Thorne, Sally PhD, RN, FAAN, FCAHS; Oliffe, John L. PhD, RN; Stajduhar, Kelli I. PhD, RN; Oglov, Valerie BSW, MA; Kim-Sing, Charmaine MD, FRCPC; Hislop, T. Gregory MDCM, MSc
Despite a generation of psychosocial care guidelines, sensitivity training approaches, and well-intended patient-centered mission statements, preventing and managing poor communication between cancer patients and their healthcare providers remain a high-priority concern. It is well documented that both excellent communication and poor communication influence quality of life for cancer patients and their clinical outcomes.1 Most oncology clinicians are committed to facilitating sensitive and informed communication.2 Effective communication is universally acknowledged as a core value within health professional training and care delivery systems.3 However, far too many patients still suffer the adverse consequences of exposure to poor communication at some point in their cancer trajectory.4,5
Clinical communication can be defined as the dynamic, interpersonal process of mutual influence that occurs during the exchange of verbal and nonverbal messages between patients and healthcare providers.6 In a seminal review, Ong and colleagues7 signaled the scope of this influence. They noted 3 basic communicative functions in the cancer setting: creating effective interpersonal processes, exchanging information, and facilitating appropriate treatment-related decisions. A recent comprehensive narrative review further confirms the role of communication in regulating patients’ emotions, enhancing their psychological adjustment, and improving their mental health.8 Thus, effective (also termed good or helpful) communication during oncology consultations is well recognized as a highly relevant factor in both care quality and patient outcomes. Recent analyses of the available literature confirm links between ineffective (also termed poor, unhelpful, or problematic) communication in cancer care and a range of adverse outcomes associated with reduced patient quality of life, clinical decision making, and system effectiveness.5,9 Well-documented untoward consequences include unmet emotional needs,10 heightened uncertainty,11 hopelessness,12 impaired informed consent,13 ineffective use of information services,14 and generally poor care coordination.1
Across the spectrum of the cancer care communication literature, we can see an increasing awareness of the impact of everyday communication on the illness experience and quality of life of cancer patients6 as well as recognition of the complexity and multidimensionality it entails.8 Although a considerable body of empirical findings helps inform our approaches to communication in such highly sensitive contexts as the delivery of “bad news” and the transition from curative to palliative care,15,16 the communication that takes place between cancer patients and the nurses, physicians, and allied health professionals with whom they interact in the course of their routine care is less well understood.17 While psychosocial support is identified as essential to a high-quality cancer care service, it is often interpreted as access to the specialized services of psychologists, psychiatrists, or social workers by the subset of patients who have serious psychosocial distress, and not as a component of everyday care.18,19 Because of this, much of the communication research emphasis in cancer care has arisen from the specialized psychosocial support domain, rather than the general oncology care context. However, patient-centered research consistently reveals that encounters with the clinicians who manage and deliver their routine care have a profound influence on patients’ emotional well-being, decision making, and quality of life throughout the course of their cancer journey.4,20 Clearly, cancer communication is a complex problem, and effective solutions will require multifaceted approaches.4,21
State of the Science
At least 18 published systematic reviews exist on various aspects of cancer communication, attesting to the major effort that has been directed toward trying to understand this problem. Systematic reviews focusing on evidence for the effectiveness of various approaches to the communication of information to cancer patients have generally produced inconclusive results. Although they confirm that patients have information needs across the continuum of care,22 they conclude that the diversity among patients in terms of their needs and preferences means that it is impossible to confirm that any one method of communicating information is necessarily guaranteed to be superior.23 Attempts to compare specific approaches, such as audio- or video-taped recordings versus written information summaries,24 or to confirm a relationship between information provision mechanisms and various psychosocial outcome measures25 have also proven inconclusive.
Results are also inconclusive in relation to several other key components of the cancer communication challenge. Reviews of approaches to communicating prognostic information reveal little evidence as to the best method of approaching these communications or on the impact of this information on patient outcomes either in early-stage cancer26 or in late-stage or end-of-life discussions.27 However, it does seem clear that patients want information communicated to them and prefer that the context and extensiveness are negotiated with individuals who understand their needs. Although consensus exists around the need to balance hope with honesty during prognostic and end-of-life care discussions with patients, there seems little agreement among researchers as to how to accomplish this.28 The potential benefit of decision aids to facilitate various aspects of communication in cancer care has also been a focus of systematic inquiry. To date, there is little evidence of their improving communication23 or of their impact on patient outcomes such as anxiety.29 Systematic reviews focusing on population subgroup differences in cancer communication have concluded that there are meaningful differences between, for example, Asian and white populations.30,31 Although there seems little evidence to explain health professional–patient communication across differences, one review did conclude that characteristics in both professionals and patients play a role in communication and that certain clinical environments are better than others in being conducive toward communications that patients find effective.31
Much of the research documenting problems in cancer communication concludes with recommendations relating to health provider communication skills training. However, a significant body of systematic reviews has explored the evidence with regard to its effectiveness. Although we can conclude that longer, less didactic, and more interactive training methods do seem to produce better results,32 improvements in communication skills are modest at best.33 Results of this kind of research have been both inconsistent and inconclusive in relation to the effectiveness of communication training on patient outcome measures such as satisfaction or distress.34
Why the Formal Evidence Remains Inconclusive
Although the extensive body of research and the significant number of systematic reviews confirm an explosion of interest in the challenge of cancer care communication, they have yielded inconclusive evidence to support efforts to standardize approaches to communication. Although many authors claim that high-quality, controlled, quantitative studies would benefit the field, few critically examine the reasons why conventional methodologies have not yielded definitive findings.
Systematic reviews rely on quantified results conducted within controlled conditions. This is problematic in the study of cancer communication for several reasons. Such studies focus on common experiential elements of the communication experience, such as “bad news” transmissions, attempting to distill them from the complex contexts within which they naturally occur. They also rely on inherently imperfect outcome measures, such as use of emotion-focused language or patient satisfaction scales, which are not particularly representative of an experience in its entirety. For the most part, quantitative investigations of discrete components of communication fail to generate reproducible findings because they ignore the balance of content and context required when complex biomedical issues must be integrated with patient-centered values.35,36 Thus, by trying to distill from the total body of potentially useful empirical science only that which conforms to conventional ideas about evidence, quantitative communication research tends to generate dubious meanings that can complicate, rather than clarify, understandings of the inherently experiential lived reality that communication entails, with all of its unique and individualized variables.
We approach our work in this field from the foundational assumption that communication is inherently “complex and messy,” especially when emotions such as anxiety and fear are involved. Patients and professionals bring complexity to the process, and the care contexts in which cancer care communication occurs are highly dynamic, often changing in profound ways as a cancer journey evolves. Although we can extract from the empirical research and clinical wisdom a number of general principles from which to generate “best practice” understandings, these may be inadequate in accounting for the infinite range of nuances and diversities when difficult and emotive concepts are transmitted between 2 or more people.37 The science of communication in cancer care is therefore inherently imperfect. Because of this, the advancement of clinically relevant knowledge must be approached with an appreciation for the limits of what can be generalized about populations that will apply to the individual particularities that constitute real-life patient care.38,39 In this context, qualitative and longitudinal research approaches help contextualize the meaning of what we can learn from measurement and population-based studies and could provide us with a viable way forward.
Although it has been difficult to make confident claims about what constitutes good communication, there is much to be learned from thoughtful consideration of what contexts give rise to poor communication. Constructivist problem-based learning approaches have also capitalized on this approach, engaging healthcare trainees in clinical scenarios whereby they can deconstruct mistakes and generate solutions. Therefore, by focusing on what makes communication poor, we are also deeply invested in addressing “what to do about it.”
Methodological Orientation to the Patient-Perspective Research
In an ongoing program of qualitative longitudinal and cross-sectional research addressing helpful and unhelpful cancer care communication, funded by national Canadian health research and cancer nonprofit organizations, we have been analyzing how patients’ needs and preferences related to communication with healthcare professionals change across the trajectory of the cancer journey. In this work, we look for the commonalities across cases and also unique attributes and sensibilities that each individual brings to the cancer experience so that we can better understand patterns in communication experience and interpret the knowledge, skills, and attitudes that will allow clinicians to extend their competencies beyond what can be represented in a standardized protocol. The overarching questions guiding our research are as follows:
1. How do cancer patients describe and explain helpful and unhelpful communication?
2. How do the needs, preferences, and priorities of patients in relation to their communications with professional healthcare providers change over the course of a cancer illness?
The methodological approach informing our research program is interpretive description,40 which is a qualitative method designed to expand beyond the social theorizing of Grounded Theory41 and the contextual examination of Naturalistic Inquiry,42 drawing on the explicit logic of how knowledge is used in the applied health disciplines.43 Instead of trying to fit a study into a theoretical grounding drawn from the social science origins of conventional qualitative methods, this approach relies on the knowledge-to-practice orientation of health disciplinary logic. In this sense, it helps the researcher seek out the kind of knowledge that is needed to inform, and potentially change, practice.
In keeping with this method, multiple approaches were used to recruit voluntary samples representing a diversity of study participants with various demographic and disease variables. The protocol for the ongoing longitudinal study, which has held approval over time from our local university’s ethical review board, involves face-to-face initial individual interviews followed by an ongoing series of bimonthly face-to-face or telephone interviews, in accordance with patient preference. The interviewers, who have both health professional and qualitative inquiry training, adjust the schedule as needed, according to the patient’s changing clinical circumstances. As might be expected, several members of the initial cohort have died, and the priorities of others have shifted away from focusing on cancer as they enter survivorship. Repeated interviews over an extended period provide unique insights about a changing clinical portrait. This large and complex database provides a rich resource for the exploration of evolving themes, including not only themes that were expected in the original research protocol, but also themes that arise as a result of ongoing data collection and analysis.
In an initial phase of the study (2005–2009), we recruited 60 newly diagnosed cancer patients, conducted in-depth interviews in relation to their experiences with communication in the cancer care system, and followed them bimonthly over time. In a second phase (2009–2013), we expanded that cohort to include more patients with advanced disease as well as those with additional diversity in demographic and clinical conditions (Table). Currently, the large qualitative database we are continuing to build consists of more than 500 transcribed individual interviews with 125 cancer patients.
Table Ongoing Cohort...Image Tools
Verbatim transcripts of interview data have been coded using the NVivo (QSR International Pty Ltd, Melbourne, Australia) qualitative data management software system for patient, disease, and treatment attributes as well as trajectory elements. Study participants tend to initially convey perceptions about communication in anecdotal form. Our interview techniques encourage them to expand upon their narratives to deepen our capacity to understand their intended meanings. We code data related to these communication narratives as helpful or unhelpful as well as in relation to the numerous variables that arise from the evolving analysis. This coding system helps us “see” emerging patterns in the overall data set and facilitates comprehensive thematic interpretations about the broader context in which these narratives reside.
Findings: A Typology of Communication Error Patterns
On the basis of analysis of extensive patient accounts of unhelpful communication, we have discerned 3 distinct categories of communication error corresponding to differing degrees of poor communication from patients’ perspectives. We conceptualize these as occasional misses, systemic misunderstandings, and repeat offenders. Each domain reflects an experientially different kind of communicative encounter between patients and professionals and ultimately points us toward alternative directions for problem resolution.
One category of unhelpful communication that patients describe reflects unfortunate departures within what is otherwise understood as a helpful encounter. Although some of these occasional misses had a significant untoward impact on patients, their accounts suggested that, for the most part, they were willing to forgive and move onward when they recognized them as exceptions or errors within a generally appropriate communicative approach. Often, the descriptions were paired with excuses, such as “I’m sure he doesn’t mean to…”, “he’s busy…,” or “he’s not mean….” These patients clearly understood that occasional misses are a part of the human condition and that clinicians can never be entirely accurate and consistent in predicting how their intended messages might be received. Some developed strategic approaches to preventing occasional misses, such as discussing the communication episode with the clinician or modifying their own communication strategy in future encounters. One patient, for example, used a published article to try to introduce the topic of communication into her discussions with her oncologist.
When I saw her last time I gave her a, a piece of information published by the AMA, and the title was Good Communication Between Healthcare Provider and Patient Leads to Better Treatment, and it was just a really short 1-page article. I just thought it would be good for all of them to read.
In many instances, they greatly appreciated the willingness they found in their clinician to work with them to ensure the most effective communication possible over time.
We know that, with skill and ongoing attention, clinicians greatly improve their odds of selecting the medium and the message most likely to produce the intended effect upon the patient. However, no matter how skillful the communicator, there will be occasions on which they get it wrong. It seems evident from the literature review that much of the communication training we deliver is targeting this kind of communication—well-intended and well-informed communicators who are simply trying to reduce the number of occasions whereby they miss the mark. Communication training tends to reflect a set of general competencies that must then be applied to an infinitely various constellation of people and circumstances. Thus, it becomes understandable why the significant investment that has been made in communication training for cancer care professionals produces incremental improvements at best. Although clinicians may well value this kind of knowledge to make their occasional misses less frequent, the benefits will not be all that meaningful or measurable, especially in the short term.
Another category of poor communication these patients described had to do with more generalized or “systemic” misunderstandings that clinicians hold as a result of the professional lens with which they view care priorities and their resultant inability to attend to the patient’s perspective. As a patient put it, “from their paradigm, everything was done well; from a communication paradigm, it wasn’t.” Reflecting on these kinds of accounts, we were able to discern a number of “common wisdoms” that arise within the clinical community in relation to generally accepted practices that may actually create unintended harm.
One example of such a misunderstanding is the provision of excessive information in the process of securing informed consent. A number of patients described such communicative encounters as being “brutally frank” to the extent that they seemed motivated more by concern for institutional or professional liability than by the decisional and emotional support needs of the patient. One patient with advanced disease remembered being asked to make a difficult treatment decision immediately on receiving unexpected bad news. “I was very disoriented mentally because I just, I’d never been told things like that.” Several patients attributed the excess of information in such circumstances as a misapplication of the philosophy of shared decision making:
It’s just a whole conflict of informed consent that has come up a number of times and you know. And it’s all, it’s all ballyhooed and everything… informed consent is such a wonderful thing blah, blah, blah. But again I’ve had doctors say to me, “Well what do you want to do? Which to me is kind of laughable because, you know what, if there aredifferent options, is it up to me to make a decision? What informed consent is all… sounds like a nice concept, but how can I decide with no medical background what is the best option?
In contrast, some patients encountered what they interpreted as withholding essential information based on misunderstandings of what would be best for the patient. One woman with advanced cancer recalled, “I asked the oncologist, ‘How long would it be until I die?’ And she said, ‘We don’t talk that way around here.’” Embedded in this example is an implication that the patient had transgressed an institutional norm as to what constituted an appropriate topic for discussion.
A related instance of systemic misunderstanding pertained to the use of numeric probabilities to convey messages about the uncertain course of illness. One patient described the cognitive effect of having received numeric information this way: “It’s like walking around with a loaded gun pointed at your head. You’re a category 3. You have an 80% chance of reoffending again.” For many, information in numeric form had a power all on its own that clinicians seemed unaware of:
It takes a lot of shifting of dialogue, you know. The doubt that’s there since that number is always there, even though it’s really a meaningless number that’s sort of been thrown out there based on the wrong information. But just a lot of positive thought in pushing away of sort of away, but I don’t know if I’ve fully recovered the feeling I had before.
Another patient quipped, “They’re so hell-bent on giving you the facts that they forget that they don’t know for certain.” These examples of systemic misunderstandings remind us that while dominant discourses about the war on cancer may be a driver for healthcare providers, they may fuel inner battles and tensions for many cancer patients who take little solace from muted conversations about death or outcome probabilities.
A third example of what some patients took to be a systemic misunderstanding had to do with what they interpreted as the privileging of realism over hope. One patient recalled her physician saying, “‘You know, you have to maintain a sense of realism about the situation.’ And I thought, ‘Yeah, it’s pretty real, for me.’” The account of another patient suggested a creative way to confront what she saw as a shared misunderstanding. “My husband has just ordered me a whole lot of buttons from Monty Python’s Flying Circus, which says, ‘I’m not dead yet,’ [laughter] and I’m, I’m intending to wear these to all my doctor’s appointments and I shall even give them one each.” Although irony is clearly at play in her account, the participant draws attention to how numbers and grave predictions can be received, retained, and resented, while other potentially more relevant individualized details transition across time. Analyzing these patterns within patient experience, it becomes possible to deconstruct some of the untoward effects of communications that may well be helpful and supportive for some patients but not others.
A distinct pattern of poor communication from the participants’ perspectives was what we have termed the “repeat offender.” This category revealed the challenge of dealing with certain clinicians who, from the patient’s perspective, seemed unwilling or unable to convey basic courtesy, compassion, or respect in their communications. The accounts of these encounters reflected vivid and memorable examples of what the patients took to be characteristic attitudes for these particular clinicians. For example, a patient described the dispassionate manner in which a physician had conveyed news of her diagnosis:
He came back to my cubicle and like he was telling me I had, you know, a cold, he said to me, “Well you’ve got lung cancer, so I suggest you go home and get your life together because lung cancer, the average is about 8 to 10 months…. It was upsetting, but it blew me away that they would just blurt it out like it was, you know, like I had hangnails or something.
Another patient with advanced cancer described a diagnostic encounter in which she felt her experience as a human being was completely disregarded:
He sat down and he said, “You have a tumor, and it’s malignant. It’s called a GIST. It’s inoperable and you have to take a drug called imatinib. And he stood up to leave the room. I said, “Excuse me, could you please sit down for a minute?” And he kind of looked at me and he said, “Why?” And I said, “I have some questions to ask.”
A third patient described a conversation in her hospital room between her oncologist, a consulting oncologist, and 3 residents:
The consultant said, “Okay, I’ll continue treating her from the head up, and you can look after her from the head down.” Then a resident said to one of the others, “This disease doesn’t have a good outcome in the elderly.” I was in the room, but it was as if I wasn’t there…. And I wanted to say, “Hello, I’m here.”
A fourth confirmed, “It’s like, you’re just this thing going on this conveyor belt, and people are talking about what they’re seeing, but there’s a person attached to that.” Another remembered a particularly telling encounter with her oncologist. “He acts kind of like he cares, but one time he said, ‘I don’t have time for anecdotes.’ And then one time my husband was there, and he [the doctor] was looking at his watch!”
Beyond conveying expressions of anger and a sense of deep anguish from having encountered such individuals, many of the patients attempted to theorize about the offensive manner of some clinicians. One commented:
I think over the years what has happened is, is that they keep it so impersonal that they can’t let out their own feelings. You know, like when you talk to somebody, you want to empathize. And there seems to be a lack of empathy anymore because they are so disassociated themselves, from their own feelings. ‘Cause like who knows what kind of feelings they have about doing the procedures they do every day.
The ones that are noncaring probably came into it, I would think, with maybe it wasn’t the right decision for them. And maybe they’ve since discovered that. However it’s, it’s an incredible investment of time and resources and energy on their part and lots of sacrifices. So it, it must be very difficult.
As we have observed across previous cancer communication studies, most participants had encountered at least 1 clinician they characterized as repeatedly exhibiting such patterns of poor communication. Because of the high importance patients place on clinical communication to guide their thinking, feeling, and decision making and to allow them to feel that they are in safe hands in the cancer care system, it seems evident that encounters with repeat offenders may have a profoundly negative impact on their emotional and cognitive experience. While any such instance might be deeply distressing, they are naturally more potent when the clinician holds a position of particular authority in their case, such as their oncologist or surgeon, or when they must rely on such an individual for their ongoing care management. They may be reluctant or ill-equipped to leave such relationships despite intense dissatisfaction. Even when they represent a fraction of the total overall communication experience, these kinds of encounters therefore tend to be disproportionately memorable and distressing within patient accounts of communication in cancer care.
From the accounts of these patients, it would seem that serious communication problems are not uniformly distributed among clinicians, but typically concentrate around particular individuals whose lack of regard for others, or what one might consider a basic lack of emotional intelligence,44 or compassion fatigue,45 leads them to behave in a manner that could inflict harm on a regular basis. Skilled technicians of medical craft they may be, but they lack the inclination or aptitude to recognize the importance of applying it within an array of human contexts. Such individuals exist, and cancer patients routinely encounter them. Thus, a component of the solution to the cancer communication problem must be to develop systems of care within which either they are helped to change, or their potentially toxic influence is effectively managed.
Although the problem of poor communication has been the focus of considerable research attention,4,5 methodological limitations have precluded useful evidence-based conclusions as to appropriate resolutions. The approaches that might seem self-evident using conventional studies, such as expanding communication training at the basic and continuing professional development levels, have produced incremental improvements at best.46,47 This is largely because they have focused almost exclusively on the clinician perspective rather than that of patients.48 What we learn from patient perspectives is that lasting improvements will require that we move beyond the level of individual clinical responsibility to pay serious attention to such factors as professional attitudinal norms49 and practice routines,50 as well as organizational obstacles that may compromise care quality deriving from such factors as leadership styles, budgetary conditions, and operational vision.51
An advantage of constant comparative techniques within our larger qualitative research program is the capacity for thematic examination across a diversity of patient contexts, allowing for increasingly nuanced understandings that place the situation in its complexity and take an array of factors into consideration.39,40 Each patient example reveals a generally appropriate and responsible communication approach that may turn out to be powerfully problematic for some patients. Thus, this kind of inquiry offers a way of surfacing new knowledge with which we can continue to identify what patients interpret as perceptual errors within our care delivery approaches. The insights that arise from an in-depth study of human experience help us move beyond standardized options and closer to generating the kind of clinical intelligence that enables increasingly informed action. Because we know that skilled communication requires an iterative and interactive approach in which interpreting the behavioral cues and communication responses of the patient shapes subsequent communicative approaches to that patient,20,52,53 we see this kind of research as unpacking these complexities into a form that can be taken up and applied by clinicians in their everyday work.43
The Complex Nature of the Communication Challenge
Having been immersed in the patient-reported effects of care communication across contexts and through the cancer trajectory, we have come to appreciate that truly effective communication in cancer care is among those human qualities that defy truly meaningful categorization and measurement. What distinguishes one human encounter from another in the sense of transmitting courage or confidence is essentially ineffable and for the most part inarticulable.54 Capturing the essence of brilliant clinical communication may more properly lie in the domain of poets and philosophers than in the realm of conventional science. We know that it cannot be standardized—and paradoxically where we attempt to capture and standardize communication, we inherently defeat it, because a standardized response is so often interpreted as one in which individuality is being disregarded.52 Thus, although we can be inspired by the fact that brilliant communication exists—and patient-perspective data certainly confirm that to be the case—the direction forward will not lie in dissecting its essence and encouraging others to mimic it. Rather, we must recognize that clinicians are, for the most part, “ordinary” people, with the same kinds of flaws that we attribute to the normal state of being human.
The Relevance of a Focus on Poor Communication
In conceptualizing poor communication in terms of these 3 distinct categories, we have brought new clarity to why it is that directing our emphasis toward capturing, and promoting, and trying to measure the essence of good communication may be insufficient to create meaningful improvements. Redirecting our focus toward the kind of patient-perspective knowledge that expands our understanding of the intricate dimensions of poor communication on an experiential level contributes significantly to the selection of targeted intervention approaches and our capacity to evaluate relevant outcomes. The typology of poor communication that has surfaced from the accounts of these patients helps us understand why multiple and layered approaches are needed to address the distinct dimensions that comprise the spectrum of problematic cancer care communication.
Practically speaking, occasional misses will never be eliminated. However, we can reasonably assume that they can normally be reduced through the kinds of basic and continuing education, professional socialization, and access to communication mentorship that all of the health disciplines would consider the hallmark of an appropriately maturing clinical practice.55 Indeed, the fact that good communication exists as often as it does is a testament to the integrity and effectiveness of these processes.56
Systemic misunderstandings will require a more research-oriented approach. At this point in the development of our knowledge, it seems most appropriate to advocate for the deconstructive and illuminating potential of qualitative patient-perspective research rather than simply suggesting that better measurement and more systematic reviews will address the gaps in our understanding. In particular, we might purposefully aim our qualitative investigations toward the aspects of cancer care communication where we are most likely to assume the appropriateness of standardized approaches so that we can identify which patients might be suboptimally served. Toward this end, we would be wise to carefully consider the kinds of junctures where patients report dissatisfaction or clinicians sense potential vulnerabilities. Because their discipline’s proximity to patient-professional interactions affords opportunities to observe communication in action and because they are optimally positioned to support patients when communication doers not go well, nurses seem ideally placed to take a leading role in this kind of research agenda.
Opportunities for Care System Solutions
The management and buffering of repeat offenders clearly require more complex and strategic intervention strategies. Voluntary continuing education or expectations of professional insight are clearly inadequate for correcting insensitive or disrespectful communication patterns,57 and it seems morally reprehensible to simply assume that nothing can be done until there is tangible evidence of malpractice or demonstrable harm.55 Rather, we need proactive approaches that heighten our collective sense of responsibility within care settings so as to ensure that our ideals of patient safety extend to their communication experience.58 Beyond compassionate, patient- and family-centered organizational cultures in which communication is deeply valued as a component of professional competence,59 we might envision engaged interprofessional healthcare teams within which problematic communication patterns are not tolerated. Furthermore, we might aspire to models of care delivery in which, if certain clinicians cannot overcome their communication disabilities, patients are skillfully protected through the strategic buffering mechanisms afforded by effective interprofessional care models. For example, it may well be that certain oncologists should never dispense bad news to a patient outside the presence of a skilled nurse.
On the basis of this research, it seems apparent that as meaningful solutions to protect patients and increase the likelihood of their receiving the best possible communication across all encounters throughout their entire cancer journey, we must strategically target multiple points within the system. Our analysis reveals 3 key components of the path forward: (a) an ongoing clinician learning environment in which lifelong development of communication expertise is valued and mentored, (b) a strategic knowledge generation approach in which useful patterns in interpreting the complexities of cancer communication from the patient perspective are brought to light to inform our systemic understandings, and (c) an engaged interprofessional team approach to cancer care delivery in which the important work of supporting and enhancing the patient experience is intimately embedded within the work of diagnosing disease, deciding on a course of action, and delivering treatment.
Communication is a curious and ubiquitous component of a cancer care system. Despite some common features within what constitutes either helpful or unhelpful cancer care communication from the patient perspective, there is also a wide range of variation across context, culture, and condition. A statement or expression that one patient finds particularly helpful may prove distasteful or distressing to another. Patients facing cancer are understandably vulnerable and highly attuned to the nuances of the messaging that surrounds them. Effective communication informs, supports, comforts, guides, and sustains hope; ineffective communication confuses, disorganizes, demeans, and distresses. If communication were a drug, its potential harm would be well described in our compendium of safe pharmaceutical products, and its administration would be restricted to healthcare providers with established competencies. Nevertheless, because communication is the context within which all of the human operations of our cancer care systems occur, we must take it seriously as a focus of consideration. Understanding communication within the complexity that patient perspectives offer us, we can appreciate why the available evidence will never be perfect. Thus, making inroads toward solving the challenge of cancer communication will require models of care delivery and approaches to research that are mutually informative in a process of dynamic interaction, developing and refining our knowledge while thoughtfully putting it to use.
1. Aiello Bowles EJ, Tuzzio L, Wiese CJ, et al. Understanding high-quality cancer care: a summary of expert perspectives. Cancer. 2008; 112 (4): 934–942.
2. Back A, Arnold R, Tulsky J. Mastering Communication With Seriously Ill Patients: Balancing Honesty With Empathy and Hope. Cambridge: Cambridge University Press; 2009.
3. Schofield NG, Green C, Creed F. Communication skills of health-care professionals working in oncology: can they be improved? Eur J Oncol Nurs. 2008; 12 (1): 4–13.
4. Epstein RM, Street RL. Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. Bethesda, MD: NIH; 2007. NIH Publication 07-6225.
5. Baile WF, Aaron J. Patient-physician communication in oncology: past, present, and future. Curr Opin Oncol. 2005; 17 (4): 331–335.
6. Albrecht T, Penner L, Cline R, Eggly S, Ruckdeschel J. Studying the process of clinical communication: issues of concepts, context, and research directions. J Health Commun. 2009; 14: 47–56.
7. Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor-patient communication: a review of the literature. Soc Sci Med. 1995; 40 (7): 903–918.
8. Ha JF, Longnecker N. Doctor-patient communication: a review. Oschner J. 2010; 10: 38–43.
9. Thorne SE, Bultz BD, Baile WFThe SCRN Communication Team. Is there a cost to poor communication in cancer care? A critical review of the literature. Psychooncology. 2005; 14 (10): 875–884.
10. Hack TF, Degner LF, Parker PAThe SCRN Communication Team. The communication goals and needs of cancer patients: a review. Psychooncology. 2005; 14 (10): 831–845.
11. Thomsen DK, Pedersen AF, Johansen MB, Jensen AB, Zachariae R. Breast cancer patients’ narratives about positive and negative communication experiences. Acta Oncol. 2007; 46 (7): 900–908.
12. McClement SE, Chochinov HM. Hope in advanced cancer patients. Eur J Cancer. 2008; 44 (8): 1169–1174.
13. Albrecht T, Franks M, Ruckdeschel J. Communication and informed consent. Curr Opin Oncol. 2005; 17 (4): 336–339.
14. Shaw BR, Han JY, Hawkins RP, Stewart J, McTavish F, Gustafson DH. Doctor-patient relationship as motivation and outcome: examining uses of an interactive cancer communication system. Int J Med Inform. 2007; 76 (4): 274–282.
15. Back AL, Arnold RM, Baile WF, Tulsky JA, Fryer-Edwards K. Approaching difficult communication tasks in oncology. CA Cancer J Clin. 2005; 55 (3): 164–177.
16. Barclay JS, Blackhall LJ, Tulsky JA. Communication strategies and cultural issues in the delivery of bad news. J Palliat Med. 2007; 10 (4): 958–977.
17. Beach WA, Easter DW, Good JS, Pigeron E. Disclosing and responding to cancer “fears” during oncology interviews. Soc Sci Med. 2005; 60 (4): 893–910.
18. Bultz BD, Thorne S, Fitch MF. Who owns emotional care of the cancer patient? Untangling the conceptual confusion. Oncol Exchange. 2004; 3: 32–35.
19. Surbone A, Baider L, Weitzman TS, Brames MJ, Rittenberg CN, Johnson J. Psychosocial care for patients and their families is integral to supportive care in cancer: MASCC position statement. Support Care Cancer. 2009; 18 (2): 255–263.
20. Thorne SE, Hislop TG, Armstrong EA, Oglov V. Cancer care communication: the power to harm and the power to heal? Patient Educ Couns. 2008; 71 (1): 34–40.
21. Ferrell B, Paice J, Koczywas M. New standards and implications for improving the quality of supportive oncology practice. J Clin Onc. 2008; 26 (23): 3824–3831.
22. Rutten LF, Arora NK, Bakos AD, Aziz N, Rowland J. Information needs and sources of information among cancer patients: a systematic review of research (1980–2003). Patient Educ Couns. 2005; 57 (3): 250–261.
23. Rodin G, Mackay JA, Zimmermann C, et al. Clinician-patient communication: a systematic review. Support Care Cancer. 2009; 17 (6): 627–644.
24. Lockhart K, Dosser I, Cruickshank S, Kennedy C. Methods of communicating a primary diagnosis of breast cancer to patients. Cochrane Database Syst Rev. 2007; 18 (3):article no. CD006011.
25. Husson O, Mols F, van de Poll-Franse LV. The relation between information provision and health-related quality of life, anxiety and depression among cancer survivors: a systematic review. Ann Oncol. 2011; 22 (4): 761–772.
26. Hagerty RG, Butow PN, Ellis PM, Dimitry S, Tattersall MHN. Communicating prognosis in cancer care: a systematic review of the literature. Ann Oncol. 2005; 16 (7): 1005–1053.
27. Parker SM, Clayton JM, Hancock K, et al. A systematic review of prognostic/end-of-life communication with adults in the advanced stages of a life-limiting illness: patient/caregiver preferences for the content, style, and timing of information. J Pain Symptom Manage. 2007; 34 (1): 81–93.
28. Clayton JM, Hancock K, Parker S, et al. Sustaining hope when communicating with terminally ill patients and their families: a systematic review. Psychooncology. 2008; 17 (7): 641–659.
29. O’Brien MA, Whelan TJ, Villasis-Keever M, et al. Are cancer-related decision aids effective? A systematic review and meta-analysis. J Clin Oncol. 2009; 27 (6): 974–985.
30. Fujimori M, Uchitomi Y. Preferences of cancer patients regarding communication of bad news: a systematic literature review. Jpn J Clin Oncol. 2009; 39 (4): 201–216.
31. Tay LH, Hegney D, Ang E. Factors affecting effective communication between registered nurses and adult cancer patients in an inpatient setting: a systematic review. Int J Evid Based Healthc. 2011; 9 (2): 151–164.
32. Gysels M, Richardson A, Higginson IJ. Communication training for health professionals who care for patients with cancer: a systematic review of training methods. Support Care Cancer. 2005; 13 (6): 356–366.
33. Gysels M, Richardson A, Higginson IJ. Communication training for health professionals who care for patients with cancer: a systematic review of effectiveness. Support Care Cancer. 2004; 12 (10): 692–700.
34. Uitterhoeve RJ, Bensing JM, Grol RP, Demulder PH, Van Achterberg T. The effect of communication skills training on patient outcomes in cancer care: a systematic review of the literature. Eur J Cancer Care. 2010; 19 (4): 442–457.
35. Back AL, Arnold RM, Baile WF, et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med. 2007; 167 (5): 453–460.
36. Surbone A. Communication preferences and needs of cancer patients: the importance of content. Support Care Cancer. 2006; 14 (8): 789–791.
37. Feldman-Stewart D, Brundage MD, Tishelman CSCRN Communication Team. A conceptual framework for patient-professional communication: an application to the cancer context. Psychooncology. 2005; 14 (10): 801–809.
38. Siminoff LA, Graham GC, Gordon NH. Cancer communication patterns and the influence of patient characteristics: disparities in information-giving and affective behaviors. Patient Educ Couns. 2006; 62 (3): 355–360.
39. Thorne SE. Communication in cancer care: what science can and cannot teach us. Cancer Nurs. 1999; 22 (5): 370–378.
40. Thorne SE. Interpretive Description. Walnut Creek, CA: Left Coast Press; 2008.
41. Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago, IL: Aldine; 1967.
42. Lincoln YS, Guba EG. Naturalistic Inquiry. Beverly Hills, CA: Sage; 1985.
43. Thorne S. Toward methodological emancipation in applied health research. Qual Health Res. 2011; 21 (4): 443–453.
44. Birks Y, McKendree J, Watt I. Emotional intelligence and perceived stress in healthcare students: a multi-institutional, multi-professional survey. BMC Med Educ. 2009; 9. Article 61. doi:10.1186/1472-6920-9-61.
45. Najjar N, Davis LW, Beck-Coon K, Doebbling CC. Compassion fatigue: a review of the research to date and relevance to cancer-care providers. J Health Psychol. 2009; 14 (2): 267–277.
46. Rask MT, Jensen ML, Andersen J, Zachariae R. Effects of an intervention aimed at improving nurse-patient communication in an oncology outpatient clinic. Cancer Nurs. 2009; 32 (1): E1–E11.
47. Bernard M, Roten Y, Despland J, Stiefel F. Communication skills training and clinicians’ defences in oncology: an exploratory, controlled study. Psychooncology. 2010; 19: 209–215.
48. Brundage M, Feldman-Stewart D, Tishelman C. How do interventions designed to improve provider-patient communication work? Illustrative applications of a framework for communication. Acta Oncol. 2010; 29 (3): 136–143.
49. Favre N, Despland JN, de Roten Y, Drapeau M, Bernard M, Stiefel F. Psychodynamic aspects of communication skills training: a pilot study. Support Care Cancer. 2007; 15 (3): 333–337.
50. Fleissig A, Jenkins V, Catt S, Fallowfield L. Multidisciplinary teams in cancer care: are they effective in the UK? Lancet Oncol. 2006; 7 (11): 935–943.
51. Visser A, Wysmans M. Improving patient education by an in-service communication training for health care providers at a cancer ward: communication climate, patient satisfaction and the need of lasting implementation. Patient Educ Couns. 2010; 78 (3): 402–408.
52. Thorne SE, Kuo M, Armstrong E-A, McPherson G, Harris S, Hislop G. “Being known”: patient perspectives on human connection in cancer care. Psychooncology. 2005; 14: 887–898.
53. Hilen MA, Onderwater AT, van Zweiten MCB, de Haes HCJM, Smets EMA. Disentangling cancer patients’ trust in their oncologist: a qualitative study. Psychooncology. 2012; 12: 392–399.
54. Thorne S, Oglov V, Armstrong E-A, Hislop TG. Prognosticating futures and the human experience of hope. Palliat Support Care. 2007; 5 (3): 227–239.
55. Gelhaus P. The desired moral attitude of the physician: empathy. Med Health Care Philos. 2012; 15: 103–113.
56. Fuks A, Brawer J, Boudreau JD. The foundation of physicianship. Perspect Biol Med. 2012; 55 (1): 114–126.
57. Grob C, Leng J, Gallagher A. Educational responses to unethical healthcare practice. Nurs Stand. 2012; 26 (41): 35–41.
58. Borges NJ, Kirkham K, Deardorff AS, Moore JA. Development of emotional intelligence in a team-based learning internal medicine clerkship. Med Teach. 2012; 34 (19): 802–806.
59. Birks YF, Watt IS. Emotional intelligence and patient-centred care. J R Soc Med. 2007; 100: 368–374.