An evidence base for patient-centered cancer care: A meta-analysis of studies of observed communication between cancer specialists and their patients

https://doi.org/10.1016/j.pec.2009.09.015Get rights and content

Abstract

Objective

In the context of patients visiting cancer specialists, the objective is to test the association between both patient-centered communication (including Affective Behavior and Participation Behavior) and Instrumental Behavior and patients’ post-visit satisfaction with a variety of visit phenomena.

Methods

Meta-analysis of 25 articles representing 10 distinct data sets.

Results

Both patient-centered- and instrumental behavior are significantly, positively associated with satisfaction, with patient-centered communication having a relatively stronger association.

Conclusion

There is an evidence base for the efficacy of patient-centered care.

Practice implications

Cancer specialists need to train to improve their patient-centered communication.

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.

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