Clinician Confidence About Conversations at the End of Life Is Strengthened Using the Four Habits Approach

Communicating about cancer is not easy. At a time when patients are asked to make complicated choices about treatment and to be responsible for most of their own care, communication problems are consistently presented as a barrier to satisfactory medical treatment. This article identifies problems in communication and describes interventions the multidisciplinary team can use to improve the exchange of information and feelings among patients, families, and health care providers. The specific focuses are communication at the time of diagnosis and during progressive disease and the challenges and difficulties of communicating about pain, sexual functioning, and financial problems throughout the cancer experience.     

Medical oncology job satisfaction: Results of a global survey

Background

While physician burnout is increasingly recognized, little is known about medical oncologist job satisfaction, and the factors associated with low satisfaction. Here, we report the results of an international survey of medical oncologists.

The Seventh Door

An oncologist reflects on the personal toll physicians experience while taking care of the very sick and the journey they must take, facing real and perceived failures when patients suffer poor outcomes, to find the renewed energy to go on with their chosen mission.     

Japanese physicians encounter various ethical dilemmas in medical decisions concerning the end of life

Background. Medical decisions concerning the end of life (MDEL) have recently been the subject of sustained ethical debate in Japan. However, no study has been undertaken to provide a picture of the kinds of ethical dilemmas Japanese physicians encounter in their care of the terminally ill. We therefore conducted a national survey of Japanese physicians involved in medical care for the terminally ill in their everyday practice. Methods. A postal questionnaire was sent to 500 physician members of the Japan Society of Cancer Therapy for an inquiry into their experience on ethical dilemmas in MDEL. Results. A total of 339 physicians (68%) responded, of whom 11% answered that they were always, 26% often, and 39% sometimes perplexed by ethical dilemmas in MDEL. A total of 386 dilemmas were reported by 267 respondents as the most perplexing, including those related to decisions about life-sustaining treatment, patients' families' demands or requests for medical care, patients' refusal of or demand for medical care, and truth-telling to a terminal cancer patient. Many respondents wondered whether cardiopulmonary resuscitation should be performed for a terminally ill patient, in what situation life-sustaining treatment should be withheld, and whose wishes for medical care should be prioritized in the face of disagreement between patients and their families. Conclusion. Our study suggests that Japanese physicians are faced with various perplexing ethical dilemmas. Serious efforts to resolve these problems in research, education, and physician-patient communication are imperative.     

Physicians are different when they learn communication skills: influence of the locus of control

PURPOSE: Although it is widely recognised that educational interventions may be more effective for people with an 'internal' Locus of Control (who believe that life outcomes are controlled by their own characteristics or actions) compared to people with an 'external' Locus of Control (who believe that life outcomes are controlled by external forces such as luck, fate or others), no study has yet assessed the influence of physicians' Locus of Control (LOC) on communication skills learning. This study aims to test the hypothesis that, in a communication skills training program, physicians with an 'internal' LOC would demonstrate communication skills acquisition to a greater degree than those with an 'external' LOC. METHODS: A non-randomised longitudinal intervention study was conducted between January 1999 and April 2001. Sixty-seven volunteer physicians from private and institutional practice in Belgium participated in a learner-centred, skills-focused, practice-oriented communication skills training program. Communication skills changes were assessed in 2 standardised simulated interviews before and after training (one two-person and one three-person interview). Communication skills were assessed using the Cancer Research Campaign Workshop Evaluation Manual. Physicians' LOC was assessed using the Rotter I-E scale. Communication skills changes of the upper and lower third of physicians in respect of their scores on this scale were compared using group by time repeated measures of variance. RESULTS: In the two-person and three-person interviews, changes in the use of open directive questions were more important among physicians with an "internal" LOC compared with changes observed among physicians with an 'external' LOC (P=0.066 and P=0.004, respectively). In the three-person interview, changes in the use of directive questions, assessing functions and moderate feelings stated explicitly were more important among physicians with an 'internal' LOC compared with changes observed among physicians with an 'external' LOC (P= 0.001; P=0.002 and P=0.011 respectively). CONCLUSION: This study shows that physicians' LOC is a psychological characteristic that could influence the efficacy of a communication skills training program. This evidence supports the idea that a psychological characteristic such as 'internal' LOC may facilitate communication skills acquisition through physicians' belief that communication with patients may be controlled by physicians themselves.     

Odyssey of hope: a physician’s guide to communicating with brain tumor patients across the continuum of care

The optimal treatment of a patient with a malignant brain tumor requires attention to the physical and emotional well-being of the affected individual and the family. We review the concept of hope as a critical support modality throughout the continuum of care for brain tumor patients and families. We offer suggestions based on our own observations over 17 years as well as the lessons taught to us by our patients and their families over that time and through a structured interview process. Just as despair can come to one another only from other human beings, hope, too, can be given to one only by other human beings —Elie Wiesel     

妇科肿瘤学的一些问题及妇科肿瘤专科医师培养

[编者按] 科学研究贵在创新,这是科技工作追求的境界.然而,创新不可能一蹴而就,更非空中楼阁,而是由长期实践经验积淀做基础的.所以,前人经验的传承实为后人创新的必要借鉴.为此,本刊遵循百家争鸣的方针,特邀请毕生从事科学探索并卓有贡献的老专家,就自己的实践感悟,包括学术思想、研究思路、方法经验、成败得失等,撰写一批具有独到见解和反思精神的文章,陆续发表在本栏内,以飨读者,希望对科研临床工作能有所启迪.     

Measuring psychosocial outcomes: is the consumer or the professional the best judge?

In this review, we explore professionally‐driven and consumer‐driven paradigms in measuring psychosocial outcomes for cancer care. Early measures of psychosocial well‐being focussed on clinically‐derived concepts of dysfunction. Recent literature reflects a paradigm shift toward a consumer‐driven approach to the conceptualisation and measurement of psychosocial well‐being. The key distinction between the two approaches rests on whether the professional or consumer retains judgement authority and raises the question of whether it is necessary to include both perspectives in research and practice. Research is proposed to clarify our interpretation of these approaches with a view to devising novel interventions to benefit patient well‐being.     

Physician factors associated with discussions about end‐of‐life care

BACKGROUND:

Guidelines recommend advanced care planning for terminally ill patients with <1 year to live. Few data are available regarding when physicians and their terminally ill patients typically discuss end‐of‐life issues.

METHODS:

A national survey was conducted of physicians caring for cancer patients about timing of discussions regarding prognosis, do not resuscitate (DNR) status, hospice, and preferred site of death with their terminally ill patients. Logistic regression was used to identify physician and practice characteristics associated with earlier discussions.

RESULTS:

Among 4074 respondents, 65% would discuss prognosis “now” (defined as patient has 4 months to 6 months to live, asymptomatic). Fewer would discuss DNR status (44%), hospice (26%), or preferred site of death (21%) immediately, with most physicians waiting for patient symptoms or until there are no more treatments to offer. In multivariate analyses, younger physicians more often discussed prognosis, DNR status, hospice, and site of death “now” (all P < .05). Surgeons and oncologists were more likely than noncancer specialists to discuss prognosis “now” (P = .008), but noncancer specialists were more likely than cancer specialists to discuss DNR status, hospice, and preferred site of death “now” (all P < .001).

CONCLUSIONS:

Most physicians report they would not discuss end‐of‐life options with terminally ill patients who are feeling well, instead waiting for symptoms or until there are no more treatments to offer. More research is needed to understand physicians' reasons for timing of discussions and how their propensity to aggressively treat metastatic disease influences timing, as well as how the timing of discussions influences patient and family experiences at the end of life. Cancer 2010. © 2010 American Cancer Society.     

Factors Influencing Delayed Presentation of Congenitally Hearing Impaired Children in Rural India

A study was conducted to determine why there was a delay in detection of hearing loss in congenitally hearing impaired children in rural India. It was found that although the parents of these children visited a primary care physician, relevant information regarding investigation and rehabilitation of hearing loss was not available to the patient. In the absence of a universal hearing screening programme in this country, it is a matter of importance to strengthen this aspect of community otolaryngology in the undergraduate ENT programme. There is also a need for continuing medical education programmes for primary care physicians regarding available methods of investigation and rehabilitation for a hearing impaired person.     

The views and practice of oncologists towards nutritional support in patients receiving chemotherapy

Malnutrition in patients with cancer is common and an adverse prognostic indicator. A questionnaire answered by 357 (72%) UK specialist oncological trainees suggests that they lack the ability to identify factors that place patients at risk from malnutrition. Major barriers to effective nutritional practice included lack of guidelines, knowledge and time.     

An evaluation of clinical follow-up in women with early stage breast cancer among physician members of the American Society of Clinical Oncology

Summary Routine clinical follow-up for distant metastatic disease among women with early stage breast cancer is of uncertain clinical benefit. In order to evaluate current practice patterns, we administered a mailed survey to a stratified random sample of physician members of the American Society of Clinical Oncology (ASCO) (N = 435). The survey assessed the frequency and motivation for ordering follow-up medical tests in asymptomatic postmenopausal women with stage I or II breast cancer. The response rate was 55%, distributed as 39% radiation oncologists, 32% medical oncologists, and 29% surgeons. In the first year after treatment, physicians performed, on average, one physical examination every 3 months, one blood panel (CBC, alkaline phosphatase and liver function tests) every 4 months, and one chest radiograph every 9 months. In addition, 38% of the respondents ordered CEA and 21% ordered CA 15-3 levels, 28% ordered bone scans, and less than 4% ordered CT scans, bone surveys, or bone marrow biopsies in the first year after treatment. A logistic regression analysis controlling for physician age, gender, sub-specialty, practice type, years of experience, number of breast cancer patients treated annually, geographic region, and community size, showed that surgeons were less likely to order blood tests (p < 0.001) and tumor markers (p < 0.0029) than medical oncologists in years 3 and 5 of follow-up. Compared to physicians practicing in the northeast, those from the midwest were less likely to order chest radiographs in year 3 of follow-up (p = 0.0028). Other provider characteristics had no significant effect on test ordering behavior. The results of this survey suggest that relatively uniform practice patterns in regard to the follow-up of postmenopausal women with early stage breast cancer exist among ASCO physicians.     

Health care strategies to promote earlier presentation of symptomatic breast cancer: perspectives of women and family physicians

Background

Many women with symptoms suggestive of a breast cancer diagnosis delay presentation to their family physician. Although factors associated with delay have been well described, there is a paucity of data on strategies to mitigate delay.

Objectives

We conducted a qualitative research project to examine factors related to delay and to identify health care system changes that might encourage earlier presentation.

Methods

Individual semi-structured interviews were conducted with women who sought care 12 weeks or more after self-detection of breast cancer symptoms and with family physicians whose practices included patients meeting that criterion.

Results

The women and physicians both suggested a need for clearer screening mammography guidelines for women 40–49 years of age and for better messaging concerning breast awareness. The use of additional hopeful testimonials from breast cancer survivors were suggested to help dispel the notion of cancer as a “death sentence.” Educational initiatives were proposed, aimed at both increasing awareness of “non-lump” breast cancer symptoms and advising women that a previous benign diagnosis does not ensure that future symptoms are not cancer. Women wanted empathic nonjudgmental access to care. Improved methods to track compliance with screening mammography and with periodic health exams and access to a rapid diagnostic process were suggested.

Conclusions

A list of “at-risk situations for delay” in diagnosis of breast cancer was developed for physicians to assist in identifying women who might delay. Health care system changes actionable both at the health policy level and in the family physician’s office were identified to encourage earlier presentation of women with symptomatic breast cancer.     

Knowledge and attitudes of physicians in Iran with regard to chronic cancer pain.

BACKGROUND AND AIM: The knowledge and attitudes of health care professionals with regard to pain and its impact on the patient are among identified barriers that prevent health care professionals from providing effective treatment for pain. The purpose of the present study was to evaluate knowledge about and attitudes towards cancer pain and its management in Iranian physicians with patient care responsibilities. METHODS: We surveyed 122 physicians in six university hospitals in Tehran. Fifty-five (45.1%) questionnaires were completed. RESULTS: The majority of physicians (76%) recognized the importance of pain management priority and about one half of the physicians acknowledged the problem of inadequate pain management in their settings. Most cited inability to access professionals who practice specialized methods in this field, and inadequate staff knowledge of pain management as barriers to good pain management. A large majority of them expressed dissatisfaction with their training for pain management in medical school and in residency. Furthermore a considerable widespread knowledge deficit among all medical subspecialties and all levels of experience was noted which was significantly more profound in the non-oncologists group and only correlated poorly with number of total treated patients in past 6 months. CONCLUSION: The most significant barrier to the effective management of pain in cancer patients in Iran is deficit in knowledge as identified in this survey. A combination of an active continuing education program on both the international guidelines with routine professional education and dissemination of guidelines is needed to bring about significant improvement in cancer pain control.     

Burnout and psychiatric morbidity among physicians engaged in end-of-life care for cancer patients: a cross-sectional nationwide survey in Japan

PURPOSE: To determine the prevalence of burnout and psychiatric morbidity among physicians engaged in end-of-life care for cancer patients in Japan and to explore associated factors related to end-of-life care. METHODS: Questionnaires were mailed to 1436 Japanese clinical oncologists and palliative care physicians with a request to complete the Maslach Burnout Inventory (MBI), the General Health Questionnaire (GHQ-12), and to report on individual factors, including confidence in patient care. High levels of burnout and psychiatric morbidity were identified using cut-off scores of the MBI and GHQ-12. RESULTS: A total of 697 physicians returned the questionnaires (response rate, 49.6%). Twenty-two percent of the respondents had a high level of emotional exhaustion, 11% had a high level of depersonalization, 62% had a low level of personal accomplishment, and 20% had psychiatric morbidity. Clinical oncologists showed a significantly higher psychiatric morbidity than palliative care physicians. Confidence in having sufficient time to communicate with patients was significantly associated with all the burnout subscales. CONCLUSIONS: A low level of personal accomplishment was relatively high among Japanese physicians compared with previous studies. Insufficient confidence in the psychological care of patients was associated with physician burnout rather than involvement in end-of-life care.