Information exchange in oncology outpatient clinics: source, valence and uncertainty

Content and Duration of Doctor-Patient Communication in Outpatient Oncology Follow-Up Consultations in China

Purpose This study aimed to analyze the content of counseling between cancer patients and physicians during outpatient follow-up, assess the duration of different communication content, and explore the influencing factors. Patients and methods We observed consecutive cancer patients without a first diagnosis of malignancy who presented to the oncology outpatient clinic of a public hospital from October through December 2023. A structured observation form was used to record the content and duration of doctor-patient communication. All variables were electronically recorded and stored on a data management platform. Multiple linear regression was used to examine the determinants of consultation duration. Results Our study included 620 cancer patients, of whom 281 individuals had distant metastasis. The average consultation duration for 620 cancer patients was 4.85 minutes (standard deviation of 3.09 minutes). The category of doctor-patient communication was routine outpatient follow-up, involving 182 patients, with an average consultation duration of 3.81 minutes (standard deviation of 2.24 minutes). The main communication content for 51 patients was about the admission procedures, with an average consultation duration of 3.00 minutes (standard deviation of 1.92 minutes). For 67 patients, the primary communication involved the prescription of anti-tumor medications, with an average consultation duration of 3.70 minutes (standard deviation of 2.30 minutes). Symptom control discussions were the main communication content with 107 patients, with an average consultation duration of 5.91 minutes (standard deviation of 3.44 minutes). The main communication content of 24 patients involved medical insurance reimbursement, with an average duration of 7.75 minutes (standard deviation of 4.63 minutes). Consultations accompanied by caregivers and the presence of metastatic tumors were positively associated with consultation duration, whereas female patients with genital malignancies were negatively associated with consultation duration. Communication about symptom management and communication about medical insurance reimbursement was positively associated with the duration of medical consultations. Communication about administering the formalities requisite for patient admission was negatively associated with the consultation duration. Conclusion We classified the main contents of doctor-patient communication in the oncology outpatient clinic and found that the contents of doctor-patient communication tended to be monotone and systematized. Oncology outpatient models should consider the integration of caregiver involvement. The reason for the shorter outpatient consultation duration in female patients of cancer primary in the reproductive system needs further investigation. The intricate medical insurance reimbursement process poses an increasing time challenge for outpatient clinicians. In addition, the adequacy and effectiveness of symptom management services provided to cancer patients during oncology outpatient follow-up require further evaluation and review.

Shared decision-making between older people with multimorbidity and GPs: focus group study

Background

Shared decision making (SDM), utilising the expertise of both patient and clinician, is a key feature of good-quality patient care. Multimorbidity can complicate SDM, yet few studies have explored this dynamic for older patients with multimorbidity in general practice.

Aim

To explore factors influencing SDM from the perspectives of older patients with multimorbidity and GPs, to inform improvements in personalised care.

Design and setting

Qualitative study. General practices (rural and urban) in Devon, England.

Method

Four focus groups: two with patients (aged ≥65 years with multimorbidity) and two with GPs. Data were coded inductively by applying thematic analysis.

Results

Patient acknowledgement of clinician medicolegal vulnerability in the context of multimorbidity, and their recognition of this as a barrier to SDM, is a new finding. Medicolegal vulnerability was a unifying theme for other reported barriers to SDM. These included expectations for GPs to follow clinical guidelines, challenges encountered in applying guidelines and in communicating clinical uncertainty, and limited clinician self-efficacy for SDM. Increasing consultation duration and improving continuity were viewed as facilitators.

Conclusion

Clinician perceptions of medicolegal vulnerability are recognised by both patients and GPs as a barrier to SDM and should be addressed to optimise delivery of personalised care. Greater awareness of multimorbidity guidelines is needed. Educating clinicians in the communication of uncertainty should be a core component of SDM training. The incorrect perception that most clinicians already effectively facilitate SDM should be addressed to improve the uptake of personalised care interventions.

Mothers' reproductive and medical history misinformation practices as strategies against healthcare providers' domination and humiliation in maternal care decision-making interactions: an ethnographic study in Southern Ghana

Background

Pregnant women can misinform or withhold their reproductive and medical information from providers when they interact with them during care decision-making interactions, although, the information clients reveal or withhold while seeking care plays a critical role in the quality of care provided. This study explored ‘how’ and ‘why’ pregnant women in Ghana control their past obstetric and reproductive information as they interact with providers at their first antenatal visit, and how this influences providers’ decision-making at the time and in subsequent care encounters.

Methods

This research was a case-study of two public hospitals in southern Ghana, using participant observation, conversations, interviews and focus group discussions with antenatal, delivery, and post-natal clients and providers over a 22-month period. The Ghana Health Service Ethical Review Committee gave ethical approval for the study (Ethical approval number: GHS-ERC: 03/01/12). Data analysis was conducted according to grounded theory.

Results

Many of the women in this study selectively controlled the reproductive, obstetric and social history information they shared with their provider at their first visit. They believed that telling a complete history might cause providers to verbally abuse them and they would be regarded in a negative light. Examples of the information controlled included concealing the actual number of children or self-induced abortions. The women adopted this behaviour as a resistance strategy to mitigate providers’ disrespectful treatment through verbal abuses and questioning women’s practices that contradicted providers’ biomedical ideologies. Secondly, they utilised this strategy to evade public humiliation because of inadequate privacy in the hospitals. The withheld information affected quality of care decision-making and care provision processes and outcomes, since misinformed providers were unaware of particular women’s risk profile.

Conclusion

Many mothers in this study withhold or misinform providers about their obstetric, reproductive and social information as a way to avoid receiving disrespectful maternal care and protect their privacy. Improving provider client relationship skills, empowering clients and providing adequate infrastructure to ensure privacy and confidentiality in hospitals, are critical to the provision of respectful maternal care.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1916-9) contains supplementary material, which is available to authorized users.

Managing diagnostic uncertainty in primary care: a systematic critical review

Background

Diagnostic uncertainty is one of the largest contributory factors to the occurrence of diagnostic errors across most specialties in medicine and arguably uncertainty is greatest in primary care due to the undifferentiated symptoms primary care physicians are often presented with. Physicians can respond to diagnostic uncertainty in various ways through the interplay of a series of cognitive, emotional and ethical reactions. The consequences of such uncertainty however can impact negatively upon the primary care practitioner, their patients and the wider healthcare system. Understanding the nature of the existing empirical literature in relation to managing diagnostic uncertainty in primary medical care is a logical and necessary first step in order to understand what solutions are already available and/or to aid the development of any training or feedback aimed at better managing this uncertainty. This review is the first to characterize the existing empirical literature on managing diagnostic uncertainty in primary care.

Methods

Sixteen databases were systematically searched from inception to present with no restrictions. Hand searches of relevant websites and reference lists of included studies were also conducted. Two authors conducted abstract/article screening and data extraction. PRISMA guidelines were adhered to.

Results

Ten studies met the inclusion criteria. A narrative and conceptual synthesis was undertaken under the premises of critical reviews. Results suggest that studies have focused on internal factors (traits, skills and strategies) associated with managing diagnostic uncertainty with only one external intervention identified. Cognitive factors ranged from the influences of epistemological viewpoints to practical approaches such as greater knowledge of the patient, utilizing resources to hand and using appropriate safety netting techniques. Emotional aspects of uncertainty management included clinicians embracing uncertainty and working with provisional diagnoses. Ethical aspects of uncertainty management centered on communicating diagnostic uncertainties with patients. Personality traits and characteristics influenced each of the three domains.

Conclusions

There is little empirical evidence on how uncertainty is managed in general practice. However we highlight how the extant literature can be conceptualised into cognitive, emotional and ethical aspects of uncertainty which may help clinicians be more aware of their own biases as well as provide a platform for future research.

Trial registration

PROSPERO registration: CRD42015027555

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-017-0650-0) contains supplementary material, which is available to authorized users.

Sexual health needs and educational intervention preferences for women with cancer

PURPOSE

To assess sexual/vaginal health issues and educational intervention preferences in women with a history of breast or gynecologic cancer.

METHODS

Patients/survivors completed a cross-sectional survey at their outpatient visits. Main outcome measures were sexual dysfunction prevalence, type of sexual/vaginal issues, awareness of treatments, and preferred intervention modalities. Descriptive frequencies were performed, and results were dichotomized by age, treatment status, and disease site.

RESULTS

Of 218 eligible participants, 109 (50%) had a history of gynecologic and 109 (50%) a history of breast cancer. Median age was 49 years (range 21-75); 61% were married/cohabitating. Seventy percent (n = 153) were somewhat-to-very concerned about sexual function/vaginal health, 55% (n = 120) reported vaginal dryness, 39% (n = 84) vaginal pain, and 51% (n = 112) libido loss. Many had heard of vaginal lubricants, moisturizers, and pelvic floor exercises (97, 72, and 57%, respectively). Seventy-four percent (n = 161) had used lubricants, 28% moisturizers (n = 61), and 28% pelvic floor exercises (n = 60). Seventy percent (n = 152) preferred the topic to be raised by the medical team; 48% (n = 105) raised the topic themselves. Most preferred written educational material followed by expert discussion (66%, n = 144/218). Compared to women ≥50 years old (41%, n = 43/105), younger women (54%, n = 61/113) preferred to discuss their concerns face-to-face (p = 0.054). Older women were less interested in online interventions (52%, p < 0.001), despite 94% having computer access.

CONCLUSION

Female cancer patients/survivors have unmet sexual/vaginal health needs. Preferences for receiving sexual health information vary by age. Improved physician-patient communication, awareness, and educational resources using proven sexual health promotion strategies can help women cope with treatment side effects.

Sexual Activity and Function in Patients With Gynecological Malignancies After Completed Treatment

Objective

Sexual activity (SA) and sexual function (SF) after completion of treatment are central for quality of life (QoL) in women affected by gynecological cancer (GC). The aim of this study was to analyze the sexual outcome and overall QoL of women after treatment for primary GC compared with a healthy control group (CG).

Methods

In a multicenter cross-sectional study, 77 women aged 28 to 67 years were surveyed at least 12 months after completion of primary therapy for cervical, endometrial, or vulvar cancer [gynecological cancer group (GCG)]. Data were collected through validated questionnaires (Female Sexual Function Index-d, EORTC Quality of Life Questionnaire-C30, and Sexual Activity Questionnaire) and compared to a control of 60 healthy women (CG).

Results

In the GCG, 41.3% were sexually active compared to 78.0% in the CG. Twelve women of the CG and 42 women of the GCG indicated the reasons for their sexual inactivity. The most common reason for sexual inactivity in the GCG was “the-presence-of-a-physical-problem” [18/42 (42.9%) vs 2/12 (16.7%) in the CG], whereas in the CG, “because-I-do-not-have-a-partner” was most common [6/12 (50.0%) vs 11/42 (26.2%) in the GCG]. Sexually active patients in the GCG had an SF comparable to the CG. In multivariate analysis of the total cohort (n = 137), relationship status [solid partnership vs living alone; odds ratio (OR), 33.82; 95% confidence interval (CI), 4.83–236.70], smoking (OR, 0.25; 95% CI, 0.06–1.03), and age (OR, 0.87; 95% CI, 0.79–0.94) influenced SA significantly. The probability of SA thereby decreased with increasing age. Quality of life and subjective general health status were not significantly different between the GCG and the CG (EORTC Quality of Life Questionnaire-C30 score 68.25 vs 69.67).

Conclusions

A high number of patients with GC remain sexually inactive after treatment, indicating that women experience persistent functional problems. However, women who regain SA after completed treatment have a good overall SF and vice versa.

The physical consequences of gynecologic cancer surgery and their impact on sexual, emotional, and quality of life issues

INTRODUCTION

Surgical management of gynecologic cancer can cause short- and long-term effects on sexuality, reproductive function, and overall quality of life (QOL) (e.g., sexual dysfunction, infertility, lymphedema). However, innovative approaches developed over the past several decades have improved oncologic outcomes and reduced treatment sequelae.

AIM

To provide an overview of the standards of care and major advancements in gynecologic cancer surgery, with a focus on their direct physical impact, as well as emotional, sexual, and QOL issues. This overview will aid researchers and clinicians in the conceptualization of future clinical care strategies and interventions to improve sexual/vaginal/reproductive health and QOL in gynecologic cancer patients.

MAIN OUTCOME MEASURES

Comprehensive overview of the literature on gynecologic oncology surgery.

METHODS

Conceptual framework for this overview follows the current standards of care and recent surgical approaches to treat gynecologic cancer, with a brief overview describing primary management objectives and the physical, sexual, and emotional impact on patients. Extensive literature support is provided.

RESULTS

The type and radicality of surgical treatment for gynecologic cancer can influence sexual function and play a significant role in QOL. Psychological, sexual, and QOL outcomes improve as surgical procedures continue to evolve. Procedures for fertility preservation, laparoscopy, sentinel lymph node mapping, and robotic and risk-reducing surgery have advanced the field while reducing treatment sequelae. Nevertheless, interventions that address sexual and vaginal health issues are limited.

CONCLUSIONS

It is imperative to consider QOL and sexuality during the treatment decision-making process. New advances in detection and treatment exist; however, psycho-educational interventions and greater patient-physician communication to address sexual and vaginal health concerns are warranted. Large, prospective clinical trials including patient-reported outcomes are needed in gynecologic oncology populations to identify subgroups at risk. Future study designs need clearly defined samples to gain insight about sexual morbidity and foster the development of targeted interventions.

Oncologists’ perceptions of cancer pain management in Spain: The real and the ideal

AIM

Studies in some countries suggest that cancer pain is often not adequately controlled, but little is known about the situation in Spain. The objective of this study was to identify medical oncologists' perceptions about pain management in their patients.

METHODS

Two-round Delphi survey of 24 medical oncologists from 22 large, geographically diverse hospitals in Spain. Physicians rated each of 150 statements on a Likert scale (1=strongly disagree; 5=strongly agree). The mean, standard deviation and frequency of replies in three agreement categories were calculated for each item. Statements allowing comparison of oncologists' perceptions of how pain is managed in routine clinical practice with how it should be managed were grouped together and analyzed.

RESULTS

The most notable discrepancies between the real and the ideal occurred in the failure to provide written information or to confirm that patients understand what they are told, the lack of comprehensive and systematic evaluation of pain, and the lack of use of non-pharmacological treatments (NPTs) for cancer pain.

CONCLUSIONS

Medical oncologists need to improve their communication skills, providing patients with both written and verbal information about their disease and the plan for pain management. Pain should be evaluated at each patient visit using validated scales, and greater attention should be paid to the possible use of NPTs.

Contemporary quality of life issues affecting gynecologic cancer survivors

Regardless of cancer origin or age of onset, the disease and its treatment can produce short- and long-term sequelae (ie, sexual dysfunction, infertility, or lymphedema) that adversely affect quality of life (QOL). This article outlines the primary contemporary issues or concerns that may affect QOL and offers strategies to offset or mitigate QOL disruption. These contemporary issues are identified within the domains of sexual functioning, reproductive issues, lymphedema, and the contribution of health-related QOL in influential gynecologic cancer clinical trials.

Can cancer patients influence the pain agenda in oncology outpatient consultations?

Pain in cancer patients is common, yet it is often inadequately managed. Although poor assessment has been implicated, how patients contribute to this process has not been explicated. This study aims to uncover patients' contributions to discussions about pain during oncology outpatient consultations. Seventy-four medical encounters were observed and audiotaped. Verbatim transcriptions of pain talk were examined using conversational analysis. Thirty-nine of 74 patients talked about pain with 15 different doctors during consultations for follow-up or active treatment. Patients' talk about pain varied consistently according to how pain talk was initiated. In 20 consultations where pain was put on the agenda by patients, they used communication tactics that emphasized their pain experiences, seemingly to attract and maintain their doctors' attention. These tactics appear necessary, as the cancer treatment agenda restricts opportunities for patients to have supportive care needs addressed. On the other hand, in 19 consultations where doctors elicited information about pain, patients used communication tactics that minimized their pain experiences, seemingly to conceal potential disease progression or recurrence, the very focus of these specialist consultations. Where cancer was implicated as the source of pain, chemotherapy or radiotherapy was offered, and where cancer was suspected, referrals for investigations were made. Two of the 20 patients appeared to influence the treatment-focused agenda and were given referrals to pain clinic rather than further cancer therapy as initially recommended.

Unmet needs in cancer patients: development of a supportive needs screening tool (SNST)

GOALS OF WORK

A diagnosis of cancer can have a profound impact on the physical, emotional, psychological, social and spiritual areas of a person's life. Supportive care services are directed towards this full range of issues associated with cancer. Identification of need is the first step in meeting supportive care concerns, but there is a lack of tools and processes regularly used in clinical practice. This article reports the first steps in the development of a supportive needs screening tool appropriate for use in an oncology outpatient setting.

MATERIALS AND METHODS

A review of the literature was undertaken, and a draft tool developed using a process of item reduction. A small pre-test followed by a pilot test with 87 patients attending Peter MacCallum Cancer Centre, Melbourne Australia was undertaken. Evaluation to identify usability and acceptability in clinical practice included descriptive statistics to profile patient needs and referrals generated by the supportive needs screening tool (SNST), interviews with a small sample of participants and surveys completed by staff.

MAIN RESULTS

The SNST was developed with 41 questions, the majority requiring a yes/no response. From the tool, a total of 1,085 needs were identified (mean = 12 needs/patient). A total of 264 referrals were generated, with 72% of patients receiving at least one referral. Patients and staff reported high acceptability.

CONCLUSIONS

The SNST has face validity and demonstrated usability in an ambulatory care oncology stetting, as first steps in instrument development. Further testing of reliability and validity are being undertaken.

Meeting the ongoing needs of survivors of rarer cancer

With more treatment options for people with cancer long-term survivorship is increasing. Physical and psycho-social needs have been identified in survivors of common cancers but very little has been written about the needs of patients with rarer cancers. Patients treated for rarer cancer are discharged to the primary health care team (PHCT), yet little is known about the assessment, management and support of these patients. Thirty-nine semi-structured interviews were conducted with (1) survivors of and (2) people living with rarer cancer (i.e. <5% of cancer burden). Participants were asked about physical and psycho-social needs and service provision. Data were analysed thematically using Atlas ti. Contrary to expectation, disease-free survivors of rarer cancer were indistinguishable from those living with disease in their ability to cope, and range of symptoms and needs. Participants with a clinical nurse specialist (CNS) reported that they were well supported on their return home and their needs were met. Participants without a CNS were referred to the PHCT who were unsure how to assess or support them. These participants felt abandoned. There is a need for the rehabilitation of patients with rarer cancer to strengthen individual coping mechanisms, and family and social support. Although there are resource and training implications, this is a potential role for the PHCT, district nursing in particular, and may lead to more focused and targeted provision of services.

Follow-up in breast cancer clinics: reassuring for patients rather than detecting recurrence

Despite evidence that questions the value of routine hospital follow-up after treatment for breast cancer, there is little evidence to indicate what actually takes place during follow-up consultations and whether patients benefit from the experience. This study aimed to investigate the nature and content of hospital follow-up visits following treatment for breast cancer using a mixed methods approach. Methods included direct observation and audio-recording of 104 consultations, semi-structured interviews with 14 health care professionals (HCP) involved in follow-up service provision and a patient survey. Consultations were focused on detection of recurrent disease by clinical examination, despite this being a rare event. HCPs' style of interaction could foster the illusion that follow-up visits were intended to detect recurrence. Consultations were generally of brief duration (mean 6 min) and were overwhelmingly optimistic, although patients gained reassurance from minimal interaction. Few opportunities were available to meet information and psychosocial needs. The costly system of follow-up currently in operation is historically rather than evidence based, and subject to increasing demands and limited resources. Alternative approaches are needed that address the diversity of patients' needs rather than searching for recurrent disease. However, when formulating policy and evaluating new approaches, patients' expectations of what constitutes follow-up care need to be clearly addressed.

Is there a cost to poor communication in cancer care?: a critical review of the literature

In this paper, the authors engage in a critical analysis of the existing empirical literature which addresses the impact of ineffective communication between cancer patients and clinicians. It is increasingly accepted that communication plays a significant role in many aspects of the care experience, and that poor communication can have a significantly negative influence on the patient's psychosocial experience, symptom management, treatment decisions, and quality of life. However, scant attention has been given to the idea that poor communication may also have an economic impact worthy of attention. This area has not been the focus of systematic inquiry or substantive critical consideration. On the basis of critical analysis of the limited empirical evidence that exists across a wide range of studies in related areas, the authors propose that the existential and material costs associated with poor communication in cancer care may well be considerable, and conclude with a call to mobilize a heightened enthusiasm for addressing the research challenges in this field.

The communication goals and needs of cancer patients: a review

The aim of this review paper is to critique the empirical literature pertaining to the communication needs and goals of cancer patients, and to provide direction for research in this area. According to the conceptual framework of Feldman-Stewart et al., patient-physician communication occurs for the fundamental purpose of addressing each participant's goal(s). This review is divided into two categories of goals: (a) optimal medical management of the cancer, and (b) optimal attention to the patient's psychosocial response to cancer. Optimal medical management includes discussions about disease status and the treatment plan, and the effectiveness of these discussions is frequently determined by assessing patient understanding, satisfaction, and well-being. The literature suggests that cancer patients continue to have unmet communication needs, and communication outcomes are enhanced when physicians attend to the emotional needs of patients. Research gaps in communication research are highlighted, including the need for additional study of several external factors affecting the patient and provider.

Participation as an expression of patient uncertainty: An exploration of bowel cancer consultations

AIMS

The paper explores the factors that influence patient involvement in treatment decision-making.

METHODS

An observation study of 49 new consultations between oncologists and recently diagnosed bowel cancer patients was conducted at a regional cancer centre in the South West of England. The dialogue was recorded verbatim during each consultation and transcribed. The data were coded into relevant themes and analysed using the constant comparison method.

RESULTS

A significant minority (23 out of 49) of patients were involved to varying degrees in decision-making. 'Active' involvement usually resulted from: (1) conflicting expectations between the doctor and the patient about the most appropriate treatment; (2) unexpected information; (3) issues related to treatment costs and benefits and (4) the lack of a clear treatment recommendation from the oncologist.

CONCLUSION

The informed consent procedure requests that full information is provided to patients about their condition and its treatment, although there is no parallel requirement to offer an interpretation of the information. In order to help patients make optimal decisions regarding treatment, oncologists need to provide an adequate level of information as well as interpretation to patients about the pros and cons of treatment.

Breathlessness in cancer and chronic obstructive pulmonary disease: Using a qualitative approach to describe the experience of patients and carers

Objective: To investigate and document the effects of breathlessness on the everyday lives of patients with cancer and COPD and their carers. This subject has been little researched, although dyspnoea is recognized as a disabling, distressing symptom. The number of breathless people is increasing as patients with all types of cardio-respiratory disease live longer.

Methods: Patients with severe COPD and cancer and their carers were interviewed at home using a semistructured format to record their perceptions of the impact of breathlessness, the help they had received from medical and caring services, and their ideas on how these could be improved.

Results: 10 patients with COPD (6 male) and 10 with cancer (6 male) and their spouses were interviewed. All patients found breathlessness frightening, disabling, and restricting. Patients developed a stoical, philosophical approach in order to live with dyspnoea and the difficulties it imposed: this was also an important way of reducing the emotional impact of breathlessness. Patients' spouses suffered significantly, experiencing severe anxiety and helplessness as they witnessed their partners' suffering and felt powerless to reduce it. The restrictions imposed by breathlessness affected their lives profoundly. Support of all kinds, practical, medical, and psychosocial was highly valued but was provided inconsistently and sporadically. Where help was given it came most frequently from general practitioners (GPs, family physicians) and specialist respiratory nurses.

Significance of results: This study is the first to document the psychosocial needs of carers, which are not adequately recognized or addressed at present. Patients and carers may feel most isolated and need support outside the working hours of most services and future provision needs to reflect this. Patients with cancer experience a more rapid onset of breathlessness. More clinicians need to be educated in the management of chronic breathlessness so known helpful strategies are more widely employed.