Absolute versus relative values: effects on family practitioners and psychiatrists. (Original Article).

Background: Research demonstrates that religious values clearly impact on the judgments made by physicians and their patients. One basic dichotomy--belief in ethical values that do not change (absolute values) versus belief in values that change depending on the situation (relative values)--has recently been experimentally associated with different ethical decision-making patterns.

Methods: An anonymous, randomized, national survey and 1-week response prompt with 1-month follow-up mailing as necessary were distributed to nationwide samples of board-certified American family practitioners and psychiatrists. Physicians answered descriptive questions and standardized personality assessments and responded to three vignettes describing ethically sensitive scenarios concerning birth control medication for sexually active single women, euthanasia, and abortion.

Results: Response rates were 34% for psychiatrists and 38% for family practitioners. Family practitioners and absolutists were significantly more supportive of religious activities and had more religious parents than psychiatrists and relativists. Furthermore, family practitioners and absolutists were less approving of the vignettes than other groups.

Conclusion: Family practitioners were more supportive of religious activities than psychiatrists as reported in previous research. The absolute versus relative value dichotomy is a useful concept in examining physician attitudes as they affect health care and personal behavior. However, questions concerning place of worship attendance and giving in addition to specific religious value labels may be more efficient experimentally. Physicians should be aware of their own biases in discussions with patients, families, and other health care providers.

Key Words: decision making, ethics, family practice, medical, psychiatry, religion and medicine

**********

Key Points

* Family practitioners and absolutists were more supportive of religious activities and had parents who were more religious than those of psychiatrists and relativists.

* Family practitioners were less approving of a scenario describing birth control medication use for a single woman than were psychiatrists. Relativists were more approving of a euthanasia vignette than were absolutists.

* The absolute versus relative values dichotomy is useful, but information concerning specific behaviors (eg, worship attendance frequency) may be more efficient experimentally.

Religious values clearly impact on the personal lives of physicians and on their professional decisions. (1) Many theistic and nontheistic value systems compete for adherents. One conceptualization involves a dichotomy between absolute versus relative value systems. (2) This dichotomy reflects historical differences between such value systems as orthodox Judaism or Christianity and adherents of more recent postmodern, humanistic principles such as New Age beliefs. Absolutists believe in ethical values that do not change as a function of situational factors (eg, cultural context, particular personal attributes), whereas relativists believe ethical values may change depending on particulars of a situation.

Empiric studies support the utility of the absolute versus relative value dichotomy. A nationwide physician survey compared conservative Protestants and Catholics who endorsed an "absolute authority" with atheistic humanists and agnostics who affirmed that truth was individually determined. (3) Respondents who believed in an absolute authority were more tolerant or approving of medical in-service vignettes reflecting a variety of values than the others. More recently, a regional survey of physicians found that absolutists as defined in this study were less approving than relativists of birth control medication for sexually active single women, euthanasia, and abortion. (2) Suggestive psychological correlates have also been found to vary with this dichotomy. With medical inpatients, absolutists reported less hostility than relativists. (2)

Medical specialty may be another significant variable influencing ethical decisions. Multiple studies have found psychiatrists less involved in religious activities such as church attendance than other medical specialists or the general public. (4) Religious beliefs and practices of family physicians, in contrast, are almost comparable to the general population. (5) However, the extent to which psychiatrists' personal religious values affect referrals to clergy or other health care decisions relative to other specialists is unclear, given the limited data available from research. (4,6,7) Parental theistic faith variables also appear to vary with medical specialty and physician personal involvement in religious activities. For example, psychiatrists' religious values were significantly less similar to the values of their parents than general surgeons, internists, pathologists, or family practitioners. (6)

This study replicated and extended many facets of our initial study (2) concerning the absolute-relative value dichotomy. General improvements in this project include use of a randomized and nationwide larger sample size and incorporation of better psychometric testing. The primary purposes of this study were to evaluate the extent to which both the absolute/relative dichotomy and the professional group (psychiatrists/family practitioners) variables impacted on medically relevant decision making. The study hypotheses were the following:

* Hypothesis 1: Family practitioners would be less approving of all three vignettes than psychiatrists.

* Hypothesis 2: Relativists would be more approving of all three vignettes than absolutists.

* Hypothesis 3: Anger scores would be higher and forgiveness scores lower in the relativist group compared with the absolutist group. No professional group personal differences were hypothesized because of the lack of data in this area.

Methods

Study Population and Methods

Institutional review boards at James H. Quillen College of Medicine and VA Medical Center approved the project. Randomized, nationwide lists of 500 board-certified family physicians and 500 board-certified psychiatrists were purchased from, the American Board of Medical Specialties (New Providence, NJ). From the psychiatrists' mailing, 56 were returned with incorrect addresses and two potential responders had died, leaving 442 potential responders. Of the family practitioners' mailing, 65 were returned with incorrect addresses and one had died, leaving 434 potential volunteers. The psychiatrist response rate was 34% with 150 usable replies, and the family physician response rate was 38% with 166 usable replies.

Survey procedures generally followed a total design survey methodology. (8) Physicians were first mailed a cover letter explaining the purpose of the survey, coding procedures were used to maintain confidentiality, and participants were given a means of obtaining a summary of the project results and the survey materials. A reminder post card was mailed 4 days after the first mailing. A follow-up letter and all survey materials were mailed to nonresponders approximately 1 month after the initial distribution.

Survey Content

The survey consisted of three basic divisions. Physicians were asked to respond to items addressing general demographics and lifestyle factors (eg, race, alcohol intake, worship attendance) and the four statements in Table 1. These statements are very similar to a previous study (2) and were used to operationally define the absolute and relative value response groups. A respondent indicating agreement with at least three of the four statements was defined as a relativist, whereas an absolutist would disagree with at least three out of the four items. The descriptive questions asked volunteers to provide estimates (eg, actual weight in pounds) or respond to Likert-type scales. For example, the item concerning continuing life stress for the past 6 months ranged from I ("none") to 5 ("extreme"). The last section of this area asked respondents to check their religious value system from a list of 15 categories used in previous research. (2,3) Each category had a label and brief descriptive phrase. For example, Lib eral Protestant was defined as "Believe in the general guidance of the Bible but not in a literal or exact sense in daily living," whereas Conservative Protestant equated with "Believe in the absolute authority of the Bible in faith and daily living." Summary data are given in Table 2.

A second response set, the ethically sensitive vignettes, are available in a previous article. (2) Briefly, participants indicated extent of approval on a Likert-type scale ranging from I ("do not approve") to 7 ("do approve") in response to each of three paragraph-length vignettes. Vignette 1 described a sexually active single woman asking for birth control medication; vignette 2 described a 70-year-old man in a coma after a myocardial infarction whose family asks the physician for euthanasia; and vignette 3 described a pregnant woman with a family history of a genetic disease who requests an abortion.

The third major category included two published psychological assessments. A forgiveness index contained 12 items, each item rated on a five-point scale ranging from 1 ("strongly disagree") to 5 ("strongly agree"). The Avoidance and Revenge subscales each have six items.(9) The Ketterer Stress Symptom Frequency Checklist has been used in previous survey research(10) and provides scale scores reflecting depression, anxiety/worry, and aggravation/anger. This assessment consists of 58 items, each rated with a frequency score ranging from 0 ("never") to 9 ("constantly").

Statistical Analysis

Descriptive data such as age or gender are given as means and percentages. Identifying meaningful group differences in descriptive data enabled us to both note these differences and use identified variables in later analyses of covariance. Given that survey data are not completely crossed (ie, not all psychiatrists or family practitioners were either absolutists or relativists as defined in this project), descriptive data for professional group (family practitioners versus psychiatrists) and value group (relativist versus absolutist), comparisons were initially examined by multiple two-tailed t tests for independent means for ratio or interval data and nonparametric proportion tests for ordinal data. Homogeneity of variance testing was used to determine appropriate t test in all cases. Interaction effects between professional groups were investigated by performing two-way analysis of variance across professional and value group types. Only clearly significant (P < 0.05) data are given in this article. All si gnificant group differences were used as covariates for the single-factor analysis of covariance in hypothesis testing for both the professional group and value group comparisons. Not all subjects responded to all items. Further survey detail and statistical data may be obtained by writing the first author (JKN).

Results

Respondent Characteristics

Respondent characteristics are given as a function of both professional group and value group in Table 3, with significant (P < 0.05) group differences noted. The number of family practitioners who 1) did not meet certain criteria for one of the value groups (n = 75), 2) were relativists (n = 30), or 3) were absolutists (n = 61) did not differ significantly from that of psychiatrists (n = 81, 30, and 38, respectively). However, psychiatrists did have more "not sure" ratings in response to the criteria questions than family practitioners (P = 0.003). The typical participant was a middle-aged white man.

Psychiatrists were older (54 versus 43). Health habit ratings in Table 3 also indicate psychiatrists drank more coffee and reported less continuing life stress in the past 6 months than family practitioners. Furthermore, psychiatrists were more likely than family practitioners to think patients "should be able to decide their own treatment." In terms of religious variables, family practitioners reported more frequent worship attendance and financial giving to a place of worship than psychiatrists. Financial giving was highest among respondents who were family practitioners and absolutists, and lowest for subjects who were psychiatrists and relativists. The current religious values of family practitioners were more similar to their mothers' values than psychiatrists. Worship attendance ratings of both father and mother when participants were children were higher in family practitioners than psychiatrists. Regardless of particular self-value label, family practitioners believed more strongly in their value sys tem than psychiatrists. These 10 significantly different variables were used as covariates in the hypotheses testing analyses of covariance for the professional group factor.

Absolutists engaged in less exercise (both aerobic and anaerobic) than relativists, but smoked fewer cigarettes than relativists. In fact, whereas the average cigarette use of relativists was low (a couple of cigarettes per day), all 99 absolutist physicians rated their own cigarette use as "none." In terms of religious factors, absolutists reported both higher frequency of worship attendance and financial giving than relativists. Second, the current religious values of absolutists were more similar to their mothers' values than relativists. In addition, the worship attendance of the absolutist's mother and father when they were children rated as higher than the attendance rates of the relativist's parents. Relativists report an overall lower strength of belief than absolutists. The worship attendance, income giving, and father's worship attendance replicate previous reported differences between absolutists and relativists. (2) All eight of these significant group differences were used as covariates in the a nalyses of covariance to test value group hypotheses.

Hypotheses Testing

Hypothesis 1. Hypothesis 1 was not clearly confirmed. Psychiatrists tended to be more approving of birth control for sexually active single women than family practitioners but not significantly so (P = 0.081). Worship attendance (P = 0.001), coffee intake (P = 0.035), and patient autonomy (P = 0.007) ratings were all more related to these vignette ratings than professional group. Worship attendance was negatively correlated with vignette approval, whereas coffee and patient autonomy ratings were positively correlated. Professional group was clearly not associated with approval of euthanasia (P = 0.142) and abortion (P = 0.390) vignettes.

Hypothesis 2. Hypothesis 2 was partially confirmed. As in a previous study, (2) relativists were significantly more approving of the euthanasia vignette (P = 0.004) than absolutists. No covariate was significantly associated with these vignette ratings. Value group was not significantly associated with approval of the contraceptive (P = 0.915) or abortion (P = 0.252) vignettes. The covariate worship attendance was negatively associated with approval of the contraception scenario (P = 0.027). The covariate aerobic exercise was positively associated with abortion vignette approval (P = 0.027), and the correlation with this scenario for financial giving to a place of worship was negative (P < 0.001).

Hypothesis 3. Hypothesis 3 was not clearly confirmed. Relativists did tend to be less forgiving (ie, avoidant) than absolutists generally (P = 0.9). No significant associations or trends were found between value group and depression, anxiety, anger, or revenge indices. In addition, no trends or significant differences were found between professional group and any of the psychological assessment indices.

Subgroup Analysis 

There were significant differences between proportion of relativist versus absolutist value adherents in the following self-label value categories: Liberal Protestant, with more absolutists than relativists (P = 0.008); Conservative Protestant, with more absolutists than relativists (P = 0.001); and Liberal Jewish, with more relativists than absolutists (P = 0.014).

Comparisons were only calculated between Liberal Protestants and Conservative Protestants who all affirmed absolute values, because (1) there was no group variation in the Conservative Protestant category, as only one respondent met relativist criteria; (2) the total group numbers of the next most frequent groups, Liberal Jewish (n = 12) and Liberal Catholic (n = 17), were too low; and (3) these subgroups were investigated in a previous study using the same self-label definitions. Conservative Protestants within the absolute value group reported giving more money to church (p < 0.001) and having stronger beliefs (P = 0.0 12). Liberal Protestants within the absolute value group were more likely to approve contraception for single women (P 0.032), euthanasia (P = 0.075), and abortion (p < 0.001) vignettes than the Conservative Protestants within the same value group. The euthanasia and abortion findings replicate previous work. (2) No subgroup significant differences or trends were found with any of the psychol ogical assessment variables.

Discussion

Theistic and nontheistic religious values are an important but controversial aspect of medicine in pluralistic societies. Interest in religious factors in medical education, research, and clinical care has increased, but no consensus exists as to how or whether organized medicine should address this area. (11, 12) Anecdotally, many physicians thanked us for this survey, but some wrote negative remarks. For example, one family practitioner wrote "Western medicine paradigm of curing 'the body' of illness by applying principles of medicine has strong limitations. It is high time that organized medicine, politicians, and business/consumer groups get together and plan interventions which apply not only to physical mind/spirit issues. This then should lead to forcing the insurance companies to cover such benefits without gouging the consumer." In contrast, a psychiatrist wrote "All beliefs here are delusional symptoms. Religion is a collective delusional system."

The response rates and result patterns correspond well to previous research. (2,5,6) However, methodologic problems limit generalization. First, the response rates were less than 50%. Although these are expected rates given the sensitive nature of the questionnaire, it is unclear how data from nonresponders would have impacted on results. Second, the data also reflect self-reports. How physicians would have responded when actually confronted with vignette scenarios is not established. Third, other unmeasured factors (eg, personality factors) may vary with the independent variables (professional group and value group), which were not assessed. These other variables may influence result patterns in this project.

Absolute versus Relative Values

This study contributes to understanding the interconnection between medicine and religious values by examining two primary factors: 1) the absolute versus relative value dichotomy and 2) differences between two established groups within medicine (ie, family practice and psychiatry). Previous absolute versus relative value dichotomy findings were partially confirmed. (2) Relativists were more approving of euthanasia and tended to be less forgiving than absolutists. Absolutists reported stronger belief in their values and more attendance and financial support of their organized places of worship than relativists. Parental factors such as church attendance affect this variable.

The extent to which the dichotomy of absolute versus relative values is experimentally helpful is less clear given covariate analyses. Many factors relate to decisions concerning ethical decision making. Ratings of worship attendance, for example, were actually more highly correlated with disapproval of birth control medication for a sexually active single woman than the absolute versus relative value dichotomy. Our study suggests that simply asking respondents to rate their place of worship attendance frequency and financial support as well as specific religious values may be quite adequate in reflecting "real-life" behavioral variations, as others have found. (13) Another limitation of the absolute versus relative value dichotomy is that many individuals do not meet criteria for inclusion in either group.

Professional Group

Family practitioners reported stronger beliefs and more support of religious activities than psychiatrists in terms of both attendance and financial giving. Similarity to other religious values and parental church attendance was also higher in the family practitioner group. The religious differences in value affiliation, activity, and parental involvement replicate previous work. (7,14) Psychiatrists were more likely than family practitioners to "think patients should be able to decide their own treatment." Many physicians anecdotally commented about mental competency being an important variable in this rating. However, psychiatrists might be expected to rate patient control much lower if this was a primary consideration. Perhaps other factors (ie, appointment duration or frequency, extent to which psychotherapy is provided) correlate with this dimension.

Religion Value Groupings

The specific value groupings (eg, Conservative Protestant, Liberal Protestant) significantly influenced results in this study and previous research. (2,3) Use of general labels such as Protestant, Catholic, Jewish, or other have limited utility in describing a respondent group. However, such broad religious categorical divisions are still used. (15) There is so much variation within a category such as "Protestant" that any lack of group differences may be more related to a deficient labeling system than actual lack of effect of the religious variable. The group labels in this study may have increased utility if behavioral examples were included with the short value descriptions.

Research Implications

Research implications for medicine are widespread and require ardent self-evaluation and further investigation. To what extent do our religious preferences influence who will likely be admitted to medical training? What influence does that training have on medical student values? Dans (16) found little change in attitudes concerning abortion over 4 years in medical school. Technical training in medicine does not change strongly held personal values. Laws that require training in ethically sensitive procedures such as elective abortion are simply likely to result in an exodus of those opposed to these procedures. Thus, religious value diversity in the specialty will be substantially reduced. Professional self-evaluation is necessary to determine whether opting out is easily accessible for trainees or whether ethically sensitive procedures are really even basic to a medical specialty's core of knowledge.

Conclusion

We found that family practitioners and those with absolute values engaged in more theistic religious activities than psychiatrists and those with relativistic values. However, the information obtained in the absolute versus relative value dichotomy may more simply be obtained by asking respondents questions concerning place of worship attendance and giving in addition to asking them to place themselves in particular religious value groups. As indicated by vignette response patterns, religious values clearly relate to clinical care, and physicians should be aware of their own biases in discussions with patients, families, and other health care providers. (17)

Table 1

Screening questions used to establish value groups

Statement                            Agree  Disagree  Not sure

When it comes to matters of morals,
 truth means different things to
 different people.

Nothing morally can be known for
 certain except the things that you
 experience in your life.

People may define moral truth in
 contradictory ways and still be
 correct.

Everything in life is negotiable.

Table 2

Frequency of self-indicated values by medical specialty (a)

                            Family
Value label              practitioner  Psychiatrist  Total (%)  P value

No label checked               0             2         2 (1)      NS
Liberal Protestant            36            16        52 (17)   <0.001
Conservative Protestant       45             8        53 (17)   <0.001
Liberal Catholic              25            19        44 (14)     NS
Conservative Catholic          7             1         8 (3)     0.018
Liberal Jewish                 7            20        27 (9)    <0.001
Conservative Jewish            1             3         4 (1)      NS
Spiritual Humanist            10            19        29 (9)     0.018
Atheist Humanist               4            18        22 (7)    <0.001
Buddhist                       0             2         2 (1)      NS
Islam                          1             1         2 (1)      NS
Hindu                          2             4         6 (2)      NS
Latter-Day Saints              1             2         3 (1)      NS
New Age                        9             5        14 (4)      NS
Agnostic                       7             9        16 (5)      NS
Others (b)                    11            21        32(10)     0.012

(a)NS, nonsignificant.

(b)Includes respondents who checked two or more categories.

Table 3

Respondent characteristic descriptive statistics (a)

                                         Professional group

Variable                                  FP           Psyc

General Faction
Total                                    166            150
Age (years)                          43.0 (10.3)    54.3 (14.1)
Gender (% male)                           63            69
Race (% white)                            88            86

Health numbers and ratings

 Aerobic exercise no./wk              2.6 (2.1)      2.5 (2.1)
 Anaerobic exercise no./wk            1.2 (1.5)      1.3 (1.8)
 Coffee use, cups/d (1 = none,        2.0 (1.1)      2.3 (1.1)
  3 = 2-3 cups/d)
 Alcohol use to "high" (1 = none,     1.4 (0.8)      1.5 (1.0)
  2 = 1/mo)
 Cigarette use, per day (1 = none,    1.0 (0.2)      1.1 (0.2)
  2 = 1-10)
 Stress (1 = none, 3 = average)       3.3 (0.9)      3.0 (1.0)
 Friends (1 = none, 3 = 3 or 4)       3.8 (1.5)      4.0 (1.4)
 Physical problems (1 = none, 3 =     2.3 (1.0)      2.3 (1.1)
  occasionally)
 Patient decide own treatment (1 =    5.0 (1.4)      5.4 (1.4)
  none, 5 = frequently)

Religious ratings

 Worship attendance (1 = none, 3 =    2.6 (1.4)      1.8 (1.1)
  1/wk)
 Financial giving (b) (1 = none,      3.0 (1.4)      2.0 (1.3)
  3 = 3-5%)

 Similarity to (1 very similar,
  3 = somewhat similar)

  Father's values                     3.2 (1.9)      3.6 (2.1)
  Mother's values                     3.1 (1.8)      3.7 (2.0)

 Attendance of (1 = almost never,
  5 = somewhat frequently)

  Father                              4.3 (2.5)      3.3 (2.3)
  Mother                              5.1 (2.2)      3.9 (2.4)
 Strength of belief (1 = not          5.6 (1.3)      5.1 (1.5)
  strongly, 7 = very strongly)

                                                     Value group

Variable                            P value        Rel           Abs

General Faction
Total                                              60            99
Age (years)                         <0.001     49.7 (14.0)   48.0 (12.9)
Gender (% male)                       NS           71            65
Race (% white)                        NS           84            88

Health numbers and ratings

 Aerobic exercise no./wk              NS        3.1 (2.2)     2.3 (1.9)
 Anaerobic exercise no./wk            NS        1.6 (1.7)     1.0 (1.6)
 Coffee use, cups/d (1 = none,       0.013      2.3 (1.2)     2.0 (1.2)
  3 = 2-3 cups/d)
 Alcohol use to "high" (1 = none,     NS        1.5 (1.0)     1.3 (0.7)
  2 = 1/mo)
 Cigarette use, per day (1 = none,    NS        1.1 (0.3)     1.0 (0.0)
  2 = 1-10)
 Stress (1 = none, 3 = average)      0.004      3.3 (1.0)     3.2 (1.0)
 Friends (1 = none, 3 = 3 or 4)       NS        3.9 (1.4)     3.8 (1.4)
 Physical problems (1 = none, 3 =     NS        2.1 (0.9)     2.2 (0.9)
  occasionally)
 Patient decide own treatment (1 =   0.019      5.2 (1.6)     5.2 (1.4)
  none, 5 = frequently)

Religious ratings

 Worship attendance (1 = none, 3 =  <0.001      1.6 (0.9)     2.9 (1.5)
  1/wk)
 Financial giving (b) (1 = none,    <0.001      1.7 (1.0)     3.4 (1.7)
  3 = 3-5%)

 Similarity to (1 very similar,
  3 = somewhat similar)

  Father's values                     NS        3.6 (2.2)     3.3 (2.1)
  Mother's values                    0.005      3.9 (2.1)     3.1 (1.9)

 Attendance of (1 = almost never,
  5 = somewhat frequently)

  Father                            <0.001      3.3 (2.6)     4.3 (2.4)
  Mother                            <0.001      3.8 (2.5)     5.0 (2.2)
 Strength of belief (1 = not        <0.016      5.0 (1.3)     5.8 (1.4)
  strongly, 7 = very strongly)



Variable                            P value

General Faction
Total
Age (years)                           NS
Gender (% male)                       NS
Race (% white)                        NS

Health numbers and ratings

 Aerobic exercise no./wk             0.027
 Anaerobic exercise no./wk           0.029
 Coffee use, cups/d (1 = none,        NS
  3 = 2-3 cups/d)
 Alcohol use to "high" (1 = none,     NS
  2 = 1/mo)
 Cigarette use, per day (1 = none,   0.009
  2 = 1-10)
 Stress (1 = none, 3 = average)       NS
 Friends (1 = none, 3 = 3 or 4)       NS
 Physical problems (1 = none, 3 =     NS
  occasionally)
 Patient decide own treatment (1 =    NS
  none, 5 = frequently)

Religious ratings

 Worship attendance (1 = none, 3 =  <0.001
  1/wk)
 Financial giving (b) (1 = none,    <0.001
  3 = 3-5%)

 Similarity to (1 very similar,
  3 = somewhat similar)

  Father's values                     NS
  Mother's values                    0.020

 Attendance of (1 = almost never,
  5 = somewhat frequently)

  Father                             0.012
  Mother                             0.002
 Strength of belief (1 = not        <0.001
  strongly, 7 = very strongly)

(a)FP, family practitioner; Psyc, psychiatrist; Rel, relativist; Abs,
absolutist; NS, nonsignificant. Data are given as means (SD) unless
otherwise indicated.

(b)Interaction effect with highest giving by FPs who were Abs, P =
0.018, of net income.

Accepted October 2, 2002.

Acknowledgments

We thank Earnestine Stewart for her fine clerical assistance. In addition, Earnestine Stewart and David Paul Roberts were quite helpful in mailing, receiving, and scoring project materials.

References

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From the Psychology Department and the Department of Internal Medicine, James H. Quillen VA Medical Center/College of Medicine, Johnson City, TN.

Presented in part at the meeting of the Southern Regional Society of General Internal Medicine, New Orleans, LA, March 2, 2001.

This work was supported by resources and facilities of the James H. Quillen VA Medical Center and James H. Quillen College of Medicine, Johnson City, TN.

Reprint requests to Joseph K. Neumann, PhD, Psychology Department, Greene Valley Developmental Center, P.O. Box 910, Greeneville, TN 37744-0910. Email: [e-mail]

Copyright [c] 2003 by The Southern Medical Association 0038-4348/03/9605-0452