Cancer communication patterns and the influence of patient characteristics: Disparities in information-giving and affective behaviors

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Abstract

Objective

To examine whether patient characteristics are associated with communication patterns between oncologists and breast cancer patients.

Methods

The study was conducted at 14 practices with 58 oncologists with 405 newly diagnosed patients with no prior history of breast cancer. The initial consultation between oncologist and patient was audiotaped and a detailed communication analysis performed. Interviews were conducted with patients and physicians immediately before and after consultations.

Results

Disparities were found across all patient demographics. Younger patients asked more questions as did those who were white had more than a high school education and when they reported an income that was high or medium income, compared to low (p < 0.01). Patient proactive behavior, such as volunteering information to the physician unasked, was similarly related with all demographic predictors as was physician tendency to ask patients questions. Despite the inherently emotional nature of this encounter, there was surprisingly little overt discussion about how the patient felt about her diagnosis and how she was coping. Both patients and physicians spent time trying to establish an interpersonal relationship with each other, although patients spent more time. Patients differed in the number of relationship building utterances by age, education and income and physicians spent more time engaged in relationship building with white than non-white patients (p < 0.01) and more educated and affluent patients (p < 0.05).

Conclusion

This study indicates that patient demographic factors, such as race, income level, education and age seem to influence the amount of time physicians spend in almost all communication categories with patients. One recurring difference across most communication categories was race. Racial differences occurred in almost every one of the communication categories examined. White patients had many more utterances in almost every communication category than their non-white counterparts. These differences may mean a less adequate decision-making process for patients who are members of racial or ethnic minorities, patients who are less affluent, older, and have less education.

Practice implications

This study found that providers communicate differently with patients by age, race, education and income. These differences in communication may lead to disparities in patient outcomes. Communication skills training should explicitly train clinicians to recognize these tendencies. Patients with different demographics characteristics may also required education that is tailored to them.

Introduction

Disparities in cancer incidence, prevalence and mortality have been well-documented for racial and ethnic minorities [1], [2] as well as for low-income and elderly populations [3]. Cancer mortality rates for African-Americans are substantially higher for breast, colon, prostate, and other cancers [4]. In a recent study of 677 women with early-stage breast cancer, minorities and women without insurance had double the risk of white women than those with insurance of not receiving appropriate adjuvant therapy, even when their rates of consultation with an oncologist was the same [5]. Ashton and colleagues [6] have suggested that African-Americans and other minorities have lower rates of utilizing certain services even when their access to care and illness severity are equivalent to white Americans. They have argued that some of these disparities may be attributable to poor communication that undermines the patient's ability to convey problems and for the physician to make sense of patient concerns [6], [7].

Lack of culturally sensitive care creates obstacles to effective communication between patients and physicians, which in turn can jeopardize patient outcomes. A substantial body of literature indicates that patients who experience effective communication report greater satisfaction with their medical care, lower levels of anxiety and depression, higher levels of understanding about their condition, are more likely to adhere to treatment, and have higher overall levels of well-being and quality of life [8], [9], [10], [11].

For example, compared to whites, Hispanics and Asians are less likely to say that their doctors listen to everything they have to say, that they understand everything the doctor says, that the doctor involves them as much as they want in decision-making about their care, and that the doctor spends as much time with them as they want [12], [13]. One study found that primary care physicians were 23% more verbally dominant but engage in 33% less patient-centered communication with African-American patients compared to white patients [14]. Researchers have reported that less thorough information is disclosed to cancer patients who have less education, are elderly, or have a poor prognosis [9]. Here we briefly report on a study that examined how the sociodemographics characteristics of breast cancer patients is associated with how they and their clinical oncologists communicate during a consultation about whether or not the patient should take chemotherapy (adjuvant therapy) after surgery.

Section snippets

Sample

The study employed direct observation of communication between breast cancer patients and medical oncologists. The study was conducted at 14 practices with 58 oncologists and 405 breast cancer patients in two large metropolitan communities in two states. The practices consisted of 4 academic practices and 10 community-based oncology practices. Patients were eligible for the study if they were candidates for adjuvant therapy with no prior history of breast cancer. Patients were asked to

Methods

To capture and analyze communication between doctor and patient, we used the Roter Interaction Analysis System (RIAS). The RIAS system has been used to examine the structure of cancer communications to determine communication patterns. Interactions between patients, their family members, and their consulting physicians were audiotaped, transcribed, and coded by trained research assistants. We examined communication behaviors by the following characteristics: (1) age—older (>60 years) and

Results

The focal point of these consultations was the decision concerning what type of adjuvant therapy to take, and these conversations reflected this goal with most of discussions focused on medical issues. Overall, 65% of all utterances were made by physicians (median number of utterances = 350) compared to 35% by patients (median number of utterances = 202). Physicians spent more than half (54%) of their time with patients counseling and educating them. Of the information gathered, 98% related

Discussion

Medical encounters occur within interactive environments and physicians often dominate these environments. We note that much of the physician talk was “scripted” and not especially tailored to the individual patient. In other words, talk was repetitively used with all patients. This study indicates that patient demographic factors, such as race, income level, education and age seem to influence the number of physician utterances in almost all communication categories with patients. One

Acknowledgement

This project was supported by Grant number # R01-HS08516 from the National Cancer Institute.

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