Home Print this page Email this page
Users Online: 87
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 2  |  Page : 66-72

Breaking bad news among cancer physicians


1 Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
2 Department of Pediatrics, Dalla Lana School of Public Health, Toronto, Ontario, Canada

Date of Web Publication24-Apr-2017

Correspondence Address:
Sami Ayed Alshammary
King Fahad Medical City, Riyadh
Saudi Arabia
Login to access the Email id


DOI: 10.4103/jhs.JHS_10_17

Rights and Permissions
  Abstract 

Background: Breaking bad news to patients with cancer diagnosis is not an easy task for physicians. The diagnosis must be explicitly stated and understood, and prognosis must be well-discussed in the most gentle and comfortable manner. It is important that the disclosure is performed in a way that patients will not lose all hope and get very depressed, leading them to undergo an abrupt change of their outlook in life.
Objective: The aim of this study was to explore the physicians' perceptions and perspectives of breaking bad news to cancer patients.
Methods: A cross-sectional survey of all comprehensive cancer centre physicians currently working in a university teaching hospital in the Middle East was conducted from August to September 2016.
Results: Sixty-eight percent responded to the survey. Eighty-four percent were comfortable with breaking bad news, and 70% had training in breaking bad news. Eighty-six percent of responders stated that patients should be told about their cancer. Almost 30% of the respondents stated that they would still disclose the diagnosis to patients even if it would be against the preference of the relatives. Nearly 61% said that they would only tell the details to the patients if asked while 67% of them disagreed that patients should be told about the diagnoses only if the relatives consent. About 51% of physicians wanted to discuss the bad news with the family members and patient together, whereas 24% stated that the patient alone should be involved in the discussion.
Conclusion: Physicians face a dilemma when families do not wish the patient to know the cancer diagnosis and this highlights the necessity of taking into consideration the social circumstances in healthcare. When taking these into considerations, curriculum in the medical school must, therefore, be updated and must integrate the acquisition of skills in breaking bad news early in training.

Keywords: Attitude, breaking bad news, comprehensive cancer centre, perception, psychosocial distress, survey


How to cite this article:
Alshammary SA, Hamdan AB, Tamani JC, Alshuhil A, Ratnapalan S, Alharbi M. Breaking bad news among cancer physicians. J Health Spec 2017;5:66-72

How to cite this URL:
Alshammary SA, Hamdan AB, Tamani JC, Alshuhil A, Ratnapalan S, Alharbi M. Breaking bad news among cancer physicians. J Health Spec [serial online] 2017 [cited 2017 Jul 23];5:66-72. Available from: http://www.thejhs.org/text.asp?2017/5/2/66/205070


  Introduction Top


Bad news is defined as 'Any news that adversely and severely affects an individual's view of his or her future.'[1] Providing serious case disclosure to anyone needs expertise, experience and compassion.

Breaking bad news is never an easy or comfortable task for physicians. However, disclosure of bad news is inevitable in medical institutions and is a vital part of the duties of doctors and other healthcare professionals.

Breaking bad news needs skills and strategies where a physician should be able to disclose bad news to patient and family while addressing their concerns accordingly. However, subtle differences in the content manner or behaviour during disclosure change the interpretation of the patient or family and affect their understanding and attitudes of dealing with the news. It has also been shown that a patients' outlook on their disease depends much on the delivery of the bad news.[2]

Considering such matters makes most people feel anxious and afraid to do the task. On the contrary, there are professionals, specifically doctors and other healthcare providers, who have the distinct skills and confidence of breaking bad news with ease and comfort without provoking anyone. There are also some who may not be that honed of doing the task, but they are committing themselves with all willingness to learn the techniques needed.

Cancer is a serious illness and oncologists, usually, break the bad news to cancer patients and their families. Most cancer patients desire that their oncology doctors extend their compassion and understanding in order to help them understand their situation more without the great fear of the worst case scenarios. Honesty, compassion, care and optimism are considered some of the attributes that oncologists must possess.[3]

Cancer patients want to be well-informed and updated about the progress of their case and prefer to have disclosures with their doctor in a private setting.[4] However, there are times that the cancer patients request some of their relatives to be with them during discussions with their oncologists. It is imperative to inform these patients personally the details of their condition in the manner that they are most comfortable. Their convenience and comfort in disclosing bad news are of the utmost priority.[4],[5]

Cancer patients do not only aspire to find very competent and well-versed physicians in order to facilitate the treatment of their condition; they are also seeking to find a doctor who is compassionate enough to communicate with them in the most efficient and comprehensive manner.[4],[5] Thus, there must be guidelines and a system to follow when breaking bad news.[6] These should highly consider the patients' welfare and comfort as well as their level of understanding.

Breaking bad news is a serious and very challenging task for physicians and may become very stressful for all parties concerned, including doctors and patients.[7] However, a structured procedure for disclosure with proper practice have been associated with positive and meaningful outcome.[8]

Anecdotally, some cancer patients in Saudi Arabia do not know their diagnosis. At present, there is less information and education regarding disclosure patterns or disclosure training offered to oncologists and other physicians involved in breaking bad news in the Middle East. The purpose of this research is to identify the comprehensive cancer centre (CCC) physicians' perspectives and practices about breaking bad news to cancer patients in Saudi Arabia.

Related literature

There have been accounts in the history of medicine, during the earlier era, that Hippocrates recommended hiding any information that would cause despair to patients and may worsen situations. This scenario is in concurrence with the first ethical code in medicine (1847) that states that doctors should not disclose bad news to the patients as this has a greater possibility of shortening their life span. Furthermore, in numerous Asian cultures, and in the Middle East, it is perceived as unnecessary to inform the patients about a cancer diagnosis directly; they believe there is a better way of doing it. Consequently, it has become a collected worldwide approach to keep the patient unaware of their condition in order to prevent any harm. However, there have been no validated psychological accounts of the notion that receiving unfavourable information is consistently harmful.

There have also been several studies in various communities which show that a high number of patients prefer to know directly if they have cancer, get a realistic estimate of survival as well as the available therapies that they could avail and their corresponding benefits and adverse effects. Receiving accurate information regarding their case is what most of the patients prefer in order for them to generate specific decisions that may have a great impact on their quality of life and plans.[9] In a survey given as part of the study conducted by MD Anderson, it was revealed that physicians' expertise, discussion of options, clarity and honesty in providing the information were the attributes most preferred by the patients on disclosing bad news. The survey revealed a lesser percentage with regard to physicians' communication skills, especially in giving comforting words. Patients also prefer to discuss bad news with their family doctors rather than the oncologists. Therefore, oncologists should invite the presence of the family physicians during the discussion of bad news to patients.

In a research conducted regarding breaking bad news in relevance to caregivers' perspective, it was revealed that an effective strategy was to first relay encouraging words to patients before exposing the bad news which can contribute to feelings of hopelessness. Thus, caregivers must bear in full consideration how to promote a sense of identification to patients before striking hopelessness. However, most of the caregivers were not qualified on the concern related to breaking bad news. This finding was generated after a 35-item questionnaire was distributed to doctors, nurses and patients. The data showed that caregivers and patients both gave similar importance to the presence of family members during the 'bad news' interview. Moreover, patients gave more attention than caregivers during disclosure of bad news and diagnosis, their possible treatment, and its adverse effects. There was also a common agreement on the issue concerning the fact that the patient, and not the caregiver, should be the one to select the amount of information to be delivered.[10]

One of the most challenging instances in the clinical practice are when relatives interfere and demand not to let the patient know the current condition. In a study conducted, 66.7% of its respondents preferred not to let the patient know about their real health status in order to prevent intense negative emotions such as downfall and heartbrokenness.[11]

In Italy, there was a survey about disclosure practices and cultural narratives. The results revealed that only 44% of the responding physicians preferred to inform the patients of the cancer diagnosis and their respective prognosis if the patients themselves wanted to; even if the family members opposed.[12] In another physician survey, it was revealed that the majority of its responders felt the need of having guidelines for breaking bad news to patients. It showed that in practice, only 25% of them gave diagnosis disclosure to their patients. Moreover, 44.8% believe that patients with cancer should always be informed of their condition, whereas 46.6% believed that patients should be told the truth but should be limited to some cases only.[13] Meanwhile, in this study, approximately 29.4% of the respondents felt that it would be better if they would undergo training in doing disclosures to acquire the necessary skills needed.

A six-step protocol (termed SPIKES) aims to give an effective method of bad news disclosure to cancer patients. SPIKES stands for: Setting, perception, invitation, knowledge, emotion and strategy (summary). On finalising the subject for disclosure, there should be constant communication between all the people concerned (setting up the interview). The disclosing physician should understand that the main focus of the disclosure is the patient. There must be an assessment of the patient's perception, his/her invitation to the amount of details desired, giving knowledge and information to the patient while addressing the patient's emotion with emphatic responses and devising a strategy for future management in collaboration with the patient. Finally, closing the disclosure by summarising the discussion to avoid misinformation.[1]

During the annual meeting of the American Society of Clinical Oncology on 1998, an informal survey was conducted using select delegates. The results showed that 60% of the total respondents disclosed bad news to cancer patients 5-20 times in a month while 14% did disclosure for 20 times only. On the other hand, 55% believed that the most difficult task in breaking bad news was maintaining honestly without taking away hope, whereas 25% considered that the most difficult part of the process was dealing with the emotional reactions of the patients. There were only 10% who confirmed that they had undergone training in bad news disclosure to cancer patients while around half of them have rated their communication skills as poor or fair.

Breaking bad news is commonly perceived to affect patients' self-control concerning emotions, confidence, professionalism and trust. This idea was generated after an interview was conducted with some Swedish physicians who have been in the medical field for >21 years. Nearly 30% of them confirmed that they had not received any formal training in doing disclosures. There were 87% who believed that breaking bad news is indeed a difficult task. Despite this condition, 90% of them affirmed that they had performed disclosures to patients for >5 times, during the year prior to the period the interview was conducted.[14]

Nowadays, majority of the medical schools in the Western areas are integrating communication skills training in their undergraduate and postgraduate curriculum as part of their academic activities in order to mold their students as they become doctors to also be skilled communicators as well. In contrary to the old belief that communication skills would be enhanced as they practice their profession in the field, tutorials, lectures, textbooks and other aides (CD-ROMS, websites) are some of the established didactic means of delivering principles of communications skills. These may be enhanced through their experiences in the medical institutions. Since communication plays as vital skills, in each physician, workshops related to this are always included in most annual meetings of numerous cancer societies.[15]


  Methods Top


Study design

A quantitative survey was performed in CCC at King Fahad Medical City (KFMC) from June to August 2016. At present, CCC includes 94 in-patient beds and approximately 1,500 out-patient visits per month.

A cross-sectional study was carried out to physicians (n = 75) who are currently working in a university teaching hospital in the Middle East. The study population comprised of all (oncology, haematology, paediatric, radiation and palliative) physicians working in CCC. Those who were not directly in contact with patients, for instance, forensic and doctors' full time working in hospital administration were excluded from the study.

Before beginning the study, a self-administered questionnaire was distributed with the aim of the study explained to the participants; of course, a nonymity was maintained. The Ethical Committee of the Institutional Research Centre granted their approval for the study protocol.

The questionnaire was composed of two sections [Appendix 1 [Additional file 1]]. The first section obtained demographic details, including age, gender, clinical position, speciality, qualifications and year of graduation, whereas the second part tried to elicit the respondents' opinions and practices about breaking bad news which included 17 items.

Statistical analysis procedure

All categorical variables: age group, speciality, job title, etc., were presented as numbers and percentages. Chi-square/Fisher's exact test was used according to whether the cell expected frequency was smaller than 5 and furthermore to determine the significant relationship between trained professionals breaking bad news and survey responses as well as other categorical variables. The value of P< 0.05 was considered statistically significant. All data were entered and analysed through statistical package IBM Corp. 1989, 2013. IBM SPSS Statistics, Version 22.0.


  Results Top


Overall, 68% (n = 51/75) of physicians responded to the survey. As shown in [Table 1], age of the majority of the doctors working in the cancer center was between 36 and 45 years old. There was only one senior consultant that belonged to 56 years old and beyond, and only 9 (17.6%) of these respondents were female physicians, while 42 (82.4%) were males.
Table 1: Demographic data

Click here to view


High response was received from the Haematology and Oncology specialties 31% (n = 16) of respondents were from the Oncology Department, and 27.5% (n = 14) were haematology respondents. Majority of the respondents were assistant consultants 41% (n = 21) [Table 1].

[Table 2] illustrates the statistical interpretation of the responses of physicians related to breaking bad news. Nearly 84% (n = 43) of the physicians stated that they were comfortable enough while breaking bad news. This is not a surprise since 70.6% of them confirmed that they received training. More than half of the responders (51%) stated that the presence of both the patient and his/her family was necessary for breaking bad news.
Table 2: Questions and responses pertaining to breaking bad news to cancer patients responses (total=51)

Click here to view


Eighty-six percent of responders said that patients should be told about their cancer. Furthermore, 15 (29.4%) of the respondents stated that they would still disclose the diagnosis to patients even if it would be against the preference of the patient's relatives of not saying so. In contrary, 31 (60.8%) of them preferred only to tell the details to the patients if they are asked to. Meanwhile, 34 (66.7%) chose to disagree with the point that patients should be told about the diagnoses only with the relatives's consent.

Ninety-four percent stated that information regarding the patient's case could be given over multiple visits. In this manner, there will be a more comprehensive and more efficient acceptance to the information conveyed. More than half of them do not agree that breaking bad news will take away the patient's hope and lessens his/her survival.

With regard to the impact of breaking bad news, about 30% of the respondents who felt that they would benefit further if they would undergo training about managing disclosures.

Thirty-nine (76.5%) of respondents believed that patients were keen on knowing about their disease. Only 21 (41.2%) of the respondents agreed that they felt depressed after disclosing bad news to patients. A similar number of 21 (41.2%) did not report having any particular feeling on doing such. Interestingly, 43 (84.3%) considered giving false hope to patients was more stressful than disclosure of diagnosis.

[Table 3] shows the relationship between respondents who were trained and not trained for breaking bad news. 47.2% (n = 17) of the respondents who trained for breaking bad news belonged to the age group of 35–45 years, 30.6% (n = 11) belonged to the age group of 25–35 years, while those who were not trained belonged to the age groups between 25 and 45 years old.
Table 3: Relationship between respondents who were and were not trained for breaking bad news

Click here to view


Majority of the respondents were male, out of which 86.1% (n = 31) were trained, while 73.3% (n = 11) were not. Among the physicians who underwent breaking bad news training, 36.1% (n = 13) came from the Department of Haematology, 25% (n = 9) came from Palliative, 22.2% (n = 8) came from Oncology, 13.9% (n = 5) from Paediatric and 2.8% (n = 1) was from Radiation Oncology. From the respondents list who were trained, 36.1% (n = 13) were consultants, 30.6% (n = 11) were Assistant Consultants, 19.4% (n = 7) were Fellows, 11.1% (n = 4) were Residents and 2.8% (n = 1) was an Associate.


  Discussion Top


In this study's context, breaking bad news is defined as any information given to patients, which could adversely and seriously affect their view and perspective of their future. Disclosures are indeed very challenging to physicians dealing with cancer patients as these often cause stress. Breaking bad news has been a dilemma in all generations of people in the medical field.

The leap with the rates of the comfort among the patients during breaking bad news is quite higher than the rest of the previous studies. This could be due to the fact that KFMC is a tertiary medical hospital which has exposed the participants in this study to the most relevant factors of patients such as advanced routinely encountered instances in daily clinical practice. This can also be reflected by the 41.2% of the participants who felt depression in an unspecified level after they have been into bad news disclosures. Politely explaining the diagnosis and prognosis to a sick patient is never easy which may indulge them to shift tempers and feel dissatisfaction in the end.

In the previous eras, the doctors were the ones who decided the fate of their sick patients. It is in contrary to the majority of the concerned patients who are more eager to know about their condition and their health status. Furthermore, they even want to get involved in the decision-making, wherein 76.5% of the respondents confirmed that their patients were eager to know about their illness. Moreover, this also concurs with the international guidelines that patients should be aware of their disease. However, the manner of disclosure must not be at one interview setting. The information about a patient's disease must be informed in a gradual manner to prevent patient's emotional downfall and promote more comprehension.

It is common to the populace's perception that cancer, as a diagnosis, is directly relevant to death.[16],[17] In this context, the responsibility lies on the treating physicians. He/She must be able to assess the patients' capability to accept information in order for them to act accordingly or else, he/she will just be striking them unnecessarily or re-assure them falsely. Influenced by modern culture, it has been an accepted practice nowadays to disclose details to patients with cancer which have been evident in most western areas.

The effective strategy is to first relay encouraging words to patients before exposing the bad news which contributes to feelings of hopelessness.[18] In this study, majority of the physicians believed that sick patients gave importance to the presence of family members during the 'bad news' interview. In previous studies, it was the patient who determines the amount of information needed to disclose.[19],[20] Furthermore, the disclosure of patients' clinical information should best rely on the patients' preference.[21],[22] He/She has the right not to let his/her relatives know the details of his/her condition, and this is a vital ethical principle that all doctors must bear in mind.[10] However, in this communication, the doctor must be at his/her modest condition for him/her to appear as very approachable and not provoking at all. Assertively, he/she needs to explain to the patient's relatives in the most comprehensive manner the ethical purpose of keeping information from the patient as it may lead to some effects such as confusion and loss of confidence. He/She must also give an assurance that he/she would be able to set the discussion with the patient with high sensitivity while limiting the information as to what the patient prefers to share.[23],[24]

One of the previous studies showed that 66.7% of its respondents preferred not to let the patient know their very real health condition to prevent intense negative emotions such as downfall and heartbrokenness.[11] Meanwhile, 51% among all of the respondents in the current study concur with the idea that the undesirable breaking of bad news regarding a patient's diagnosis was related to the limitation of life expectancy with unfavourable diagnosis disclosure. In comparison with our study, the result showed that 39 (76.5%) versus 44 (86.3%) among the respondents preferred to tell all the information, whereas 31 (60.8%) indicated that they would not volunteer themselves to relay the information; however, they would do such as the need requires.

KFMC is a busy hospital setting and it is indeed tough to implement the idea of disclosing bad news to patients even if the family members do not agree that the physician would tell it all in full details. There are times that doctors would cater others' suggestions on how to disclose bad news in order to make quicker decisions and maximise the time for other aligned activities.


  Conclusion Top


Our physicians working in the cancer centre believe that patients are keen on knowing their medical conditions, their diagnosis as well as their prognosis. Although most doctors working in the cancer centre felt that they are just comfortable in breaking the bad news to patients, there are statements that show that physicians felt depressed after disclosure and need on-going training and support. The social context in the Middle East where there are an extended family set-up and family support during illness, the relatives' attitudes and beliefs versus patients' wishes remain a tricky area.

It is, therefore, a vital need to incorporate breaking of bad news in medical school curriculum focusing more on legal issues in cancer patients. In connection to the various beliefs and practices observed, it is recommended that breaking bad news education should be part of the residency medicine curriculum, especially in the oncology, haematology, paediatric oncology and radiation oncology fields. Availability of guidelines from some professional organisations (i.e., Saudi Association of Palliative Care or Saudi Oncologists society) in this would go a long way in resolving some of these issues to a large extent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: Application to the patient with cancer. Oncologist 2000;5:302-11.  Back to cited text no. 1
    
2.
Fujimori M, Akechi T, Morita T, Inagaki M, Akizuki N, Sakano Y, et al. Preferences of cancer patients regarding the disclosure of bad news. Psychooncology 2007;16:573-81.  Back to cited text no. 2
    
3.
Bramley L, Matiti M. How does it really feel to be in my shoes? Patients' experiences of compassion within nursing care and their perceptions of developing compassionate nurses. J Clin Nurs 2014;23:2790-9.  Back to cited text no. 3
    
4.
Ptacek JT, Ptacek JJ. Patients' perceptions of receiving bad news about cancer. J Clin Oncol 2001;19:4160-4.  Back to cited text no. 4
    
5.
Parker PA, Baile WF, de Moor C, Lenzi R, Kudelka AP, Cohen L. Breaking bad news about cancer: Patients' preferences for communication. J Clin Oncol 2001;19:2049-56.  Back to cited text no. 5
    
6.
Narayanan V, Bista B, Koshy C. 'BREAKS' protocol for breaking bad news. Indian J Palliat Care 2010;16:61-5.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ 2002;325:697-700.  Back to cited text no. 7
    
8.
Ha JF, Longnecker N. Doctor-patient communication: A review. Ochsner J 2010;10:38-43.  Back to cited text no. 8
    
9.
Levit L, Balogh E, Nass S, Ganz P. In: Board on Health Care Services, Institute of Medicine, editors. Committee on Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population. Washington, (DC): National Academies Press (US); 2013.  Back to cited text no. 9
    
10.
Rassin M, Levy O, Schwartz T, Silner D. Caregivers' role in breaking bad news: Patients, doctors, and nurses' points of view. Cancer Nurs 2006;29:302-8.  Back to cited text no. 10
    
11.
Searight HR, Gafford J. Cultural diversity at the end of life: Issues and guidelines for family physicians. Am Fam Physician 2005;71:515-22.  Back to cited text no. 11
    
12.
Gordon DR, Paci E. Disclosure practices and cultural narratives: Understanding concealment and silence around cancer in Tuscany, Italy. Soc Sci Med 1997;44:1433-52.  Back to cited text no. 12
    
13.
Grassi L, Giraldi T, Messina EG, Magnani K, Valle E, Cartei G. Physicians' attitudes to and problems with truth-telling to cancer patients. Support Care Cancer 2000;8:40-5.  Back to cited text no. 13
    
14.
Friedrichsen M, Milberg A. Concerns about losing control when breaking bad news to terminally ill patients with cancer: Physicians' perspective. J Palliat Med 2006;9:673-82.  Back to cited text no. 14
    
15.
Arnold SJ, Koczwara B. Breaking bad news: Learning through experience. J Clin Oncol 2006;24:5098-100.  Back to cited text no. 15
    
16.
Keusch GT, Wilentz J, Kleinman A. Stigma and global health: Developing a research agenda. Lancet 2006;367:525-7.  Back to cited text no. 16
    
17.
Ling BG, Phelan JC. Stigma and its public health implications. Lancet 2006;367:528-9.  Back to cited text no. 17
    
18.
Halpern J. What is clinical empathy? J Gen Intern Med 2003;18:670-4.  Back to cited text no. 18
    
19.
Butow PN, Maclean M, Dunn SM, Tattersall MH, Boyer MJ. The dynamics of change: Cancer patients' preferences for information, involvement and support. Ann Oncol 1997;8:857-63.  Back to cited text no. 19
    
20.
Back AL, Arnold RM, Baile WF, Tulsky JA, Fryer-Edwards K. Approaching difficult communication tasks in oncology. CA Cancer J Clin 2005;55:164-77.  Back to cited text no. 20
    
21.
Cavanna L, Di Nunzio C, Seghini P, Anselmi E, Biasini C, Artioli F, et al. Elderly cancer patients' preferences regarding the disclosure of cancer diagnosis. Experience of a single institution in Italy. Tumori 2009;95:63-7.  Back to cited text no. 21
    
22.
Marwit SJ, Datson SL. Disclosure preferences about terminal illness: An examination of decision-related factors. Death Stud 2002;26:1-20.  Back to cited text no. 22
    
23.
Farhat F, Othman A, El Baba G, Kattan J. Revealing a cancer diagnosis to patients: Attitudes of patients, families, friends, nurses, and physicians in Lebanon-results of a cross-sectional study. Curr Oncol 2015;22:e264-72.  Back to cited text no. 23
    
24.
Baile WF. Communication competency in oncology: Legal, ethical and humanistic imperatives. Psychooncology 2006;15 Suppl 2:S6.  Back to cited text no. 24
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Methods
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed731    
    Printed10    
    Emailed0    
    PDF Downloaded86    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]