An evidence base for patient-centered cancer care: A meta-analysis of studies of observed communication between cancer specialists and their patients
Introduction
One unique contribution of health communication as a field of inquiry has been its focus on the health-related effects of observed (i.e., taped and coded, vs. self-reported) physician–patient communication variables [1]. In the last decade, with a worsening global cancer crisis [2], the physician–patient literature has been re-focusing its attention from primary care delivered by general-practice physicians to cancer care delivered by specialists (e.g., oncologists). The current (and relatively small) pool of studies of observed cancer communication suffer from two limitations. First, similar to a critique made 20 years ago by Roter et al. [3], different studies focus on different independent and dependent variables, and even similarly conceptualized (and labeled) variables tend to be differently operationalized. Second, studies suffer from reduced statistical power due to small sample sizes. Combined, these two limitations virtually prohibit empirically rigorous claims regarding the effects of particular communication behaviors on particular outcomes. Stated differently, these weaknesses stand as major barriers to achieving the goal of evidence-based medicine [4]. One solution to this problem is meta-analysis [5], [6], [7]. In the context of studies of observed communication between cancer specialists and their patients, this paper uses meta-analysis to investigate whether or not patient-centered care is significantly associated with patients’ health outcomes. This paper begins by briefly describing the unique ecology of cancer care, and then reviews patient-centered-care communication (Table 1).
The diagnosis of cancer most commonly emerges from biopsies and imaging tests ordered by patients’ primary-care physicians (e.g., internists), who then refer patients to specialists (e.g., oncologists). For this reason, studies of cancer-care communication between physicians and patients focus, almost exclusively, on visits that take place after patients are diagnosed with cancer (most exceptions to this are qualitative/discursive analyses of the delivery of ‘bad’ cancer news; e.g., Maynard [8]). In at least three ways, visits between patients who have already been diagnosed with cancer and specialists represent a unique ecology [9] for communication and its effects. First, there is evidence that, relative to primary-care physicians, specialists are less competent communicators [10] and more resistant to changing their communication skills [11]. From cancer patients’ perspectives, cancer-care specialists need to improve patient-centered aspects of their communication [12], [13]. Second, research has shown that the types of problems that get dealt with during medical visits – such as new acute problems (e.g., flu) and chronic-routine problems (e.g., diabetes) – differentially affects physicians’ and patients’ goals for visits, which differentially shapes the content and process of communication [14], [15]. Relative to most types of primary-care visits, the goals of many cancer-care visits are different and more narrow. For example, many cancer-care visits are with various types of oncologists and have the goal of developing treatment plans. These visits emphasize treatment information and decision making, and do not typically include a traditional problem presentation, history taking, physical examination, and diagnosis.
Third, relative to primary care, the psychosocial (vs. biomedical) dimension of illness (vs. disease) [16] is more pronounced when the problem is cancer [17]; i.e., relative to acute problems in primary care (e.g., flu, back pain, etc.) [18], cancer presents patients with higher levels of uncertainty, anxiety, fear, frustration, and vulnerability. Akin to organizational communication generally [19], physicians’ and patients’ discriminate between two underlying dimensions of communication: medical-technical (i.e., instrumental) and affective-relational [20]. The affective-relational dimension is particularly salient to patients. For example, patients do not abide strictly by a rational-consumer model of medicine. That is, patients seldom evaluate physicians and their medical care/competence, nor do patients retain physicians, based solely on physicians’ medical-technical skills and patients’ health outcomes [21]. Although patients base their evaluations of physicians’ communicative competence on both the instrumental and affective dimensions, which are positively correlated [22], [23], [24], there is an accumulation of evidence that patients’ evaluations of the quality of physicians’ and their medical care are influenced more heavily by the affective dimension [22], [25], [26]. In sum, the unique ecology of cancer-communication warrants an examination independent from that of primary care.
It is well established that physicians’ and patients’ communication behaviors, generally speaking, have the potential to positively shape patients’ post-visit health outcomes, such as their satisfaction and their physical and psychological quality of life (for review, see Stewart [1]). Given that patients prioritize the affective-relational (vs. instrumental) dimension of communication (see above), one type of communication that has been shown to be strongly associated with patients’ health outcomes is patient-centered communication, or that which attends to: (1) patients’ affective states (e.g., fear, vulnerability, hopelessness, uncertainty); (2) patients’ (vs. physicians’) values, needs, and preferences, including psychosocial (vs. biomedical) content; and (3) patient empowerment in terms of having control over topical directions, decision making, etc. [4], [18], [27], [28]. Patient-centered communication is typically operationalized in two main ways: (1) Affective Behavior [14], [29], [30], including physicians’ displays of empathy, concern, reassurance, etc.; and (2) Participation Behavior, including patients’ questions and physicians’ prompts for them [31], [32], [33], [34], [35], [36], [37].
In the context of cancer care, prior research consistently suggests that patient-centered communication is associated with a variety of types of patients’ health outcomes. For example, communication behaviors that address the affective (vs. instrumental) dimension “positively” (e.g., reassurance) have been associated with decreases in patients’ requests for post-operative narcotics [38], [39] and increases in patients’ levels of physical functioning, such as their levels of blood glucose and diastolic blood pressure [40]. However, in the context of observed cancer communication, by far the most frequently studied health outcome has been patients’ satisfaction-like constructs (e.g., satisfaction with physicians’, their communication, information received, treatment decisions, etc.). Research suggests that patient-centered aspects of care are significantly, positively associated with patients’ satisfaction [41], which is important in a variety of ways. For example, patients’ satisfaction with oncologists is positively associated with patients’ willingness to participate in breast-cancer clinical trials [42] and adherence to medical recommendations [43], [44], and has become an important determinant of health-care services’ and medical schools’ communication-training objectives [45]. Patients’ satisfaction with treatment decisions has been positively associated with patients’ adherence to/continuance of treatment [46] and with their post-treatment quality of life [47], [48]. Patients’ dissatisfaction with treatment decisions has been positively associated with their experimentation with alternative therapies [49].
One type of communication that is typically not considered to be patient-centered is Instrumental Behavior [18], [27], [28], [50], including physicians’ question asking and patients’ information giving. Importantly, Instrumental Behavior is medically necessary, and thus not pejorative, and has also been found to be associated with patients’ post-visit satisfaction [51].
This article uses meta-analysis [5], [6], [7] to answer three research questions pertaining to studies of observed (i.e., taped and coded) communication between cancer-specialists and their patients:
RQ 1: What is the association between patient-centered communication and satisfaction-like health outcomes?
RQ 2: What is the association between instrumental behavior and satisfaction-like health outcomes?
RQ 3: Are patient-centered communication and instrumental behavior significantly different in terms of their strength of association with satisfaction-like health outcomes?
Section snippets
Literature search
The article search began January 2007 and ended March 2009. The study pool for the meta-analysis was initially created utilizing the web-based search engines PsychINFO, EbscoHost, and Medline using combinations of the keywords cancer, communication, oncologist, physician, patient, audio, and video. In order to be included, articles had to have been reported in English, had to involve visits in which patients who were already diagnosed with cancer, who interacted with physicians (vs. nurses,
Research question 1
Answering RQ 1, Patient-Centered Communication (which included the combination of Affective Behavior and Participation Behavior) was significantly, positively associated with patients’ post-visit Satisfaction (which included a range of satisfaction-like measures): k = 38, N = 3467, average r = .143, χ2 = 62.33, p < .05. Although Affective Behavior was itself significantly, positively associated with Satisfaction, k = 22, N = 2240, average r = .163, χ2 = 47.1, p < .05, Participation Behavior was not: k = 16, N = 1227,
Discussion
Ultimately, the goal of basic research on the relationship between physicians’ and patients’ communication behaviors, and the effects of such behaviors on patients’ healthcare outcomes, is the implementation and testing of communication interventions toward the goal of improving patients’ biopsychosocial wellness. Effectively changing health behavior necessitates a connection between scientific evidence and critical analysis [69]. Making this a connection can be facilitated by meta-analysis [70]
Conflict of interest
There are no conflicts of interest.
Acknowledgements
The four authors are the sole contributors to the manuscript.
References (78)
- et al.
Patient–doctor communication: a descriptive summary of the literature
Patient Educ Couns
(1988) Bridging the gap. The separate worlds of evidence-based medicine and patient centered medicine
Patient Educ Couns
(2000)“Does it mean I’m gonna die?”: on meaning assessment in the delivery of diagnostic news
Soc Sci Med
(2006)- et al.
Breast cancer patients’ experience of patient–doctor communication: a working relationship
Patient Educ Couns
(2000) - et al.
Physician communication in different phases of a consultation at an oncology outpatient clinic related to patient satisfaction
Patient Educ Couns
(2003) - et al.
Concepts of trust among patients with serious illness
Soc Sci Med
(2000) - et al.
Measuring patient-centered communication in patient–physician consultations: theoretical and practical issues
Soc Sci Med
(2005) - et al.
Doctor–patient communication: a review of the literature
Soc Sci Med
(1995) - et al.
The clinical context and patient participation in post-diagnostic consultations
Patient Educ Couns
(2006) - et al.
Reduction of psychological stress in surgical patients
J Exp Soc Psychol
(1975)
Interacting with cancer patients: the significance of physician's communication behavior
Soc Sci Med
Decision-making and breast cancer clinical trials: how experience challenges attitudes
Contemp Clin Trials
The effects of physician communications skills on patient satisfaction, recall, and adherence
J Chron Dis
Doctor–patient communication and cancer patients’ quality of life and satisfaction
Patient Educ Couns
Patient participation in the cancer consultation: evaluation of a question prompt sheet
Ann Oncol
Information seeking during “bad news” oncology interactions: question asking by patients and their companions
Soc Sci Med
Listening for feelings: identifying and coding empathic and potential empathic opportunities in medical dialogues
Patient Educ Couns
Physician–patient dialogue surrounding patients’ expression of concern: applying sequence analysis to RIAS
Soc Sci Med
Sharing decisions in cancer care
Soc Sci Med
Physician–patient communication and patient satisfaction in Japanese cancer consultations
Soc Sci Med
The interaction between physician and patient communication behaviors in Japanese cancer consultations and the influence of personal and consultation characteristics
Patient Educ Couns
How breast cancer outpatients perceive mutual participation in patient–physician interactions
Patient Educ Couns
Efficacy of a cancer research UK communication skills training model on oncologists: a randomized controlled trial
Lancet
Helping cancer patients disclose their concerns
Eur Cancer
Effective physician–patient communication and health outcomes: a review
Can Med Assoc J
Replication and meta-analysis. A necessary condition
J Soc Behav Pers
Methods of meta-analysis: correcting for artifact and bias in research.
Meta-analysis: recent developments in quantitative methods for literature reviews
Annu Rev Psychol
Communication in medical encounters: an ecological perspective
The effect of primary care training on patient satisfaction ratings
J Gen Intern Med
Improving communication between doctors and breast cancer patients
Ann Fam Med
How to improve the counseling skills of doctors and nurses in cancer care
Brit Med J
An interactional structure of medical activities during acute visits and its implications for patients’ participation
Health Commun
Uncertainty in illness
J Nurs Scholarship
The need for a new medical model: a challenge for biomedicine
Science
A patient-centered approach to cancer communication research
Communicating and organizing
Instrumental and affective aspects of physician behavior
Med Care
Cited by (145)
A qualitative inquiry of communication based barriers to the diagnosis of pediatric cancer: Perceptions of primarily Spanish-speaking caregivers
2022, Patient Education and CounselingAutomated rating of patient and physician emotion in primary care visits
2021, Patient Education and CounselingCitation Excerpt :At present, there are currently limited methods of measuring patient emotions during medical appointments. Patient emotions in medical settings are primarily evaluated using surveys that measure general experiences in treatment [31], which place a burden on the patient, are subject to social desirability and recall biases [32–34]. Direct observation and feedback is the gold standard for supporting physicians in attuning to emotions during medical appointments, but it is time-consuming, expensive, and generally not feasible in most clinical settings [35].
The European Code of Cancer Practice
2021, Journal of Cancer PolicyImproving secure messaging: A framework for support, partnership & information-giving communicating electronically (SPICE)
2021, Patient Education and Counseling