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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Discussion of comments so far regarding Communicating wth Breast Cancer Patients
Improving Communication
Importance of Educational Research
Impact Method and Style of Communicating Information has on Breast Cancer Patients
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Moira Stewart, London, Canada Professor, Department of Family Medicine
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I read seven themes in the welcomed comments by three separate colleagues: Fallowfield, Carney and Shockney. The dose-response of the education approaches that have been studied is evident. The three day sessions show effects through to the clinic and after lengthy follow-up, as Fallowfield has found. But for those for whom three days is not feasible, it is heartening to learn that the 6 hour program can show effects into the clinic altough no follow-up at 3 or 18 months was done. All outcomes were found to differ between the intervention and control groups in the hypothesized direction i.e. of all the signifiant findings shown in Tables 3 and 4, none differed in the opposite direction. The finding on patients psychological distress was in the opposite direction but was small and not statistically significant (line 3 Table 4 ). Table 4 shows the findings relevant to transfer of learnings to the clinical setting, an important feature of this education evaluation. With regard to internet access that patents are increasingly participating in, in the qualitative study that was part of this research program on communicating with breast cancer patients this acivity was found to be a constructive engagement. McWilliam et al. found that internet searching was part of the patients' activity to enhance their regaining control over their health and health care. The diagnosis was seen as a spiral of loss of control over their trust in their body. The need to try to regain control ought not to be minimized by professionals. This was one of the important messages during the "Patients Perspectives" component of the education intervention. I interpret the comment about translation of knowledge to be referring to knowledge tansfer and exchange reaching out not only to policy-makers and providers but also to patients. There is an increasing interest in conceptalizng the communication between patients and providers as knowledge transfer and exchange. This is likely to be a fruitful area of future research and development. With regard to the comment about the need for tailored education for different medical providers, I see two sides to the argument. I think there are general principles of patient-provider communication that are common to all medical specialties and indeed to the other heath professionals as well. However, it is also true that we had a great deal of difficulty creating video and other teaching tools that would suit all three medical specialties in the education inervention. I am so happy to read the comment about non-verbal communication because I feel it is a topic that deserves to be the focus of a longterm and well orchestrated research program. I encourage researchers to continue to build on past work and move that research agenda forward. The ways that providers present the diagnosis of breast cancer needs to ecourage paients' hope. This was a major findng of McWilliams et al.'s qualitative study that preceeded the education and trial reported in the paper we are commenting on. I concur with Shockney's exampes and recommend them to other educators. I thank the contributors for their comments. I welcome furher discussion. Competing interests: None declared |
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Lesley J Fallowfield, Brighton, England Psycho-oncologist, Director CR-UK Psychosocial Oncology Group, Brighton & Sussex Medical School
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Great to see another attempt to produce hard efficacy data via an RCT. Pity not all outcomes were in the hypothesised direction but the authors are demanding a lot from an intervention lasting a mere 6 hours (albeit better than the 2 hours in the control (standard) intervention. My own group have tried various models of training for years and found that we needed a minimum of 3 days to achieve objective improvements but at least these transferred into the clinic setting and were still apparent 3 months and 18 months post intervention. As with many things you probably 'gets what you pays for' and there is a clear dose-response relationship with communication skills training no matter how good the basic model. Competing interests: None declared |
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Patricia A. Carney, Portland OR, USA Professor of Family Medicine and of Public Health and Preventive Medicine
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This research underscores the importance of educational research, more specifically in this case on what it takes to enhance physician communication on a difficult topic. Internet access to pubic information has expanded the role of the physician, and especially the primary healthcare provider, about informing and educating patients about what to expect in their medical care. Further, if translational research reaches or exceeds its promise, educational research across the learning continuum will be a vital area of research focus if the primary outcome is to improve the public's health. As this study's findings suggest, educational interventions will likely need to be tailored to specific types of learners if they are to have their intended impact. I commend Dr. Stewart and her colleagues for undertaking this complex but rigorous study. Much more research is needed in this area. Competing interests: None declared |
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Lillie D Shockney, Baltimore, MD USA Johns Hopkins Breast Center
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More research is needed in this area and particularly more educational programs to teach health care providers in the art of communication. Specifically tailored education is needed for each specialty, as I do not believe one general communication program can cover the information and knowledge needed for all. This includes non-verbal communication. The timing of when bad news is communicated to a cancer patient (learning she is newly diagnosed with breast cancer or learning 4 years later she has metastatic disease) may influence how much she retains, what her perception is of the news (prognosis), and how she will approach decision making about treatment. For example, if a patient has a 1.8cm invasive ductal carcinoma and 3 positive lymph nodes, one surgical oncologist may present it like this: "I have bad news. You had 3 positive nodes so you will need a lot of chemo and radiation. Of course scans have to be done to see if the cancer has already spread to other organs. If so, then you will be stage 4." Versus a different approach-- "your surgery is behind you. Margins are clear. That's good news. No additional surgery is needed. You have now rid your body of the source of this cancer growing. I removed 15 nodes; 12 were clean and 3 had some cancer in them. For that reason, you'll need more treatment to carry you further up the survival curve. Chemo and radiation and possibly hormonal therapy. Our nurse is going to match you to a breast cancer survivor volunteer who was your age at diagnosis and had the same pathology results and treatment. She will be a bosom buddy for you as you continue your journey to wellness. We'll follow up with a basline bone scan and cat scan now before your chemo gets started. You haven't had any physical symptoms of disease being elsewhere so I'm hopeful the scans will look good. If not, we will discuss further the best treatment for you." As you can see-- same path-- different way of telling the news, one pessimistically and one more optimistically. I would also expect the second doctor to be sitting closely to the patient, holding her hand, giving her good eye contact and asking her to repeat back her understanding of what was just said. Lillie Shockney, Administrative Director, Johns Hopkins Avon Foundation Breast Center, Baltimore, MD Faculty, Dept of Surgery, JHU School of Medicine and 15 year breast cancer survivor. Competing interests: None declared |
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