Physicians’ decision-making style and psychosocial outcomes among cancer survivors

Abstract

Objective

We evaluated pathways linking physicians’ decision-making style with cancer survivors’ health-related quality of life (HRQOL).

Methods

We analyzed survey data from 623 survivors diagnosed with leukemia, colorectal, or bladder cancer in Northern California, 2–5 years prior to the study. Of these, 395 reported making a medical decision in the past 12 months and were asked about their physician's decision-making style. We evaluated the association of physician style with proximal communication outcomes (trust and participation self-efficacy), intermediate cognitive outcomes (perceived control and uncertainty), and distal health outcomes (physical and mental HRQOL).

Results

Overall, 54% of survivors reported a sub-optimal decision-making style for their physician. With the exception of physical health, physician style was associated with all proximal, intermediate, and distal outcomes (p ≤ 0.01). We identified two significant pathways by which a participatory physician style may be associated with survivors’ mental health: (1) by increasing survivors’ participation self-efficacy and thereby enhancing their perceptions of personal control (p < 0.01); (2) by enhancing survivors’ level of trust and thereby reducing their perceptions of uncertainty (p < 0.05).

Conclusion

A participatory physician style may improve survivors’ mental health by a complex two-step mechanism of improving survivors’ proximal communication and intermediate cognitive outcomes.

Practice implications

Physicians who adopt a participatory decision-making style are likely to facilitate patient empowerment and enhance patients’ HRQOL.

Introduction

There are more than 10 million cancer survivors living in the U.S. alone [1]. These individuals, at various stages of their cancer journey, are likely to have faced several complex medical decisions related to cancer treatment, symptoms management, surveillance tests, and lifestyle changes, all with potential long-term implications for their health. In part due to the rise of the shared decision-making paradigm and increased consumerism in health care, patients are increasingly expressing a desire for greater involvement in making such decisions [2], [3], [4], [5], [6], [7].

Given the reciprocal nature of communication, greater patient involvement is more likely to take place when physicians adopt more participatory decision-making styles [8], [9]. However, while there has been extensive work assessing patient preferences for who should make the final decision [10], [11], [12], [13], [14], [15], [16], [17], [18], little attention has been paid to examining patient perceptions of their physician's efforts at involving them in the decision-making process. The few studies that have been conducted in this area have reported that a participatory physician style is associated with greater patient satisfaction [19], better patient self-management [20], increased likelihood of patients discussing use of complementary and alternative medicines [21], and lower rates of hospitalization and better health-related quality of life (HRQOL) [22]. These studies however have rarely focused on the oncology setting.

To fully understand the potential impact of physician style, it is important to explore how a participatory decision-making style might lead to improvements in patient health outcomes. In general, studies on patient–clinician communication have not systematically examined the relationship between communication and patient health outcomes [23]. In this study, we examined cancer survivors’ perceptions of their physicians’ decision-making style and explored the association of physician style with survivors’ HRQOL. Based on a conceptual framework developed by Epstein and Street [24], we simultaneously evaluated several pathways by which physician style might be linked with survivors’ HRQOL. Epstein and Street [24] suggest that while patient–clinician communication may in some instances exert a direct influence on patient health outcomes, in most situations, “a more complex series of mechanisms links communication to health outcomes.” They propose a two-step mediation process where in communication is likely to result in improved distal health outcomes as a result of its association with more immediate/proximal communication outcomes as well as intermediate outcomes.

Fig. 1 presents the conceptual model that we empirically tested in this study. Physicians’ decision-making style was the main independent variable. Trust in the physician and survivors’ self-efficacy for participating in decision-making were used as indicators of proximal communication outcomes and survivors’ perceptions of control and uncertainty were our intermediate cognitive outcomes. As shown in the figure, we examined both the direct association between physician style and survivors’ HRQOL (see path A in Fig. 1) as well as several mediated pathways that linked physician style with HRQOL (e.g., paths B-F-L; E-M; etc., in Fig. 1).

We also explored whether the association between physicians’ participatory decision-making style and survivor outcomes may vary with patient preferences for participation in decision-making. The expectancy-value framework proposed by Linder-Pelz [25] as well as a recent study by Xu [26] suggests that relationships between physician behaviors and patient outcomes may not be consistent across all patients and may vary with patient expectations and preferences. We speculated that the salience of a more participatory physician style may be greater for survivors who prefer more active roles in decision-making [9]. Specifically, we explored whether the association between a participatory physician style and survivor outcomes was stronger for those cancer survivors who either wanted to share decision-making control with their physician or who wanted primary responsibility for decision-making, compared to survivors who preferred to delegate decision-making to their physician.

To summarize, our study had the following goals:

• Assess cancer survivors’ reports of the extent to which their follow-up care physician engages in participatory decision-making and identify correlates of physicians’ decision-making style.

• Evaluate the association of physicians’ decision-making style with multiple outcomes among cancer survivors:

  • self-efficacy for participating in decision-making, trust in physician (proximal);

  • perceptions of personal control and uncertainty (intermediate);

  • physical and mental components of HRQOL (distal).

• Examine the mediating effect of proximal and intermediate outcomes on the relationship between physician style and survivors’ distal health outcomes.

• Explore whether the association between physician style and survivor outcomes varies with survivors’ participation preferences.