PHACES (Photographs of Academic Clinicians
and Their Educational Status): ATool to Improve
Delivery of Family-Centered Care
Robert A. Dudas, MD; Hanna Lemerman, MD, MPH;
Michael Barone, MD, MPH; Janet R. Serwint, MD
Objective.—The aim of this study was to determine if an infor-
mation sheet containing photographs and explanations of the
training level of medical providers could enhance a parent’s
ability to identify their child’s providers and whether this would
impact parental attitudes toward trainee involvement and patient
Methods.—This was a prospective, mixed methods study of
parent-child dyads admitted to an academic general pediatric
inpatient service. The intervention group received a photo infor-
mation sheet (Photographs of Academic Clinicians and Their
Educational Status [PHACES] tool) consisting of passport-sized
training. Parents were asked to name their child’s providers, were
surveyed about their attitudes toward trainees, participated in
a brief, semistructured interview and completed the patient satis-
faction questionnaire (ABIM-PSQ).
Results.—Comparing intervention with control parents, 40 of 49
(82%) versus 19 of 51 (37%) were able to name at least one
provider (adjusted odds ratio 8.0; P < .01). Parents who received
the intervention were more likely to correctly match the facewith
the name of the medical student (67% vs 14%; P < .01) and
attending (80% vs 24%; P < .01). Parents who received the inter-
vention were more likely to report acceptance of the involvement
of medical students and house staff as well as an improved under-
standing of their roles. Parents who received the intervention
scored higher on the ABIM-PSQ (mean 48.3 vs 45.4; P ¼ .008).
Conclusions.—An information sheet containing the photographs
improves recognition of the health care team members, improves
care delivered by physicians in training.
KEY WORDS: communication; family-centered care; medical
education; patient-centered care, patient satisfaction; pediatrics;
photographs; physician-patient relations
Academic Pediatrics 2010;10:138–45
aims for improvement.’’1In 2003, the American Academy
of Pediatrics requested that pediatricians incorporate the
core concepts of family-centered care by examining
systems of care and individual interactions with families.2
The core concepts of patient and family-centered care
include information sharing, participation, collaboration,
and maintaining dignity and respect.3This is best achieved
through personal relationships, yet the academic inpatient
setting presents many barriers to relationship building.
This is particularly true at teaching hospitals, where clin-
tion of trainees. As a result, patients encounter multiple
providers, are frequently unable to identify members of
their health care team, and are often unaware of the roles
and responsibilities of the individual team members,
despite wanting to know.4–6
he 2001 Institute of Medicine report Crossing the
Quality Chasm: A New Health System for the 21st
Century made patient centeredness one of its ‘‘6
Although the American Medical Association and the
American College of Physicians ethics manuals state that
physicians in training should inform patients of their
training status and role on the medical team,7,8evidence
suggests that adult patients display limited understanding
are unaware that they are receiving care from a trainee
despite introductions and identification badges.9,10Others
have found that patients do not understand the terms
stand the roles associated with different levels of
training.12,13Ultimately, this can hinder the patient and
family’s understanding concerning with whom they should
be sharing information and negotiating treatment plans,
potentially impairing their ability to make informed deci-
sions. Such confusion about caregivers was implicated in
the death of a 15-year-old boy, resulting in passage of the
Lewis Blackman Hospital Patient Safety Act in South Car-
olina in 2005.14,15
A prior study with adult patients suggested that placing
physician photographs in a patient’s room can aid identifi-
cation.16In an effort to provide clarity to parents of hospi-
talized children, we developed the Photographs of
Academic Clinicians and their Educational Status (PHA-
CES) tool. The tool consists of a single sheet of paper
with photographs of the physicians and trainees, tailored
Medicine, Baltimore, Md.
Address correspondence to Robert A. Dudas, MD, Johns Hopkins
Bayview Medical Center, 4940 Eastern Ave, Baltimore, Maryland
21224 (e-mail: email@example.com).
Received for publication June 24, 2009; accepted December 30, 2009.
Copyright ? 2010 by Academic Pediatric Association
Volume 10, Number 2
to an individual patient, supplemented by a brief explana-
tion of their roles and training. The purpose of this study
was to determine if this tool could enhance a parent’s
ability to identify their child’s providers and whether this
would impact parental attitudes toward trainee involve-
ment and patient satisfaction.
This was a prospective mixed methods comparative
study of 100 parent-child dyads admitted to 1 of 3 general
pediatric services in a single large tertiary care academic
hospital. We use the term parent to include mother, father,
or caretaker with medical decision-making authority. The
constituency of the medical team at our institution remains
generally static for a 4-week time period, after which time
there is complete turnover among providers. The medical
team is comprised of an attending who supervises a day
team (2 supervisory residents and 2 interns) and a night
team (1 supervisory resident and 1 intern). During this 4-
week block, the constituency of the day team is constant
but the night team serves for 2 weeks and then is relieved
the day and night teams during the month.
To ensure that our measured outcomes were a result of
the intervention and not due to differences in the constitu-
ency of the medical team, we decided upon a prestudy-
poststudy design as follows. Patients admitted during the
first 2 weeks of a 4-week rotation received standard admis-
sion protocol (control group), whereas for the latter 2
weeks the parents received a tailored photo information
sheet (PHACES tool) in addition to standard admission
protocol (intervention group). This process allowed us to
compare the impact of the intervention on data obtained
from a single team to minimize any confounders intro-
duced by a change in providers or variations in provider
characteristics. Parents were approached within 24 hours
of admission and asked to participate in the study. If they
expressed interest, verbal informed consent was obtained.
We collected nonidentifying demographics including
patient age (years), gender, race, hospital length of stay
(days), and length of time on that team. The Institutional
Review Board of the Johns Hopkins University School of
Medicine approved this study.
We calculated our sample size to identify a difference in
the proportion of parents able to correctly identify their
primary providers. We estimated that 50% of families
would be able to correctly identify any primary provider
at baseline (attending, intern, or medical student) and
thought an increase to 75% by using the PHACES tool
upon the assumption that the intervention could only
increase identification of providers. Using an alpha of .05
and a beta of .20 resulted in the requirement of 46 subjects
in each arm of the study for a total of 92 participants.
The PHACES Tool
The intervention group, in addition to receiving the stan-
dard admission protocol, was handed an individually
tailored photo information sheet (PHACES tool) by one
of the investigators, and a second sheet was posted at the
bedside. Each sheet was created using Microsoft Word
(Microsoft Corporation, Redmond, Wash) and consisted
of a single-sided 8.5- ? 11-inch paper with passport-sized
photographs of the medical students, interns, residents and
attending on their child’s medical team, along with infor-
mation regarding the training and roles of the providers
offered in text below each photograph (Figure). The day
and night teams were both represented on a single sheet.
We report 2 primary variables: parents’ attitudes toward
trainee involvement in the care of their children and patient
satisfaction. We assessed parents’ attitudes by creating
a survey. Variables were selected based upon review of
the existing literature concerning patient attitudes toward
trainee involvement and expert consensus among the
authors. We piloted our survey with a group of parents of
hospitalized children not involved in this study prior to
study initiation to identify ambiguity and made changes
based upon parent feedback. Questions were brief (less
than 15 words), direct, and structured to enhance validity
and reliability, although we did not specifically test for reli-
ability and validity of our survey instrument. Survey
domains included parental attitudes toward physicians in
training, parental understanding of their training levels
and roles as well as their perception about the amount of
level of agreement with each statement by using a 5-point
Likert scale in which ‘‘1’’ denoted strong disagreement,
‘‘3’’uncertainty, and ‘‘5’’ strong agreement. Using this
rating scale, parents were asked questions about their
knowledge of the training level and roles of their providers,
their comfort with students and physicians in training, and
their feeling of collaboration with their health care team.
We also surveyed patient satisfaction through use of the
American Board of Internal Medicine Patient Satisfaction
Questionnaire (ABIM-PSQ), which consists of items de-
ities.17This survey was chosen because of its known
psychometric properties as well as the availability of prior
publications using this tool.18Internal consistency has been
shown to be high (Cronbach’s a ¼ .98).19Responses to the
ABIM-PSQ scale include 5 responses (1 ¼ poor, 2 ¼ fair, 3
¼ good, 4 ¼ very good, and 5 ¼ excellent). However, it is
uted and tend to cluster toward the high end of the scale.20
For both survey instruments, we chose to analyze
responses by comparing those who gave a score of 5
(strongly agree) to any other response (1–4). We adopted
the method of viewing any response other than the highest
possible as less than ideal. This approach has been
described elsewhere and eliminates the need to convert
ordinal responses to mean scores.18,20
ACADEMIC PEDIATRICSPHACES: Improved Delivery of Family-Centered Care 139
One of 2 investigators (Hanna Lemerman and Robert A.
Dudas) approached all patient-parent dyads within 24
hours of admission. Those in the control group who agreed
to participate were told that an investigator would return at
the time of discharge to administer a survey about satisfac-
tion with care. Those in the intervention group receivedthe
PHACES tool andwere also told thatan investigatorwould
return at discharge to administer a survey about satisfac-
tion. Parents were then asked to complete the survey in
their room in the presence of 1 of the 2 investigators,
who remained available to answer questions about the
Figure. Example of photo information sheet (Photographs of Academic Clinicians and Their Educational Status [PHACES] tool) used at Johns Hopkins
140 Dudas et al ACADEMIC PEDIATRICS
survey and then engage the parent in a brief semistructured
interview by using standardized questions. The investiga-
tors were instructed not to vary from the script and to
provide no prompting. All outcomes were collected from
the parent or guardian with primary medical decision-
making responsibilities for the patient. We excluded non-
English speaking families and language/hearing impaired
families, as we lacked the resources to interview them.
No incentives were offered to complete the survey, which
took 10 minutes to complete. Data were gathered from
December 2007 to May 2008.
Brief Semistructured Interview Administration
Provider Identification by Name or Photograph
who provided care to your child during this hospitaliza-
tion.’’ Next, parents were presented a sheet containing the
names and photographs of all the providers on the team.
The names and photos were scrambled and parents were
asked to identify (we use the term identify to indicate the
ability to match a name with a photograph) their providers
Parents in both groups were shown the PHACES tool at
the time of discharge. Parents in the PHACES group were
asked, ‘‘Did you find this photo intervention sheet help-
ful?’’ If so, ‘‘How was it helpful?’’ And ‘‘Do you have
any suggestions to improve it?’’ Parents in the control
group were asked, ‘‘Were there instances during this hospi-
talization when you would have benefitted from a sheet
containing the photographs of your doctors?’’ If so,
‘‘How would it have helped?’’ Both groups were asked,
‘‘Which provider did you find the most helpful during
this hospitalization?’’ The investigator then recorded the
Data analysis was performed with the use of Stata,
version 9.2 (StataCorp LP, College Station, Tex). Descrip-
tive statistics were used to summarize parents’ ability to
name and identify their providers. Frequencies and simple
means, where appropriate, were calculated. We used c2
and t tests to test differences in participant characteristics
between groups. Simple logistic regression was used to
to the ability to name or identify a provider and responses
to the survey questions. This is presented as odds ratios
with 95%confidence intervals. Multiple logistic regression
was performed controlling for the variables of patient age
(years), race, gender, and length of stay (days), and results
are presented as adjusted odds ratios with 95% confidence
intervals. Although priority was given to quantitative data,
our triangulation mixed methods design allowed us to
evaluate qualitative data to better explain results. Shorter
responses were recorded verbatim, and 2 readers coded
the responses and identified themes. Where necessary, we
used additional cycles of independent coding and reconcil-
iation to characterize responses, and disagreements about
themes were resolved by consensus.
A total of 112 parent-child dyads were approached at
admission. Three families did not speak English and
and 100 were ultimately interviewed at discharge. Wewere
unable to interview 8 parents at discharge because they left
before the interview could be conducted, and they were
evenly distributed between intervention (4 parents) and
control (4 parents) groups. Forty-nine families were as-
signed to the PHACES intervention and 51 families to
the control group.
The mean ages (years) of the children were not signifi-
cantly different (Table 1) between the PHACES group
(3.65) and the control group (3.94). In total, there were
34 infants (aged <1 year) and 9 teenagers (aged >12
years). The groups were evenly matched for gender and
length of stay, but the PHACES group had disproportion-
ately more white respondents than the control group (27
[55%] vs 17 [33%]; P ¼ .03).
Ability to Name and Identify Providers
Ninety-four percent of the parents inthe PHACES group
were able to identify at least 1 provider correctly compared
with 41% of the control group (Table 2). In our unadjusted
multiple linear regression model that includes only the
significant relationship with an R2of 0.46, indicating that
the intervention explains 46% of the variability in the total
number of providers named. After adjusting for race, age,
gender, and length of stay, this association remained posi-
tive and significant with a resultant adjusted R2of 0.50.
Table 1. Patient Demographics*
CharacteristicPHACES n ¼ 49
Control n ¼ 51
3.94Patient age, y
Length of stay on team, d
Length of stay in hospital, d
*Values are expressed as No. (%) except where noted.
†P ¼ .03; All other values are not statistically significant.
ACADEMIC PEDIATRICS PHACES: Improved Delivery of Family-Centered Care141
Mean scores were calculated for each of the ABIM-PSQ
items, and our control group scores are similar to those
previously reported for a group of pediatric residents.21
Multivariate analysis (controlling for patient age, race,
gender, and length of stay) revealed that the total scores
for the intervention group were higher than the control
group (48.3 vs 45.4; P ¼ .008) and specific items related
to being truthful, sharing decisions, and using plain
language were significantly higher (Table 3).
Understanding of Roles and Attitudes Toward
Table 4 summarizes the results of the 5 questions that
were asked. The intervention group reported significantly
higher understanding of the roles of the providers and
greater acceptance of student involvement.
All 100 parents provided a response to questions during
the interviews, with the following 3 themes emerging:
clarity of the roles of providers, the importance of names,
and the impact on parental attitudes toward trainees.
Parental Impressions of the PHACES Tool
Parents commented on the large number of providers
the members of the health care team.
‘‘I like to be very involved in [son’s] care. He is in the
hospital a lot and I realize he is very complicated. Every
time we come in it is new doctors and it is very hard for
me to know who is who. This sheet has helped me a lot
and I used it every day. One time I asked to speak to
someone and they sent in a student. He was very nice
but I needed someone with decision-making authority.
This made it much clearer to me about who I needed to
of all the people. I loved the explanation of their roles. I’ve
heard the terms many times but never knew what they did. I
have seen the child psychiatrist 4 times and I don’t know
her name. Maybe you could keep the sheet for the primary
A great number of parents reported that the tool helped
them remember the names of the providers and personalize
Table 2. Parent’s Ability to Name or Identify Providers*
PHACES† (n ¼ 49) No. (%)
Control (n ¼ 51) No. (%)
Unadjusted OR‡ (95% CI§)Adjusted ORk (95% CI)
Name: any provider
Identify: any provider
*The term identify is used to indicate the ability to match a name with a photograph.
†PHACES ¼ Photographs of Academic Clinicians and their Educational Status.
‡OR ¼ odds ratio.
§CI ¼ confidence interval.
kMultiple logistic regression adjusted for patient age (years), race (white or non-white), gender, and length of stay (days).
Table 3. Patient Satisfaction Questionnaire Results*
Item PHACES,† %Control, %OR‡ Unadjusted (95% CI§) OR Adjustedk (95% CI)
Using plain language
Communicating during physical examination
*Reported as percentage selecting highest response (5 vs 1–4).
†PHACES ¼ Photographs of Academic Clinicians and their Educational Status.
‡OR ¼ odds ratio.
§CI ¼ confidence interval.
kMultiple logistic regression adjusted for patient age (years), race (white or non-white), gender, and length of stay (days).
142Dudas et alACADEMIC PEDIATRICS
‘‘It would help to refresh our memories about who we
just saw’’ (family reported feeling embarrassed that they
could not match a single name to a face).
‘‘I would talk to them [the doctors] more directly. It
would personalize the experience.’’
‘‘I would like to ask for a specific person instead of
asking to see the ‘doctor.’ ’’
Parental Attitudes Toward Trainees
Many parents expressed surprise that trainees provided
care to their children and were unexpectedly impressed
with the care delivered by trainees.
‘‘It gave me respect for the student because I got the
sheet after we had talked to the student and got to know
each other in the emergency room. I would’ve not wanted
astudenttaking careofher.Becauseyougavemea paperit
makes me feel different about students. After I got the
paper I treated him the same even though I now knew he
was a student.’’
‘‘I wouldn’t have known that he (student) was a medical
student without the sheet.
‘‘The student was very good and I didn’t know he was
a student when we were admitted last night. It surprised
me when I got the sheet and saw he was a student. It
made me think differently about students.’’
Several anecdotes deserve mention, as it is difficult to
capture some important nuances within our study design.
For example, the PHACES sheet was sometimes used to
clear up a miscommunication. One parent was told by
one of the providers that a certain procedurewas scheduled
to occur, but other team members were not aware of this
plan and gave contradictory information to the parent.
The parent was able to point to a photograph to identify
who told her that information, and the providers were
able to contact the source to clarify. Also, our hospital
utilizes a night-team system in which some members of
the pediatric team are only present during the nighttime
hours. Frequently these providers are called during a crisis
situation to the aid of a child with a parent that they have
not previously met. Some parents recognized the night-
team membersfrom the PHACES tool and reported greater
comfort in their care. We did not explicitly differentiate the
day team from the night team on the PHACES tool in an
effort to present the health care team as a single entity.
Finally, during the course of this study, we were frequently
approached by nursing staff to obtain a PHACES tool.
They reported that they were interested in the tool for their
own personal use, as they admitted not knowing the names
of some of the interns, residents, and students. The medical
students, who rotate monthly, were all new faces to the
nurses, and many of the interns were participating in their
first ward month. Nurses expressed they would find it help-
ful to be able to differentiate between the new interns and
medical students, as this may present patient safety issues.
The photograph-based tool, PHACES, offers a simple
strategy to increase parents’ recognition of their children’s
providers, improves acceptance of trainee involvement,
and improves patient satisfaction. Our results suggest that
the large volume of providers and resultant anonymity at
a large tertiary care center may impede the ability to
develop the personal relationships put forward by the
core concepts of patient-centered care. This tool fosters
greater understanding of which providers have ‘‘decision-
making authority’’ and assists in appropriate information
sharing and collaboration. It is worth noting that all
providersare required towear photo ID badges at all times,
and our trainees are taught to introduce themselves during
the initial patient encounter. Nevertheless, our findings
suggest that name tags and simple introductions may be
insufficient. Families in the intervention group reported
Table 4. Survey Responses
n ¼ 49 No. (%)
n¼ 51 No. (%)
I was frequently confused about who I was talking to
and what their role was
I usually knew if the doctor caring for my child was
a medical student, intern, resident, or attending
I am comfortable having students and doctors-in-
training involved in the care of my child
Having students and doctors-in-training improved
the care my child received during this
Which provider did you find the most helpful during
Medical student identified as most helpful
Intern identified as most helpful
Resident identified as most helpful
Attending identified as most helpful
None or other§ identified as most helpful
Strongly disagree 10.1 (4.0–25.3) 9.7 (3.8–25.0)
Strongly agree 39 (81)15 (30) 10.4 (4.1–26.7) 12.1 (4.4–33.2)
Strongly agree 35 (73) 17 (34)5.4 (2.3–12.8)5.4 (2.2–13.4)
Strongly agree 25 (52)10 (20) 4.5 (1.8–10.9) 4.8 (1.8–12.4)
*PHACES ¼ Photographs of Academic Clinicians and their Educational Status.
†OR ¼ odds ratio.
‡CI ¼ confidence interval.
§Most respondents who chose ‘‘other’’ identified a nurse.
**Multiple logistic regression adjusted for patient age (years), race (white or non-white), gender, and length of stay (days).
ACADEMIC PEDIATRICS PHACES: Improved Delivery of Family-Centered Care143
that their providers were more truthful and displayed more
interest in their child, which may promote dignity and
respect. It is possible that an enhanced ability to name
providers leads to an increased accountability and alters
provider behavior. Families in the intervention group also
reported feeling more empowered in sharing decisions
and reported feeling more involved in their child’s care.
Our qualitative comments suggest that they were more
likely to report that they ‘‘know’’ their provider and felt
more comfortable talking to them directly.
Our results suggest that parents may not be completely
comfortable with allowing students and physician trainees
to care for their children with our current approach. This
may represent a lack of understanding of the structure and
supervision of the medical team as suggested by some of
the qualitative comments. Importantly, these responses
improved significantly for those receiving the PHACES
tool. It is noteworthy that nearly three quarters of the PHA-
CES group felt that having students and trainees led to
improved care. It may be that greater transparency of the
teaching mission leads to an environment where it is safe
to ask questions and may help build trust. Alternatively,
control parents might have felt that their academic health
care team was being disingenuous by not being more
Our PHACES tool led to a 4.8-fold increase in the odds
of identifying the student as the most helpful provider
compared with the control. This suggests that parents are
perhaps better able to value the medical student if they
are more fully informed about their role on the team. The
qualitative comments suggest that parents are often
surprised by the abilities of medical students, suggesting
that they have preconceived notions about students before
they begin to interact. It should be noted that the majority
and this is when medical students have the opportunity to
take a medical history and perform a physical examination
in conjunction with the senior resident and intern. It was
not until the following day, after they had interacted with
the student, that parents were approached and supplied
with the PHACES tool.
Our study has several limitations. Notably, our study is
most susceptible to selection treatment interaction, as our
population consists only of families of children admitted
to a general pediatric service at a single tertiary care insti-
tution in a single location. This is a threat to generaliz-
ability, as children and families admitted to other
hospitals may be quite different. Additionally, we noted
a higher proportion of white patients in our intervention
compared with the control group. However, our multiple
regression analysis demonstrated that the PHACES inter-
vention was the more powerful determinant of our primary
outcome. Also, our randomization method (first 2 weeks to
control, second 2 weeks of rotation to PHACES group)
dents may have functioned more effectivelytoward the end
of the month, resulting in parental enhanced satisfaction;
conversely they may have been more fatigued, resulting
in diminished satisfaction. We chose this method to ensure
comparisons within the same medical teams and because
we did not want some families to receive the tool, whereas
others did not within the same shared room. However, this
limitation would only have influenced the patient satisfac-
tion and not the recognition of providers. Lastly, the inter-
viewers were not blinded to group assignment. However,
a standardized questionnaire was used, and there was no
prompting on the part of the interviewer.
We undertookthis study priorto our hospital initiativeto
institute routine bedside rounding with parents. At the time
of this writing, we continue to use PHACES as an adjunct
to bedside rounding to promote family-centered care.
An information sheet containing the photographs of
health care providers along with an explanation of their
training improves recognition of the health care team
members, improves acceptance of trainee involvement,
and improves satisfaction with care delivered by physi-
cians in training. Further development of similar tools
should consider inclusion of nursing, social work, and
others that playa roleindirectpatientcare.Futureresearch
needs to be done to determine the feasibility of implemen-
impact of improved provider recognition on quality and
patient safety outcome indicators.
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