Toward a basic science of communication in serious illness

High-quality communication can mitigate suffering during serious illness. Innovations in theory and technology present the opportunity to advance serious illness communication research, moving beyond inquiry that links broad communication constructs to health outcomes toward operationalizing and understanding the impact of discrete communication functions on human experience. Given the high stakes of communication during serious illness, we see a critical need to develop a basic science approach to serious illness communication research. Such an approach seeks to link "what actually happens during a conversation" - the lexical and non-lexical communication content elements, as well as contextual factors - with the emotional and cognitive experiences of patients, caregivers, and clinicians. This paper defines and justifies a basic science approach to serious illness communication research and outlines investigative and methodological opportunities in this area. A systematic understanding of the building blocks of serious illness communication can help identify evidence-informed communication strategies that promote positive patient outcomes, shape more targeted communication skills training for clinicians, and lead to more tailored and meaningful serious illness care.

The many "Disguises" of patient-centered communication: Problems of conceptualization and measurement

OBJECTIVE

To critically examine different approaches to the measurement of patient-centered communication.

METHODS

Provides a critique of 7 different measures of patient-centered communication with respect to differences in their assumptions about what constitutes patient-centeredness and in their approaches to measurement.

RESULTS

The measures differed significantly with regard to whether the measure captured behavior (what the interactants did) or judgment (how well the behavior was performed), focused on the individual clinician or on the interaction as a whole, and on who makes the assessment (participant or observer). A multidimensional framework for developing patient-centered communication measures is presented that encompasses the patient's perspective and participation, the biopsychosocial context of the patient's health, the clinician-patient relationship, quality of information-exchange, shared understanding, and shared, evidence-based decision-making.

CONCLUSIONS

The state of measurement of the patient-centered communication construct lacks coherence, in part because current measures were developed either void of a conceptual framework or from very different theoretical perspectives.

PRACTICE IMPLICATIONS

Assessment of patients' experiences with quality of communication in medical encounters should drill down into specific domains of patient-centeredness.

Clinician-patient communication measures: drilling down into assumptions, approaches, and analyses

OBJECTIVE

To critically examine properties of clinician-patient communication measures and offer suggestions for selecting measures appropriate to the purposes of research or clinical practice assessment.

METHODS

We analyzed different types of communication measures by focusing on their ontological properties. We describe their relative advantages and disadvantages with respect to different types of research questions.

RESULTS

Communication measures vary along dimensions of reporter (observer vs. participant), focus of measurement (behavior, meaning, or quality), target, and timing. Observer coded measures of communication behavior function well as dependent variables (e.g., evaluating communication skill interventions, examining variability related to gender or race), but are less effective as predictors of perceptions and health outcomes. Measures of participants' judgments (e.g., what the communication means or how well it was done) capture patients' or clinicians' experiences (e.g., satisfaction) and can be useful for predicting outcomes, especially in longitudinal designs.

CONCLUSION

In the absence of a theoretically coherent set of measures that could be used across research programs and applied setting, users should take steps to select measures with properties that are optimally matched to specific questions.

PRACTICE IMPLICATIONS

Quality assessments of clinician-patient communication should take into account the timing of the assessment and use measures that drill down into specific aspects of patient experience to mitigate ceiling effects.

How clinician-patient communication contributes to health improvement: modeling pathways from talk to outcome

OBJECTIVE

Although researchers have long investigated relationships between clinician-patient communication and health outcomes, much of the research has produced null, inconsistent, or contradictory findings. This essay examines challenges in the study of how clinician-patient communication contributes to a patient's health and offers recommendations for future research.

DISCUSSION

Communication may directly impact outcomes, but more often it will have an indirect effect through its influence on intervening variables (e.g., patient understanding, clinician-patient agreement on treatment, adherence to treatment). For example, a patient communication skills intervention may not directly improve pain control for cancer patients. However, it may do so indirectly by activating patients to talk about cancer pain, which prompts the physician to change pain medication, which leads to better pain control. Additionally, communication measurement is complicated because relationships among communication behavior, meaning, and evaluation are complex.

CONCLUSION

Researchers must do more to model pathways linking clinician-patient communication to the outcomes of interest, particularly pathways in which the communication effects are indirect or mediated through other variables. To better explicate how communication contributes to health outcomes, researchers must critically reflect on the assumptions they are making about communication process and choose measures consistent with those assumptions.