Important Outcomes of Communication
Patient satisfaction reflects how well patient health care needs, expectations, or preferences are met. The measurement of satisfaction with patient care is complicated by a patient bias to skew responses in favor of high satisfaction scores. In oncology, some studies support the concept that communication skills are related to patient satisfaction in several areas. Specifically, several studies relate patient satisfaction to psychological adjustment, including patient satisfaction with the amount and kind of information provided at the time of diagnosis; clinician willingness to discuss treatment options; patient perception of the oncologist as caring, attentive, or emotionally supportive;[3-5] and patient rating of communication with the physician. Basic communication skills have also been related to satisfaction in other studies,[6,7] which have demonstrated that among gynecology and medical oncology patients, satisfaction was associated with attentiveness, interest, and friendliness and with providing information. These findings among oncology patients parallel those found in other medical specialties.
Informed decision making is an essential component of the ethical practice of prescribing cancer treatments and conducting research. However, fully involving patients in clinical decision making is a challenging task for physicians, who nonetheless have been urged in recent years to take a less legalistic and more interactive approach with patients in explaining treatments.[8,9] The aim of informed consent is to emphasize more effective communication between patients and physicians, where information disclosure and patient participation in decision making are the goals rather than the notions of an administrative requirement to have patients sign a document or to protect a physician from legal liability. Such a dialogue would also allow the clinician to determine how much information a patient actually desires and would respect the patient’s right to shun information that might be unwanted.[10,11]
There are few data to describe how oncologists practice informed consent, and there are inadequate guidelines for communicating with patients about treatment decisions. The best information comes from studies of communication in clinical trials, which show that oncologists scored poorly on measures of the quality of the information provided to the patient and explanation of randomization, implicitly expressing favoritism of one treatment over another; that physicians overestimate patient satisfaction with specific treatment information; and that not all patients understand the unproven nature of the treatment. Inflexibility in the timing of information may represent a physician barrier to clinical trial recruitment. For example, treatment of breast cancer for patients on clinical trials cannot begin until the patient has signed the informed consent form. This requirement effectively compels physicians to reveal information to patients soon after the diagnosis is confirmed. Sixty-one percent of the physicians in one study  explained that they would have preferred to tell patients about their diagnosis and prognosis in small increments. They argued that patients need time to absorb the shock of the diagnosis before hearing a detailed description of the uncertainty of treatment options but that the need to obtain informed consent constrained their schedule for disclosure to patients.
The reason that eligible patients decline participation in clinical trials has been explored in several studies, which reflect many of the issues surrounding inadequate communication. In one study, patients were found more likely to participate in clinical trials when their physicians were cordial, able to establish trust and rapport with the patient, and attentive to patient concerns. Other than increasing monetary incentives to the investigators conducting the studies, few interventions have been successful at finding ways to improve accrual to clinical trials in oncology, including an intervention study to improve communication about randomized clinical trials  and an intervention program designed to increase the enrollment of rural American patients who have cancer. A pilot study that examined barriers to the participation of African American patients with cancer in clinical trials concluded that factors associated with religion, education, and income rather than race may be major barriers to clinical trial participation. The authors of the study concluded that interventions that target education and income could increase the recruitment of African American oncology patients onto clinical trials. More work in this area is needed to increase the participation of all oncology patients in clinical trials, regardless of race or educational and income level.
Interventions to improve the informed consent process also show that having a study team member or educator spend more time talking one-on-one with the patient to improve understanding of clinical trials are more successful than the use of multimedia or enhanced consent forms. One study using a staged approach in which parents or guardians consented to more limited segments of treatment showed promise.
A small number of physicians appears to generate a disproportionate number of lawsuits. Although there are a number of risk factors for malpractice claims—including physician specialty, number of patients seen, and physician characteristics—they do not seem to be predicted by the characteristics of a physician’s patients, the technical aspects of care, or the complexity of care. Rather, patient dissatisfaction—especially with the interpersonal aspects of care—seems to be an important determining factor. These interpersonal aspects include the following:
- Time spent with the patient.
- Ability of the physician to meet patient expectations for care.
- Ability of the physician to convey information to the patient.
- Physician concern for patient worries.
- Friendliness and courteousness of the physician.
Other but more scarce research has suggested that communication skills are also related to patient retention, compliance with treatment, practitioner burnout, collaboration among oncology teams, and increased difficulty in transitioning to palliative care.
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