COMMUNICATION SKILLS IMPORTANT FOR MEDICAL ONCOLOGISTS

July 13, 2010 — A diagnosis of cancer can be the most devastating news that a doctor has to deliver, and many physicians need to hone their communication skills when disclosing such a diagnosis.

According to the results of a survey, published online July 6 in the Journal of Clinical Oncology, approximately two thirds of patients reported being told of their cancer diagnosis in person and in a private setting. However, a sizeable minority of patients surveyed stated that their diagnosis was revealed in an impersonal manner, such as over the telephone (18%) or in an emergency department (7%).

One patient reported discovering the diagnosis after reading a radiology report; another reported that the physician telephoned and left a voice message saying "you have lymphoma . . . call me if you have any questions."

Many physicians are not practicing good communication skills, explained lead author William D. Figg, PharmD, chief of the Molecular and Clinical Pharmacology Section, Medical Oncology Branch, National Cancer Institute/National Institutes of Health (NIH), in Bethesda, Maryland.

"The survey shows that the majority of physicians did sit down face to face with the patient in a private setting," he told Medscape Medical News. However, he added, "the examples of when it's done poorly tend to stand out."

"Doctors who are not comfortable giving bad news should consider obtaining additional training in doing so," suggested Walter F. Baile, MD, professor of behavioral science and director of the ICARE (Interpersonal Communication and Relationship Enhancement) Program at the University of Texas M.D. Anderson Cancer Center in Houston, who was not involved in the survey.

It is a misconception that you either have good communication skills or you don't, Dr. Baile told Medscape Medical News. "Many studies indicate that communication is a skill and must be learned. Moreover, some studies indicate that physicians who think that they are good communicators rate at the lower end of the scale."

Disclosure Setting Varies, Most in Person

Dr. Figg and colleagues conducted the study to gain a better understanding of how diagnoses of cancer are disclosed and the consequences of different disclosure approaches.

They distributed a self-administered questionnaire to 460 oncology patients who were receiving treatment at the NIH Clinical Center. The survey contained 34 questions, 7 of which assessed the circumstances of the actual disclosure of cancer to the patient.

The survey was completed by 437 patients (median age, 53 years), of whom 37% had lymphoma or leukemia, 22% had brain cancer, 14% had prostate cancer, and 27% had other cancers.

In all, 233 patients (54%) were informed of their cancer diagnosis in their physician's office.

Another 122 patients (28%) were told of their diagnosis in person, but in the hospital. Of this group, 43% were told in their personal hospital room, 23% in the emergency room, 13% in the recovery room, 7% in the radiology department, and the remaining 13% in a variety of different hospital locations.

The remaining 82 patients (18%) reported that they were given their cancer diagnosis over the telephone. The majority of patients (96%) received their cancer diagnoses from physicians, but 4% received the information from a number of other sources, including radiology technicians, nurses, physician assistants, and relatives.

Some Discussions Short, Treatment Not Mentioned

Many patients reported that the discussion surrounding their cancer diagnosis was very short and almost one third stated that treatment options were not discussed. "Even if patients are anticipating a cancer diagnosis, they want to talk to someone and talk about treatment options," said Dr. Figg. "Sitting down with patients and giving them the information they want is important, especially today when impersonal interactions are becoming so common."

Of the patients responding to the survey, 44% reported that discussions lasted 10 minutes or less, 53% reported discussions lasting longer than 10 minutes, and 5% could not remember. Among patients who were able to clearly recall their conversation, 13% said that the diagnosis was not explained at all, and 31% said that treatment options were not discussed. Almost one third (30%) were not given referrals to other specialists.

"These results reveal a significant departure from recommended best practice, which is that a diagnosis of cancer is always delivered in person by the physician in a private setting," said Penelope Schofield, PhD, director of strategy and development, Department of Nursing and Supportive Care Research at the Peter MacCallum Cancer Centre, in Melbourne, Australia. "There should be sufficient time for the person to assimilate the bad news and discuss their emotions."

"After initial shock has subsided, a discussion of treatment options should be offered," said Dr. Schofield, who was contacted by Medscape Medical News for independent comment. "The person needs the opportunity to ask questions throughout the consultation. Finally, the physician should check the person's understanding of what was discussed and offer a follow-up consultation to discuss treatment options further."

Although giving a patient a cancer diagnosis over the telephone is not ideal, it sometimes can't be avoided, Dr. Baile noted.

After diagnosis, patients usually want a lot of information, especially about treatment, Dr. Baile explained. "But this must be done in language a patient can understand. Doctors should be aware that after hearing a diagnosis of cancer, patients may be emotional and might not remember what is told to them," he pointed out.

Satisfaction Higher With In-Person and Longer Disclosure

Dr. Figg and colleagues hypothesized that a patient given a diagnosis of cancer in a personal manner, such as face to face in a private setting, would be more satisfied with the manner in which they were told they had cancer.

The results bear this out. The median overall satisfaction score was 73.5 (of 100; interquartile range, 45 to 93). The majority of patients (84%) reported higher than neutral satisfaction in communicating with their physician, but 5.6% reported very poor communication. Higher mean satisfaction scores were associated with diagnoses that were given in person rather than over the phone (68.2 vs 47.2), and when a diagnosis was given in a personal rather than an impersonal setting (68.9 vs 55.7).

Similarly, higher ratings were given to discussions that
lasted longer than 10 minutes (73.5 vs 54.1) and discussions that included treatment options (72.0 vs 50.7).

About half of all patients responding to the survey (57%) changed physicians after their cancer diagnosis, for a wide number of reasons, including referrals, desire to received experimental therapy, and wanting a second opinion. But within this group, 15% stated that they switched because they had lost trust in their physicians — 10% because of poor communication and 12% because of general dissatisfaction.

"Patients are often dissatisfied when communication about a cancer diagnosis is given insensitively, and poor communication is a main cause of malpractice suits," Dr. Baile reported.

The authors have disclosed no relevant financial relationships.

J Clin Oncol. Published online July 6, 2010. Abstract