Interacting with cancer patients: the significance of physicians’ communication behavior
Introduction
“You have cancer,” these words almost always cause devastation in the lives of their recipients. Feelings of uncertainty about and loss of control over one's life are common reactions (McWilliam, Brown, & Stewart, 2000; Molleman, Krabbendam, & Annyas, 1984). Over time, cancer patients face several situations that further disrupt their quality of life (QOL). Examples include: making sense of complex medical information; making difficult treatment decisions; dealing with treatment side effects; living with the fear of recurrence; and for some facing the possibility of impending death. In addition to prolonging survival, a key goal of cancer care thus, is to minimize the impact of the disease and treatment on patients’ functioning and well-being (Arora et al., 2001; Gotay, & Muraoka, 1998).
At every stage of their journey, patients look towards their healthcare providers to meet several of their information and support needs, which if met, are likely to reduce the disruption in their QOL (Rose, 1990; Schain, 1990). The patient–physician interaction, a central component of the care delivery process, thus assumes an even greater significance in the cancer setting. As Siminoff, Ravdin, Colabianchi, and Sauders-Sturm (2000) observe, while the communication process between physicians and cancer patients shares most of the general features of standard patient–physician interactions, the stigma and fear associated with a cancer diagnosis, the complexity of medical information, and uncertainty regarding the course of the disease and treatment benefits adds a greater emotional dimension to the interaction. The manner in which physicians communicate with their cancer patients can thus have a significant impact on patients’ QOL. Indeed, a growing body of literature has shown a significant association between physicians’ communication behavior and patient health outcomes. These studies are discussed later in this paper.
Given the significance of the cancer patient–physician interaction, it is encouraging to see that research in this area is attracting the attention of cancer researchers (e.g., Blanchard, Labrecque, Ruckdeschel, & Blanchard, 1990; Butow, Dunn, Tattersall, & Jones, 1995; Ford, Fallowfield, & Lewis, 1996; Maguire, Faulkner, Booth, Elliott, & Hillier, 1996; Ong et al., 1999). In an attempt to encourage and aid additional research on patient–physician communication in cancer, this paper presents a critical evaluation of the literature on physicians’ communication behavior. Following detailed description of key elements of physician behavior, the paper highlights two important aspects of research in this area: (1) Methods of assessment of physicians’ communication behavior and (2) Relationship of physicians’ communication behavior with cancer patient health outcomes. Finally, the paper identifies limitations of existing studies and presents recommendations for future research. Given that significant literature in this area exists in primary care that may also have relevance in a cancer setting, findings from studies conducted in non-cancer settings are discussed, as appropriate. Conversely, while the cancer context is emphasized throughout the paper, the discussion on limitations and future directions is applicable to other illness settings as well.
I acknowledge that physicians’ communication behavior does not get generated in isolation and is likely to be influenced by a number of factors including patients’ communication patterns. Indeed, several studies have focused on determinants of physician behavior including patient factors and have also specifically examined patients’ communication behavior (e.g., Hall, Roter, Milburn, & Daltroy, 1996; Ishikawa et al., 2002; Street, 1991); however, evaluation of such studies was considered to be beyond the scope of this review. Similarly, studies focusing on interventions for improving patient–physician communication were also considered to be beyond the scope of this review; interested readers may refer to Anderson and Sharpe (1991) for a review of such studies. Finally, I also acknowledge that over the course of their cancer journey, besides physicians, patients interact with several other healthcare providers (e.g., nurses, social workers, nutritionists, pharmacists) who are as likely to impact patients’ care experience as well as their health outcomes. While a majority of studies on patient–provider communication have focused on the patient–physician dyad, research on the interaction between non-physicians and patients is relatively limited and needs to be encouraged.
Section snippets
Elements of physicians’ communication behavior
The paternalistic, medical model that once dominated patient–physician interactions is increasingly giving way to a shared decision-making or relationship-centered model of communication, especially for interactions between physicians and patients with chronic illnesses such as cancer (Charles, Gafni, & Whelan, 1999; Emanuel & Emanuel, 1992; Quill & Brody, 1996). Consistent with this model, three important goals have been identified for physicians to accomplish during their interactions with
Assessment of physician behavior
Two different approaches have been utilized for measuring physicians’ communication behavior. One approach records (either by standardized observation, audiotape, or videotape) actual medical encounters and analyzes them to code behavior using one of several interaction analysis systems (IAS) also called observational instruments (e.g., Bertakis, Callahan, Helms, Azari, & Robbins, 1993; Blanchard et al., 1983; Cegala, 1997; Maguire et al., 1996; Ong, Visser, Kruyver, Bensing, & van den
Physician behavior and patient health outcomes
Although the relationship between physicians’ communication behavior and patient outcomes has been actively researched for 30 years, studies have predominantly focused on patient satisfaction and adherence (see Hall, Roter, & Katz, 1988; Inui, & Carter, 1985). With the exception of a small (but growing) body of work, the relationship between physician behavior and patient health outcomes such as QOL has been typically inferred than evaluated directly.
Communication research focusing on cancer
Research limitations and future directions
The following discussion highlights potential limitations of existing research and presents recommendations for future studies emphasizing three key areas: conceptual refinement, measurement, and study design.
Conclusion
National surveys conducted in the US report that Americans rate communication ability to be one of the most important skills for physicians to have (DiMatteo, 1998). At the same time, surveys also identify a number of issues related to patient–physician communication as key quality concerns of the American public (Davis et al., 2002). It has been suggested that patient–physician communication is often poor as physicians themselves may not know what aspects of their behavior are responsible for
Acknowledgements
I gratefully acknowledge the detailed review and guidance provided by Gary Kreps, Ph.D., and Joseph Lipscomb, Ph.D. from the Division of Cancer Control and Population Sciences, National Cancer Institute, USA; Judith Hall, Ph.D. from the Northeastern University, USA; and Betty Chewning, Ph.D. from the University of Wisconsin-Madison, USA. Their comments along with the wonderful feedback provided by the editor and three anonymous reviewers have greatly improved this paper.
References (129)
- et al.
Communication between older patients and their physicians
Clinics in Geriatric Medicine
(2000) - et al.
Improving patient and provider communicationA synthesis and review of communication interventions
Patient Education and Counseling
(1991) Generalists and specialists caring for patients with heart diseaseUnited we stand, divided we fall
American Journal of Medicine
(2000)- et al.
Patient-health care provider communication during chemotherapy treatmentThe perspectives of women with breast cancer
Patient Education and Counseling
(2001) - et al.
Information and decision-making preferences of hospitalized adult cancer patients
Social Science, & Medicine
(1988) - et al.
The dynamics of changeCancer patients’ preferences for information, involvement and support
Annals of Oncology
(1997) - et al.
Decision-making in the physician-patient encounterRevisiting the shared treatment decision-making model
Social Science & Medicine
(1999) - et al.
Taking responsibility for cancer treatment
Social Science & Medicine
(2001) - et al.
Decision making during serious illnessWhat role do patients really want to play?
Journal of Clinical Epidemiology
(1992) - et al.
Effective communication skills are the key to good cancer care
European Journal of Cancer
(1999)