Christina G. Blanchard

Information and decision-making preferences of hospitalized adult cancer patients.

Physician behaviors and patient responses were studied in 439 interactions between hospitalized adult cancer patients and oncologists to investigate patient preferences for a participatory role in the interaction. Patients were asked their preference for information to be given (minimal; only if it is good news; or all information, good or bad) and their preference for participation in decision-making (prefer doctor makes therapeutic decisions or prefer to participate in decisions). The majority (92%) preferred all information be given, but only 69% preferred to participate in therapeutic decisions. Of those wanting all the information, 24.9% preferred the physician to make the therapeutic decisions. This group was comprised primarily of older, sicker males. Those who did not want to participate were also slightly more satisfied (P less than 0.05). These data suggest that, although most patients prefer all information to be given to them, almost one-fourth of them preferred a more authoritarian, rather than participatory, relationship with their oncologist.

Physician behaviors, patient perceptions, and patient characteristics as predictors of satisfaction of hospitalized adult cancer patients

To examine potential predictors of cancer patient satisfaction with physician behavior, 366 cases were studied. Physician behavior was measured on morning rounds using the Physician Behavior Check List (PBCL). Patient satisfaction and perceptions were assessed after the visit. Patient characteristics were obtained from the chart and the physician. Results showed wide variation in physician behavior; no “standard” set of behaviors was seen in all interactions. Patient satisfaction was high (x̌=87.8 mm on a 100‐mm scale). Path analysis showed four variables predicted 62% of the variance in patient satisfaction. The strongest predictor was the patient perception item, “perception of needs addressed that day.” Other predictors were perception of emotional support provided by the physician, age (older), and one physician behavior, “discusses treatment.” Patient perceptions of needs met or emotional support provided were predicted by perceptions of the occurrence of physician behaviors involving information such as the diagnosis and tests and treatment. Overall, patient perceptions of physician behaviors were stronger predictors of patient satisfaction than the actual occurrence or absence of those behaviors.

Strategic Physician Communication and Oncology Clinical Trials

PURPOSE Clinical trials are the primary means for determining new, effective treatments for cancer patients, yet the number of patients that accrue is relatively limited. The purpose of this study was to explore the relationship between physician behavior and patient accrual to a clinical trial by videotaping the interaction. PATIENTS AND METHODS Forty-eight patient-physician interactions involving 12 different oncologists were videotaped in several clinics at the H. Lee Moffitt Cancer Center and Research Institute (Tampa, FL). The purpose of each interaction was to present the possibility of a clinical trial to the patient. A coding system, the Moffitt Accrual Analysis System, was developed by the authors to code behaviors that represented both the legal-informational and social influence models of communication behavior. Thirty-two patients agreed to participate in the clinical trial. RESULTS Videotaping was found to be a viable, valid, and reliable method for studying the interaction. Physicians who were observed to use both models of influence were found to enroll more patients. Thus, patients were more likely to accrue to the trial when their physician verbally presented items normally included in an informed consent document and when they behaved in a reflective, patient-centered, supportive, and responsive manner. Discussion of benefits, side effects, patient concerns and resources to manage the concerns were all associated with accrual. CONCLUSION This research has implications for modifying physician behavior and, thus, increasing the numbers of patients accruing to oncology clinical trials.

Posttraumatic stress disorder in breast cancer patients following autologous bone marrow transplantation or conventional cancer treatments.

We assessed 17 women who had undergone autologous bone marrow transplants (BMT) for their breast cancer and 20 other women who had been treated for breast cancer (but not with BMT) by structured clinical interviews examining each stage of the breast cancer experience (e.g. initial diagnosis, initial treatment, recurrence of cancer (if applicable) and BMT (if applicable)) and at follow-up points; 3, 6 and 12 months (if applicable) posttreatment. The two groups did not differ on incidence of posttraumatic stress disorder (PTSD), major depressive disorder (MDD) or generalized anxiety disorder at any stage. We found a high rate of PTSD over the cancer experience, 35% for the combined sample, with cancer diagnosis being the most likely point for developing PTSD, 27% for the combined sample. None of the 17 women who had undergone BMT developed PTSD as a result of the treatment.

The Role of Social Support in Adaptation to Cancer and to Survival

Social support continues to be studied by many investigators as a variable associated with adaptation to the stress of cancer and its treatment. Recent selected studies are reviewed and limitations of the studies are noted, including the predominance of cross-sectional designs, lack of agreement on instruments to use to assess social supports and outcome measures, and the dearth of substantive models for guiding research and interventions. Although studies have also explored the relationship between support and survival, results are inconclusive. Future studies should include longitudinal designs, analyze support as an interactional process based on mutual influence, and explore the relationship between social support and the domains of quality of life (in addition to mood).

Interactions Between Oncologists and Patients During Rounds

Physician behavior during inpatient rounds was observed and quantified for 394 interactions between patients with cancer and physicians. Most patients had solid tumors (90%) and a limited prognosis despite treatment (61%). The physicians spent 1.45 +/- 0.58 h on morning rounds seeing an average of 9.3 +/- 3.39 patients. For each patient an average of 3.61 +/- 2.83 min was spent in the room. The rest of the time was involved in reviewing the results of diagnostic tests, discussing treatment plans, and updating patients charts. Time spent in the room was significantly related to the patients sex and diagnosis. Physicians spent more time with patients having the poorest prognosis (p = 0.009). Specific behaviors were analyzed using a Physician Behavior Check List that allows accurate recording of behavior during a brief patients-physician encounter. Factor analysis of responses to the check list resulted in four factors that explained 58.7% of the variance. The physician behavior factor scores failed to correlate with factor scores from the responses of the same physicians to the Cancer Attitude Survey. In addition, the physicians were unable to accurately estimate the time they actually spent with patients or the frequency of specific behaviors that occurred during these interactions.

Communication and consumer decision making about cancer clinical trials

Communication between patients and physicians likely mediates traditional patient and physician predispositions in determining patient outcomes, including perceptions and decision making. However, the extent to which a mediating effect occurs is unclear. The purpose of this essay is to outline the need for conceptualizing more holistic models of consumer-provider interaction that demonstrate the role of the therapeutic relationship in treatment outcomes. We focus on an important communicative context for exploring this question: the situation where patients, with the help of oncologists, are faced with making treatment choices, particularly whether to enroll in a clinical trial in response to their life-threatening cancer diagnosis. We explore the question from the perspectives of the medical provider, the patient, and the accompanying family member, in order to better frame the complex interactional dynamics occurring during the interaction.

The young widow: depressive symptomatology throughout the grief process.

The purpose of this investigation was to examine patterns of abatement of depressive symptomatology in 30 young widows at three time periods: immediately following the death of the husband, a year later, and at present. Data on all three time periods were gathered during one interview. The study thus provides retrospective information on patterns of depressive symptomatology. It was expected that such information would enhance understanding of the stages of the grief process described by Glick et al. and by Maddison.

A portable, unobtrusive device for videorecording clinical interactions.

Recording and analyzing real-time interactions in clinical settings is important for basic and applied research in psychology and other disciplines. Investigators frequently have used simple audiotaping procedures to record these encounters (e.g., Roter, Geller, Bernhardt, Larson, & Doksum, 1999), but videorecording is increasingly viewed as more reliable and valid, because it captures the full range of complex and interdependent verbal and nonverbal behaviors that occur in an interaction. This article describes a system designed to videotape clinical interactions in a manner that can be moved in and out of different clinical rooms to preserve flexibility in its use. Data are presented to demonstrate that the system is unobtrusive during the interaction, yet fully compatible with institutional review board guidelines to protect human participants’ privacy and freedom to control the recording process.

Attitudes towards cancer. II: A comparative analysis of cancer patients, medical students, medical residents, physicians and cancer educators

The current investigation was designed to determine how cancer patients, medical students, medical residents, nononcologically oriented physicians, and cancer educators differ with respect to attitudes towards cancer. A total of 372 individuals completed the Cancer Attitude Survey. Cancer educators displayed more confidence in the patients ability to cope with diagnostic and prognostic information than students, other physicians, and patients themselves. Patients and cancer educators favored aggressive therapy to a greater extent than other physicians, students, and alumni. Among nononcologic physicians and students there were significant effects of respondents sex and prior personal experience with cancer on the attitudes expressed. Cancer educators differed significantly by specialty with surgical oncologists most likely to favor aggressive therapy. When compared to physician groups studied in the 1960s, our overall physician group (residents, cancer educators, and other physicians) was more likely to exhibit: (1) confidence in the patients coping ability; (2) skepticism about the efficacy of early diagnosis and the value of aggressive treatment; and (3) stronger beliefs in the patients ability to prepare for and accept death. Comparisons of our medical student group with students studied by Haley and his colleagues revealed a similar picture. Implications of these findings for the education of medical students are discussed.