Information is not enough: the place of statistics in the doctor-patient relationship

Communicating Uncertain News in Cancer Consultations

In cancer communication, most of the literature is in the realm of delivering bad news while much less attention has been given to the communication of uncertain news around the diagnosis and the possible outcomes of the illness. Drawing on video-recorded cancer consultations collected in two Italian hospitals, this article analyzes three communication practices used by oncologists to interactionally manage the uncertainty during the visit: alternating between uncertain bad news and certain good news, anticipating scenarios, and guessing test results. Both diagnostic and personal uncertainties are not hidden to the patient, yet they are reduced through these practices. Such communication practices are present in 32 % of the visits in the data set, indicating that the interactional management of uncertainty is a relevant phenomenon in oncological encounters. Further studies are needed to improve both its understanding and its teaching.

Formulating treatment recommendation as a logical consequence of the diagnosis in post-surgical oncological visits

OBJECTIVE

the article analyzes how a doctor delivers diagnoses and recommends treatment in a set of post-surgical oncological visits. The pattern of activities are explored in two different cases: when all diagnostic information is available, and when information is still missing.

METHODS

The data consist of 12 video-recorded visits of breast cancer patients to a senior oncologist. Conversation analysis is employed to analyze sequences in which the delivery of diagnosis and treatment recommendation unfold.

RESULTS

The oncologist formulates the treatment recommendation as a logical consequence deriving from the available diagnostic information. In cases when definitive diagnostic information on the cancer type is missing, the oncologist opts to anticipate hypothetical diagnostic scenarios, and to draw the therapeutic alternatives as logical outcomes envisionable from each of the different scenarios.

CONCLUSION

The communicative practice appears functional to encourage the patients' acceptance of a single treatment option rather than present the patients to and involve them in deliberating over multiple available treatment alternatives.

PRACTICE IMPLICATIONS

Rather than a normative adoption of existing protocols of communication in cancer care, a better understanding of communication practices in use can help practitioners to reflect upon and make intentional choices about different arrangements for the patient's participation.

Breaking the news in amyotrophic lateral sclerosis

Diagnosis communication is a mainstay of the patient-physician relationship and in ALS represents the beginning of the treatment. In Europe, the diagnosis is now communicated to most patients, but with some differences from north to south. Communication is the basis of the patient's autonomy. When adequately informed, patients are able to consider their preferences about life-extending interventions. However, this discussion is sometimes entertained too late. Both the style and the context of this discussion have profound impact on patient satisfaction. The content of the communication should include all relevant information about the disease and should be performed honestly while preserving hope. Collusion with relatives can create difficulties in the relationship with a patient and isolate them from their family. Diagnostic communication is an ongoing process and should form part of every follow-up visit. Communication with the dying patient is often reinforced by non-verbal messages, acknowledgements of patients' emotions, and by listening. Written material may increase satisfaction of patients and their relatives, but should never substitute for face-to-face discussion.

Differences in pediatric oncologists' estimates of curability and treatment recommendations for patients with advanced cancer

BACKGROUND

When goals of therapy for children with advanced cancer are called into question, physician recommendations regarding treatment goals have been shown to be important for families. However, there has been no demonstration of the degree of variation between pediatric oncologists' recommendations in such situations.

PROCEDURE

We provided 48 pediatric oncologists with two identical case histories and identical prognostic data from the literature. Individual interviews were then performed to assess variation in (1) recommended treatment goal, (2) perceived chances for cure, and (3) degree to which further curative intervention would be considered desirable for each patient.

RESULTS

There was a large variability in each of the areas examined. For both patients, there was wide divergence (2:1 and 2:3) in whether to recommend cure as the goal of treatment. There were also differences in physician estimates for likelihood of cure for each patient. Finally, even among those with identical estimates for likelihood of cure, there were differences in the treatment goals physicians would recommend and how strongly they would counsel for them.

CONCLUSIONS

This study demonstrates that even with identical clinical data and prognostic evidence from the literature, pediatric oncologists vary widely in their recommendations regarding goals of treatment for children with advanced cancer.

Patient preferences of decision-making in the context of genetic testing for breast cancer risk

PURPOSE

We conducted a study on women's preferred physician involvement in the decision to obtain genetic testing for breast cancer risk.

METHODS

Women from a primary care physician network completed a telephone survey and a written baseline questionnaire.

RESULTS

The majority preferred to make up their own minds. Predictors of leaving the decision to providers were less education, less knowledge, and higher external health locus of control. Trust in one's physician mediated the effect of health locus of control on decision method.

CONCLUSION

Physicians will face requests from low-risk women and will need effective communication skills to inform women about the test.