Walter F. Baile

Oncologists’ Attitudes Toward and Practices in Giving Bad News: An Exploratory Study

PURPOSE To examine the attitudes and practices of oncologists in disclosure of unfavorable medical information to cancer patients. METHODS A questionnaire was administered to a group of physicians who attended the 1999 Annual Meeting of the American Society of Clinical Oncology. The questionnaire assessed demographic and practice-related information and the frequency of patient encounters in which unfavorable cancer-related information was disclosed. Participants were also asked about difficulties they had when approaching stressful discussions and communication strategies used in giving unfavorable information. RESULTS The questionnaire was completed by 167 oncologists. Sixty-four percent were medical oncologists. Thirty-eight percent practiced in North America, 26% practiced in Europe, 13% practiced in South America, and 13% practiced in Asia. Participants gave bad news to patients an average of 35 times per month. Discussing no further curative treatment and hospice was reported as most difficult. In disclosing the cancer diagnosis and prognosis, physicians from Western countries were less likely to withhold unfavorable information from the patient at the familys request, avoid the discussion entirely, use euphemisms, and give treatments known not to be effective so as not to destroy hope than physicians from other countries. There was significant variability in opinions regarding the best time to discuss resuscitation, with 18% of respondents believing that it should be done close to the end of life. CONCLUSION There was significant variability in how physicians approach information disclosure to cancer patients. Factors such as geographical region and cultural and family variables may be important influences in this process.

Patient-physician communication in oncology: Past, present, and future

Purpose of review Contemporary oncology practice acknowledges the importance of partnering with the patient and family in dealing with the illness. Patients also value their physicians as important sources of support when they provide information about the illness, encouragement, and hope, discuss treatment options, and address their concerns. For this reason outcomes associated with the quality of the physician-patient relationship have received increasing recognition. This review highlights relevant studies bearing on important outcomes of communication with the cancer patient and discusses the implication for training oncologists of the future. Recent findings Evidence is mounting that effective and empathic communication with the cancer patient and family can influence desirable outcomes in cancer care, which affect patient quality of life, satisfaction with care, and medical outcomes. Evidence also exists that communication and interpersonal skills can be taught and learned. Oncology training programs traditionally do not offer experience in this aspect of care although communication skills have now been defined as a core competency for oncology trainees. Finding motivated faculty to teach and providing time and structure in the curriculum are also major obstacles to be overcome. Summary Communication skills are the cornerstone of comprehensive cancer care. Learning this aspect of patient care can expand the supportive role of the oncologist especially at crucial times for the patient and family such as diagnosis, disease recurrence, and transition to palliative care.

How families communicate about HNPCC genetic testing: Findings from a qualitative study

Little is known about how hereditary nonpolyposis colon cancer (HNPCC) genetic counseling and testing information is communicated within at‐risk families. This article describes findings from a qualitative study of 39 adult members from five families with known HNPCC‐predisposing mutations. We evaluated how information from HNPCC genetic counseling and testing was disseminated in these families and how family members reacted to and acted on this information. We included family members who had been diagnosed with an HNPCC syndrome cancer, unaffected individuals who were at 50% risk of carrying a mutation, and their spouses. Participants included those who had undergone testing and those who had not. In general, all families had shared the news about an HNPCC mutation with at‐risk relatives. Communication about HNPCC genetic counseling and testing followed the norms used for conveying other nonurgent family news. Mutation noncarriers, nontesters, and those who were not biological relatives were less involved in discussing genetic counseling and testing and perceived these processes as less relevant to them. Although all family members were generally willing to share information about HNPCC, probands and mutation carriers informed extended family members and actively persuaded others to seek counseling or testing. Family members who were persuaded to seek those services by the proband were more likely to have counseling and testing and were more likely to seek those services sooner. Genetic counseling should attempt to identify the existing communication norms within families and ways that family members can take an active role in encouraging others to learn about their cancer risk and options for testing. Interventions may also need to emphasize the relevance of hereditary cancer information beyond the immediate family and to unaffected family members who may be central to the communication process (e.g., spouses of mutation carriers).

The effects of depressed mood on smoking cessation: Mediation by postcessation self-efficacy

This study evaluated the relationship between precessation depressed mood and smoking abstinence and assessed the mediation of this effect by postcessation self-efficacy, urges to smoke, nicotine withdrawal, and coping behavior. The sample included 121 smokers previously treated in a randomized controlled trial involving behavior therapy and the nicotine patch. The results showed that precessation depressed mood was inversely related to 6-month abstinence. This effect remained significant after controlling for treatment, possible depression history, baseline smoking rates, and several other demographic factors. Postcessation self-efficacy, at the 2-, 4-, and 8-week postquit assessments, was the strongest mediator of the effects of precessation depressed mood on abstinence, accounting for 32%, 38%, and 48% of the effect of mood on abstinence, respectively.

Psychological impact of genetic testing for hereditary nonpolyposis colorectal cancer

PURPOSE This study examines the impact of hereditary nonpolyposis colorectal cancer (HNPCC) genetic test results on psychological outcomes among cancer-affected and -unaffected participants up to 1 year after results disclosure. PATIENTS AND METHODS A total of 155 persons completed study measures before HNPCC genetic testing, and at 2 weeks and 6 and 12 months after disclosure of test results. RESULTS Mean scores on all outcome measures remained stable and within normal limits for cancer-affected participants, regardless of mutation status. Among unaffected carriers of HNPCC-predisposing mutations, mean depression, state anxiety, and cancer worries scores increased from baseline to 2 weeks postdisclosure and decreased from 2 weeks to 6 months postdisclosure. Among unaffected noncarriers, mean depression and anxiety scores did not differ, but cancer worries scores decreased during the same time period. Affected and unaffected carriers had higher mean test-specific distress scores at 2 weeks postdisclosure compared with noncarriers in their respective groups; scores decreased for affected carriers and all unaffected participants from 2 weeks to 12 months postdisclosure. Classification of participants into high- versus low-distress clusters using mean scores on baseline psychological measures predicted significantly higher or lower follow-up scores, respectively, on depression, state anxiety, quality of life, and test-specific distress measures, regardless of mutation status. CONCLUSION Although HNPCC genetic testing does not result in long-term adverse psychological outcomes, unaffected mutation carriers may experience increased distress during the immediate postdisclosure time period. Furthermore, those with higher levels of baseline mood disturbance, lower quality of life, and lower social support may be at risk for both short- and long-term increased distress.

Correlates of Psychologic Distress in Colorectal Cancer Patients Undergoing Genetic Testing for Hereditary Colon Cancer

In this article the authors describe the demographic and psychosocial correlates of 2 measures of psychologic distress among 200 colorectal cancer patients undergoing genetic testing for hereditary nonpolyposis colon cancer. The prevalence of symptoms of depression on the Center for Epidemiologic Studies Depression (CES-D) Scale was 24%. In multivariate analysis, female sex, less formal education, fewer sources of social contacts, and less satisfaction with them were associated with high scores on the CES-D Scale. Characteristics associated with high scores on the State-Trait Anxiety Inventory were younger age, less formal education, non-White race, local-regional stage of disease, fewer social contacts, and less satisfaction with them. Information on psychosocial correlates of psychologic distress may prove useful in guiding genetic counseling sessions, in identifying subgroups that need more intensive follow-up, and in developing interventions to facilitate adjustment to genetic test results.

Reflective teaching practices: An approach to teaching communication skills in a small-group setting

Small-group teaching is particularly suited for complex skills such as communication. Existing work has identified the basic elements of small-group teaching, but few descriptions of higher-order teaching practices exist in the medical literature. Thus the authors developed an empirically driven and theoretically grounded model for small-group communication-skills teaching. Between 2002 and 2005, teaching observations were collected over 100 hours of direct contact time between four expert facilitators and 120 medical oncology fellows participating in Oncotalk, a semiannual, four-day retreat focused on end-of-life communication skills. The authors conducted small-group teaching observations, semistructured interviews with faculty participants, video or audio recording with transcript review, and evaluation of results by faculty participants. Teaching skills observed during the retreats included a linked set of reflective, process-oriented teaching practices: identifying a learning edge, proposing and testing hypotheses, and calibrating learner self-assessments. Based on observations and debriefings with facilitators, the authors developed a conceptual model of teaching that illustrates an iterative loop of teaching practices aimed at enhancing learners’ engagement and self-efficacy. Through longitudinal, empirical observations, this project identified a set of specific teaching skills for small-group settings with applicability to other clinical teaching settings. This study extends current theory and teaching practice prescriptions by describing specific teaching practices required for effective teaching. These reflective teaching practices, while developed for communication skills training, may be useful for teaching other challenging topics such as ethics and professionalism.

Smoking following myocardial infarction: a critical review of the literature.

This paper critically reviews the available research on the effects of smoking cessation following acute myocardial infarction (MI). Studies that have examined the rate of smoking cessation following an MI indicate that approximately 1/3 to 1/2 of the smokers who suffer from MI subsequently reduce or quit smoking. Furthermore, studies that have examined subsequent mortality and morbidity suggest that individuals who quit smoking following MI exhibit lower mortality and morbidity than those who continue to smoke. It is argued that past studies may have overestimated post-MI smoking cessation rates, and by failing to control for a priori differences between quitters and continuing smokers (e.g., MI severity) may have underestimated the negative effects of smoking following MI. Suggestions for future research are proposed.

A retrospective study of the psychiatric management and outcome of delirium in the cancer patient

This report describes the evaluation and treatment of delirium in the cancer patient in a major comprehensive cancer center. Ninety consecutive cases of delirium seen by the inpatient psychiatry consultation/liaison service were analyzed in a retrospective fashion to evaluate demographic information, alcohol use, central nervous system disease, coexisting medical disease, and past psychiatric history. Delirium cases were divided into hyperalert, hypoalert, and mixed subtypes. For these three subtypes, medication profiles including dose of medication, duration of delirium, outcome, and the venue where the delirium began were also evaluated. The hyperalert subtype of delirium was the commonest type observed (71%) and had the shortest duration (P <0.0001) and best outcome (P <0.001). The patients with a hyperalert delirium subtype were treated with the least amount of haloperidol (P <0.0001). Patients were delirious for longer when the delirium began in the intensivecare units (P < 0.04). In general, patients who received no haloperidol experienced delirium of longer duration (P < 0.02) than those receiving haloperidol. Since the data represent patients who were referred for psychiatric treatment, this may explain the increased number of hyperalert deliriums and, therefore, the generalizability of the results is limited. Delirium in the cancer patient is particularly problematic given the coexisting medical problems these patients experience. Because the outcome of delirium is better when the duration is shorter, it is important for clinicians to be sensitive to early symptoms so that treatment can be implemented faster, leading to less morbidity and mortality.

Faculty development to change the paradigm of communication skills teaching in oncology

Dr B, a faculty oncologist supervising fellows at an outpatient oncology clinic, faces a common teaching quandary. A second-year oncology fellow presents a patient with metastatic lung cancer, which has progressed despite second-line palliative chemotherapy. The fellow concludes his presentation, which was technically impeccable, by saying, “I thought the patient was not getting how bad this is, so it was time to hang crepe. I told him it was a choice between phase I or nothing.” Dr B knows the fellow to be a careful physician who is genuinely concerned about the well-being of his patients. Yet the fellows comment about hanging crepe raises a red flag for Dr B, because in his experience, blunt disclosures of poor prognoses may lead patients to wonder if their physician is still on their side. In addition, Dr B does not like telling patients that there is nothing more to be done. But he is not sure how to get the fellow to understand this. Should he confront the fellow about this, or just let the comment pass?