Developing communication competency in the context of cancer: a critical interpretive analysis of provider training programs

Informing Patients With Esophagogastric Cancer About Treatment Outcomes by Using a Web-Based Tool and Training: Development and Evaluation Study

Background

Due to the increasing use of shared decision-making, patients with esophagogastric cancer play an increasingly important role in the decision-making process. To be able to make well-informed decisions, patients need to be adequately informed about treatment options and their outcomes, namely survival, side effects or complications, and health-related quality of life. Web-based tools and training programs can aid physicians in this complex task. However, to date, none of these instruments are available for use in informing patients with esophagogastric cancer about treatment outcomes.

Objective

This study aims to develop and evaluate the feasibility of using a web-based prediction tool and supporting communication skills training to improve how physicians inform patients with esophagogastric cancer about treatment outcomes. By improving the provision of treatment outcome information, we aim to stimulate the use of information that is evidence-based, precise, and personalized to patient and tumor characteristics and is communicated in a way that is tailored to individual information needs.

Methods

We designed a web-based, physician-assisted prediction tool—Source—to be used during consultations by using an iterative, user-centered approach. The accompanying communication skills training was developed based on specific learning objectives, literature, and expert opinions. The Source tool was tested in several rounds—a face-to-face focus group with 6 patients and survivors, semistructured interviews with 5 patients, think-aloud sessions with 3 medical oncologists, and interviews with 6 field experts. In a final pilot study, the Source tool and training were tested as a combined intervention by 5 medical oncology fellows and 3 esophagogastric outpatients.

Results

The Source tool contains personalized prediction models and data from meta-analyses regarding survival, treatment side effects and complications, and health-related quality of life. The treatment outcomes were visualized in a patient-friendly manner by using pictographs and bar and line graphs. The communication skills training consisted of blended learning for clinicians comprising e-learning and 2 face-to-face sessions. Adjustments to improve both training and the Source tool were made according to feedback from all testing rounds.

Conclusions

The Source tool and training could play an important role in informing patients with esophagogastric cancer about treatment outcomes in an evidence-based, precise, personalized, and tailored manner. The preliminary evaluation results are promising and provide valuable input for the further development and testing of both elements. However, the remaining uncertainty about treatment outcomes in patients and established habits in doctors, in addition to the varying trust in the prediction models, might influence the effectiveness of the tool and training in daily practice. We are currently conducting a multicenter clinical trial to investigate the impact that the combined tool and training have on the provision of information in the context of treatment decision-making.

Shared Decision Making in Practice and the Perspectives of Health Care Professionals on Video-Recorded Consultations With Patients With Low Health Literacy in the Palliative Phase of Their Disease

Introduction. An important goal of palliative care is improving the quality of life of patients and their partners/families. To attain this goal, requirements and preferences of patients need to be discussed, preferably through shared decision making (SDM). This enhances patient autonomy and patient-centeredness, requiring active participation by patients. This is demanding for palliative patients, and even more so for patients with limited health literacy (LHL). This study aimed to examine SDM in practice and assess health care professionals’ perspectives on their own SDM. Methods. An explanatory sequential mixed methods design was used. Video recordings were gathered cross-sectionally of palliative care consultations with LHL patients (n = 36) conducted by specialized palliative care clinicians and professionals integrating a palliative approach. The consultations were observed for SDM using the OPTION⁵ instrument. Potential determinants of SDM were examined using multilevel analysis. Sequentially, stimulated recall interviews were conducted assessing the perspectives of professionals on their SDM (n = 19). Interviews were examined using deductive thematic content analysis. Results. The average SDM score in practice was moderate, varying greatly between professionals, as shown by the multilevel analysis and by varying degrees of perceived patient involvement in SDM mentioned in the interviews. To improve this, professionals recommended 1) continuously discussing all options with patients, 2) allowing time for patients to talk, and 3) using strategic timing for involving patients in SDM. Discussion. The implementation of SDM for people with LHL in palliative care varies in quality and needs improvement. SDM needs to be enhanced in this care domain because decisions are complex and demanding for LHL patients. Future research is needed that focuses on supporting strategies for comprehensible SDM, best practices, and organizational adaptations.

Outcomes and outcome measures used in evaluation of communication training in oncology - a systematic literature review, an expert workshop, and recommendations for future research

BACKGROUND

Communication between health care provider and patients in oncology presents challenges. Communication skills training have been frequently developed to address those. Given the complexity of communication training, the choice of outcomes and outcome measures to assess its effectiveness is important. The aim of this paper is to 1) perform a systematic review on outcomes and outcome measures used in evaluations of communication training, 2) discuss specific challenges and 3) provide recommendations for the selection of outcomes in future studies.

METHODS

To identify studies and reviews reporting on the evaluation of communication training for health care professionals in oncology, we searched seven databases (Ovid MEDLINE, CENTRAL, CINAHL, EMBASE, PsychINFO, PsychARTICLES and Web of Science). We extracted outcomes assessed and the respective assessment methods. We held a two-day workshop with experts (n = 16) in communication theory, development and evaluation of generic or cancer-specific communication training and/or outcome measure development to identify and address challenges in the evaluation of communication training in oncology. After the workshop, participants contributed to the development of recommendations addressing those challenges.

RESULTS

Out of 2181 references, we included 96 publications (33 RCTs, 2 RCT protocols, 4 controlled trials, 36 uncontrolled studies, 21 reviews) in the review. Most frequently used outcomes were participants' training evaluation, their communication confidence, observed communication skills and patients' overall satisfaction and anxiety. Outcomes were assessed using questionnaires for participants (57.3%), patients (36.0%) and observations of real (34.7%) and simulated (30.7%) patient encounters. Outcomes and outcome measures varied widely across studies. Experts agreed that outcomes need to be precisely defined and linked with explicit learning objectives of the training. Furthermore, outcomes should be assessed as broadly as possible on different levels (health care professional, patient and interaction level).

CONCLUSIONS

Measuring the effects of training programmes aimed at improving health care professionals' communication skills presents considerable challenges. Outcomes as well as outcome measures differ widely across studies. We recommended to link outcome assessment to specific learning objectives and to assess outcomes as broadly as possible.

COMSKIL Communication Training in Oncology-Adaptation to German Cancer Care Settings

Medical communication is a skill which can be learned and taught and which can substantially improve treatment outcomes, especially if patients' communication preferences are taken into account. Here, we give an overview of communication training research and outline the COMSKIL program as a state-of-the-art communication skills training in oncology. COMSKIL has a solid theoretical foundation and teaches core elements of medical communication in up to ten fully operationalized modules. These address typical situations ranging from breaking bad news to responding to difficult emotions, shared decision-making, and communicating via interpreters.

A randomized controlled trial of a skills training for oncologists and a communication aid for patients to stimulate shared decision making about palliative systemic treatment (CHOICE): study protocol

BACKGROUND

Systemic treatment for advanced cancer offers uncertain and sometimes little benefit while the burden can be high. Hence, treatment decisions require Shared Decision Making (SDM). The CHOICE trial examines the separate and combined effect of oncologist training and a patient communication aid on SDM in consultations about palliative systemic treatment.

METHODS

A RCT design with four parallel arms will be adopted. Patients with metastatic or irresectable cancer with a median life expectancy <12 months who meet with a medical oncologist to discuss the start or continuation of palliative systemic treatment are eligible. A total of 24 oncologists (in training) and 192 patients will be recruited. The oncologist training consists of a reader, two group sessions (3.5 h; including modelling videos and role play), a booster feedback session (1 h) and a consultation room tool. The patient communication aid consists of a home-sent question prompt list and a value clarification exercise to prepare patients for SDM in the consultation. The control condition consists of care as usual. The primary outcome is observed SDM in audio-recorded consultations. Secondary outcomes include patient and oncologist evaluation of communication and decision-making, the decision made, quality of life, potential adverse outcomes such as anxiety and hopelessness, and consultation duration. Patients fill out questionnaires at baseline (T0), before (T1) and after the consultation (T2) and at 3 and 6 months (T3 and T4). All oncologists participate in two standardized patient assessments (before-after training) prior to the start of patient inclusion. They will fill out a questionnaire before and after these assessments, as well as after each of the recorded consultations in clinical practice.

DISCUSSION

The CHOICE trial will enable evidence-based choices regarding the investment in SDM interventions targeting either oncologists, patients or both in the advanced cancer setting. The trial takes into account the immediate effect of the interventions on observed communication, but also on more distal and potential adverse patient outcomes. Also, the trial provides evidence regarding the assumption that SDM about palliative cancer treatment results in less aggressive treatment and more quality of life in the final period of life.

TRIAL REGISTRATION

Netherlands Trial Registry number NTR5489 (prospective; 15 Sep 2015).

Risk, Activism, and Empowerment

The prevalence of breast cancer in Venezuela is particularly alarming, which is attributed to healthcare inequalities, low health literacy, and lagging compliance with prevention methods (i.e., screening and mammography). While the right to health is acknowledged by the Venezuelan constitution, activism beyond governmental confines is required to increase women's breast cancer awareness and decrease mortality rates. Through the development of social support and strategic communicative methods enacted by healthcare providers, it may be possible to empower women with the tools necessary for breast cancer prevention. This paper discusses issues surrounding women's breast cancer, such as awareness of the disease and its risks, self-advocacy, and the roles of activists, healthcare providers, and society. Specifically, it describes a four-year action-oriented research project developed in Venezuela, which was a collaborative work among researchers, practitioners, NGOs, patients, journalists, and policymakers. The outcomes include higher levels of awareness and interest among community members and organizations to learn and seek more information about women's breast cancer, better understandings of the communicated messages, more media coverage and medical consultations, increasing positive patient treatments, expansion of networking of NGOs, as well as a widely supported declaration for a national response against breast cancer in Venezuela.

Communication, Documentation, and Training Standards in Pediatric Psychosocial Oncology

As part of a larger effort to create standards for psychosocial care of children with cancer, we document consensus and evidence-based data on interprofessional communication, documentation, and training for professionals providing psycho-oncology services. Six databases were searched. Sixty-five articles and six guidelines and consensus-based documents were identified; 35 met inclusion criteria. Data support strong recommendations for standards of care in communication/collaboration, documentation of patient information, and training in pediatric psycho-oncology. These are areas where extensive research is unlikely to be conducted; however, professional expectations and qualifications may be further clarified and strengthened with time.

Risk, Activism, and Empowerment: Women's Breast Cancer in Venezuela

The prevalence of breast cancer in Venezuela is particularly alarming, which is attributed to healthcare inequalities, low health literacy, and lagging compliance with prevention methods (i.e., screening and mammography). While the right to health is acknowledged by the Venezuelan constitution, activism beyond governmental confines is required to increase women's breast cancer awareness and decrease mortality rates. Through the development of social support and strategic communicative methods enacted by healthcare providers, it may be possible to empower women with the tools necessary for breast cancer prevention. This paper discusses issues surrounding women's breast cancer, such as awareness of the disease and its risks, self-advocacy, and the roles of activists, healthcare providers, and society. Specifically, it describes a four-year action-oriented research project developed in Venezuela, which was a collaborative work among researchers, practitioners, NGOs, patients, journalists, and policymakers. The outcomes include higher levels of awareness and interest among community members and organizations to learn and seek more information about women's breast cancer, better understandings of the communicated messages, more media coverage and medical consultations, increasing positive patient treatments, expansion of networking of NGOs, as well as a widely supported declaration for a national response against breast cancer in Venezuela.

Patient and health professional's perceived barriers to the delivery of psychosocial care to adults with cancer: a systematic review

OBJECTIVE

To explore the barriers experienced and perceived by health professionals and patients in the delivery of psychosocial care to adults with cancer.

METHODS

Systematic searches were undertaken using the PsychInfo, Medline and CINAHL electronic databases, up to October 2013. Research reporting health professional or patient experiences and perceptions of barriers to psychosocial care are included in the review. The systematic review includes studies that have non-experimental, exploratory and observational designs, as is appropriate to answer the review question. Included studies were critically appraised. The results of individual quantitative studies were aggregated. Qualitative content analysis was used to analyse the qualitative results.

RESULTS

Twenty-five papers met the pre-specified inclusion criteria for the final review. The most commonly perceived barrier for patients relates to receiving adequate support from elsewhere and a lack of perceived need for psychosocial care. Health professionals report barriers at an organisational level most frequently followed by cultural and then individual clinician-related barriers.

CONCLUSIONS

Barriers exist on a variety of levels. People with cancer need clear appropriate information and communication about psychosocial services, including information about the role of psychosocial care in addition to existing supports. Interventions that target the complex interplay of individual, organisational and cultural factors need to be developed. Strategies that improve health professional communication skills, identify clear referral pathways, improve acceptability of interventions and clearly identify the need for services could address many of the barriers identified in this review.

Assessing patient-centered communication in cancer care: stakeholder perspectives

PURPOSE

Patient-centered communication is critical to quality cancer care. Effective communication can help patients and family members cope with cancer, make informed decisions, and effectively manage their care; suboptimal communication can contribute to care breakdowns and undermine clinician-patient relationships. The study purpose was to explore stakeholders' views on the feasibility and acceptability of collecting self-reported patient and family perceptions of communication experiences while receiving cancer care. The results were intended to inform the design, development, and implementation of a structured and generalizable patient-level reporting system.

METHODS

This was a formative, qualitative study that used semistructured interviews with cancer patients, family members, clinicians, and leaders of health care organizations. The constant comparative method was used to identify major themes in the interview transcripts.

RESULTS

A total of 106 stakeholders were interviewed. Thematic saturation was achieved. All stakeholders recognized the importance of communication and endorsed efforts to improve communication during cancer care. Patients, clinicians, and leaders expressed concerns about the potential consequences of reports of suboptimal communication experiences, such as damage to the clinician-patient relationship, and the need for effective improvement strategies. Patients and family members would report good communication experiences in order to encourage such practices. Practical and logistic issues were identified.

CONCLUSION

Patient reports of their communication experiences during cancer care could increase understanding of the communication process, stimulate improvements, inform interventions, and provide a basis for evaluating changes in communication practices. This qualitative study provides a foundation for the design and pilot testing of such a patient reporting system.

Education in patient-physician communication: how to improve effectiveness?

OBJECTIVE

Despite educational efforts expertise in communication as required by the CanMEDS competency framework is not achieved by medical students and residents. Several factors complicate the learning of professional communication.

METHODS

We adapted the reflective-impulsive model of social behaviour to explain the complexities of learning professional communication behaviour. We formulated recommendations for the learning objectives and teaching methods of communication education. Our recommendations are based on the reflective-impulsive model and on the model of deliberate practice which complements the reflective-impulsive model. Our recommendations are substantiated by those we found in the literature.

RESULTS

The reflective-impulsive model explains why the results of communication education fall below expectations and how expertise in communication can be attained by deliberate practice. The model of deliberate practice specifies learning conditions which are insufficiently fulfilled in current communication programmes.

CONCLUSION

The implementation of our recommendations would require a great deal of effort. Therefore we doubt whether expertise in professional communication can be fully attained during medical training.

PRACTICE IMPLICATIONS

We propose that the CanMEDS communication competencies not be regarded as endpoints in medical education but as guidelines to improve communication competency through deliberate practice throughout a professional career.

Oncology clinicians' defenses and adherence to communication skills training with simulated patients: an exploratory study

The aim of this exploratory study was to assess the impact of clinicians' defense mechanisms-defined as self-protective psychological mechanisms triggered by the affective load of the encounter with the patient-on adherence to a communication skills training (CST). The population consisted of oncology clinicians (N=31) who participated in a CST. An interview with simulated cancer patients was recorded prior and 6 months after CST. Defenses were measured before and after CST and correlated with a prototype of an ideally conducted interview based on the criteria of CST-teachers. Clinicians who used more adaptive defense mechanisms showed better adherence to communication skills after CST than clinicians with less adaptive defenses (F(1, 29) =5.26, p=0.03, d=0.42). Improvement in communication skills after CST seems to depend on the initial levels of defenses of the clinician prior to CST. Implications for practice and training are discussed. Communication has been recognized as a central element of cancer care [1]. Ineffective communication may contribute to patients' confusion, uncertainty, and increased difficulty in asking questions, expressing feelings, and understanding information [2, 3], and may also contribute to clinicians' lack of job satisfaction and emotional burnout [4]. Therefore, communication skills trainings (CST) for oncology clinicians have been widely developed over the last decade. These trainings should increase the skills of clinicians to respond to the patient's needs, and enhance an adequate encounter with the patient with efficient exchange of information [5]. While CSTs show a great diversity with regard to their pedagogic approaches [6, 7], the main elements of CST consist of (1) role play between participants, (2) analysis of videotaped interviews with simulated patients, and (3) interactive case discussion provided by participants. As recently stated in a consensus paper [8], CSTs need to be taught in small groups (up to 10-12 participants) and have a minimal duration of at least 3 days in order to be effective. Several systematic reviews evaluated the impact of CST on clinicians' communication skills [9-11]. Effectiveness of CST can be assessed by two main approaches: participant-based and patient-based outcomes. Measures can be self-reported, but, according to Gysels et al. [10], behavioral assessment of patient-physician interviews [12] is the most objective and reliable method for measuring change after training. Based on 22 studies on participants' outcomes, Merckaert et al. [9] reported an increase of communication skills and participants' satisfaction with training and changes in attitudes and beliefs. The evaluation of CST remains a challenging task and variables mediating skills improvement remain unidentified. We recently thus conducted a study evaluating the impact of CST on clinicians' defenses by comparing the evolution of defenses of clinicians participating in CST with defenses of a control group without training [13]. Defenses are unconscious psychological processes which protect from anxiety or distress. Therefore, they contribute to the individual's adaptation to stress [14]. Perry refers to the term "defensive functioning" to indicate the degree of adaptation linked to the use of a range of specific defenses by an individual, ranging from low defensive functioning when he or she tends to use generally less adaptive defenses (such as projection, denial, or acting out) to high defensive functioning when he or she tends to use generally more adaptive defenses (such as altruism, intellectualization, or introspection) [15, 16]. Although several authors have addressed the emotional difficulties of oncology clinicians when facing patients and their need to preserve themselves [7, 17, 18], no research has yet been conducted on the defenses of clinicians. For example, repeated use of less adaptive defenses, such as denial, may allow the clinician to avoid or reduce distress, but it also diminishes his ability to respond to the patient's emotions, to identify and to respond adequately to his needs, and to foster the therapeutic alliance. Results of the above-mentioned study [13] showed two groups of clinicians: one with a higher defensive functioning and one with a lower defensive functioning prior to CST. After the training, a difference in defensive functioning between clinicians who participated in CST and clinicians of the control group was only showed for clinicians with a higher defensive functioning. Some clinicians may therefore be more responsive to CST than others. To further address this issue, the present study aimed to evaluate the relationship between the level of adherence to an "ideally conducted interview", as defined by the teachers of the CST, and the level of the clinician' defensive functioning. We hypothesized that, after CST, clinicians with a higher defensive functioning show a greater adherence to the "ideally conducted interview" than clinicians with a lower defensive functioning.

The communication competency of medical students, residents and consultants

OBJECTIVE

The model of expert performance predicts that neither physicians in training nor experienced physicians will reach an expert level in communication. This study tested this hypothesis.

METHODS

Seventy-one students, twenty-five residents and fourteen consultants performed a 'breaking bad news' exercise with a simulated patient. Their communication competency was assessed with the CELI instrument. Actor assessments were also obtained. The differences in communication competency between students, residents and consultants were established.

RESULTS

The mean performance scores ranged from bad to adequate. An expert level of performance was seldom reached. Novice students scored lower than the other groups in their competency and in the actor assessment. First-year students scored lower than the consultants in their competency and in the actor assessment. No differences in performance were found between third-year students, interns, residents and consultants.

CONCLUSION

Students acquire a 'satisfactory' level of communication competency early in the curriculum. Communication courses in the curriculum do not enhance this level. Clinical experience has also a limited effect.

PRACTICE IMPLICATIONS

The learning conditions for deliberate practice must be fulfilled in medical curricula and in postgraduate training in order to provide medical students and physicians the opportunity to attain an expert level in communication.

Assessment of physician competency in patient education: reliability and validity of a model-based instrument

OBJECTIVE

Establish the inter-rater reliability and the concept, convergent and construct validity of an instrument for assessing the competency of physicians in patient education.

METHODS

Three raters assessed the quality of patient education in 30 outpatient consultations with the CELI instrument. This instrument is based on a goal-directed model of patient education and assesses distinctive skills for patient education categorized in four subcompetencies. The inter-rater reliability was calculated. The concept validity was explored by factor analysis. The convergent validity was established by a comparison with two measures of patient-centred behaviour. The construct validity was explored by relating the subcompetencies with physician gender and patient satisfaction.

RESULTS

The inter-rater reliability for the subcompetencies varied between 0.65 and 0.91. The factor analysis distinguished the four subcompetencies. All subcompetencies correlated with the measures of patient-centred behaviour. Female physicians performed better than male physicians on three subcompetencies. Positive correlations were found for three subcompetencies and patient satisfaction.

CONCLUSION

The CELI instrument appears to be a reliable and valid instrument. However, further research is needed to establish the generalizability and construct validity.

PRACTICE IMPLICATION

The CELI instrument is a useful tool for assessment and feedback in medical education since it assesses the performance of distinctive skills.

Eliciting adaptive emotion in conversations with parents of children receiving therapy for leukemia

Clinician-parent communication may often be difficult, especially soon after the diagnosis. The aims of this article are to identify the communication strategies associated with expressions of adaptive emotions in parents and to explore the effect of the type of leukemia and of parent's gender on parents' expressions of emotions. The data are obtained from 4.622 conversational turns of 20 videotaped interviews with 10 mothers and 10 fathers of children at their first hospitalization for leukemia. A coding scheme for parent emotional expressions was reliably applied by two independent judges. An original self-report questionnaire on parents' emotional states was used before and after the interview. Positive politeness of interviewer elicits adaptive emotional expressions in parents. Mothers of children with acute myeloid leukemia and fathers of children with acute lymphoblastic leukaemia appear more distressed during the interview. This interview can be identified as an innovative technique of communication with parents of children with cancer.

Psychometric Analysis of the JSPE Nursing Student Version R: Comparison of Senior BSN Students and Medical Students Attitudes toward Empathy in Patient Care

Background. Empathic communication skills are critical to providing high-quality nursing care to holistically understand the patient's perspective. A survey research design was used to address the research questions discussed in this study. Data consisted of responses from nursing students attending accredited programs in the southeastern United Sates using the Jefferson Scale of Physician Empathy Nursing Student Version R (JSPE-R). Findings. Comparisons of the total scores from JSPE Versions S and R yielded similar means and standard deviations with 115 and 114.57, respectively, and standard deviations of 10 and 10.94, respectively. The results of a one-sample t-test failed to render statistical significance (t = −1.22, P = .224), indicating that the overall attitudes of nursing students and medical students are similar. The 25th, 50th, and 75th percentiles and overall instrument reliability were also comparable. Conclusions. This paper supports the emergence of alternative factor analysis structures as applied to nursing students through statistical progression from exploratory factor analysis to confirmatory structures. Implications for practice explore the utility of empathy instruments in nurse education, such as empathy progression through curriculum. As nursing educators, the utility of development of instruments to measure effectiveness of teaching strategies and pedagogy for empathy enhancement in practice is important.

Program evaluation of nursing school instruction in measuring students' perceived competence to empathetically communicate with patients

The purpose of this survey study was to examine the relationship between senior baccalaureate nursing students' perceptions of their nursing program effectiveness in teaching them to empathetically communicate with patients and family members and perceived competence in empathetic communication. Nursing program components and students' perceived competence were divided into five areas: academic exposure to patient care situations, curricular emphasis during the nursing program, perceived program effectiveness, academic sources, and perceived competence. Outcomes of the regression analysis showed that the primary factors related to perceived competence were academic exposure, curricular emphasis, and program effectiveness. Data from this study reinforce the need for greater attention to be focused on clinical instruction, maximization of faculty input and feedback, and reinforcement of theoretical tenets that are taught academically.

An intervention to improve communication between breast cancer survivors and their physicians

Breast cancer survivors often use clues to convey their concerns to their oncologists. The authors conducted a randomized trial of a communication coaching intervention in which 22 female breast cancer survivors were randomized to the coaching and 22 to treatment as usual. They hypothesized that the intervention would increase breast cancer self-efficacy, improve mood, and reduce fears of recurrence. Through a series of ANCOVAs they found that the intervention led to increases in self-efficacy. Changes in self-efficacy predicted changes in anxiety, depression, and womanhood fears. This coaching intervention shows promise but requires additional studies to establish is efficacy and effectiveness.

A randomized controlled trial of communication training with primary care providers to improve patient-centeredness and health risk communication

OBJECTIVE

to determine the efficacy and effectiveness of training to improve primary care providers' patient-centered communication skills and proficiency in discussing their patients' health risks.

METHODS

twenty-eight primary care providers participated in a baseline simulated patient interaction and were subsequently randomized into intervention and control groups. Intervention providers participated in training focused on patient-centered communication about behavioral risk factors. Immediate efficacy of training was evaluated by comparing the two groups. Over the next 3 years, all providers participated in two more sets of interactions with patients. Longer term effectiveness was assessed using the interaction data collected at 6 and 18 months post-training.

RESULTS

The intervention providers significantly improved in patient-centered communication and communication proficiencies immediately post-training and at both follow-up time points.

CONCLUSIONS

this study suggests that the brief training produced significant and large differences in the intervention group providers which persisted 2 years after the training.

PRACTICE IMPLICATIONS

the results of this study suggest that primary care providers can be trained to achieve and maintain gains in patient-centered communication, communication skills and discussion of adverse childhood events as root causes of chronic disease.

The implementation and assessment of a comprehensive communication skills training curriculum for oncologists

OBJECTIVE

The objective of this paper is to report the implementation and assessment of the Comskil Training Curriculum at Memorial Sloan-Kettering Cancer Center.

METHOD

Twenty-eight attending physicians and surgeons participated in communication skills training modules as part of a train-the-trainer program. Doctors were video recorded in clinical consultations with patients two times before training and two times after training, resulting in 112 video recordings for analysis. Recordings were coded using the Comskil Coding System.

RESULTS

Communication skills related to two of the six major skill sets, Establishing the Consultation Framework and Checking, increased following training. Limited changes emerged in three skill sets, while one skill set, Shared Decision Making, did not change. Doctors who attended more training modules had higher levels of change. Female participants demonstrated three skills more frequently than males post-training.

CONCLUSIONS

The intervention produced significant communication skills uptake in a group of experienced attending clinicians, mediated by the amount of training. Future research should focus on the dose of training necessary to achieve skills uptake and the effect of skills training on patient outcomes.

Communication skills training and clinicians' defenses in oncology: an exploratory, controlled study

OBJECTIVE

The underlying mechanisms modifying clinician's communication skills by means of communication skills training (CST) remain unknown. Defense mechanisms, defined as psychological processes protecting the individual against emotional stress, may be a mediating factor of skills improvement.

METHODS

Using an adapted version of the Defense Mechanism Rating Scale-Clinician, this study evaluated clinicians' defense mechanisms and their possible modification after CST. Interviews with simulated patients of oncology clinicians (N=57) participating in CST (pre-/post-CST with a 6-month interval) were compared WITH interviews with the same simulated patients of oncology clinicians (N=56) who did not undergo training (T1 and T2 with a 6-month interval).

RESULTS

Results showed (i) a high number (mean=16, SD=6) and variety of defenses triggered by the 15-min interviews, (ii) no evolution difference between groups, and (iii) an increase in mature defenses after CST for clinicians with an initial higher level of defensive functioning.

CONCLUSIONS

This is the first study describing clinicians' defensive functioning; results indicate a possible mediating role of defenses in clinician-patient communication.

Patient real-time and 12-month retrospective perceptions of difficult communications in the cancer diagnostic period

Communication is a notoriously complex challenge in the cancer care context. Our program of research involves exploration of patient-provider communications across the cancer trajectory from the patient perspective.Toward this end, we have been following a cohort of 60 cancer patients, representing a range of tumor sites, from immediately after diagnosis through to recovery, chronic, or advanced disease. Drawing on interpretive description analytic techniques, we documented patterns and themes related to various components of the cancer journey. In this article, we report on findings pertaining to poor communication during the initial diagnostic period, as described by patients at the time of diagnosis and 1 year later.These findings illuminate the dynamics of communication problems during that complex period, and depict the mechanisms by which patients sought to confront these challenges to optimize their cancer care experience. On the basis of these findings, considered in the context of the body of available evidence, suggestions are proposed as to appropriate directions for system-level solutions to the complex communication challenges within cancer care.

Cancer informational support and health care service use among individuals newly diagnosed: a mixed methods approach

AIM

To report on the integration of quantitative and qualitative findings to increase understanding of the role of cancer informational support and use of health care services among individuals newly diagnosed with breast or prostate cancer.

METHODS

A mixed methods sequential design was used. First, a quantitative secondary analysis considered self-report data from a large number of individuals newly diagnosed with cancer (n = 250); next, a follow-up, in-depth qualitative inquiry with distinct individuals also newly diagnosed was conducted (n = 20); last, using a quantitative-hierarchical strategy, quantitative and qualitative findings were merged and re-analyzed.

RESULTS

Quantitative analyses showed significant relationships between informational support and health care services. For instance, individuals who received more intense cancer informational support [face-to-face and information technology (IT)] spent more time with nurses. Women with breast cancer as opposed to men with prostate cancer also were found to rely primarily on nurses for cancer information and information on health services available, whereas men relied mostly on their oncologists. In-depth interviews revealed that informational support could be construed as positive, unsupportive, or mixed depending on context. The mixed design analysis documented positive experiences for individuals who reported to be better prepared for consultations and treatments with information provided by more than one source. Negative experiences with physicians were reported by both women and men but the former was about quality of cancer information provided and the latter in terms of quantity.

CONCLUSIONS

A mixed methods approach allowed a deeper understanding of the role of informational support on subsequent use of health care services by individuals with cancer. Further studies may include other types of cancer and diverse background characteristics to clarify how informational support and subsequent use of health services may be jointly determined by these factors.

Clinicians' defences: An empirical study

OBJECTIVE

Clinicians' defence mechanisms are strategies used to manage the stress and the negative affects emerging during a therapy session. The first objective of the study is to adapt the defence mechanisms rating scales (DMRS), originally created by Perry for assessing patient defences, in order to evaluate clinician defences. The second objective is to explore the type of defence mechanisms used by clinicians in oncology. The third objective is to study the sensitivity of the instrument by assessing changes in defensive functioning after specific communication skills training (CST) in oncology.

DESIGN

Participants (N=20) were oncology clinicians participating in oncology CST. The defence mechanism rating scales for clinicians (DMRS-C) was used to assess the use of the clinicians' defences before and after CST.

RESULTS

The instrument showed promising preliminary psychometric properties. Numerous and very varied defences were coded in each session and corresponding to a great variety of defences. After CST, the clinicians' overall defensive functioning (ODF) increased. Considering the defences' levels, a decrease in the use of immature defences was observed.

CONCLUSIONS

Taking into consideration the importance of clinicians' variables in treatment outcome, this instrument constitutes a promising way of assessing the clinician's strategies used to face the emotional difficulties emerging during the therapeutic encounter.

Shifting goals in medical communication. Determinants of goal detection and response formation

OBJECTIVES

Research and education of medical communication different perspective, making the extraction of clear recommendations from research that can be applied in education not always possible. In education, medical communication is encountered from a goal-oriented perspective, which is often lacking in quantitative research where the relationship between process variables and the content of medical practice is often ignored. The aim of this paper is to bring the worlds of research and education together by presenting a comprehensive model of determinants explaining the behavior of physicians in daily practice. A basic notion in this model is that medical communication is goal-oriented, problem-solving behavior. Goals in communication are not fixed, but permanently changing over time. Hence, communication abilities do not rely on behavioral skills only but also on perceptual skills in identifying goals. A number of determinants affect the cognitive processes of goal appraisal and response formation: knowledge, attitudes, social norms, self-efficacy, stressors and interfering goals.

CONCLUSION

Modeling medical communication as goal-oriented problem-solving behavior, and recognizing the complexity of goal appraisal and other key determinants of response formation may provide a common focus for both research and education in measuring, explaining and improving the HCP's behavior.

PRACTICE IMPLICATIONS

In education not only skill practicing but also reflection on the process and outcomes is important to understand how one acts in practice situations and should act in future situations. In research measurements should be expanded to take contextual and goal-oriented dimensions of the process of communication into account to make findings more relevant for education and practice.

Cultural aspects of communication in cancer care

Cultural competence in oncology requires the acquisition of specific knowledge, clinical skills, and attitudes that facilitate effective cross-cultural negotiation in the clinical setting, thus, leading to improved therapeutic outcomes and decreased disparities in cancer care. Cultural competence in oncology entails a basic knowledge of different cultural attitudes and practices of communication of the truth and of decision-making styles throughout the world. Cultural competence always presupposes oncology professionals' awareness of their own cultural beliefs and values. To be able to communicate with cancer patients in culturally sensitive ways, oncologists should have knowledge of the concept of culture in its complexity and of the risks of racism, classism, sexism, ageism, and stereotyping that must be avoided in clinical practice. Oncologists should develop a sense of appreciation for differences in health care values, based on the recognition that no culture can claim hegemony over others and that cultures are evolving under their reciprocal influence on each other. Medical schools and oncology training can teach communication skills and cultural competence, while fostering in all students and young doctors those attitudes of humility, empathy, curiosity, respect, sensitivity, and awareness that are needed to deliver effective and culturally sensitive cancer care.

Quality of life in long-term survivors of ovarian germ cell tumors: a Gynecologic Oncology Group study

PURPOSE

This report describes the strength and significance of the association between antecedent and mediating variables across four categories of quality of life (QOL) outcomes in 132 disease free women with ovarian germ cell survivors.

METHODS

Survivors (n=132) participated in a mailed questionnaire and computer-assisted telephone survey. Participants in four prospective GOG protocols were contacted their treating physician for verbal consent to be approached by investigators at the Indiana University Cancer Center about a quality of life study. Similar patients treated at the MD Anderson Cancer Center were also included. If women verbally consented after being contacted by investigators at Indiana University, an informed consent and questionnaire packet was sent via mail. After return of the written informed consent and background questionnaire, a trained research assistant scheduled a computer-assisted interview to complete data collection.

RESULTS

Median follow-up from diagnosis was 10.2 years. Mediating variables of self-efficacy or social support played a significant role (p=0.05 to p=0.001) in all four QOL categories: physical functioning, psychological functioning, sexual functioning, and spiritual functioning. Being a younger age at diagnosis and married were positively related to sexual functioning (p=0.05). Menstrual and gynecological symptoms were inversely related.

IMPLICATIONS

Results indicate that clinicians may want to be especially sensitive to identifying a survivor's social support and confidence (self efficacy) in handling issues evolving from treatment since these skills may be related to overall quality of life outcomes.

Cultural aspects of communication in cancer care

Cancer is increasing in incidence and prevalence worldwide, and the WHO has recently included cancer and its treatments as a health priority in developed and developing countries. The cultural diversity of oncology patients is bound to increase, and cultural sensitivity and competence are now required of all oncology professionals. A culturally competent cancer care leads to improved therapeutic outcome and it may decrease disparities in medical care. Cultural competence in medicine is a complex multilayered accomplishment, requiring knowledge, skills and attitudes whose acquisition is needed for effective cross-cultural negotiation in the clinical setting. Effective cultural competence is based on knowledge of the notion of culture; on awareness of possible biases and prejudices related to stereotyping, racism, classism, sexism; on nurturing appreciation for differences in health care values; and on fostering the attitudes of humility, empathy, curiosity, respect, sensitivity and awareness. Cultural competence in healthcare relates to individual professionals, but also to organizations and systems. A culturally competent healthcare system must consider in their separateness and yet in there reciprocal influences social, racial and cultural factors. By providing a framework of reference to interpret the external world and relate to it, culture affects patients' perceptions of disease, disability and suffering; degrees and expressions of concern about them; their responses to treatments and their relationship to individual physicians and to the healthcare system. Culture also influences the interpretation of ethical norms and principles, and especially of individual autonomy, which can be perceived either as synonymous with freedom or with isolation depending on the cultural context. This, in turn, determines the variability of truth-telling attitudes and practices worldwide as well as the different roles of family in the information and decision-making process of the cancer patient. Finally, culture affects individual views of the patient-doctor relationship in different contexts.

What do we know about facilitating patient communication in the cancer care setting?

Throughout the cancer diagnosis and treatment period, patients interact with multiple healthcare providers. In order to facilitate these communications, researchers have developed interventions primarily for providers, and, more recently, for patients. The aim of this paper is to conduct a critical examination of a sample of the empirical literature regarding current knowledge about the types of interventions that have been designed to facilitate cancer patients' communication with their healthcare providers. Overall, the empirical literature suggests that some types of patient-based interventions (e.g. prompt sheets, audiotapes, coaching sessions) may be beneficial in specific areas (e.g. increasing the number of questions asked, increased patient satisfaction). However, there are few consistent findings and the outcome measures that have been examined have varied substantially across studies. More controlled studies using carefully chosen outcome variables are needed. Increasing patients' communication skills so that their goals are met has the potential to positively affect the communication process.

Patient-professional communication research in cancer: an integrative review of research methods in the context of a conceptual framework

This paper uses the conceptual framework of Feldman-Stewart et al. to organize and review the types of research methodologies used to investigate various aspects of patient-health care professional communication in the context of cancer. Research methods employed are classified as either non-experimental or experimental. Non-experimental designs include naturalistic observational studies (e.g. participant observation, audio- or videotaping of interactions) and retrospective introspective descriptions (e.g. self-report questionnaires, qualitative interview methods). Experimental designs often involve interventions aimed at improving communication, such as physician or patient training, and the use of technology to enhance communication (e.g. audiotapes, computers). Using the conceptualization of the communication framework description, we argue that the outcome measures used in these studies address either primary goals, enabling goals, or secondary communication outcomes. Outcomes that are related to primary goals of the communication exchange include assessing the level of understanding of information conveyed, aspects of decision making, planning around treatments, or general provision of care. Outcomes related to enabling goals focus on elements that affect the ability to achieve primary goals. Outcomes secondary to the communication do not relate directly to what the communication is attempting to achieve. We conclude by identifying priority areas for further research, such as identifying the goals of both participants, understanding how particular aspects of the communication process affect their ability to achieve their goals, and examining the external environment in which communication takes place.