The Impending Surplus of Child Health Care Providers: Implications For Patients, Practitioners and Pediatric Training Programs

Gerald B. Hickson, Department of Pediatrics, Vanderbilt University School of Medicine
ABSTRACT - Causes of the impending crisis in child health care and implications for physicians, patients and residency training are explored from the perspective of a pediatric teacher/practitioner. To survive in this new medical environment, physicians muse develop a greater understanding of patients as consumers of medical services. Directions for future research are outlined including the need to understand: how patients select providers, how practice characteristics impact on patient satisfaction, how satisfaction relates to subsequent health care behavior, and whether the impending surplus can be utilized constructively to deliver new marketable physician services designed to assist parents with unmet needs.
[ to cite ]:
Gerald B. Hickson (1985) ,"The Impending Surplus of Child Health Care Providers: Implications For Patients, Practitioners and Pediatric Training Programs", in NA - Advances in Consumer Research Volume 12, eds. Elizabeth C. Hirschman and Moris B. Holbrook, Provo, UT : Association for Consumer Research, Pages: 247-251.

Advances in Consumer Research Volume 12, 1985      Pages 247-251

THE IMPENDING SURPLUS OF CHILD HEALTH CARE PROVIDERS: IMPLICATIONS FOR PATIENTS, PRACTITIONERS AND PEDIATRIC TRAINING PROGRAMS

Gerald B. Hickson, Department of Pediatrics, Vanderbilt University School of Medicine

ABSTRACT -

Causes of the impending crisis in child health care and implications for physicians, patients and residency training are explored from the perspective of a pediatric teacher/practitioner. To survive in this new medical environment, physicians muse develop a greater understanding of patients as consumers of medical services. Directions for future research are outlined including the need to understand: how patients select providers, how practice characteristics impact on patient satisfaction, how satisfaction relates to subsequent health care behavior, and whether the impending surplus can be utilized constructively to deliver new marketable physician services designed to assist parents with unmet needs.

Private practitioners find themselves unprepared to face the impending crisis in health care created by the growing surplus of providers, declining demand for service, and changing patterns of physician reimbursement. Physicians are ill equipped because until recently they have practiced in an environment where demand has exceeded supply and funding has been limitless. Consequently, there has been little motivation for residency training programs to invest the resources needed to rigorously explore practice issues and to teach residents the organization/ management and communication skills that may be critical to their survival in a eight market. In spite of this lack of commitment and late hour, there may still be time to equip practitioners with the understanding and skills needed to face a new health care environment. To do this, however, academic and private practitioners must recognize that a crisis exists and explore its causes and implications for both physician and consumer behavior. They need to collaborate with psychologists, business and marketing experts and investigate practice survival issues including: how and why patients select specific providers, how practice and provider characteristics impact on satisfaction/dissatisfaction, how satisfaction influences patient behavior and whether unmet patient needs can be identified and converted into new marketable physician services. An improved understanding of these issues should enable the private practitioner to develop survival strategies needed to remain competitive in the health care market of the next decade. Although this paper will focus primarily on issues as they relate to child health care and pediatric residency training, it is clear that all fields of medicine eventually will experience the problems of excess supply and declining demand.

The causes of the crises in child health care easily identified and related to changes in the supply and demand aspects of practice (Burnett & Bell 1978, U.S. Dept. of Health and Human Services 1980, Budetti 1981). Over the next decade the number of pediatricians will increase steadily while family practitioners and nurse clinicians will join in growing numbers the ranks of child health care providers. In 1978 the Graduate Medical Education National Advisory Committee (GMENAC) counted 24,850 active pediatricians in the U.S. accounting for 40% to 50% of all child health care visits (U.S. Dept. of Health and Human Services 1980). Estimates for 1990 range from 47,000(GMENAC) to a high of 53,000 (Bureau of Health Manpower 1978). Although the number of family practitioners should grow only from 67,900 in 1978 to 88,250 in 1990 (U.S. Dept. of Health and Human Services 1980), it is unlikely that pediatricians will be able to expand their market share since non-physician providers in increasing numbers (26,800 in 1978 to 56,000 by 1990) (U.S. Dept. of Health and Human Services 1980) will compete for pediatric patients. At the same time, the number of children less than 18 years of age will not increase proportionally and if Bureau of the Census (1977) predictions are correct, will remain essentially unchanged from 63,327 in 1978 to 64,776 for 1990. In addition, improvements in public health and the development of new vaccines should diminish the importance of many acute illnesses further reducing demand for care (American Academy of Pediatrics 1979). Because these trends are likely to continue, the GMENAC has projected a 25% surplus of pediatricians by 1990.

Third party carriers recognize that the impending surplus provides an opportunity to impose on physicians both practice and financial restrictions designed to control skyrocketing health care costs. Although these programs will contribute to the precarious position of the private pediatric practitioner, it is unlikely that physicians already seeing 10% to 15% fewer patients now than in 1976 (Owen 1983) will refuse to participate, especially if they believe acceptance will ensure access to enough patients to support their practices. Individual providers also recognize that even if they refuse to participate others, worried about survival, will Opt for these programs ensuring their success.

The elements of the crisis will impact upon all components of health care system. For example, the increasing number of child health professionals is having at present a constructive effect by alleviating shortages and geographic maldistribution of physicians. However, if unrestrained growth continues it may lead to intense competition for patients which may contribute to provider economic insecurity, job dissatisfaction and higher dropout rates within the profession. This insecurity may also provide physicians incentives for excessive treatment or scheduling which may have an adverse effect upon patients by increasing costs and threatening the quality of medical care. Supportive data is provided by studies examining the relationship between numbers of physicians per capita and elective surgery involving non-functional tissues. Wennberg and Gittelsohn (1973) found that rates for tonsillectomy (a procedure with rare therapeutic benefit but measurable morbidity) were dependent on physician density and ranged from 8% to 622 across 13 Vermont areas. A study by Mathamatica Policy Research (1978) also suggested that physicians can induce demand for care. A 1% increase in the number of physicians in Quebec resulted in a 0.61% rise in visits per capita and a 1.54% increase in the number of low priority surgery payments.

Excessive provider competition may also support continuing erosion of public confidence in physician authority. The technical quality of care is at an all time high, however, practitioners frequently see patients who are suspicious and have little confidence in the medical profession (Anderson, Kravits et al. 1971, Eisenberg 1977, Haug & Lavin 1979). Although few studies have asked how competition motivated physician behavior might impact on medical consumer confidence, an abundance of anecdotal evidence suggests that it may increase dissatisfaction, doctor shopping, maternal anxiety and distrust of the medical profession. For example, University physicians often encounter patients with trivial but persistent symptoms (i.e. nasal congestion, cough, colic, spitting up in infancy) whose parents fear their child has a dreaded but yet unrecognized disease. While taking a history and examining the active well-nourished infant it becomes apparent that the child is well and that the perception of illness has occurred in response to a ploy utilized occasionally by physicians to save time (avoid explanations) and maintain satisfaction. Physicians intuitively understand Needle and Murray's (1977) finding that meeting patient expectation is a significant determinant of satisfaction. Because pediatricians recognize that parents do not like leaving the office empty-handed and fear losing them to other providers, they may resort to prescribing symptomatic treatments with limited therapeutic benefit (decongestants, cough medicine, antispasmodics, and formula changes) or indiscriminate antibiotic usage for minor symptoms and viral illness. Because these treatments are usually benign and childhood disease self limited, therapy often appears effective to both physician and patient. However in the occasional child where trivial symptoms become persistent, parents may decide that the provider does not know what he is doing and begin to doctor shop. After the second or third encounter where parents experience variations on the same theme (new formulas, different antibiotics or decongestants), they either recognize what has occurred and become disenchanted with the medical community or convinced that their child is seriously ill. Problems such as this may become more prevalent with increasing provider competition and contribute to patient dissatisfaction with the medical profession.

Cost containment strategies also will impact on provider and patient behavior. Beside threatening provider financial security, these plans may create problems for physicians and patients by limiting free choice. Donabedian (1981) has suggested that freedom to select a physician not only provides the patient evidence of self worth but also offers the opportunity through repeated trials if necessary of matching the social and psychological attributes of client and practitioner in a manner that is likely to improve satisfaction of both. Dissatisfaction may result from either loss of the notion of freedom or actual inability to leave a provider or practice. For example Hooper et al. (1982) have demonstrated that patient characteristics (age, ethnicity, sex and appearance) can influence physician behavior. Consequently, if patients have difficulty leaving a practice where a mismatching of attributes exist it is likely that the physician patient relationship will deteriorate further.

These plans also may impact upon patient satisfaction by altering provider availability. For example, several studies have documented that patients utilizing prepaid health programs wanting to see their physician must wait longer to schedule and may have less time with that provider than their counterparts who use traditional fee for service physicians (Mechanic 1975, Wolinsky & Marder 1983). These observations support the notion that some prepaid physicians with scheduled hours maybe less patient dependent than their fee-for-service colleagues. When fee-for-service physicians encounter periods of increased demand they maybe more likely to respond by working longer hours than salaried physicians who may respond by processing patients more rapidly or by rationing services by changing scheduling policies (Mechanic 1975, Freidson 1970). Many pediatricians, by convincing parents that their door is always open and there is always time for one more question, utilize their availability as a mechanism of communicating interest and concern. Because parents recognize these policies as costly to the physician, they are likely to influence parents' perceptions of provider motivation. Consequently, any change in practice style limiting provider availability might be expected to decrease patient satisfaction and trust.

Although these changes should affect provider security, patient satisfaction and quality of care, pediatricians will be unable to avoid this crisis by altering its causes. Consequently, they muse take this opportunity to collectively reevaluate practice, improve their understanding of patients as medical consumers and develop survival strategies cognizant of the impending changes. Because of inexperience however, they must enlist assistance from psychologist, business and marketing experts and explore critical survival questions including: how and why parents select specific health providers, how practice and provider characteristics impact on satisfaction/dissatisfaction, how satisfaction influences subsequent health behavior and whether the impending provider surplus can be utilized constructively to develop new marketable physician services designed to assist parents with unmet needs.

Few studies have explored medical consumers' search and decision making strategies and asked whether those who select different types of physicians (i.e. pediatricians versus family practitioners) seek different sees of benefits from them. In general it appears that most patients tend to select health care providers almost blindly (Parsons 1951, Glassman & Glassman 1981, Stewart et al. 1984). Both Glassman and Glassman (1981) studying selection of obstetricians and Stewart and Hickson et al. (1984) in studying selection of child health providers (pediatricians, family/general practitioners) found that patients/parents had consulted only 1.2 sources of information per selection and that the most common source was a friend or neighbor. While search strategies appear consistent for patients selecting various types of providers, there is evidence that consumers may seek different sets of benefits at lease from pediatricians versus family practitioners (Stewart et. al. 1984). Although cross sectional in nature this study suggested that those selecting family practitioners were more interested in issues related to cost and convenience, while families selecting a pediatrician were more interested in issues related to provider availability and perceived technical competence. Prospective studies are needed to validate these observations and to explore what psychological and health belief variables may be responsible for these differences. Understanding how patients shop, what they are looking for and why should help physicians recruit and retain patients in a eight market. Additional benefits might be realized if the information obtained could be utilized to develop means of teaching parents to become more discriminating medical shoppers and thereby improve their access to quality care. One of the problems with free choice in the medical market place is that parents have the opportunity to select inferior physicians and facilities. For example, Donabedian (1981) has suggested that although Medicaid has enabled many patients to transfer from old crowded public institutions to the private sector for care, the results often have been harmful to the patient and costly to society because of poor provider selection.

Studies of patient satisfaction with office characteristics also may be beneficial to providers and their patients. Physicians must understand how various practice characteristics: location, office hours, waiting time, decor, phone services and billing impact on consumer satisfaction. Techniques such as importance-performance analysis might be useful to practitioners who could target for improvement practice characteristics perceived important by customers. In addition, pediatric residency programs could utilize this information to develop training sessions designed to meet a very important educational need.

Of greater importance, however, will be studies designed to expand our understanding of satisfaction and how it influences the health care consumer's behavior. Satisfaction is recognized as a multidimensional concept involving patient attitudes about various components of the health care system: access, convenience, availability, continuity, cost, technical quality of care and provider humanness, (Deisher et al. 1965, Alpert et al. 1970, Hulka et al. 1970, Fisher 1972, Ware & Snyder 1975, Doyle & Ware 1977). Resident physicians recognize that the technical quality of care and outcome have only moderate correlations with satisfaction and are often reminded of this truth while trying to reeducate intensely loyal patients of technically weak, but kind and compassionate practitioners. The high marks that faith healers receive further supports the notion that outcome may be of only limited importance in predicting satisfaction (Cobb 1954).

Probably more important than outcome is the quality of the interpersonal relationship (rapport) between physician and patient. Provider characteristics which appear to promote good rapport include the ability to convey concern and understanding, communicate clearly and adequately and receive and send appropriate nonverbal messages. Patients view the empathetic qualities of their providers (i.e. kindness, interest, concern, understanding) as their most important attributes (Reader et al. 1957, Deisher et al. 1965). If they identify these qualities in their provider, patients are more likely to establish continuity of care (DiMatteo et al. 1979). Physicians who establish rapport and meet or exceed patients' information expectations are also likely to receive high marks and be recognized as highly competent (Ben-Sira 1976, 1980, DiMatteo & Hays 1980), while those who do not are likely to engender patient dissatisfaction (Korsch et al. 1968, Waitzkin et al. 1972). In addition to verbal communication, nonverbal messages appear to have a significant role in the physician-patient relationship. Physicians more adept at receiving and sending nonverbal signals receive higher patient ratings on their interpersonal skills (Friedman 1979, DiMatteo et al. 1980). Further investigation is needed to explore how additional physician and patient characteristics impact on rapport and whether residents can be taught the verbal and nonverbal skills needed to ensure optimal patient satisfaction. Not only will failure to explore these issues impair the private practitioner's ability to survive the coming decade, it may also have a measurable impact upon patient health.

Multiple studies have documented the relationship between satisfaction and patient behavior. Ware and Davies (1983) have suggested that satisfied and dissatisfied patients behave differently and that changes in satisfaction with care may impact on at lease two categories of consumer behavior: adherence (compliance to care regimens) and reactive (changing providers, doctor shopping). For example, dissatisfied patients are less likely to comply with treatment regimens and more likely to drop out of care than their satisfied colleagues (Davis 1968, Caplan 1979, Taylor 1979). In addition, dissatisfied consumers are less likely to establish continuity of care (ware et al. 1975, Breslau & Mortimer 1981), more likely to doctor shop (Kasteler et al. 1976), drop out of prepaid care groups (Ware & Davies 1983) and seek help from nonmedical healers (Cobb 1954). There also appears to be a relationship between patient disenchantment with the medical profession and the number and size of malpractice suits (Vaccarino 1917). These studies suggest that attention to patient satisfaction (both in research and residency training) offers potential benefit to all components of the health care system: providers, patients, and third party carriers.

Even equipped with new organization and communication skills, the residency graduate of the next decade will face a difficult struggle in a medical market of increasing supply and declining demand. Although numerous studies suggest that physicians may create some demand (Wennberg & Gillelsohn 1973, Mathamatica Policy Research 1978), it is unlikely that fee for service pediatricians will be able to survive by increasing the number of follow up visits for otitis media or piercing ears. In addition, it is doubtful that parents will comply with scheduling changes or purchase new services unless chose services fulfill a perceived need. Even so, the surplus will exist and provide practitioners the opportunity to spend more time with patients and expand the types of services delivered. Consequently, the key is to identify unmet patient health care needs and develop new marketable physician services for them that families need and are willing to purchase.

With this in mind, a recent study (Hickson et al. 1983) sought to identify the concerns of 207 mothers seeking care in private pediatric offices. Only 30% of those interviewed were most worried about aspects of their children's physical health. The remaining 70% were most concerned about problem parenting, child behavior, development and adjustment to life changes (psychosocial concerns). Although the majority of these psychosocial concerns conceivably could be handled in private offices, only 28% of chose interviewed indicated that they had asked for help or even mentioned their concern to a pediatrician.

Communication about these issues was explored in a number of ways. Mothers were asked why they had failed to make their health provider aware of their concern. The most frequent responses were that they were unaware that their pediatrician could provide assistance or did not believe he wanted to help. Characteristics of parents communicating were compared with those who had not. Higher father occupation ratings, maternal education, age and the Caucasian race correlated significantly with communication. Maternal occupation, marital status, and intensity of concern did not correlate with communication. The final analysis, however, suggested that physician interest in psychosocial concerns was a more important predictor of communication that sociodemographic characteristics or intensity of concern and suggests that physicians overly or otherwise influence parents' decisions about whether or not to seek help for these needs. Consequently pediatricians may be successful in promoting demand for new services, if they can convince parents that they are interested and able to assist. Training programs must help the practitioner identify legitimate unmet child health care needs and provide training required to deal with these issues. Finally, both academic and private pediatricians must enlist assistance from marketing and business experts to develop cost effective means of delivering these services in the average practice.

The supply and demand aspects of child health care are changing rapidly. These changes are likely to have a significant impact upon both physician and patient behavior. Consequently, medical training programs if they are going to adequately equip their graduates to face the health care market of 1990, must invest the raisers necessary to teach and investigate issues related to medical consumer satisfaction. Finally they must explore ways to constructively utilize the health care provider excess to assist parent with unmet child health care needs.

REFERENCES

Alpert, J.L. Kosa, J. Haggerty, R. J. Robertson, L.S. & Heagarty, M.C. (1970), "Attitudes and Satisfactions of Low-Income Families Receiving Comprehensive Pediatric Care," American Journal of Public Health, 60, 499-508.

American Academy of Pediatrics: Committee on Expanding Pediatric Careers. (1979), " Career in Pediatrics," Pediatrics, 64, 259-268.

Anderson, R. Kravits, J. & Anderson, O.W. (1971), "The Public's View of the Crisis in Medical Care: An Impetus for Changing Delivery Systems," Economic and Business Bulletin, 24, 44-52.

Ben-Sira, Z. (1976), "The Function of the Professional's Affective Behavior in Client Satisfaction: A Revised Approach to Social Interaction Theory," Journal of Health and Social Behavior, 21, 170-180.

Breslau, N. & Mortimer, E.A. (1981), "Seeing the Same Doctor: Determinants of Satisfaction with Specialty Care for Disable Children," Medical Care, 19, 741-752.

Budetti, P.P. (1981), "The Impending Pediatric 'Surplus': Causes, Implications and Alternatives," Pediatrics, 67, 497-506.

Bureau of Health Manpower, Health Resources Administration. (1978), A Report to the President and Congress on the Status of Health Professions Personnel in the United States, Hyattsville: U.S. Department of Health. Education and Welfare.

Burnett, R.D. & Bell, L.S. (1978), "Projecting Pediatric Practice Patterns: Report of Survey by Pediatric Manpower Committee," Pediatrics, 62 (suppl), 627-665.

Caplan, R.D. (1979), "Patient, Provider and Organization: Hypothesized Determinants of Adherence," In S.J. Cohen (ed.) New Directions in Patient Compliance. Lexington, Massachusetts: D.C. Heath.

Cobb, B. (1954), "Why Do People Detour to Quacks," The Psychiatric Bulletin, 3, 66-69.

Davis, M.S. (1968), "Variations in Patients' Compliance with Doctors' Advice: An Empirical Analysis of Patterns of Communication," American Journal of Public Health, 58, 274-288.

Deisher, R.W. Engle, W.L. Spielholz, R. & Standfast, S.J. (1965)," Mothers' Opinions of Their Pediatric Care," Pediatrics, 35, 82-89.

DiMatteo, M.R. & Hays, R. (1980), "The Significance of Patients' Perceptions of Physician Conduct: A Study of Patient Satisfaction in a Family Practice Center," Journal of Community Health, 6, 18-34.

DiMatteo, M.R. Prince, L.M. & Tavanta, A. (1979), "Patients' Perceptions of Physicians' Behavior: Determinants of Patient Commitment to the Therapeutic Relationship," Journal of Community Health, 4, 280-290.

Donabedian, A. (1981), "Perspectives on the Free Choice of the Source of Personal Health Care," Milbank Memorial Fund Quarterly, 59, 586-595.

Doyle, B.J. Ware, J.E., Jr. (1977), "Physician Conduct and Other Factors That Affect Consumer Satisfaction with Medical Care," Journal of Medical Education, 52, 793-801.

Eisenberg, L. (1977), "The Search for Care," Daedalus, 106, 235-246.

Fisher, A.W. (1972), "Patient's Evaluation of Outpatient Medical Care," Journal of Medical Education, 46, 238-244.

Friedman, H.S. (1979), "Nonverbal Communication Between Patients and Medical Practitioners,B' Journal of Social Issues, 35, 82-99.

Freidson, E. (1970), Profession of Medicine: A Study of the Sociology of Applied Knowledge, New York: Dodd, Mead.

Glassman, M. & Glassman, N. (1981), "A Marketing Analysis of Physician Selection and Patient Satisfaction," Journal of Health Care Marketing, 1(4), 25-31.

Haug, M.R. & Lavin, B. (1979), "Public Challenge to Physician Authority," Medical Care, 17, 844-858.

Hickson, G.B. Altemeier, W.A. & O'Conner, S. (1983), "Concerns of Mothers Seeking Care in Private Pediatric Offices: Opportunities for Expanding Services," Pediatrics, 72, 619-624.

Hooper, E.M. Comstock, L.M. Goodwin J.M. & Goodwin, J.S. (1982), "Patient Characteristics That Influence Physician Behavior," Medical Care, 20, 630-638.

Hulka, B.S. Zyzanski, S.J. Cassel, J.C. & Thompson, S.J. (1970), "Scale for the Measurement of Attitudes Toward Physicians and Primary Medical Care," Medical Care, 8, 429-436.

Kasteler, J. Kane, R.L. Olsen, D.M. & Thetford, C. (1976), "Issues Underlying Prevalence of 'Doctor-Shopping' Behavior," Journal of Health and Social Behavior, 17, 328-339.

Korsch, B.M. Gozzi, E.K. & Negrette, V.F. (1968), "Gaps in Doctor-Patient Communication: I. Doctor-Patient Interaction and Patient Satisfaction," Pediatrics, 42, 855-869.

Mathamatica Policy Research. (1978), A Study of the Responses of Canadian Physicians to the Introduction of Universal Medical Care Insurances: The First Five Years in Quebec, Washington, D.C.: US Department. of Health, Education and Welfare.

Mechanic, D. (1975), "The Organization of Medical Practice and Practice Orientations Among Physicians in Prepaid and Nonprepaid Primary Care Settings," Medical Care, 13, 189-196.

Needle, R.H. & Murray, B.A. (1977), "The Relationship Between Race and Sex of Health Provider, the Quality of Care Provided, and Levels of Satisfaction with Gynecological Care Among Black College Women," Journal of the American College Health Association, 26. 127-131.

Parsons, I. (1951), The Social System, New York: Free Press.

Office of Graduate Medical Education, Health Resources Administration. (1980), Final Report of the Modeling Panel of the Graduate Medical Education National Advisory Committee, Washington, D.C.: US Department of Health and Human Services.

Owens, A. ( 1983), "Where the Primary Care Squeeze is Hurting GP's and FP's," Medical Economics, (June 13).

Reader, G.G. Pratt, L. & Mudd, M.C. (1957), "What Patients Expect From Their Doctor," Modern Hospital, 89, 88-94.

Stewart, D.W. Hickson, G.B. Ratneshwar, S. Pechmann, C. & Altemeier, W.A. (1984), "Information Search and Decision Strategies Among Health Care Consumers," Association for in Consumer Research, Accepted for presentation.

Taylor, S.E. (1979), "Hospital Patient Behavior: Reactance, Helplessness or Control?," Journal of Social Issues, 35, 156-184.

U.S. Bureau of the Census. (1977), Projections of the Population of the United States: 1977-2050, Washington, D.C., Census Bureau.

U.S. Department of Health and Human Services. (1980), Report of the Graduate Medical Education National Advisory Committee of the Secretary (Summary Report), Washington, D.C.: U.S. Department of Health and Human Services.

Vaccarino, J.M. (1977), "Malpractice: The Problem in Perspective," Journal of the American Medical Association, 238, 861-863.

Waitzkin, H. & Stoeckle, J.D. (1972), "The communication of Information about Illness," Advances in Psychosomatic Medicine, 8, 180-215.

Ware, J.E. Jr. & Snyder, M.K. (1975), "Dimensions of Patient Attitudes Regarding Doctors and Medical Care Services," Medical Care, 13, 669-682.

Ware, J.E Wright, W.R. Snyder, M.K. & Chu, G.C. (1975), "Consumer Perceptions of Health Care Services: Implications for Academic Medicine," Journal of Medical Education, 50, 839-845.

Wennberg, G.L. & Gittelsohn, R.S. (1973), "Small Area Variations in Health Care Delivery," Science, 182, 1102-1108.

Wolinsky, F.D. & Marder, W.D. (1983), "Waiting to See the Doctor", Medical Care, 21, 531-542.

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