Factors which motivate cancer doctors to involve their patients in reaching treatment decisions

Objective

Cancer patients increasingly expect to be involved in treatment decision-making. We investigated factors that motivate cancer doctors to involve their patients in treatment decisions.

Methods

We conducted 22 telephone interviews with doctors treating breast, colorectal, gynaecological, haematological or prostate/urological cancer. Interviews probed doctors for attitudes to shared decision-making (SDM), views of when patient involvement is appropriate and what motivated them to encourage involvement. Interviews were audio-recorded. Themes were identified using framework analysis.

Results

Cancer doctors described disease, patient, doctor and societal influences on their support for patient involvement in treatment decisions. Treatment recommendations were described as ‘clear-cut’ or ‘grey’. When treatment options were clear-cut, the impact of treatment on patients’ quality of life and self-image and the influence of consumer groups motivated doctors’ support of patient involvement.

Conclusion

Australian cancer doctors express differing support of patient involvement in decision-making dependent on context, impact and effect that involvement may have. Doctors described meeting patient involvement preferences as a challenge, and needing to identify different characteristics, anxiety levels and levels of understanding to guide them to involve patients in decisions.

Practice implications

Models of shared decision-making may warrant refinement to better guide doctors to elicit and discuss information and involvement preferences.     

Patient validation of cues and concerns identified according to Verona coding definitions of emotional sequences (VR-CoDES): A video- and interview-based approach

Objective

A challenging but main task for clinicians is to identify patients’ concerns related to their medical conditions. The study aim was to validate a new coding scheme for identifying patients’ cues and concerns.

Methods

12 videotaped consultations between nurses and pain patients were coded according to the Verona Coding Scheme for Emotional Sequences (VR-CoDES). During a metainterview each patient watched his/her own video interview with the researcher to confirm or disconfirm the identified cues and concerns. A directive or an open format was applied. Quantitative and qualitative data analyses were performed.

Results

Patients’ confirmation in relation to the coding gave a sensitivity of 0.95 and specificity of 0.99 in the directive format and a sensitivity of 0.99 and specificity of 0.70 applying the open format. Through a qualitative analysis 83% of researcher-identified cues and concerns were validated. 17% were not confirmed or uncertain.

Conclusion

The VR-CoDES seems to capture what are experienced as real concerns to patients, and proves to be a coding scheme with a high degree of ecological validity.

Practice implications

The VR-CoDES provides a valid framework for detecting patients’ cues and concerns, and should be explored as a training tool to develop clinicians’ empathic accuracy.     

Shared decision making in medicine: The influence of situational treatment factors

Objective

Although shared decision making (SDM) has become increasingly important in bioethical discussions and clinical practice, it is not clear in which treatment situations SDM is suitable. We address this question by investigating social norms on the appropriateness of SDM in different situations.

Methods

We conducted qualitative expert interviews with patients, general practitioners, and health administration and research professionals.

Results

SDM was considered to be most important in severe illness and chronic condition. Furthermore, SDM was indicated to be required if there is more than one therapeutic option, especially if it is not clear which option is best. Interviewees classified end-of-life decisions and decisions about prevention as those that primarily should be made by informed patients. On the other hand a paternalistic decision was considered most appropriate in emergency situations and when the patient does not want to participate in decision making.

Conclusion

This study demonstrates that multiple situational factors and their interactions must be considered regarding the scope of SDM in medical consultation.

Practice implications

Research addressing this question will help physicians adjust their consultation style and allow implementations of SDM and decision aids to be tailored more appropriately to complex treatment situations.     

Measuring providers' verbal and nonverbal emotion recognition ability: reliability and validity of the Patient Emotion Cue Test (PECT)

Objective

To describe the development and validation of the Patient Emotion Cue Test (PECT) as a tool to measure providers’ emotion cue recognition ability.

Methods

The PECT consists of 47 video clips depicting emotion cues that systematically vary in intensity of both verbal and nonverbal contents. The PECT assesses the provider's ability to detect and identify patients’ emotion cues accurately. A multi-stage development process produced the PECT. Reliability and validity were assessed in three studies.

Results

Scores on the PECT are normally distributed with significantly above chance responding. Across three studies, the PECT demonstrates convergent validity through significant correlations with standardized tests representing multiple channels of emotion recognition, including the face, body, and voice. The PECT shows adequate inter-item and split-half reliability.

Conclusion

The PECT is an easily administered, reliable, and valid test of emotion cue recognition.

Practice implications

The PECT can be used in future research on providers’ emotion recognition ability, for evaluating self-assessment of ability, and as a teaching tool in medical schools.     

Effects of an interactive tailored patient assessment tool on eliciting and responding to cancer patients' cues and concerns in clinical consultations with physicians and nurses

Objective

To test the effect of Choice, an interactive tailored patient assessment tool (ITPA), on cancer patients’ expressed cues and concerns (C&Cs), and clinicians’ responses to these C&Cs.

Methods

97 experimental group consultations, where patients used the Choice ITPA to report their symptoms and problems in preparation to their consultation, were compared to 99 control group consultations. All consultations were audio-taped and coded using the Verona Coding Definitions of Emotional Sequences (VR-CoDES).

Results

We identified 473 cues and 109 concerns with a mean number of 3.0 (SD = 3.2). The most frequent utterance was cue B (45.2%), indicating expression of uncertainty or hope. We found more C&Cs in consultations with the Choice ITPA compared to the control group (p < 0.01), and in consultations with nurses compared to physicians (p < 0.001). No differences in clinicians’ response types in the two groups were found. However, significant differences in response type between nurses and physicians were found.

Conclusion

The Choice ITPA was an effective tool to disclose cancer patients’ cues and concerns.

Practice implications

The Choice ITPA proved to be an effective intervention for cancer patients to express more C&Cs, but should be accompanied with communication skills training to potentially produce more patient-centered responses from the clinicians. (ClinicalTrials.gov number NCT00857103.)     

How information about other people's personal experiences can help with healthcare decision-making: a qualitative study

Objective

To investigate people's views of using ‘general facts’ and information about other people's ‘personal experiences’ for health-related decision-making.

Methods

Sixty-two people, who between them had experience of five different focal health issues, participated in 12 focus groups and 9 interviews. Exploration of uses of the two types of information was supported by discussion of illustrative excerpts.

Results

There was less discussion of ‘general facts’; participants thought it obvious that good decisions required these. Participants reported having used ‘personal experiences’ information to: recognise decisions that needed consideration; identify options; appraise options and make selections (including by developing and reflecting on their reasoning about possible choices); and support coping strategies. Their inclination to use ‘personal experiences’ information was apparently moderated by assessments of personal relevance, the motives of information providers and the ‘balance’ of experiences presented.

Conclusion

People can use ‘personal experiences’ information in various ways to support their decision-making, and exercise some discrimination as they do.

Practice implications

‘Personal experiences’ information may help people in a number of ways in relation to decision-making. However, ‘personal experiences’ information does not replace the need for ‘general facts’ and care should be taken when it is used in resources for patients.     

Doctors in a Southeast Asian country communicate sub-optimally regardless of patients' educational background

Objective

To explore the relationship between the style of doctor-patient communication and patients’ educational background in a Southeast Asian teaching hospital setting using the Roter Interaction Analysis System (RIAS).

Methods

We analyzed a total of 245 audio-taped consultations involving 30 internal medicine residents with 7-10 patients each in the internal medicine outpatient clinics. The patients were categorized into a group with a high and a group with a low educational level. We ranked the data into 41 RIAS utterances and RIAS-based composite categories in order of observed frequency during consultations.

Results

The residents invariantly used a paternalistic style irrespective of patients’ educational background. The RIAS utterances and the composite categories show no significant relationship between communication style and patients’ educational level.

Conclusion

Doctors in a Southeast Asian country use a paternalistic communication style during consultations, regardless of patients’ educational background.

Practice implication

To approach a more partnership doctor-patient communication, culture and clinical environment concern of Southeast Asian should be further investigated.     

More than words: Patients’ views on apology and disclosure when things go wrong in cancer care

Objective

Guidelines on apology and disclosure after adverse events and errors have been in place for over 5 years. This study examines whether patients consider recommended responses to be appropriate and desirable, and whether clinicians’ actions after adverse events are consistent with recommendations.

Methods

Patients who believed that something had gone wrong during their cancer care were identified. During in-depth interviews, patients described the event, clinicians’ responses, and their reactions.

Results

78 patients were interviewed. Patients’ valued apology and expressions of remorse, empathy and caring, explanation, acknowledgement of responsibility, and efforts to prevent recurrences, but these key elements were often missing. For many patients, actions and evidence of clinician learning were most important.

Conclusion

Patients’ reports of apology and disclosure when they believe something has gone wrong in their care suggest that clinicians’ responses continue to fall short of expectations.

Practice implications

Clinicians preparing to talk with patients after an adverse event or medical error should be aware that patients expect their actions to be congruent with their words of apology and caring. Healthcare systems need to support clinicians throughout the disclosure process, and facilitate both system and individual learning to prevent recurrences.     

Using freelisting to understand shared decision making in ADHD: Parents’ and pediatricians’ perspectives

Objective

To compare and contrast notions of ADHD among pediatricians and parents of affected children to understand the perspectives they bring to shared decision making (SDM).

Methods

In this freelisting study, 60 parents of children with ADHD and 30 primary care pediatricians listed words reflecting their understanding of (1) Attention Deficit Hyperactivity Disorder (ADHD), (2) getting/offering help for ADHD, (3) talking to doctors/families about ADHD, and (4) “mental health.” Smith's salience score established terms that were salient and cultural consensus analysis identified variation within subgroups of participants.

Results

Parents’ terms reflected ADHD's effects on the child and family, while clinicians often mentioned school. Lists suggested differing needs and goals for clinicians and subgroups of parents in SDM: “time” for clinicians, “learning” and “understanding” for non-college educated parents, and “comfort” and “relief” for college educated parents. Neither parents nor clinicians framed ADHD in the same way as “mental health.”

Conclusion

Parents and clinicians, who conceptualize ADHD differently, should negotiate a shared understanding of ADHD as a basis for SDM. Treatment discussions should be tailored to encompass families’ varied emotional and educational needs.

Practice implications

Fostering SDM in primary care is consonant with notions of ADHD as distinct from mental health.     

Patients' perception of communication with clinicians during screening and discussion of cancer supportive care needs

Objective

Effective communication between patients and clinicians is an essential aspect of supportive care for cancer patients, however many patients find this communication is inadequate. This study examined cancer patients’ perception of communication with their clinician during a supportive care screening and discussion process and the ways in which this process assisted communication.

Methods

One hundred and fifty-four patients undertaking treatment for cancer in chemotherapy, radiotherapy and surgical units in six hospitals in Australia participated in a formal supportive care screening, discussion and referral process and were interviewed about their experiences.

Results

The majority of patients interviewed felt that the process enhanced communication by encouraging them to reflect on their needs, assisting them to initiate a discussion with the clinician, validating their needs, encouraging them to seek help and support and focusing clinician attention on unmet needs.

Conclusion

Patients perceived the formal process of supportive care improved communication between themselves and their clinicians.

Practice implications

Undertaking a patient-centred process of supportive care can assist clinicians to meet the unmet needs of patients with cancer and can increase patient satisfaction.     

Preferences and experiences of chronically ill and disabled patients regarding shared decision-making: Does the type of care to be decided upon matter?

Objective

(1) To describe the importance chronically ill and disabled patients attach to involvement in decision-making when various care types are considered, and (2) to analyse the degree to which these patients are involved in shared decision-making (SDM) regarding these care types, and whether their involvement reflects the importance they attach to SDM.

Methods

The study sample consisted of 812 chronically ill and disabled patients who experienced a situation of decision-making during the last year. Data were collected by a self-report survey in 2006 and were analysed by multilevel linear regression analyses.

Results

Participants attached most importance to SDM when occupational healthcare issues were at stake, but perceived their actual involvement in these decisions as relatively low. Patients dealing with decision-making regarding medical care or home care experienced higher levels of involvement. The importance attached to SDM corresponds moderately with the actual role patients experience in the decision-making process.

Conclusion

The type of care to decide upon impacts on the importance patients attach to SDM as well as on their actual involvement in decision-making.

Practice implications

We suggest healthcare practitioners to pay attention to the preferred level of patient involvement each time a new care issue has to be decided upon.     

Measuring the impact of nurse cue-response behaviour on cancer patients’ emotional cues

Objective

This study aimed to explore the impact of nurse responses to patients’ and family members’ emotional cues and concerns during the chemotherapy education consultation.

Methods

51 cancer patients and 13 nurses participated in this study. Nurse-delivered chemotherapy education sessions were audio-recorded, and patients completed the EORTC QLQ-C30 V3.0 questionnaire before the education. The audio records were transcribed and coded.

Results

Patients expressed their emotions more than family members, but patients’ cues decreased when family were present. Patients with lower emotional wellbeing (greater psychological distress) prior to the consultation did not express more cues/concerns. Nurses responded to patients’ and families’ cues equally in a cue-facilitative fashion. Facilitative responses were associated with decreased patients’ cues.

Conclusion

Family presence appears to hinder patients’ cues/concerns. Nurses’ PS responses were associated with less cues/concerns by patients.

Practice implication

The current study challenges the common assumption that a higher number of cues is indicative of effective consultation, and indicates the influence of family in patients’ cues/concerns.     

The impact of financial incentives on physician empathy: A study from the perspective of patients with private and statutory health insurance

Objective

We hypothesized that patients’ ratings of physician empathy (PE) would be higher among those with private health insurance (PHI, referring to financial incentive) than among patients with statutory health insurance (SHI).

Methods

A postal survey was administered to 710 cancer patients. PE was assessed using the Consultation-and-Relational-Empathy measure. T-tests were conducted to analyse whether PHI and SHI-patients differ in their ratings of PE and variables relating to contact time with the physician. Structural-equation-modelling (SEM) verified mediating effects.

Results

PHI-patients rated physician empathy higher. SEM revealed that PHI-status has a strong significant effect on frequency of talking with the physician, which has a strong significant effect (1) on PE and (2) has a moderate effect on patients’ perception of medical staff stress, thereby also affecting patients’ ratings of PE.

Conclusions

Our findings suggest that PHI-status is one necessary precondition for physicians spending more time with the patient. Spending more time with the PHI-patient has two major effects: it results in a more positive perception of PE and positively impacts PHI-patients’ perception of medical staff stress, which in turn, again influences PE.

Practical implications

Health policy should discuss these findings in terms of equality in receiving high-quality care.     

Using the Extended Health Belief Model to understand siblings’ perceptions of risk for hereditary hemochromatosis

Objective

This research focuses on individuals’ reactions to news that a sibling has been diagnosed with hereditary hemochromatosis (HH). We used the Extended Health Belief Model (EHBM) to frame our analysis of siblings’ perceptions of risk for HH and decision of whether to obtain diagnostic testing.

Method

60 patient and 25 sibling interviews were transcribed and thematically analyzed for the six components of the EHBM.

Results

Patient and sibling reports of siblings’ perceptions were categorized into the six components of the EHBM: susceptibility, severity, benefits, barriers, cue to action, and self-efficacy.

Conclusion

In the case of HH, siblings’ perceptions of HH are varied and include a range of motivators and barriers that may impact family-based detection. Family-based detection can often play an important part of effective public health strategies to address inherited risk of disease. Further research should examine the EHBM with other genetic conditions.

Practice implications

This analysis using the EHBM suggests areas of importance for message development for both medical personnel and HH patients to promote diagnostic testing of at-risk siblings.     

Behavioural research in patients with end-stage renal disease: A review and research agenda

Objective

To suggest a behavioural research agenda for patients with end-stage renal disease (ESRD) based on a concise review of seven stages of psychosocial research, a literature review, and current behavioural research in other chronic somatic diseases.

Methods

Historical behavioural ESRD research was classified. The specialized register of the Cochrane Behavioral Medicine Field was also checked, and additional papers were selected by screening reference lists and related behavioural science journals, to identify promising areas for future research.

Results

The top-five topics identified via the literature search pertain to (1) psychological aspects and interventions, (2) adaptation, coping, and depression, (3) exercise, (4) counseling and education, and (5) compliance. ‘Illness and treatment beliefs’, ‘sexuality’, ‘suicide’, ‘family support’, and ‘self-management interventions’, were identified on the basis of research in other chronic illnesses as topics for future research. Regarding theory, the Common-Sense Model (CSM) was judged to offer useful theoretical perspectives; regarding methods, qualitative methods can be a valuable addition to quantitative research methods.

Conclusion

Illness beliefs, treatment beliefs, and self-management behaviours are promising concepts in the assessment and clinical care of ESRD-patients. Cognitive-behavioural treatments appear to have potential and should be specified and elaborated for specific categories and problems of ESRD-patients.

Practice Implications

This research agenda is in line with moves towards patient-centred disease-management to improve the quality of medical care for ESRD-patients.     

Exploring the community pharmacist's role in palliative care: focusing on the person not just the prescription

Objective

Changes in health care provision have led to an emphasis on providing end of life care within the home. community pharmacists are well positioned to provide services to community-based palliative care patients and carers.

Methods

A multiple qualitative case study design was adopted. A total of 16 focus groups and 19 interviews with pharmacists, nurses, general practitioners and carers were undertaken across metropolitan and regional settings in Western Australia, New South Wales, Queensland and Victoria. Data were analysed thematically using a framework that allowed similarities and differences across stakeholder groups and locations to be examined and compared.

Results

Three main themes emerged: effective communication; challenges to effective communication; and: towards best practice, which comprised two themes: community pharmacists’ skills and community pharmacists’ needs.

Discussion

A key component of the provision of palliative care was having effective communication skills. Although community pharmacists saw an opportunity to provide interpersonal support, they suggested that they would need to develop more effective communication skills to fulfil this role.

Conclusion

There is clear need for continuing professional development in this area - particularly in communicating effectively and managing strong emotions.

Practice implications

Community pharmacists are willing to support palliative care patients and carers but need education, support and resources.     

Dyadic OPTION: Measuring perceptions of shared decision-making in practice

Background

Current models of the medical consultation emphasize shared decision-making (SDM), whereby the expertise of both the doctor and the patient are recognised and seen to equally contribute to the consultation. The evidence regarding the desirability and effectiveness of the SDM approach is often conflicting. It is proposed that the conflicts are due to the nature of assessment, with current assessments from the perspective of an outside observer.

Aims

To empirically assess perceived involvement in the medical consultation using the dyadic OPTION instrument.

Method

36 simulated medical consultations were organised between general practitioners and standardized- patients, using the observer OPTION and the newly developed dyadic OPTION instruments.

Results

SDM behaviours observed in the consultations were seen to depend on both members of the doctor and patient dyad, rather than each in isolation. Thus a dyadic approach to measurement is supported.

Conclusions

This current study highlights the necessity for a dyadic approach to assessment and introduces a novel research instrument: the dyadic OPTION instrument.