Commentary (Bishop/Wingard)-Patient-Physician Communication in Oncology: What Does the Evidence Show?

As noted by Back,[1] the primary goals of effective patient- physician communication are to enhance patient understanding of the illness, to improve decision-making, and to facilitate patient adjustment. These three goals are sensible and important concerns of the communication dyad. A number of studies have examined various aspects of the communication process and the factors that influence communication outcomes, and a few even have tested interventions to improve physician communication skills. However, there remains a dearth of studies that examine communication effects on the three major goals articulated above and that evaluate the effectiveness of communication skill interventions in influencing patient outcomes.

Lack of Agreement
Back nicely reviews the empirical literature that addresses different categories of the communication process and summarizes recommendations that the findings support. What is striking about this review is the lack of agreement in prior studies of what outcomes one should examine. Indeed, much of the body of research described emphasizes the effect of physician behavior on patient preference or satisfaction, and not on the three major goals of communication described by Back.[1] It can be argued that unless there is concordance between physician behavior and patient preference, there is little chance of effective communication. It is, however, another matter to argue that meeting patient expectations leads to better patient understanding, promotes clear decision- making, and leads to optimal adjustment to the illness-the three major goals of communication.

As Back points out,[1] patients have little to compare with and "satisfaction" cannot truly be assessed without a range of options to make comparisons. Moreover, as Back notes,[1] patient-centered communication has not been shown to necessarily result in the patient becoming actively engaged in decision-making. Of the recommendations about achieving the three communication goals assessed in various studies, most recommendations supported by empirical data deal with communication skills that affect adjustment to illness, with substantially less known about the factors that influence understanding and decision-making.

Isolated Benefits
Further complicating matters, benefits in one communication goal may not lead to benefits in another. This is illustrated by several of the studies cited. As noted, Fogarty et al[2] found that a compassionate heuristic allayed anxiety associated with consultation about an experimental breast cancer therapy (tested in focus groups), but disappointingly, reduction in anxiety did not result in greater information retention. Indeed, the "patient" generally went along with whatever the physician recommended. This raises the issue of what is important to the patient in making decisions-information, how much the patient trusts the physician, or other factors-a point raised by a number of studies.

In contrast, two interventions consisting of audiotapes and/or question prompt sheets and booklets on decision- making and patient rights led, in one study, to better information about the illness but no improvement in psychological distress (and in poor prognosis patients, actually increased distress).[3] In the other study, patients became more anxious and were less likely to achieve their preferred style of decision-making.[4]

Not addressed in this review but certainly important in the longitudinal care of the cancer patient are the communication skills needed to promote patient health behaviors. Compliance to treatment regimen, adherence to follow-up activities, and information retention and recall are all matters of considerable concern in oncology care. A number of empirical studies have found that patientprovider communication can influence patient adherence to treatment recommendations, medication compliance, and patient health outcomes such as pain, symptom reports, functional status, and physiologic measures of blood pressure and blood glucose.[5-9] In addition, patient satisfaction can influence compliance with treatment recommendations.[10]

Information From the Patient
The effect of patient-provider communication on patient behavioral and physical health outcomes is not adequately captured by the three communication goals described by Back.[1] We suggest that the first goal described by Back (enhancement of patient understanding of illness) be expanded to "adequate and accurate exchange of information between patient and provider." The patient's provision of information regarding his/her symptoms and physical and mental experiences is a critical aspect of obtaining an accurate medical history, determining a diagnosis, and evaluating treatment effects. Accurate exchange of information between provider and patient is also important for adherence to treatment regimens.

In this vein, intervention research in communication should include a focus on enhancing communication from the patient, as well as from the provider. For example, Harmsen et al[11] found that a "double" intervention on communication, given to both physician and patient, decreased the gap in quality of care. Intervention studies could focus on enhancement of either, or both, patient and provider communication skills in order to improve health behaviors and health outcomes.

Future Studies
Clearly, much needs to be learned. As Back[1] notes, these studies have mostly focused on identification of what aspects of communication are associated with a limited number of patient outcomes, primarily satisfaction. Several educational interventions teaching communication skills have been evaluated (including one tested on oncologists), and a review of the effectiveness of training methods in oncology care was recently published.[ 12] These studies show that communication skills can be improved. However, we lack studies showing that these improvements result in better patient behavioral, cognitive, emotional, informational, and physical outcomes.

A review of the effect of interventions to alter the interaction between patients and practitioners suggested that a range of approaches can successfully alter these interactions and can result in improved patient health outcomes.[13] Specific characteristics of the doctor-patient interaction have been found to affect patient health behavior.[14,15] These studies should be replicated and expanded to further our understanding of patient-practitioner communication issues in general, as well as to determine their applicability to the oncology setting. Some authors have suggested future research directions for developing evidence- based interventions that might improve communication in cancer care.[16-18]

Conclusions
The focus of this review has been primarily on the physician side of the communication dyad. However, there are a number of patient factors that influence patient receptivity and understanding of information, as well as preference for how information is delivered, including mood state and psychological status,[19] sociodemographic and cultural factors,[20-22] and expectations.[23] These factors were not extensively covered in this review, which may reflect a lack of available empirical data. Nonetheless, research focused on patient communication is needed to better understand the potential influence of these factors on information exchange and subsequent compliance with treatment regimens, as well as to determine how patient communication may be enhanced.

One size may not fit all. To be truly patient-centered, one must identify the needs, preferences, mind-set, and mood state of patients in order to tailor the communication style to fit the individual encounter and optimize successful, effective communication.

Financial Disclosure:The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

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