How can communication by oncologists enhance patients' trust? An experimental study

A model of contributors to a trusting patient-physician relationship: a critical review using a systematic search strategy

BACKGROUND

The lack of trust between patients and physicians has a variety of negative consequences. There are several theories concerning how interpersonal trust is built, and different studies have investigated trust between patients and physicians that have identified single factors as contributors to trust. However, all possible contributors to a trusting patient-physician relationship remain unclear. This review synthesizes current knowledge regarding patient-physician trust and integrates contributors to trust into a model.

METHODS

A systematic search was conducted using the databases MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), and Eric (Ovid). We ran simultaneous searches for a combination of the phrases: patient-physician relationship (or synonyms) and trust or psychological safety. Six-hundred and twenty-five abstracts were identified and screened using pre-defined criteria and later underwent full-text article screening. We identified contributors to trust in the eligible articles and critically assessed whether they were modifiable.

RESULTS

Forty-five articles were included in the review. Patient-centered factors that contributed modifiable promoters of trust included psychological factors, levels of health education and literacy, and the social environment. Physician-centered factors that added to a trusting patient-physician relationship included competence, communication, interest in the patient, caring, the provisioning of health education, and professionalism. The patient-physician alliance, time spent together, and shared decision-making also contributed to trusting relationships between patients and physicians. External contributors included institutional factors, how payments are made, and additional healthcare services.

DISCUSSION

Our model summarized modifiable contributors to a trusting patient-physician relationship. We found that providing sufficient time during patient-physician encounters, ensuring continuity of care, and fostering health education are promising starting points for improving trust between patients and physicians. Future research should evaluate the effectiveness of interventions that address multiple modifiable contributors to a trusting patient-physician relationship.

Causes and solutions to workplace psychological ill-health for nurses, midwives and paramedics: the Care Under Pressure 2 realist review

Background

Nurses, midwives and paramedics are the largest collective group of clinical staff in the National Health Service and have some of the highest prevalence of psychological ill-health. Existing literature tends to be profession-specific and focused on individual interventions that place responsibility for good psychological health with nurses, midwives and paramedics themselves.

Aim

To improve understanding of how, why and in what contexts nurses, midwives and paramedics experience work-related psychological ill-health; and determine which high-quality interventions can be implemented to minimise psychological ill-health in these professions.

Methods

Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards' reporting guidelines.

Data sources

First round database searching in Medical Literature Analysis and Retrieval System Online Database ALL (via Ovid), cumulative index to nursing and allied health literature database (via EBSCO) and health management information consortium database (via Ovid), was undertaken between February and March 2021, followed by supplementary searching strategies (e.g. hand searching, expert solicitation of key papers). Reverse chronology screening was applied, aimed at retaining 30 relevant papers in each profession. Round two database searches (December 2021) targeted COVID-19-specific literature and literature reviews. No date limits were applied.

Results

We built on seven key reports and included 75 papers in the first round (26 nursing, 26 midwifery, 23 paramedic) plus 44 expert solicitation papers, 29 literature reviews and 49 COVID-19 focused articles in the second round. Through the realist synthesis we surfaced 14 key tensions in the literature and identified five key findings, supported by 26 context mechanism and outcome configurations. The key findings identified the following: (1) interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; (2) it is difficult to promote staff psychological wellness where there is a blame culture; (3) the needs of the system often override staff well-being at work ('serve and sacrifice'); (4) there are unintended personal costs of upholding and implementing values at work; and (5) it is challenging to design, identify and implement interventions to work optimally for diverse staff groups with diverse and interacting stressors.

Conclusions

Our realist synthesis strongly suggests the need to improve the systemic working conditions and the working lives of nurses, midwives and paramedics to improve their psychological well-being. Individual, one-off psychological interventions are unlikely to succeed alone. Psychological ill-health is highly prevalent in these staff groups (and can be chronic and cumulative as well as acute) and should be anticipated and prepared for, indeed normalised and expected. Healthcare organisations need to (1) rebalance the working environment to enable healthcare professionals to recover and thrive; (2) invest in multi-level system approaches to promote staff psychological well-being; and use an organisational diagnostic framework, such as the NHS England and NHS Improvement Health and Wellbeing framework, to self-assess and implement a systems approach to staff well-being.

Future work

Future research should implement, refine and evaluate systemic interventional strategies. Interventions and evaluations should be co-designed with front-line staff and staff experts by experience, and tailored where possible to local, organisational and workforce needs.

Limitations

The literature was not equivalent in size and quality across the three professions and we did not carry out citation searches using hand searching and stakeholder/expert suggestions to augment our sample.

Study registration

This study is registered as PROSPERO CRD42020172420. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172420.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129528) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 9. See the NIHR Funding and Awards website for further award information.

Effects of prognostic communication strategies on emotions, coping, and appreciation of consultations: An experimental study in advanced cancer

OBJECTIVES

We aimed to investigate effects of prognostic communication strategies on emotions, coping, and appreciation of consultations in advanced cancer.

METHODS

For this experimental study, we created 8 videos of a scripted oncological consultation, only varying in prognostic communication strategies. Disease-naive individuals (n = 1036) completed surveys before and after watching 1 video, while imagining being the depicted cancer patient. We investigated effects of the type of disclosure (prognostic disclosure vs. communication of unpredictability vs. non-disclosure) and content of disclosure (standard vs. standard and best-case vs. standard, best- and worst-case survival scenarios; numerical vs. word-based estimates) on emotions, coping, and appreciation of consultations. Moderating effects of individual characteristics were tested.

RESULTS

Participants generally reported more satisfaction (p < .001) after prognostic disclosure versus communication of unpredictability and less uncertainty (p = .042), more satisfaction (p = .005), and more desirability (p = .016) regarding prognostic information after numerical versus word-based estimates. Effects of different survival scenarios were absent. Prognostic communication strategies lacked effects on emotions and coping. Significant moderators included prognostic information preference and uncertainty tolerance.

SIGNIFICANCE OF RESULTS

In an experimental setting, prognostic disclosure does not cause more negative emotions than non-disclosure and numerical estimates are more strongly appreciated than words. Oncologists' worries about harming patients should not preclude disclosing (precise) prognostic information, yet sensitivity to individual preferences and characteristics remains pivotal.

Disentangling trust of patients with rare cancer in their healthcare professionals and the healthcare system: a qualitative interview study

PURPOSE

Patients with a rare cancer face challenges, e.g., delayed diagnosis, that may affect trust in the healthcare system and the healthcare professionals (HCPs) involved. This study aimed to explore trust of patients with a rare cancer in their HCPs and the healthcare system.

METHODS

Semi-structured interviews were conducted with 20 purposively sampled patients with a rare cancer. The interview guide included topics related to trust, including level, development, barriers and facilitators, importance, and trust dimensions. Thematic analysis was conducted with use of Atlas.ti.

RESULTS

The mean age of patients was 50 years, 60% were female, and 70% were highly educated. Three themes were constructed: (1) "Confirmed expertise is a prerequisite of trust." Patients need confirmation of their HCPs' expertise, as it could not be assumed due to the rarity of their cancer; (2) "Trust depends on the adequacy of information and how it is provided." Limited information about rare cancer reduced patients' trust in health care, whereas interpersonal trust was mainly affected by how HCPs provided information; and (3) "Trust is built on properly coordinated and supportive care." Proper organization and cooperation within and between hospitals, and integration of supportive care, enhanced trust.

CONCLUSION

Patients with a rare cancer experience challenges that influence trust in HCPs and the healthcare system. Further research should examine trust among subgroups of patients with a rare cancer, to enable development of tailored interventions.

IMPLICATIONS FOR CANCER SURVIVORS

HCPs may improve trust by focusing on expertise, effective information provision, proper coordination of care, and provision of adequate supportive care.

Creating and administering video vignettes for a study examining the communication of diagnostic uncertainty: methodological insights to improve accessibility for researchers and participants

BACKGROUND

Studying clinician-patient communication can be challenging, particularly when research seeks to explore cause-and-effect relationships. Video vignettes - hypothetical yet realistic scenarios - offer advantages to traditional observational approaches by enabling standardisation and manipulation of a clinician-patient encounter for assessment by participants. While published guidelines outline stages to create valid video vignette studies, constructing high quality vignettes which are accessible to a wide range of participants and feasible to produce within time and budget restraints remains challenging. Here, we outline our methods in creating valid video vignettes to study the communication of diagnostic uncertainty. We aim to provide practically useful recommendations for future researchers, and to prompt further reflection on accessibility issues in video vignette methodology.

METHODS

We produced four video vignettes for use in an online study examining the communication of diagnostic uncertainty. We followed established guidelines for vignette production, with specific consideration of how these might be applied pragmatically to save time and resources. Scripts were pilot-tested with 15 laypeople, and videos with 14 laypeople; pilot-testing involved both quantitative and qualitative analysis.

RESULTS AND DISCUSSION

We demonstrate the usefulness of existing guidelines, while also determining that vignette production need not necessarily be expensive or time-consuming to be valid. Our vignettes were filmed using an iPhone camera, and featured a physician rather than a professional actor; nonetheless, pilot-testing found them to be internally and externally valid for experimental use. We thus propose that if care is taken in initial script development and if pragmatic choices are made regarding filming techniques and pilot-testing, researchers can produce valid vignettes within reasonable time and budget restraints. We also suggest that existing research fails to critically examine the potential benefits and harms of online video vignette methodology, and propose that further research should consider how it can be adapted to be inclusive of those from underserved backgrounds.

CONCLUSIONS

Researchers creating video vignette studies can adapt the video vignette development process to suit time and budget constraints, and to make best use of available technology. Online methods may be harnessed to increase participant accessibility, but future research should explore more inclusive vignette design.

Harmful communication behaviors in cancer care: A systematic review of patients and family caregivers perspectives

OBJECTIVE

Issues regarding clinician communication remain an important source of complaints within healthcare. This systematic review aims to determine cancer patients' and their family caregivers' views on which clinicians' communication behaviors can harm (i.e. eliciting negative feelings/consequences for patients/family caregivers).

METHODS

We searched for all types of peer-reviewed studies that determined adult (≥18 years) cancer patients' and/or family caregivers' perspectives on which clinicians' communication behaviors can harm in several databases (PubMed, Embase, Web of Science, Cochrane Library, Emcare, PsycINFO and Academic Search Premier), supplemented by expert-consultation. Studies were screened using the Artificial intelligence screening tool of ASReview and data was analyzed using Thematic Analysis. To assess the quality of the studies the Qualsyst critical appraisal tool was used.

RESULTS

A total of 47 studies were included. Four main themes of harmful communication behaviors were identified: (1) Lack of tailored information provision (e.g. giving too little or too much/specific information) (2) Lack of tailored decision making (ranging from; patient exclusion, to the patients' responsibility, and/or haste) (3) Lack of feeling seen and heard (seen as a disease, not as a human being; not listened to concerns and emotions) (4) Lack of feeling held and remembered (forgotten agreements; lack of care continuity).

CONCLUSIONS

Our results reveal an overview of patients' and family caregivers' perspectives on which clinicians' communication behaviors can harm. Harm could be prevented when information and decision involvement are tailored and patients' and family caregivers' needs to feel seen, heard, held and remembered are met.

Communication matters when it comes to adverse events: Associations of adverse events during implant treatment with patients' communication quality and trust assessments

OBJECTIVES

Because patients' trust in their physicians is a critical factor in improving health outcomes and patient response to adverse events, it is important to analyze the determinants of trust. One of these determinants is patient-centered communication. Because the occurrence of adverse events must be communicated to the patient, we asked whether the perceived quality of patient-physician communication acts as an isolating factor between adverse events and patient trust.

METHODS

We proposed and tested a structural equation model linking the occurrence of adverse events to the mediator patient-provider communication quality and to the outcome patient trust. The model was controlled for sociodemographic and health-related factors. We used online survey data from German implant patients (n = 1312), as implant treatment is associated with frequent adverse events such as infections.

RESULTS

Our results show that adverse events during implant treatment are associated with small but significantly lower trust levels. Patient-provider communication quality partially mediates this association.

CONCLUSIONS

Patient trust does not appear to be immune to deterioration from adverse events. Patient-provider communication plays a role in mitigating this association.

PRACTICE IMPLICATIONS

To improve the quality of care, attention should be paid to how adverse events are communicated in a patient-centered manner.

Good versus bad news consultations in advanced breast cancer: the role of empathy in information recall - an observational study

OBJECTIVE

We explored, in advanced breast cancer, whether: (1) patients recall less information following bad versus good news consultations; (2) empathy has a greater effect on recalled information following bad versus good news consultations.

METHODS

Observational study using audio-recorded consultations. Participants' recall of provided information about treatment options, aims/positive effects and side-effects was assessed. Clinician-expressed empathy and consultation type were determined. Regression analyses assessed associations between consultation type and recall, exploring moderating influences of clinician-expressed empathy.

RESULTS

For 41 consultations (18 bad news, 23 good news), recall data were completed; total recall (47% vs 73%, p=0.03) and recall about treatment options (67% vs 85%, p=0.08, trend) were significantly worse following bad news compared with good news consultations. Recall about treatment aims/positive effects (53% vs 70%, p=0.30) and side-effects (28% vs 49%, p=0.20) was not significantly worse following bad news. Empathy moderated the relationship between consultation type and total recall (p<0.01), recall about treatment options (p=0.03) and about aims/positive effects (p<0.01) but not about side-effects (p=0.10). Only following good news consultations empathy influenced recall favourably.

CONCLUSIONS

This explorative study suggests that in advanced cancer, information recall is especially impaired following bad news consultations, for which empathy does not improve remembered information.

Are Patients Who Trust Their Providers More Likely to Use Medical Cannabis?

Background: Trust is an essential element of the patient-provider relationship and has been associated with better patient outcomes; however, it is not clear what role trust might play in influencing patients' willingness to try medical cannabis when it is recommended in states where it has been legalized for medical use. Objectives: To explore the relationship between peoples' trust in their health care clinicians and hospitals and their willingness to consider using medical cannabis if it is recommended by their clinician or hospital. Methods: We conducted an anonymous, cross-sectional, online survey of adults who participated in the Qualtrics Research Company Panel and used quotas to match our sample to the characteristics of the U.S. population. Results: We received 1120 completed surveys. The vast majority of respondents (84.4%) reported having a regular provider and 42.5% of those who reported having a regular physician and nearly 35.6% of those who reported having another regular provider (e.g., nurse practitioner, physician assistant) reported that they "completely" trusted that clinician. Those who reported "completely" trusting their usual clinician were more than twice as likely to report they would definitely use medical cannabis if recommended (42.5% vs 20.6%). Similarly, the greater respondents' trust in hospitals, the more likely they were to report a willingness to consider using recommended medical cannabis. Conclusion: Patient trust in their health providers is related to patients' willingness to use recommended medical cannabis.

How does physicians' educational knowledge-sharing influence patients' engagement? An empirical examination in online health communities

Online health communities (OHCs) are popular channels increasingly used by patients for acquiring professional medical knowledge to manage their own health. In OHCs, physicians provide not only consultation services but also educational medical knowledge to improve patient education. So far, it remains unknown regarding how the educational medical knowledge sharing influence engagement of patients in OHCs. Drawing on the signaling theory, we examined the effects of paid vs. free knowledge-sharing of physicians on patients' engagement behaviors (i.e., patient visit and patient consultation). Data collected from one of the largest OHCs in China show that both paid and free knowledge-sharing are favorable for patients' engagement. Particularly, these two types of knowledge-sharing vary in their impacts. Moreover, physicians' registration duration in OHCs has a positive moderating effect on the relationship between physician's knowledge-sharing and patient engagement. Managers seeking to engage patients at OHCs are advised to share educational medical knowledge to entice them and the patient engagement is more salient for the knowledge shared by physicians active at the platforms for longer time history.

A cross-sectional survey study on the use of communication methods in the dentist-geriatric patient relationship

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Patient participation in multidisciplinary tumor conferences in breast and gynecological cancer care: How patient-centered is the communication?

OBJECTIVE

Patients' participation is part of patient-centeredness, but it is so far unclear whether providers in multidisciplinary tumor conferences (MTCs) with patient participation communicate in a patient-centered way. Our aim is to explore (a) to what extent providers ask questions to breast and gynecological cancer patients during case discussion in MTCs, (b) how providers respond to patients' expressions of emotions during case discussions, and (c) which patient- and context-related characteristics and responses are associated with patients' trust in the treatment team after the case discussion.

METHODS

This observational study included survey data and audio recordings of MTCs with patient participation at three breast and gynecological cancer centers. Providers' questions to patients and responses to patients' emotional expressions were coded using the Verona Coding Definitions of Emotional Sequences. The response can be explicitly or non-explicitly related to the emotion and space-reducing or space-providing. Multiple linear regression analysis was used to determine associations between providers' responses, patient- and context-related characteristics, and patients' trust in the treatment team after the case discussion.

RESULTS

We analyzed 82 case discussions (77 breast, 5 breast and gynecological cancer patients). Providers asked a total of 646 questions, of which 86% were polar (yes/no). Providers gave 303 responses to a total of 230 emotional expressions by patients. Non-explicit responses were associated with more trust when they were space-providing, but with less trust when space-reducing.

CONCLUSIONS

The frequency of providers' closed questions and space-reducing responses to emotions shows that patient-centered communication rarely takes place in MTCs with patient participation.

Effects of Different Transitional Care Strategies on Outcomes after Hospital Discharge-Trust Matters, Too

BACKGROUND

As health systems shift toward value-based care, strategies to reduce readmissions and improve patient outcomes become increasingly important. Despite extensive research, the combinations of transitional care (TC) strategies associated with best patient-centered outcomes remain uncertain.

METHODS

Using an observational, prospective cohort study design, Project ACHIEVE sought to determine the association of different combinations of TC strategies with patient-reported and postdischarge health care utilization outcomes. Using purposive sampling, the research team recruited a diverse sample of short-term acute care and critical access hospitals in the United States (N = 42) and analyzed data on eligible Medicare beneficiaries (N = 7,939) discharged from their medical/surgical units. Using both hospital- and patient-reported TC strategy exposure data, the project compared patients "exposed" to each of five overlapping groups of TC strategies to their "control" counterparts. Primary outcomes included 30-day hospital readmissions, 7-day postdischarge emergency department (ED) visits and patient-reported physical and mental health, pain, and participation in daily activities.

RESULTS

Participants averaged 72.3 years old (standard deviation =10.1), 53.4% were female, and most were White (78.9%). Patients exposed to one TC group (Hospital-Based Trust, Plain Language, and Coordination) were less likely to have 30-day readmissions (risk ratio [RR], 0.72; 95% confidence interval [CI] = 0.57-0.92, p < 0.001) or 7-day ED visits (RR, 0.72; 95% CI, 0.55-0.93, p < 0.001) and more likely to report excellent physical and mental health, greater participation in daily activities, and less pain (RR ranged from 1.11 to 1.15, p < 0.01).

CONCLUSION

In concert with care coordination activities that bridge the transition from hospital to home, hospitals' clear communication and fostering of trust with patients were associated with better patient-reported outcomes and reduced health care utilization.

Building Patient Trust in Hospitals: A Combination of Hospital-Related Factors and Health Care Clinician Behaviors

BACKGROUND

Patients' trust in their regular clinician is relatively high in the United States, but trust in the health care system and in key institutions, such as hospitals, is considerably lower. The purpose of this study was to identify the factors that build patients' trust in hospitals.

METHODS

In early 2020 the authors conducted 38 semistructured telephone interviews with participants across the United States. Respondents were asked about trust in hospitals generally, as well as what makes them trust and not trust specific hospitals. Interviews were audio recorded, transcribed, and analyzed using a descriptive thematic approach.

RESULTS

Participants identified three mechanisms through which hospitals build their trust: (1) competence (effectively treating health issues, providing a safe and clean hospital environment, and having clinicians who are knowledgeable and thorough), (2) caring (hospital culture that prioritizes patients' comfort, welcoming physical environment, and clinicians who are compassionate), and (3) communication (hospital culture of listening to patients and explaining clearly, particularly with treatment and discharge plans). The absence of these three factors resulted in loss of trust. Hospital cost also lost patients' trust in hospitals. While the cost of hospital care affected some participants' overall level of trust in hospitals, others separated the trust they had in the medical care received from trust in billing practices.

CONCLUSION

The findings underscore the importance of perceived quality of care and hospital safety/hygiene, as well as having an organizational culture that emphasizes caring and effective communication, for building patient trust.

Tested communication strategies for providing information to patients in medical consultations: A scoping review and quality assessment of the literature

OBJECTIVES

To systematize the scientific knowledge of empirically tested strategies for verbally providing medical information in patient-physician consultations.

METHODS

A scoping review searching for terms related to physician, information, oral communication, and controlled study. Four pairs of reviewers screened articles. For each selected study, we assessed the quality and summarized aspects on participants, study, intervention, and outcomes. Information provision strategies were inductively classified by types and main categories.

RESULTS

After screening 9422 articles, 39 were included. The methodological quality was moderate. We identified four differently used categories of strategies for providing information: cognitive aid (n = 13), persuasive (n = 8), relationship- (n = 3), and objectivity-oriented strategies (n = 4); plus, one "mixed" category (n = 11). Strategies were rarely theoretically derived.

CONCLUSIONS

Current research of tested strategies for verbally providing medical information is marked by great heterogeneity in methods and outcomes, and lack of theory-driven approaches. The list of strategies could be used to analyse real life communication.

PRACTICE IMPLICATIONS

Findings may aid the harmonization of future efforts to develop empirically-based information provision strategies to be used in clinical and teaching settings.

Underpredicting pain: an experimental investigation into the benefits and risks

ABSTRACT

Expectancies can shape pain and other experiences. Generally, experiences change in the direction of what is expected (ie, assimilation effects), as seen with placebo effects. However, in case of large expectation-experience discrepancies, experiences might change away from what is expected (ie, contrast effects). Previous research has demonstrated contrast effects on various outcomes, but not pain. We investigated the effects of strong underpredictions of pain on experienced pain intensity. In addition, we assessed related outcomes including (certainty of) expectations, fear of pain, pain unpleasantness, autonomic responses, and trust. Healthy participants (study 1: n = 81 and study 2: n = 123) received verbal suggestions that subsequent heat stimuli would be moderately or highly painful (correct prediction), mildly painful (medium underprediction; study 2 only), or nonpainful (strong underprediction). Both studies showed that participants experienced less intense pain upon strong underprediction than upon correct prediction (ie, assimilation). Expected pain, fear of pain, and pain unpleasantness were generally also lowered. However, strong underprediction simultaneously lowered certainty of expectations and trust in the experimenter. Study 2 indicated that the effects of strong underprediction vs medium underprediction generally did not differ. Moreover, study 2 provided some indications for reduced heart rate and skin conductance levels but increased skin conductance responses upon strong underprediction. In conclusion, even strong underpredictions of pain can reduce pain (ie, cause assimilation), although not significantly more than medium underpredictions. However, strong underpredictions can cause uncertainty and undermine trust. These findings suggest that healthcare providers may wish to be cautious with providing overly positive information about painful medical procedures.

Preconsultation compassion intervention to reduce anxiety among patients referred to a cancer center: protocol for a randomised control trial

INTRODUCTION

Patients diagnosed with cancer commonly have a high degree of anxiety during an initial oncology consultation, which may interfere with a patient's ability to retain information required to make informed treatment decisions. A previous study randomised breast cancer survivors (volunteers) to view either (a) a brief video depicting a standard initial consultation from an oncologist or (b) an identical consultation with the addition of compassionate statements from the oncologist, and found the compassionate statements reduced anxiety among the volunteers. However, while compassionate statements reduced anxiety during simulation, it is currently unknown whether watching a video containing compassionate statements from an oncologist prior to an initial oncology consultation will reduce anxiety among patients referred to a cancer centre. The aim of this randomised control trial is to test whether watching a brief video containing compassionate statements from an oncologist, compared with watching a standard introduction video, prior to an initial oncology consultation will reduce the degree of anxiety among patients referred to a cancer centre.

METHODS AND ANALYSIS

This is a prospective, randomised controlled clinical trial at an academic cancer centre. We will enrol adult patients scheduled for an initial oncology consultation. Subjects will be randomly assigned to receive a standard introduction video or enhanced compassion video for viewing prior to the initial oncology consultation. On arrival to the cancer centre, we will measure anxiety severity using the Hospital Anxiety and Depression Scale (HADS). The HADS has two 7-item subscales (HADS anxiety and HADS depression) and is well-validated among oncology patients. We will use Wilcoxon rank-sum test to test for a difference in the HADS subscales between the two video groups.

ETHICS AND DISSEMINATION

The Cooper University Hospital Institutional Review Board approved this study. The results from this randomised control trial will be submitted for publication to a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04503681.

Treatment satisfaction mediates the association between perceived physician empathy and psychological distress in a community sample of individuals with chronic pain

OBJECTIVE

While the benefits of patient-centered care have been consistently demonstrated in the health literature, there exists a dearth of pathway research within health outcome research, especially within the chronic pain context. This study examined the relationship between perceived physician empathy and patient psychological distress and its underlying mechanism.

METHODS

A community sample of 259 adults with chronic pain completed online questionnaires measuring patient-perceived physician empathy, treatment satisfaction, depressive and anxiety symptoms. Analyses were conducted using correlational and mediation analyses.

RESULTS

Results revealed perceived empathy to be positively and strongly correlated with treatment satisfaction (r = .72, p < .001). A significant negative correlation was also demonstrated between perceived empathy and depressive symptoms (r = -.13, p < .05), but not between perceived empathy and anxious symptoms (r = .03, p = .65). Results revealed significant mediation models between perceived empathy and patient depressive symptoms (indirect effect: B = -.19, SE =.06, 95 % CI [-.31, -.09]) and anxious symptoms (indirect effect: B = -.24, SE = .06, 95 % CI [-.35, -.14]), via treatment satisfaction as mediator and including covariates.

CONCLUSION

Chronic pain patients who perceive greater levels of physician empathy experience fewer depressive and anxious symptoms, as mediated by treatment satisfaction.

PRACTICE IMPLICATIONS

Clinical training and practice should promote empathetic components of health communication within chronic pain treatment.

A Mixed Methods Examination of Health Care Provider Behaviors That Build Patients' Trust

OBJECTIVE

Patient trust in health care providers is associated with better health behaviors and utilization, yet provider trust has not been consistently conceptualized. This study uses qualitative methods to identify the key health provider behaviors that patients report build their trust, and data from a national U.S. survey of adults to test the robustness of the qualitative findings.

METHODS

In this mixed methods study, we conducted 40 semi-structured interviews with a diverse sample to identify the provider behaviors that build trust. We then analyzed a nationally representative survey (n = 6,517) to examine the relationship between respondents' trust in their usual provider and the key trust-related behaviors identified in the qualitative interviews.

RESULTS

Interviewees reported that health providers build trust by communicating effectively (listening and providing detailed explanations), caring about their patients (treating them as individuals, valuing their experience, and showing commitment to solving their health issues), and demonstrating competence (being knowledgeable, thorough, and solving their health issues). Trust in one's provider was highly correlated with all eight survey items measuring communication, caring, and competence.

CONCLUSIONS

To build trust with patients, health providers should actively listen, provide detailed explanations, show caring for patients, and demonstrate their knowledge.

Exploring patient views of empathic optimistic communication for osteoarthritis in primary care: a qualitative interview study using vignettes

Background

Osteoarthritis (OA) causes pain and disability. An empathic optimistic consultation approach can improve patient quality of life, satisfaction with care, and reduce pain. However, expressing empathic optimism may be overlooked in busy primary care consultations and there is limited understanding of patients’ views about this approach.

Aim

To explore patients’ perspectives on clinician communication of empathy and optimism in primary care OA consultations.

Design & setting

Vignette study with qualitative semi-structured interviews. Purposefully sampled patients (n = 33) aged >45 years with hip or knee OA from GP practices in Wessex (Hampshire, Dorest, Wiltshire, and Somerset).

Method

Fifteen participants watched two filmed OA consultations with a GP, and 18 participants read two case vignettes. In both formats, one GP depicted an empathic optimistic approach and one GP had a ‘neutral’ approach. Semi-structured interviews were conducted with all participants and analysed using thematic analysis.

Results

Patients recognised that empathic communication enhanced interactions, helping to engender a sense of trust in their clinician. They felt it was acceptable for GPs to convey optimism only if it was realistic, personalised, and embedded within an empathic consultation. Discussing patients’ experiences and views with them, and conveying an accurate understanding of these experiences improves the credibility of optimistic messages.

Conclusion

Patients value communication with empathy and optimism, but it requires a fine balance to ensure messages remain realistic and trustworthy. Increased use of a realistic optimistic approach within an empathic consultation could enhance consultations for OA and other chronic conditions, and improve patient outcomes. Digital training to help GPs implement these findings is being developed.

Pre-consultation information about one's physician can affect trust and treatment outcome expectations

OBJECTIVE

Information about physicians' skills is increasingly available on the internet and consulted by patients. The impact of such information on patient expectations is largely unknown. The aim of the present study was to investigate whether information about the competence and empathic skills of a physician may impact pre-consultation trust and treatment outcome expectations in mild and severe medical conditions.

METHODS

In this experimental web-based study, participants (n = 237) read vignettes describing competence and empathic skills (low versus high) of a fictive physician who would surgically remove a mole or melanoma (low versus high severity) following a 2 × 2 × 2 between-subjects design. Participants rated trust in the physician and treatment outcome expectations.

RESULTS

High competence and empathy raised trust in the physician, regardless of condition severity. High competence and high empathy both also increased expected surgery success, while only high competence reduced expected side effects.

CONCLUSION

Pre-consultation information highlighting a physician's competence and/or empathy may lead to higher trust in that physician, higher expected surgery success, and lower expected side effects.

PRACTICE IMPLICATIONS

Physicians and hospital staff should be aware of the effects of written information available and might, for example, provide profiles on hospital websites emphasizing healthcare providers' competence and empathy.

Modelling health care customer satisfaction: Evidence from Serbia

Customer loyalty, with satisfaction of customers as its main precondition, has long been regarded as an overarching goal of service businesses. With the proliferation of health care providers, which brought about rising competitive pressures on the market, the issue of how to satisfy and keep patients has been attracting increasing attention of researchers and health care management. Therefore, this study aims to examine the antecedents of patient satisfaction and its direct and mediated impact on patients' behavioural intentions in thus far under-studied context of emerging economy's health care system. The study has been conducted in a primary health care setting, on a convenience sample of 300 patients, by means of structured questionnaire. The application of structural equation modelling (SEM) revealed direct impact of health care service quality on patient satisfaction and its mediated impact on satisfaction, via perceived value of health care services. In addition to direct influence of satisfaction on patients' behavioural intentions, its total effect on positive intentions of patients is increased by the impact of patient commitment to a health care provider, which, as evidenced by this study's findings, increases with patient's rising trust into a health care provider. Implications for theory and practice are discussed and further research directions are provided.

Emotional Response of US Breast Cancer Survivors during the COVID-19 Pandemic

In a sample of 633 US adult breast cancer survivors, we examined health-related worry as a function vulnerability as influenced by communication, trust, and planning with their cancer care team during the COVID-19 pandemic. We found significant positive correlations between communication and trust, communication and planning, and trust and planning. ANCOVAs with treatment status, immunocompromised status, and delays (separately) as IVs, trust as a covariate, and cancer-related worry as a DV, yielded significant models. A noteworthy finding is the presence of trust as a significant covariate in models of vulnerability and worry.

Representativeness of personality and involvement preferences in a web-based survey on healthcare decision-making

Background

Obtaining a sample that is representative of the group of interest is of utmost importance in questionnaire studies. In a survey using a state authorized web-portal for citizen communication with authorities, we wanted to investigate the view of adult men on patient involvement in health care decision-making regarding Prostate-Specific Antigen test for prostatic cancer. In this paper, we report on sample characteristics and representativeness of our sample in terms of personality and baseline involvement preferences.

Methods

We compared personality profiles (BFI-10) and baseline healthcare decision-making preferences (CPS) in our sample (n = 6756) to internationally available datasets. Pooled data from a) US, UK, Canada, Australia, and New Zealand (n = 1512), b) Germany, Netherlands, Switzerland, and Belgium (n = 1136), and c) Norway, Sweden, Finland, and Denmark (n = 1313) were used for BFI-10 comparisons. Regarding CPS, we compared our sample with three previous datasets relating to decision-making in cancer (n = 425, 387, and 199).

Results

Although statistically significant differences particularly appeared in large dataset comparisons, sample BFI-10 and CPS profiles mostly were within the range of those previously reported. Similarity was greatest in BFI-10 comparisons with group a) where no statistically significant difference could be established in factors ‘agreeableness’ and ‘neuroticism’ (p = .095 and .578, respectively).

Conclusion

Despite some variation, our sample displays personality and baseline preference profiles that are generally similar to those described in previous international studies. For example, this was the case with the BFI-10 ‘agreeableness’ measure (incl. trust and fault-finding items), an important factor in healthcare decision-making.

What Will Keep Me Coming Back to the Clinic: Factors Identified by Filipino Colorectal Cancer Patients Seen at a National Academic Referral Center

Health-care decisions in the Philippines are widely affected by various factors such as family, community, health-care access, and educational attainment. We designed a questionnaire to evaluate patient views at the University of the Philippines-Philippine General Hospital colorectal multidisciplinary clinic to identify factors that contribute to continued follow-up at the colorectal multidisciplinary clinic. A total of 128 patients, 62% of whom were being treated with curative intent participated in the study. We found that trust in their physicians, presence of family support, and affordability of treatment were factors highly valued by patients consulting at the clinic.

Gendered racism and the sexual and reproductive health of Black and Latina Women

Objective: To understand health disparities, it is important to use an intersectional framework that examines unique experiences of oppression faced by particular groups due to their intersecting identities and social positions linked to societal structures. We focus on Black and Latina women and their experiences with 'gendered racism' - unique forms of oppression due to the intersection of race/ethnicity and gender - to foster understanding of disparities between Black and Latina versus White women in sexual and reproductive health outcomes in the U.S. Specifically, we focus on stereotype-related gendered racism (ongoing discrimination and stereotype threat based on historically-rooted stereotypes about Black and Latina women's sexuality and motherhood) and birth control-related mistrust (ongoing mistrust of the government and medical system related to birth control due to historical and current abuses).Design: We analyzed data from two survey studies with adult women in New York (Study 1: paper-and-pencil community data collection, N = 135, M_age= 43.35) and across the U.S. (Study 2: online data collection, N = 343, M_age= 29.49) who were currently pregnant or had at least one child and identified as Black, Latina, or White.Results: Black and Latina women reported greater frequency of and concern over stereotype-related gendered racism (F(3,131) = 17.90, p < .001 Study 1; F(3,339) = 22.23, p < .001 Study 2) and greater birth control-related mistrust (F(3,131) = 7.55, p < .001 Study 1; F(3,339) = 17.32, p < .001 Study 2) than White women did. In turn, stereotype-related gendered racism was positively associated with pregnancy-specific stress (ß = .40, p < .001 Study 1; ß = .33, p < .001 Study 2), and birth control-related mistrust was negatively associated with sexual relationship power (ß = -.19, p = .002 Study 2), which are factors known to contribute to birth outcomes and sexual risk, respectively.Conclusion: Findings suggest that gendered racism may play an important role in existing racial/ethnic disparities in women's sexual and reproductive health outcomes, and interventions addressing gendered racism at multiple levels are needed to promote health equity.

A Prospective Multicenter Study Evaluating Endoscopy Competence Among Gastroenterology Trainees in the Era of the Next Accreditation System

PURPOSE

The Next Accreditation System requires training programs to demonstrate competence among trainees. Within gastroenterology (GI), there are limited data describing learning curves and structured assessment of competence in esophagogastroduodenoscopy (EGD) and colonoscopy. In this study, the authors aimed to demonstrate the feasibility of a centralized feedback system to assess endoscopy learning curves among GI trainees in EGD and colonoscopy.

METHOD

During academic year 2016-2017, the authors performed a prospective multicenter cohort study, inviting participants from multiple GI training programs. Trainee technical and cognitive skills were assessed using a validated competence assessment tool. An integrated, comprehensive data collection and reporting system was created to apply cumulative sum analysis to generate learning curves that were shared with program directors and trainees on a quarterly basis.

RESULTS

Out of 183 fellowships invited, 129 trainees from 12 GI fellowships participated, with an overall trainee participation rate of 72.1% (93/129); the highest participation level was among first-year trainees (90.9%; 80/88), and the lowest was among third-year trainees (51.2%; 27/53). In all, 1,385 EGDs and 1,293 colonoscopies were assessed. On aggregate learning curve analysis, third-year trainees achieved competence in overall technical and cognitive skills, while first- and second-year trainees demonstrated the need for ongoing supervision and training in the majority of technical and cognitive skills.

CONCLUSIONS

This study demonstrated the feasibility of using a centralized feedback system for the evaluation and documentation of trainee performance in EGD and colonoscopy. Furthermore, third-year trainees achieved competence in both endoscopic procedures, validating the effectiveness of current training programs.

Provider caring and structuring treatment information to improve cancer patients' recall: Does it help?

OBJECTIVES

Patient recall of medical information is usually poor. Healthcare providers can employ affect-oriented (i.e., showing care) or cognition-oriented communication styles (i.e., structuring information) to enhance recall, but research evidence is limited especially among clinical and/or older patient populations. This video-vignette study manipulated provider caring and information structuring to examine effects on recall and trust among cancer patients/survivors.

METHODS

In an online survey, 148 participants (M_age = 62) were randomized to one of four video conditions in a two (standard communication vs. enhanced caring) by two (standard vs. enhanced structuring) design, and completed measures of active recall, recognition, and trust.

RESULTS

Increased caring or structuring did not enhance active recall or recognition, instead both were higher among younger, female, or highly educated participants. The caring condition induced higher perceived trust in the provider within the whole sample, but trust was significantly correlated with decreased recall (r = -.268) among younger participants.

CONCLUSIONS

Provider caring can strengthen the patient-provider relationship by enhancing trust. Yet, increased trust may impair recall among younger patients. Structuring treatment information did not enhance recall and recognition, but additional research is needed.

PRACTICE IMPLICATIONS

Providers may use additional ways of structuring/organizing information to help enhance recall (e.g., written information).

Does migrant background predict to what extent colorectal cancer patients want to be informed about their life expectancy? - a cross-sectional analysis

BACKGROUND

Although migrant health is a topic of interest across Europe and although health care services in Germany consider migrant health issues, people with a migrant background often experience difficulties regarding health care provision. The prevalence of various cancers among migrants is lower relative to non-migrants although this equalizes with increasing duration of residence. There are documented differences in health behavior and disease-coping strategies between migrants and non-migrants, but data are scarce on this subject. This analysis investigates the extent of information migrant and non-migrant colorectal cancer (CRC) patients in Germany want about their life expectancy and the level of trust they have in their treating physician.

METHOD

Data from 522 CRC patients were collected through a self-reported questionnaire. Migrant background was determined by the patients' and/or their parents' birthplace. Bivariate analyses were applied to determine the differences between migrants and non-migrants. A multivariate analysis was used to measure the effect of migration background, demographics, and cancer stage and treatment on the preferred extent of information about life expectancy and trust in their treating physician.

RESULTS

There were no significant differences regarding demographics or cancer stage and treatment between migrant and non-migrant CRC patients. Having a migrant background had no influence on the level of trust in the treating physician, but migrants preferred to be less informed about their life expectancy than non-migrants (21.4% vs. 13.4%, p = 0.04). The multivariate analysis showed that men (aOR = 2.102, CI: 1.123-3.932) and patients with a non-migrant background (aOR = 5.03, CI: 1.02-24.73) preferred receiving information about the approximate value of their life expectancy, rather than receiving no information.

CONCLUSION

The study found more similarities than discrepancies between migrant and non-migrant CRC patients regarding demographic factors and stage of disease and treatment, which may be a consequence of an increasingly homogeneous cross-cultural society. However, cultural differences between the minority and host population remain and should always be taken into account in daily clinical practice and in the communication skills training of health care professionals. The study also indicates that recording migration background into health registers would facilitate migrant-sensitive research.

The mediating effect of trust on the relationship between doctor-patient communication and patients' risk perception during treatment

Doctor-patient communication interacts with patients' satisfaction to influence patients' risk perception. Current theories to explain this relationship have assumed particular psychological processes to explain observations of risk-sensitive behavior in an economic setting, but as of yet, they have not addressed whether it is adaptive for a decision-maker in a health-care situation. In addition, little is known about the role of interpersonal trust between doctor and patient. We surveyed 602 patients to examine the way in which trust, communication, and patients' satisfaction are related to patients' risk perception about uncertainties in medical treatment. The results showed that patients held a relatively low level of risk perception, which means that they had insufficient preparation for the possibility of uncertainties about the treatment. The association between doctor-patient communication and patients' perceived risk was mediated by doctor-patient trust. These results suggest that there is a relationship among good doctor-patient communication, patients' trust in medical staff, and perceived risk during medical treatment. Finally, theoretical and practical implications are discussed.

Is There a Relationship between Shared Decision Making and Breast Cancer Patients' Trust in Their Medical Oncologists?

Background. Adjuvant systemic treatment for early stage breast cancer significantly reduces the risk of mortality but is associated with side effects, reducing patients’ quality of life. Decisions about adjuvant treatment are preference sensitive and are thus ideally suited to a shared decision making (SDM) approach. Whether and how SDM affects patients’ trust in their oncologist is currently unknown. We investigated the association between patients’ trust in their oncologist and 1) observed level of SDM in the consultation, 2) congruence between patients’ preferred and perceived level of participation, and 3) patient and oncologist characteristics. Methods. Decision consultations (n = 101) between breast cancer patients and their medical oncologist were audio-recorded and transcribed verbatim. Patients’ trust in their oncologist was measured using the Trust in Oncologist Scale (TiOS). The observed level of SDM was scored using the 12-item Observing Patient Involvement In Decision Making scale (OPTION-12), preferred level of participation with the Control Preferences Scale, and perceived level of participation with an open question in telephonic interviews. Results. The average TiOS score was high overall (mean [SD] = 4.1 [.56]; range, 2.6–5.0). Low levels of SDM were observed (mean [SD] = 16 [11.6]; range, 2–56). Neither observed nor perceived level of participation in SDM was associated with trust. Patients’ preferred and perceived role in decision making was incongruent in almost 50% of treatment decisions. Congruence was not related to trust. A larger tumor size (β = 4.5, P = 0.03) and the use of a risk prediction model during the consultation (β = 4.1, P = 0.04) were associated with stronger trust. Conclusion. Patients reported strong trust in their oncologist. While low levels of SDM were observed, SDM was not associated with trust. These findings suggest it may not be necessary to worry about negative consequences for trust of using SDM or risk prediction models in oncological consultations. Considering the increased emphasis on implementing SDM, it is important to further explore how SDM affects trust in clinical practice.

Communicating uncertainties when disclosing diagnostic test results for (Alzheimer's) dementia in the memory clinic: The ABIDE project

Background

The development of novel diagnostics enables increasingly earlier diagnosis of Alzheimer's disease (AD). Timely diagnosis may benefit patients by reducing their uncertainty regarding the cause of symptoms, yet does not always provide patients with the desired certainty.

Objective

To examine, using both quantitative and qualitative methods, uncertainty communicated by memory clinic clinicians in post‐diagnostic testing consultations with patients and their caregivers.

Methods

First, we identified all uncertainty expressions of 22 clinicians in audiotaped post‐diagnostic testing consultations with 78 patients. Second, we statistically explored relationships between patient/clinician characteristics and uncertainty expressions. Third, the transcribed uncertainty expressions were qualitatively analysed, determining the topic to which they pertained, their source and initiator/elicitor (clinicians/patients/caregivers).

Results

Within 57/78 (73%) consultations, clinicians expressed in total 115 uncertainties, of which 37% elicited by the patient or caregiver. No apparent relationships were found between patient/clinician characteristics and whether or not, and how often clinicians expressed uncertainty. Uncertainty expressions pertained to ten different topics, most frequently patient's diagnosis and symptom progression. Expressed uncertainty was mostly related to the unpredictability of the future and limits to available knowledge.

Discussion and conclusions

The majority of clinicians openly discussed the limits of scientific knowledge and diagnostic testing with patients and caregivers in the dementia context. Noticeably, clinicians did not discuss uncertainty in about one quarter of consultations. More evidence is needed on the beneficial and/or harmful effects on patients of discussing uncertainty with them. This knowledge can be used to support clinicians to optimally convey uncertainty and facilitate patients' uncertainty management.

Effects of communication about uncertainty and oncologist gender on the physician-patient relationship

OBJECTIVE

Physicians are increasingly expected to share uncertain information, yet there is concern about possible negative effects on patients. How uncertainty is conveyed and by whom may influence patients' response. We tested the effects of verbally and non-verbally communicating uncertainty by a male vs. female oncologist on patients' trust and intention to seek a second opinion.

METHODS

In an experimental video vignettes study conducted in The Netherlands, oncologist communication behavior (verbal vs. non-verbal and high vs. low uncertainty) and gender (male vs. female) were systematically manipulated. Former cancer patients viewed one video variant and reported trust, intention to seek a second opinion, and experience of uncertainty.

RESULTS

Non-verbal communication of high uncertainty by the oncologist led to reduced trust (β = -0.72 (SE = 0.15), p < .001) and increased intention to seek a second opinion (β = 0.67 (SE = 0.16), p < .001). These effects were partly explained by patients' increased experience of uncertainty (β = -0.48 (SE = 0.12), p < .001; and β = 0.34 (SE = 0.09), p < .001 respectively). Neither verbal uncertainty nor oncologists' gender influenced trust or intention to seek a second opinion.

CONCLUSION

Non-verbal communication of uncertainty by oncologists may affect patient trust and intention to seek a second-opinion more than verbal communication.

PRACTICE IMPLICATIONS

Further research to understand and improve oncologists' non-verbal uncertainty behavior is warranted.

Understanding patients' satisfaction with physician assistant/associate encounters through communication experiences: a qualitative study in acute hospitals in England

BACKGROUND

Physician assistants/associates (PAs) are a recent innovation in acute hospital teams in England and many other countries worldwide. Although existing evidence indicates generally high levels of patient satisfaction with their PA hospital encounters, little is known about the factors associated with this outcome. There is a lack of evidence on the process of PA-patient communication in hospital encounters and how this might influence satisfaction. This study therefore aimed to understand patients' satisfaction with PA acute hospital encounters through PA-patient communication experiences.

METHODS

A qualitative study was conducted among patients and representatives of patients seen by or receiving care from one of the PAs working in acute hospital services in England. Semi-structured interviews were undertaken face-to-face with study participants in the hospital setting and shortly after their PA encounter. Data were coded and analysed using thematic analysis. The study was framed within a theoretical model of core functions of medical encounter communication.

RESULTS

Fifteen patients and patient representatives who had experienced a PA encounter participated in interviews, across five hospitals in England. Four interrelated communication experiences were important to participants who were satisfied with the encounter in general: feeling trust and confidence in the relationship, sharing relevant and meaningful information, experiencing emotional care and support, and sharing discussion on illness management and treatment. However, many participants misconceived PAs to be doctors, raising a potential risk of reduced trust in the PA relationship and negative implications for satisfaction with their PA encounter. Participants considered it beneficial that patients be informed about the PA role to prevent confusion.

CONCLUSIONS

PA encounters offer a constructive example of successful clinician-patient communication experiences in acute hospital encounters from the patient's perspective. Study participants were generally naïve to the PA role. Hospital services and organisations introducing these mid-level or advanced care practitioner roles should consider giving attention to informing patients about the roles.

The contribution of patients' presurgery perceptions of surgeon attributes to the experience of trust and pain during third molar surgery

Background:

Patients' feeling of trust in their surgeon may modulate the experience of pain during surgery. However, factors that contribute to patients' experience of trust during surgery remain underexamined. The current study examined the contribution of patients' impressions of surgeons' warmth and competence to their experience of trust and pain during wisdom tooth extractions.

Methods:

Patients (N = 135, 47% female) scheduled for a wisdom tooth extraction reported their current distress and impressions of their surgeon's warmth and competence after a brief introduction to their surgeon immediately before surgery. Immediately after their surgery, patients reported their experience of trust (feeling safe and in good hands) and pain during surgery. Path analyses modeled perceptions of surgeon warmth, competence, and their interaction as predictors of patients' experiences of trust and pain during surgery.

Results:

Higher perceived surgeon competence, but not warmth, predicted the experience of higher trust and lower pain during surgery. Perceived competence interacted with perceived warmth such that the competence–trust relationship was only significant at moderate to high levels of perceived surgeon warmth and failed to reach significance at lower levels of perceived surgeon warmth.

Conclusion:

These results indicate that patients feel greater trust in surgeons who are perceived as higher in competence and warmth, underscoring the importance of impression management in surgical care.

Effective Information Provision About the Side Effects of Treatment for Malignant Lymphoma: Protocol of a Randomized Controlled Trial Using Video Vignettes

BACKGROUND

Informing patients with cancer about the possible implications of prospective treatment is a crucial yet challenging task. Unfortunately, patients' recall of medical information is generally poor and their information needs are not met. Effective information giving entails that oncologists help patients understand and recall the implications of their treatment, meanwhile fostering a trusting physician-patient relationship. Communication strategies that are often suggested to be effective are structuring and tailoring (cognition-oriented) but also are oncologists' expressions of caring or empathy (affect-oriented).

OBJECTIVE

The aim of this study is to provide evidence concerning the pathways linking physician communication to (improved) consultation outcomes for patients. More specifically, the aim is to determine the effects of information structuring and information tailoring, combined with physician caring, on information recall, satisfaction with information, and trust in the physician (primary objective) and on symptom distress (secondary objective).

METHODS

A randomized controlled trial, systematically testing the effects of information structuring and information tailoring, each combined with caring, in 2 video-vignette experiments (2×2 and 2×2×2 design). Using an online survey platform, participants will be randomly allocated (blinded) to 1 of 12 conditions in which they are asked to view a video vignette (intervention) in which an oncologist discusses a treatment plan for malignant lymphoma with a patient. The independent variables of interest are systematically varied across conditions. The outcome measures are assessed in a survey, using validated instruments. Study participants are (former) patients with cancer and their relatives recruited via online panels and patient organizations. This protocol discusses the trial design, including the video-vignette design, intervention pretesting, and a pilot study.

RESULTS

Data collection has now been completed, and preliminary analyses will be available in Spring 2019. A total of 470 participants completed the first part of the survey and were randomized to receive the intervention.

CONCLUSIONS

The results of the proposed trial will provide evidence concerning the pathways linking physician information, giving skills to (improved) consultation outcomes for patients.

TRIAL REGISTRATION

Netherlands Trial Register NTR6153; https://www.trialregister.nl/trial/6022 (Archived by Webcite at http://www.webcitation.org/76xVV9xC8).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12453.

Views of psycho-oncologists, physicians, and nurses on cancer care-A qualitative study

BACKGROUND

As worldwide cancer prevalence continues to increase, the challenges facing cancer care are also increasing. Various topics related to deficiencies in cancer care have been discussed repeatedly in the literature. The most frequently stated topics are the unmet psychosocial support needs of cancer patients, difficulties in multidisciplinary teamwork, difficulties in communication between physicians and patients, and issues in palliative care settings. However, there is little research regarding the views of health care providers on these topics. With the aim of gaining abundant information regarding the care of German cancer patients, this study explores the stances of psycho-oncologists, physicians, and nurses regarding the quality of cancer care.

MATERIALS AND METHODS

Semi-structured interviews were conducted at the University Medical Center Hamburg-Eppendorf (UKE) and in different oncological outpatient offices in Hamburg; twenty-five interviews in total were conducted with health care providers. Interviews were semi-structured to gain a broad range of information on cancer care. The data were analyzed using thematic analysis by Braun and Clarke with an inductive, constant comparison approach to identify themes and categorized codes.

RESULTS

The following five principle themes were identified in the interviews: "psycho-oncological care", "cooperation of health care providers", "palliative care", "health care provider-patient contact", and "coordination and organization of care". Participants seemed satisfied with the overall quality of cancer care in Germany. Nevertheless, the results showed deficiencies regarding communication among different health care providers and between health care providers and patients. Important findings in conjunction with these communication problems were a lack of psycho-oncological support, shortages in the oncology work force, language and cultural barriers, and deficient education in the communication of providers.

CONCLUSIONS

The statements of psycho-oncologists, physicians, and nurses on cancer care provide a suitable basis to conduct further focused research on the studied deficiencies in cancer care. In particular, communication in psycho-oncological care, communication within multidisciplinary teams, and health care provider-patient communication should be further explored with the aim of developing new ideas for improvements and thereby enhancing the quality of cancer care.

The Use of Expectancy and Empathy When Communicating With Patients With Advanced Breast Cancer; an Observational Study of Clinician-Patient Consultations

Background: Information provision about prognosis, treatments, and side-effects is important in advanced cancer, yet also associated with impaired patient well-being. To counter potential detrimental effects, communication strategies based on placebo and nocebo effect mechanisms might be promising to apply in daily practice. This study aimed to provide more insight into how often and how oncologists use expectancy and empathy expressions in consultations with patients with advanced breast cancer. Methods: Forty-five consultations between oncologists and patients were audiotaped. To determine how often expectancy and empathy expressions were used, a coding scheme was created. Most consultations (n = 33) were coded and discussed by two coders, and the remaining 13 were coded by one coder. To determine how expectancy and empathy expressions were used, principles of inductive content analysis were followed. Results: Discussed evaluation (i.e., scan) results were good (n = 26,58%) or uncertain (n = 12,27%) and less often bad (n = 7,15%). Uncertain expectations about prognosis, treatment outcomes, and side effects occurred in 13, 38, and 27 consultations (29%, 85%, and 56%), followed by negative expectations in 8, 26, and 28 consultations (18%, 58%, and 62%) and positive expectations in 6, 34, and 17 consultations (13%, 76%, and 38%). When oncologists provided expectancy expressions, they tapped into three different dimensions: relational, personal, and explicit. Positive expectations emphasized the doctor-patient relationship, while negative expectations focused on the severity of the illness, and uncertainty was characterized by a balance between (potential) negative outcomes and hope. Observed generic or specific empathy expressions were regularly provided, most frequently understanding (n = 29,64% of consultations), respecting (n = 17,38%), supporting (n = 16,36%), and exploring (n = 16,36%). A lack of empathy occurred less often and contained, among others, not responding to patients' emotional concerns (n = 13,27% of consultations), interrupting (n = 7,16%), and an absence of understanding (n = 4,9%). Conclusion: In consultations with mainly positive or uncertain medical outcomes, oncologists predominantly made use of uncertain expectations (hope for the best, prepare for the worst) and used several empathic behaviors. Replication studies, e.g., in these and other medical situations, are needed. Follow-up studies should test the effect of specific communication strategies on patient outcomes, to counter potential negative effects of information provision. Studies should focus on uncertain situations. Ultimately, specific placebo and nocebo effect-inspired communication strategies can be harnessed in clinical care to improve patient outcomes.

Trust and Perceptions of Physicians' Nonverbal Behavior Among Women with Immigrant Backgrounds

Previous findings suggest immigrant patients have lower trust in their physicians, and perceive nonverbal communication differently compared to non-immigrant patients. We tested discrepancies in trust and the impact of non-verbal behavior between immigrants and non-immigrants in The Netherlands. Nonverbal communication of an oncologist was systematically varied in an experimental video vignettes design. Breast cancer patients (n = 34) and healthy women (n = 34) viewed one of eight video versions and evaluated trust and perceived friendliness of the oncologist. In a matched control design, women with immigrant and non-immigrant backgrounds were paired. Immigrant women reported stronger trust. Nonverbal communication by the oncologist did not influence trust differently for immigrants compared to for non-immigrants. However, smiling strongly enhanced perceived friendliness for non-immigrants, but not for immigrants. Immigrant patients' strong trust levels may be formed a priori, instead of based on physicians' communication. Physicians may need to make extra efforts to optimize their communication.

Communication skills training for healthcare professionals working with people who have cancer

BACKGROUND

This is the third update of a review that was originally published in the Cochrane Library in 2002, Issue 2. People with cancer, their families and carers have a high prevalence of psychological stress, which may be minimised by effective communication and support from their attending healthcare professionals (HCPs). Research suggests communication skills do not reliably improve with experience, therefore, considerable effort is dedicated to courses that may improve communication skills for HCPs involved in cancer care. A variety of communication skills training (CST) courses are in practice. We conducted this review to determine whether CST works and which types of CST, if any, are the most effective.

OBJECTIVES

To assess whether communication skills training is effective in changing behaviour of HCPs working in cancer care and in improving HCP well-being, patient health status and satisfaction.

SEARCH METHODS

For this update, we searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE via Ovid, Embase via Ovid, PsycInfo and CINAHL up to May 2018. In addition, we searched the US National Library of Medicine Clinical Trial Registry and handsearched the reference lists of relevant articles and conference proceedings for additional studies.

SELECTION CRITERIA

The original review was a narrative review that included randomised controlled trials (RCTs) and controlled before-and-after studies. In updated versions, we limited our criteria to RCTs evaluating CST compared with no CST or other CST in HCPs working in cancer care. Primary outcomes were changes in HCP communication skills measured in interactions with real or simulated people with cancer or both, using objective scales. We excluded studies whose focus was communication skills in encounters related to informed consent for research.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials and extracted data to a pre-designed data collection form. We pooled data using the random-effects method. For continuous data, we used standardised mean differences (SMDs).

MAIN RESULTS

We included 17 RCTs conducted mainly in outpatient settings. Eleven trials compared CST with no CST intervention; three trials compared the effect of a follow-up CST intervention after initial CST training; two trials compared the effect of CST and patient coaching; and one trial compared two types of CST. The types of CST courses evaluated in these trials were diverse. Study participants included oncologists, residents, other doctors, nurses and a mixed team of HCPs. Overall, 1240 HCPs participated (612 doctors including 151 residents, 532 nurses, and 96 mixed HCPs).Ten trials contributed data to the meta-analyses. HCPs in the intervention groups were more likely to use open questions in the post-intervention interviews than the control group (SMD 0.25, 95% CI 0.02 to 0.48; P = 0.03, I² = 62%; 5 studies, 796 participant interviews; very low-certainty evidence); more likely to show empathy towards their patients (SMD 0.18, 95% CI 0.05 to 0.32; P = 0.008, I² = 0%; 6 studies, 844 participant interviews; moderate-certainty evidence), and less likely to give facts only (SMD -0.26, 95% CI -0.51 to -0.01; P = 0.05, I² = 68%; 5 studies, 780 participant interviews; low-certainty evidence). Evidence suggesting no difference between CST and no CST on eliciting patient concerns and providing appropriate information was of a moderate-certainty. There was no evidence of differences in the other HCP communication skills, including clarifying and/or summarising information, and negotiation. Doctors and nurses did not perform differently for any HCP outcomes.There were no differences between the groups with regard to HCP 'burnout' (low-certainty evidence) nor with regard to patient satisfaction or patient perception of the HCPs communication skills (very low-certainty evidence). Out of the 17 included RCTs 15 were considered to be at a low risk of overall bias.

AUTHORS' CONCLUSIONS

Various CST courses appear to be effective in improving HCP communication skills related to supportive skills and to help HCPs to be less likely to give facts only without individualising their responses to the patient's emotions or offering support. We were unable to determine whether the effects of CST are sustained over time, whether consolidation sessions are necessary, and which types of CST programs are most likely to work. We found no evidence to support a beneficial effect of CST on HCP 'burnout', the mental or physical health and satisfaction of people with cancer.

Do Patients Feel Well Informed in a Radiation Oncology Service?

Information received by cancer patients has gained importance in recent decades. The aim of this study was to evaluate the perception of information received by oncological patients in a radiotherapy department and to measure the importance of the other information sources. A cross-sectional study was conducted, evaluating patients who received radiotherapy. All the patients were asked two questionnaires: the EORTC QLQ-INFO26 module evaluating their satisfaction with received information, and a questionnaire analyzing other sources of information search. One hundred patients between 27 and 84 years were enrolled. Breast cancer (26 %) was the commonest cancer. Patients felt better informed about the medical tests and secondly about the performed treatment. The younger patients were those who were more satisfied with the information received and patients with no formal education felt less satisfied, with statistically significant differences. Patients did not seek external information; at the most, they asked relatives and other people with cancer. Patients were satisfied with the received information, although a high percentage would like more information. In general, patients did not search for external information sources. Age and educational level seem to influence in the satisfaction with the received information.

Achieving Goal-Concordant Care: A Conceptual Model and Approach to Measuring Serious Illness Communication and Its Impact

BACKGROUND

High-quality care for seriously ill patients aligns treatment with their goals and values. Failure to achieve "goal-concordant" care is a medical error that can harm patients and families. Because communication between clinicians and patients enables goal concordance and also affects the illness experience in its own right, healthcare systems should endeavor to measure communication and its outcomes as a quality assessment. Yet, little consensus exists on what should be measured and by which methods.

OBJECTIVES

To propose measurement priorities for serious illness communication and its anticipated outcomes, including goal-concordant care.

METHODS

We completed a narrative review of the literature to identify links between serious illness communication, goal-concordant care, and other outcomes. We used this review to identify gaps and opportunities for quality measurement in serious illness communication.

RESULTS

Our conceptual model describes the relationship between communication, goal-concordant care, and other relevant outcomes. Implementation-ready measures to assess the quality of serious illness communication and care include (1) the timing and setting of serious illness communication, (2) patient experience of communication and care, and (3) caregiver bereavement surveys that include assessment of perceived goal concordance of care. Future measurement priorities include direct assessment of communication quality, prospective patient or family assessment of care concordance with goals, and assessment of the bereaved caregiver experience.

CONCLUSION

Improving serious illness care necessitates ensuring that high-quality communication has occurred and measuring its impact. Measuring patient experience and receipt of goal-concordant care should be our highest priority. We have the tools to measure both.

Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline

Purpose To provide guidance to oncology clinicians on how to use effective communication to optimize the patient-clinician relationship, patient and clinician well-being, and family well-being. Methods ASCO convened a multidisciplinary panel of medical oncology, psychiatry, nursing, hospice and palliative medicine, communication skills, health disparities, and advocacy experts to produce recommendations. Guideline development involved a systematic review of the literature and a formal consensus process. The systematic review focused on guidelines, systematic reviews and meta-analyses, and randomized controlled trials published from 2006 through October 1, 2016. Results The systematic review included 47 publications. With the exception of clinician training in communication skills, evidence for many of the clinical questions was limited. Draft recommendations underwent two rounds of consensus voting before being finalized. Recommendations In addition to providing guidance regarding core communication skills and tasks that apply across the continuum of cancer care, recommendations address specific topics, such as discussion of goals of care and prognosis, treatment selection, end-of-life care, facilitating family involvement in care, and clinician training in communication skills. Recommendations are accompanied by suggested strategies for implementation. Additional information is available at www.asco.org/supportive-care-guidelines and www.asco.org/guidelineswiki .

How oncologists' communication improves (analogue) patients' recall of information. A randomized video-vignettes study

OBJECTIVE

Cancer patients need information provision to cope with their disease. However, only 20-60% of information provided during consultations is remembered. This study aimed to investigate whether oncologists' use of trust-conveying communication, characterized by communicating competence, honesty and caring, enhances patients' memory. Moreover, we aimed to investigate if this hypothetical relationship is mediated by a reduction in psychophysiological arousal during the consultation.

METHODS

An experimental design was used, allowing for conclusion about causality. Two versions of a scripted video-taped consultation were used in which the oncologist adopted either a standard or a trust-conveying communication style. 97 cancer-naive individuals acted as analogue patients and were randomly assigned to watch one of the consultations.

RESULTS

Free recall, assessed 24-28h after viewing, was higher (p=0.039) in the trust-conveying condition (65.3% versus 59.5%). Recognition did not differ (p=0.502). Psychophysiological assessment during watching showed a smaller heart rate response in the trust-conveying condition (p=0.037). No mediation effect nor an effect on electrodermal activity was found.

CONCLUSION

These results suggest that oncologists' use of trust-conveying communication could increase patients' free recall of information and diminish their cardiovascular response.

PRACTICE IMPLICATIONS

The underlying mechanisms by which oncologists' communication influences information recall warrants further investigation.

Development and validation of an abbreviated version of the Trust in Oncologist Scale-the Trust in Oncologist Scale-short form (TiOS-SF)

Purpose

The original 18-item, four-dimensional Trust in Oncologist Scale assesses cancer patients’ trust in their oncologist. The current aim was to develop and validate a short form version of the scale to enable more efficient assessment of cancer patients’ trust.

Methods

Existing validation data of the full-length Trust in Oncologist Scale were used to create a short form of the Trust in Oncologist Scale. The resulting short form was validated in a new sample of cancer patients (n = 92). Socio-demographics, medical characteristics, trust in the oncologist, satisfaction with communication, trust in healthcare, willingness to recommend the oncologist to others and to contact the oncologist in case of questions were assessed. Internal consistency, reliability, convergent and structural validity were tested.

Results

The five-item Trust in Oncologist Scale Short Form was created by selecting the statistically best performing item from each dimension of the original scale, to ensure content validity. Mean trust in the oncologist was high in the validation sample (response rate 86%, M = 4.30, SD = 0.98). Exploratory factor analyses supported one-dimensionality of the short form. Internal consistency was high, and temporal stability was moderate. Initial convergent validity was suggested by moderate correlations between trust scores with associated constructs.

Conclusions

The Trust in Oncologist Scale Short Form appears to efficiently, reliably and validly measures cancer patients’ trust in their oncologist. It may be used in research and as a quality indicator in clinical practice. More thorough validation of the scale is recommended to confirm this initial evidence of its validity.

Factors associated with patient preferences for communication of bad news

OBJECTIVE

Communication based on patient preferences can alleviate their psychological distress and is an important part of patient-centered care for physicians who have the task of conveying bad news to cancer patients. The present study aimed to explore the demographic, medical, and psychological factors associated with patient preferences with regard to communication of bad news.

METHODS

Outpatients with a variety of cancers were consecutively invited to participate in our study after their follow-up medical visit. A questionnaire assessed their preferences regarding the communication of bad news, covering four factors-(1) how bad news is delivered, (2) reassurance and emotional support, (3) additional information, and (4) setting-as well as on demographic, medical, and psychosocial factors.

RESULTS

A total of 529 outpatients with a variety of cancers completed the questionnaire. Multiple regression analyses indicated that patients who were younger, female, had greater faith in their physician, and were more highly educated placed more importance on "how bad news is delivered" than patients who were older, male, had less faith in their physician, and a lower level of education. Female patients and patients without an occupation placed more importance on "reassurance and emotional support." Younger, female, and more highly educated patients placed more importance on "additional information." Younger, female, and more highly educated patients, along with patients who weren't undergoing active treatment placed more importance on "setting."

SIGNIFICANCE OF RESULTS

Patient preferences with regard to communication of bad news are associated with factors related to patient background. Physicians should consider these characteristics when delivering bad news and use an appropriate communication style tailored to each patient.