Clinicians Communicating with Patients Experiencing Cancer Pain

Authors: Donna L Berry, Diana J Wilkie, Charles R. Thomas, and Paige Fortner
Source: Cancer Investigation 21(3):374-381, 2003

Background

• Pain is a common and serious symptom for cancer patients.
• Effective treatment of cancer patients requires effective communication between the patients and their health care providers.
• The method in which care providers communicate with their patients can impact quality of life (QOL) and the likelihood that patients adhere to treatment.
• Suboptimal communication can lead to erroneous information, worsened patient outcomes, and a greater likelihood of litigation.
• Barriers to communication about pain include patients' reluctance to report pain and providers' inadequate assessment skills.
• When provider-patient communication is patient-centered, patient participation in care and treatment decision is enhanced.
• Physician-related factors can also influence communication; in particular, physician gender and the use of open-ended questions (OEQ) versus close-ended questions (CEQ) by physicians can influence the quality of communication with the patient.
• This study explores physician verbal communication behaviors and interactions with patients who have cancer pain.

Methods

• Between 1994 and 1998, communication analysis was performed during a separate trial of an intervention to enhance sensory pain, the results of which are reported elsewhere.
• 17 radiation oncology or medical oncology physicians (7 women and 10 men) participated.
• Patients were cognitively functional adults who had reported tumor- or treatment-related pain in the previous week.
• Mean patient age was 60.8 years. Most patients were Caucasian (90.5%) and receiving outpatient radiation therapy.
• Four separate clinic visits between patients and their clinicians were audiotaped at weeks 0, 2, 4, and 12.
• Audiotapes were timed, transcribed verbatim, and analyzed.
• Content analysis was performed by coding each typed line of the interview for the content of and primary speaker during the conversation, the type of question used by the physician to assess patient pain, and interruptions and changes of subject by the physician.
• Inter-rater reliability was calculated on a random sample of 21 tapes, with an agreement rate of 85% as to the close-ended nature of the text unit in question.
• Text units in the 84 transcripts were coded for the nature and context of the conversion utilizing four context categories: pain, additional symptoms/side effects, tumor treatment, and personal remarks (including generic statements and social topics).
• All physician questions were coded as either open-ended or close-ended.
• The number of times the physician interrupted the patient or abruptly changed the topic was tabulated.
• A measure of verbal dominance was derived by calculating the ratio of total clinician talk text units to total patient/family talk units.
• The aims of the study were to: describe the verbal content of the clinic visit, document the frequency and nature of physician inquiry about pain, identify physician interruption of patients' pain reports, and describe physician gender effects on the verbal communication.

Results

• The average length of conversation for each clinic visit was 9.7 minutes (Standard Deviation (SD) = 8.0)
• Pain and symptoms were discussed in 90% and 99% of the visits, respectively, while tumor treatment was discussed in 65% of visits.
• Comparing male clinicians to female clinicians, a similar percent of total interview content was directed towards pain discussion (28.1% vs. 29.5%).
• The CEQ to OEQ ratio was 5.8:1 and similar between male and female clinicians (5.9:1 vs. 5.1:1).
• Clinicians interrupted or abruptly changed the subject an average of 1.5 times per visit and occurred most frequently when pain or symptoms were the conversation context.
• Clinicians spent 55% of the time doing the talking, most frequently during discussion about tumor treatment, where they did the talking 63% of the time. Clinicians also did the majority of the talking (53%) when discussing pain and symptoms.

Authors' Conclusions

• Clinicians were attentive and focused on daily problems experienced by cancer patients undergoing treatment, namely pain and symptoms and/or other side effects.
• The general pattern of daily visits included more talking than listening by the physician, many more CEQs than OEQs, and frequent interruptions and subject changes.
• It is speculated that, given the busy schedule of the clinicians, CEQs may be used in an attempt to cover pertinent topics quickly and keep the patient moving through the visit.
• While CEQs can yield useful information, omission of OEQ can produce a biased and incomplete picture of the patient's status.
• Physician dominance of the conversation in this study was similar, but slightly lower than previously published studies, which found the ratio of physician to patient talk to be 1.5-2.0:1.
• Overall, compared to women, men asked more CEQs, asked fewer CEQs about pain, and asked more CEQs about other symptoms.
• It should be noted that two of the physicians in the study were radiation oncology residents in their second and third year of training, and patient visits with these two residents accounted for 23% of all the visits in the study.
• The presence of a tape recorder in the exam room may have affected the communication.
• This study only addressed verbal communication; non-verbal cuing, which may affect communication with the patient, was not addressed.
• Interventions should be designed to enhance patient-centered communication and evaluate the impact of communication on patient care.

Discussion

This study attempts to identify patterns of communication that may affect physicians' ability to assess cancer patient pain. From this study, as well as previously reported studies, it is clear that physicians frequently use CEQs during patient assessment and are more likely to be the ones speaking during clinic visits. While there is clearly a danger in missing pertinent information if too many questions are close-ended, it should be kept in mind that OEQs do not necessarily guarantee that patients will provide all the critical information needed during a clinic visit. In addition, from a time perspective, it may not be realistic to frame a majority of questions in an open-ended manner during short clinic visits. It is more important to emphasize that physicians should listen acutely to the answers that patients give and address all concerns that a patient raises. This study did not answer whether the methods of communication utilized by the physicians resulted in missed opportunities to address significant patient concerns, including pain. Ultimately, the method in which physicians communicate with their patients should ensure that physicians become aware of all of their patients' concerns, and allow them to do so in a timely and efficient manner.