'Intentional' steps can minimize cancer miscommunication during patient encounters
Clear communication is an essential component of patient-centered care delivery in the cancer setting.
Previous research has assessed tools designed to improve patient–clinician communication, but the causes and consequences of miscommunication in cancer care have not been extensively characterized.
Although most clinicians express a commitment to providing a complete picture of a patient’s disease — including prognosis and risks vs. benefits of treatment — studies have indicated that patients are generally more optimistic about cancer cures than clinicians. Moreover, patients often base their treatment decisions on misguided or inaccurate beliefs around these treatments.
“There is a general avoidance among clinicians in delivering difficult news, instead attempting to deliver this news in a kinder, gentler way that can lead to miscommunication,” Donald R. Sullivan, MD, MA, MCR, associate professor, division of pulmonary, allergy and critical care medicine at Oregon Health and Science University, told Healio. “Some of this is the consequence of a real lack of focus in medical education and residency on communication training among clinicians and, as a result, clinicians often avoid emotionally charged conversations due to a lack of comfort delivering difficult news.”
Sullivan and William E. Rosa, PhD, MBE, APRN, assistant attending behavioral scientist in the department of psychiatry and behavioral sciences at Memorial Sloan Kettering Cancer Center, co-authored a paper in JAMA Oncology on the topic of misinformation in the cancer care setting. They spoke with Healio about the causes of this persistent problem, how it can be corrected, and what oncology providers truly owe their patients when discussing cancer treatment options.
Healio: What is the main cause of miscommunication between oncologists and patients?
Sullivan: Clearly, this is a multifactorial issue. There is an overreliance on everyday language and euphemisms among clinicians in an effort to avoid medical jargon. Unfortunately, much of this language conveys ideas and concepts that we may not intend. There is also a tendency among cancer clinicians to emphasize treatability statements when talking to patients, such as “there are things we can do” or “we have treatments for this,” even if these treatments are palliative or experimental. This is likely done to preserve hope, rather than discussing the potential for no more treatment or introducing a palliative approach.
Finally, there is the perception that effective communication is overly time-consuming in these already time-constrained encounters. However, the reverse is likely true, where miscommunication contributes to lost time and effort in the form of subsequent delays in treatment due to mistrust, the need for additional staff, or clinician follow-up phone calls for clarification and no-show appointments.
Rosa: In my opinion, there will almost always be a fundamental miscommunication in cancer communication that we must account for and anticipate. Patients come to the table as experts in their life story and personhood — clinicians come as experts in their field. The two parties have worldviews that are foundationally very different. Unless we account for this basic divide, miscommunication will be a shared currency in every encounter, especially when stakes are high, emotions are strong, interpersonal dynamics are complex and decision-making is urgent. I think clinicians can and should ask themselves: How well do I know this patient as a person? Do I know their values, preferences, goals, fears and worries? Do I know what they think is most important about themselves? If I don’t know, I need to ask, and if I don’t ask, I will always be communicating with a ‘patient who has cancer’ rather than a person with a very full life, of which cancer is just one part. The difference between the two is significant and predictive of communication outcomes.
Healio: How can oncologists more clearly convey information about a difficult prognosis knowing that it may upset the patient?
Sullivan: There is some evidence that communication about prognosis may actually support hope and peace of mind, even when the prognosis is poor. Counter to what clinicians may believe, patients expect and appreciate prognosis communication being delivered in a direct but empathetic way. This type of authentic communication does not take away hope, cause depression, increase anxiety or harm the therapeutic relationship.
Rosa: Clinicians should relieve themselves of the burden to fix, change or alter the reality of circumstances and prognoses. Our job is to sojourn with patients through their cancer journey — sometimes aiming for cure and other times focusing on palliation. But whatever the clinical context, patients will be upset, angry and emotional from time to time. Their life is deeply and perhaps interminably impacted by cancer. Our job is not to mediate upset but to take accountability for our job to deliver the information patients need, tailored to their preference for the amount and type of information they desire — and packaged in a way they can both understand and use to enable informed decisions.
I concur with Dr. Sullivan’s perspective — few relational elements can replace empathy and therapeutic presence. Patients want to experience their clinicians as partners alongside them, particularly in the face of difficulty. If the focus is on holistic person-centered support and ensuring the needed resources for patients, then clinicians will focus less on shying away from the risk for upset.
Healio: How can differences in language, race and ethnicity exacerbate miscommunication?
Sullivan: Sociocultural differences undoubtedly add another layer of complexity to communication, but we do not want to insinuate that this represents an impasse. Where trust is already fragile, due to longstanding discrimination and structural racism, extra efforts need to be made to avoid miscommunication and promptly remedy situations when they arise. Cancer centers and their care teams need to be intentional and put more effort behind programs to optimize communication among disadvantaged groups, as well as develop processes and resources for patients who speak other languages or are from specific cultures.
Rosa: Communication disparities are real, and marginalized communities have complex and painful histories of ethical, psychological and social violations by clinicians and health systems. Cultural humility training is central to dismantling patient–clinician power imbalances and urging clinicians to reflect on their own biases while committing to lifelong learning. Clinicians should include patients’ caregivers and community members, such as faith leaders, where appropriate to ensure patient-centeredness and cultural safety throughout the trajectory of illness. Clinicians should also be honest in recognizing when they feel ill equipped or insufficiently trained to meet the whole-person needs of a patient from a different sociocultural background. Ask for help, get the interpreter, seek out community resources, invite participation of the patient’s family and community, recognize patients as the experts in their experience. These actions can build trust and demonstrate humility, resulting in better communication, fewer misunderstandings and more authentic relationships with patients and colleagues.
Healio: What are the main steps oncology providers can take to improve their communication with patients?
Sullivan: At the individual level, it’s hard to say “we just need to be better” or change some of these behaviors that have become so ingrained in us from clinical training or practice over many years. It’s really about being more intentional and considering some of the language we frequently use that may be contributing to miscommunication, and trying to develop better habits. We describe several strategies and techniques for improving communication — such as using teach-back techniques, prefacing serious news with a headline and asking patients how they prefer to receive information — in our publication.
Ultimately, communication is analogous to any other medical skill, such as a complex procedure or surgery, that requires careful planning and execution using well-developed strategies gained through training, practice and, most importantly, modeling from clinicians with communication expertise. Therefore, there should be a role for communication, as well as serious illness communication training, and this should be supported at the institutional level, allowing clinicians the time and resources to develop these essential skills.
Rosa: The first step is asking clinicians to reflect on the role they believe communication skills play in the quality of care they deliver. If they don’t value communication quality as essential to improving outcomes, they will never prioritize it. I think clinicians should not be afraid to ask patients and caregivers for direct feedback on their communication approaches and skills. This type of humility can be helpful in establishing mutual respect, showing interest in the patient experience, and ensuring a commitment to excellence in care delivery and patient-related outcomes.
The need for practicing communication skills cannot be understated. Do not wait for the clinical encounter that is charged by strong emotions or high-stake decisions to try on a new communication skill — that choice will only result in extreme discomfort for all involved. For example, even if clinicians don’t perceive themselves to be naturally empathetic individuals, learning how to articulate empathy explicitly and acknowledge, normalize and validate patients’ experiences are sustainable skills that anyone can develop comfort with. All the skills that give structure to a clinical interaction (eg, negotiating agenda items, checking patient understanding, summarizing information discussed) can be integral to nurturing patient–clinician rapport and creating a safe container for effective, clear and person-centered communication. Without these skills, every encounter — especially ones that involve the sharing of serious news — has the potential to be a crapshoot.
Reference:
Sullivan D, et al. JAMA Oncol. 2023;doi:10.1001/jamaoncol.2023.2944.
For more information:
Donald R. Sullivan, MD, MA, MCR, can be reached at Oregon Health and Science University, 3181 Sam Jackson Park Road, Portland, OR 97239; email: sullivad@ohsu.edu. William E. Rosa, PhD, MBE, APRN, can be reached at Memorial-Sloan Kettering Cancer Center, 1275 York Ave., New York NY 10065; email: rosaw@mskcc.org.
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