wish to be included in the problem-solving process (diagnosis), and
wish to be involved in decision making. The present study describes 1 variable
bearing on the decision about the amount of information to be transferred.
It does not deal with the important issue of whether the amount of such information
relates to improved outcome or may have negative effects, as discussed below.
We did not obtain data in this study about how many patients derived
this information from sources outside physicians' offices. Printed information
(drug inserts) are used by patients to varying degrees. Nurses and pharmacists
have long provided such information, and there has been extensive discussion
in the literature of these professions concerning the amount of information
these professionals should give patients concerning medication effects.12, 22-23 Increasingly, such
information is derived from other sources, ie, direct-to-consumer advertising
by pharmaceutical manufacturers, the Internet, and pharmacy benefit managers.
Such nonphysician information sources may influence attitudes in a variety
of ways. Study of the correlation between information given from the various
sources has not been performed and would be of interest.
In summary, these results record the expectation on the part of a large
percentage of individuals of complete information from physicians concerning
risks for adverse effects of medication. Most individuals also indicated they
are reluctant to cede to the physician the discretion in this area that he
or she obviously uses and must have in clinical practice. As time pressures
increase on physicians, the unreality of these expectations becomes more apparent.
The decision about how much information on risks of medication is to
be given by the physician obviously involves several variables, eg, the legal
standards; the physician's time; the patient's intelligence, educational level,
and cultural background; the nature and severity of the illness; and the possibility
that excess information might adversely affect the treatment, among others.
To these we add the patient's opinion. Although such opinions, as found in
this study, clearly exceed the legal requirements, there is a trend, particularly
in surgery, for more complete disclosure of the risk for adverse effects of
treatment.24-25 To what degree
such full disclosure can have adverse effects on patient care is uncertain.
Two studies relating to the prevalence of adverse effects of medication found
that education on the subject did not increase the number of adverse effects
or decrease therapy compliance.26-27
In surgical patients, however, adverse effects such as refusal of necessary
treatment28 or dissatisfaction with their physician's
behavior29 have been found. In a controversial
editorial, Tobias and Souhami30 labeled full
disclosure of possible adverse effects of medication to every patient "a recipe
for needless cruelty and distress." The complexity of the issue is increased
by recent judicial decisions in Europe and South Africa that a physician has
legal liability if "excessive disclosure. . . has the effect of causing the
patient physical or psychological harm. The view is taken that overinforming
the patient may be tantamount to not informing him or her at all, and that
here the physician may be held legally liable on the same basis as in non-disclosure
cases."31
Results of our study suggest the possible benefit of a brief dialogue
with the patient in which the physician routinely describes the more frequent
and serious adverse effects of medication prescribed and then mentions to
the patient that there may well be other rare adverse effects that he or she
has not mentioned. In the case of a request by the patient to know all of
the latter, printed information might be supplied. This dialogue would probably
be particularly important in those groups found to be most adamant in desire
for all information, eg, the less well educated, the elderly, and those with
previous experience of adverse effects.
AUTHOR INFORMATION
Accepted for publication October 23, 2000.
Corresponding author and reprints: Dewey K. Ziegler, MD, University
of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160-7314 (e-mail: dziegler{at}kumc.edu).
From the Departments of Neurology (Dr Ziegler), Preventive Medicine
(Dr Mosier), and Family Medicine (Dr Okuyemi), University of Kansas Medical
Center, and the University of Kansas Medical School (Ms Buenaver), Kansas
City.
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