Predictors of physicians' satisfaction with their management of uncertainty during a decision-making encounter with a simulated advanced stage cancer patient.

OBJECTIVES: To optimize their training, predictors of physicians' satisfaction with their management of uncertainty should be examined. This study investigated these predictors by using a simulated advanced stage cancer patient. METHODS: Physicians (n=85) rated their satisfaction with their management of uncertainty (Visual Analog Scale-100mm) after a decision-making encounter. Communication predictors were examined with the: Observing Patient Involvement scale (OPTION), Multidimensional analysis of Patient Outcome Predictions (MD.POP) and Communication Content Analysis Software (LaComm). Psychological predictors were assessed with the: Intolerance of Uncertainty Inventory (IUI), Physicians' Reactions to Uncertainty scale (PRU), Decisional Conflict Scale (DCS), and Jefferson Scale of Physician Empathy (JSPE). RESULTS: Physicians' satisfaction (mean=67mm; standard deviation=17mm) was not predicted by their communication, but by their anxiety due to uncertainty (PRU) (ß=-.42; p=<.001) and their perceived empathy (JSPE) (ß=.26; p=.009). These variables accounted for 25% of variance in physicians' satisfaction. CONCLUSIONS: Physicians' satisfaction with their management of uncertainty was not affected by their communication performance, but by their psychological characteristics. PRACTICE IMPLICATIONS: Training programs should increase physicians' awareness regarding the communication performance required in decision-making encounters under conditions of uncertainty.

Is it possible to improve the breaking bad news skills of residents when a relative is present? A randomised study.

BACKGROUND: Although patients with cancer are often accompanied by a relative during breaking bad news (BBN) consultations, little is known regarding the efficacy of training programmes designed to teach residents the communication skills needed to break bad news in a triadic consultation. METHODS: Residents were randomly assigned to a 40-h dyadic and triadic communication skills training programme (n=48) or a waiting list (n=47). A simulated BBN triadic consultation was audiotaped at baseline, and after training for the training group, and 8 months after baseline for the waiting list group. Transcripts were analysed using content analysis software (LaComm). A coder determined the moment of bad news delivery and the relative's first turn of speech regarding the bad news. A generalised estimating equation was used to evaluate residents' communication skills, BBN timing, and the relative's inclusion in the consultation. RESULTS: Ninety-five residents were included. After training, the duration of the pre-delivery phase was found to be longer for the trained residents (relative risk (RR)=3.04; P<0.001). The simulated relative's first turn of speech about the bad news came more often during the pre-delivery phase (RR=6.68; P=0.008), and was more often initiated by the trained residents (RR=19.17; P<0.001). Trained residents also used more assessment (RR=1.83; P<0.001) and supportive utterances (RR=1.58; P<0.001). CONCLUSION: This study demonstrates that a training programme that focuses on the practice of dyadic and triadic communication skills can improve the communication skills of the participating residents in a BBN triadic consultation. Such a training should be included in resident curriculum.

Is it possible to improve residents breaking bad news skills? A randomised study assessing the efficacy of a communication skills training program.

BACKGROUND: This study aims to assess the efficacy of a 40-h training programme designed to teach residents the communication skills needed to break the bad news. METHODS: Residents were randomly assigned to the training programme or to a waiting list. A simulated patient breaking bad news (BBN) consultation was audiotaped at baseline and after training in the training group and 8 months after baseline in the waiting-list group. Transcripts were analysed by tagging the used communication skills with a content analysis software (LaComm) and by tagging the phases of bad news delivery: pre-delivery, delivery and post-delivery. Training effects were tested with generalised estimating equation (GEE) and multivariate analysis of variance (MANOVA). RESULTS: The trained residents (n=50) used effective communication skills more often than the untrained residents (n=48): more open questions (relative rate (RR)=5.79; P<0.001), open directive questions (RR=1.71; P=0.003) and empathy (RR=4.50; P=0.017) and less information transmission (RR=0.72; P=0.001). The pre-delivery phase was longer for the trained (1 min 53 s at baseline and 3 min 55 s after training) compared with the untrained residents (2 min 7 s at baseline and 1 min 46 s at second assessment time; P<0.001). CONCLUSION: This study shows the efficacy of training programme designed to improve residents' BBN skills. The way residents break bad news may thus be improved.

[Fear of falling in older people]. / La peur de chuter et le "syndrome post-chute " de la personne âgée.

Fear of falling and poor physical performance are prominent symptoms in many older people. The prevalence of fear of falling in community-living elderly ranges between 12 % and 65 %, and is higher in women than men. It commonly occurs after falls, but it also occurs without a previous fall history. One of the major consequences of fear of falling is the restriction and avoidance of activities. However, not all elderly with fear of falling avoid activities in daily life. Some elderly only become cautious, which may be functional in preventing falls. Only a small percentage of elderly show a pattern of excessive fear and restriction of activities. The consequences of this pattern may, however, be debilitating and devastating. Excessive fear and avoidance may compromise the quality of life, and may result in a decline of physical capabilities and, ultimately, in an increased risk of falls, which may further fuel fear and avoidance. Future research should investigate whether individualised intervention strategies are efficient in preventing falls and activity-related fear of falling within this population in order to improve her quality of life.

Factors that influence cancer patients' anxiety following a medical consultation: impact of a communication skills training programme for physicians.

BACKGROUND: No study has yet assessed the impact of physicians' skills acquisition after a communication skills training programme on the evolution of patients' anxiety following a medical consultation. This study aimed to compare the impact, on patients' anxiety, of a basic communication skills training programme (BT) and the same programme consolidated by consolidation workshops (CW), and to investigate physicians' communication variables associated with patients' anxiety. PATIENTS AND METHODS: Physicians, after attending the BT, were randomly assigned to CW or to a waiting list. The control group was not a non-intervention group. Consultations with a cancer patient were recorded. Patients' anxiety was assessed with the State Trait Anxiety Inventory before and after a consultation. Communication skills were analysed according to the Cancer Research Campaign Workshop Evaluation Manual. RESULTS: No statistically significant change over time and between groups was observed. Mixed-effects modelling showed that a decrease in patients' anxiety was linked with screening questions (P = 0.045), physicians' satisfaction about support given (P = 0.004) and with patients' distress (P < 0.001). An increase in anxiety was linked with breaking bad news (P = 0.050) and with supportive skills (P = 0.013). No impact of the training programme was observed. CONCLUSIONS: This study shows the influence of some communication skills on the evolution of patients' anxiety. Physicians should be aware of these influences.

Effects of a 105 hours psychological training program on attitudes, communication skills and occupational stress in oncology: a randomised study.

There is today a wide consensus regarding the need to improve communication skills (CS) of health-care professionals (HCPs) dealing with cancer patients. Psychological training programs (PTPs) may be useful to acquire the needed CS. Testing the efficacy of PTP will allow to define their optimal content. The present study was designed to assess the impact of a PTP on HCP stress, attitudes and CS, and on HCP and patients' satisfaction with HCP communication skills in a randomised study. A total of 115 oncology nurses were randomly assigned to a 105-h PTP or to a waiting list. Stress was assessed with the Nursing Stress Scale, attitudes with a Semantic Differential Questionnaire, CS used during one simulated and one actual patient interview with the Cancer Research Campaign Workshop Evaluation Manual, and satisfaction with the nurses' CS with a questionnaire completed by the patients and the nurses. Trained (TG) and control (CG) groups were compared at baseline, after 3 months (just following training for TG) and after 6 months (3 months after the end of training for TG). Compared to controls, trained nurses reported positive changes on their stress levels (P

Impact of medical specialists' locus of control on communication skills in oncological interviews.

Although is it widely recognised that physicians' characteristics could influence their communication styles, no empirical evidence is currently available. No studies are available on the impact of physicians' locus of control (LOC) on their communication skills. LOC is a generalised belief regarding the extent to which life outcomes are controlled by an individual's actions (internal LOC) or by external forces such as luck, fate or other individuals (external LOC). It was hypothesised that physicians with external LOC would take more into account others' concerns than physicians with internal LOC and would consequently use more appropriate assessment, informative and supportive functions. A total of 81 medical specialists were assessed in a simulated interview and a clinical interview. Communication skills were rated according to the Cancer Research Campaign Workshop Evaluation Manual. LOC was assessed using the Rotter I-E scale. Communication skills of the upper and lower quartiles of physicians in respect of their scores on this scale were compared using Student's t-test. Results show that physicians with external LOC give more appropriate information than physicians with internal LOC in simulated interviews (P=0.011) and less premature information than physicians with internal LOC in clinical interviews (P=0.015). This result provides evidence that physicians' LOC can influence their communication styles in oncological interviews and in particular the way they provide information to the patient.

Does training increase the use of more emotionally laden words by nurses when talking with cancer patients? A randomised study.

The emotional content of health care professionals-cancer patient communication is often considered as poor and has to be improved by an enhancement of health care professionals empathy. One hundred and fifteen oncology nurses participating in a communication skills training workshop were assessed at three different periods. Nurses randomly allocated to a control group arm (waiting list) were assessed a first time and then 3 and 6 months later. Nurses allocated to the training group were assessed before training workshop, just after and 3 months later. Each nurse completed a 20-min clinical and simulated interview. Each interview was analysed by three content analysis systems: two computer-supported content analysis of emotional words, the Harvard Third Psychosocial Dictionary and the Martindale Regressive Imagery Dictionary and an observer rating system of utterances emotional depth level, the Cancer Research Campaign Workshop Evaluation Manual. The results show that in clinical interviews there is an increased use of emotional words by health care professionals right after having been trained (P=0.056): training group subjects use 4.3 (std: 3.7) emotional words per 1000 used before training workshop, and 7.0 (std: 5.8) right after training workshop and 5.9 (std: 4.3) 3 months later compared to control group subjects which use 4.5 (std: 4.8) emotional words at the first assessment point, 4.3 (std: 4.1) at the second and 4.4 (std: 3.3) at the third. The same trend is noticeable for emotional words used by health care professionals in simulated interviews (P=0.000). The emotional words registry used by health care professionals however remains stable over time in clinical interviews (P=0.141) and is enlarged in simulated interviews (P=0.041). This increased use of emotional words by trained health care professionals facilitates cancer patient emotion words expressions compared to untrained health care professionals especially 3 months after training (P=0.005). This study shows that health care professionals empathy may be improved by communication skills training workshop and that this improvement facilitates cancer patients emotions expression.

[Improving doctor's communication skills in oncology: review and future perspectives]. / Améliorer les stratégies de communication des médecins en oncologie: état des lieux et perspectives futures.

The aim of this review is to discuss the different communication skills training designed to physician interactions with cancer patients. The development of medicine and chronic cancer treatments indicates the need to improve communication skills that combine appropriate assessment, information and support. Literature shows however that numerous factors may jeopardize the mastery of those skills. As a consequence, initiatives have been made to improve oncologists' communication skills. The objectives of those training programs are to improve patients' as well as the medical staffs' quality of life. A critical review of objectives and used techniques (theorical information, case discussion, role playing, feed-back) is presented here. This review includes also the discussion about training module integrating several techniques. This review shows the efficacy of experiential techniques as well as participative techniques. The results of available studies are finally emphasizing two difficulties: the maintenance and the consolidation of the various skills acquired over time and their successful transfer to the clinical practice.

Testing health care professionals' communication skills: the usefulness of highly emotional standardized role-playing sessions with simulators.

Although standardized role-playing sessions (SRPS) with simulators are increasingly used to assess health care professionals' (HCPs) communication skills (CS) and the effectiveness of training workshops (TWs), nothing has been done to date to define the optimal emotional content of SRPS. Three emotionally different SRPS contexts-weakly emotional (WE-), moderately emotional (ME-), and highly emotional (HE-SRPS)-were, therefore, tested in order to assess induced CS and sensitivity to TW-related changes. The study included 25 HCPs. Tape-recorded SRPS, scheduled before and after the TW, were retranscribed, and assessed according to the Cancer Research Campaign Workshop Evaluation Manual (CRCWEM), which provides a rating of form, function and structure for each utterance. Results show that induced CS are different in WE-, ME-, and HE-SRPS, regarding form (HE-SRPS induced more 'directing', 'leading' or 'multiple' questions; WE: 20.7%; ME: 19.7%; HE: 33.7% (p<0.001)); function (HE-SRPS induced more 'inappropriate' information; WE: 6. 5%; ME: 8.2%; HE: 15.6% (p<0.001)); and blocking (HE-SRPS induced more 'blocking' utterances; WE: 7.2%; ME: 13.8%; HE: 30.2% (p<0. 0001)). Finally, CS changes induced by TWs are the highest in HE-SRPS (14.8% increase of 'open' questions for the HE- versus 1.0% for the WE-SRPS; 11.6% decrease of 'inappropriate' information for the HE- versus 3.3% for the WE-SRPS; and 17.5% decrease of 'blocking' for the HE- versus 2.6% for the WE-SRPS). In conclusion, SRPS, with a HE content, induce more inappropriate CS. Moreover, they are more sensitive to TW effects. SRPS with a HE content should, thus, be recommended for the assessment of TW effectiveness.

Caring About Women and Cancer (CAWAC): a European survey of the perspectives and experiences of women with female cancers.

This paper reports on the findings of the largest ever European survey of female patients' perceptions of their cancer treatment. It has provided clarification of what women consider important in relation to their management and has identified several areas where more research is needed. It has shown that women's knowledge about cancer before diagnosis is poor and the number undergoing regular screening could be improved. Women are not being adequately prepared and educated about what to expect from treatment and steps should be taken as a matter of urgency to redress this shortcoming. It was revealed that whilst families were the primary source of support to female cancer patients, women also derive considerable support from healthcare professionals, particularly senior doctors; more attention should be paid by specialists and nurses to developing psychological skills to cope with this. In this context, further research is needed into how support groups may best meet patient needs.

Comparative study of the efficacy and safety of trazodone versus clorazepate in the treatment of adjustment disorders in cancer patients: a pilot study.

The efficacy of trazodone (mean once-daily dose 111.5 +/- 36.3 mg) versus clorazepate (mean once-daily dose 17.5 +/- 7.5 mg) to relieve anxious and depressive symptoms in 18 patients undergoing treatment for breast cancer was investigated in a 28-day randomized, double-blind study. Efficacy was evaluated using the Hospital Anxiety and Depression Scale, the Revised Symptom Checklist and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire. A successful response to treatment was achieved in 91% (10/11) of patients who received trazodone and 57% (four of seven) of patients who were administered clorazepate (P = 0.1373). Bayesian analysis revealed that the prior probability of making a wrong decision in prescribing trazodone rather than clorazepate reduced from 26% to 8%. Assessment of the clinical scales suggested a benefit of trazodone compared with clorazepate, although the differences were not significant. Safety of both treatments was similar. Trazodone is devoid of an abuse risk and dependence and, therefore, could be a valuable alternative to clorazepate in the treatment of adjustment disorders in cancer patients.

A comprehensive assessment of satisfaction with care for cancer patients.

The present paper reports on the initial development of a comprehensive questionnaire for assessing cancer patients' perception of the quality of care received in the oncology hospital. This questionnaire is primarily intended to evaluate interventions aimed at improving quality of life and focuses on patients' interactions with doctors and nurses. The current questionnaire includes 61 items assessing doctors' and nurses' technical competence, communication skills, interpersonal qualities, and availability; aspects of the hospital environment and treatment planning; and general satisfaction. Most items refer to an aspect of care rated on a five-point Likert scale from "Poor" to "Excellent". Additionally, each aspect of care is also evaluated by a dichotomous (yes/no) question on the patient's wish (or not) for its improvement. This questionnaire is the result of consecutive pilot tests (from April 1994 to September 1995). Analysis of patients' comments, items that patients omitted to respond to and score distributions have identified items needing to be rephrased, reworded, eliminated or placed in specific sections. Items showing low scores or acceptable score distributions have been stressed as appropriate for inclusion in the final questionnaire version.

Communication skills and psychological training in oncology.

Preserving the best possible quality of life for cancer patients and their families has become a major goal in cancer care. However, the cumulative effect of stressors related to cancer care, many of which involve communicating with patients and relatives, may lead to the development of burnout in staff. Many health care professionals lack the psychosocial knowledge and communications skills needed to identify patients' problems because general professional training focuses on technical care. Teaching strategies known as psychological training programs (PTP) are therefore being developed to help improve health care professionals' sensitivity to communication problems with patients and relatives. Cognitive (e.g. theoretical information), experiential (e.g. case-history discussions), behavioural (e.g. role-playing exercise) and supportive (e.g. stressor identification) training techniques are used to teach the essential skills of good communication, i.e. listening, empathy, response to cues and appropriate use of reassurance. PTP range from one-day courses and residential workshops to full-time 1- or 2-year curricula. However, one of the main obstacles to implementing PTP is scepticism among health care professionals about its usefulness. Research on training effectiveness should therefore be developed to assess the impact of communication skills on quality of care and patients' quality of life.

[Systemic approach to families dealing with cancer diagnosis, its treatment and its prognosis]. / Vers une approche systémique des familles confrontées au diagnostic de cancer, à son traitement et à son pronostic.

This paper reviews and comments the literature related to the problems families have to deal with when cancer occurs, in a psychological and relational perspective. It addresses, among other topics, communication problems and the specific aspects of the different evolutional phases of the disease, and the subsystems of the family. Considering the dramatic effects of cancer within the family and the interdependency of the patient and his family in their adjustment to the disease, we propose that psychological evaluation and support should be offered to the family system as a whole.

The psychiatrist's perspective on quality of life and quality of care in oncology: concepts, symptom management, communication issues.

The important prevalence of psychosocial problems and psychiatric disturbances that have been reported in oncology, underlines the need for comprehensive psychosocial support for cancer patients and their families. Psychosocial support is designed to preserve, restore or enhance quality of life. Quality of life refers not only to psychosocial distress and adjustment-related problems but also to the management of cancer symptoms and treatment side-effects. Psychosocial interventions designed for this purpose should be divided into five categories: prevention, early detection, restoration, support and palliation. Firstly, preventive interventions are designed to avoid the development of predictable morbidity secondary to treatment and/or disease. Secondly, early detection of patients' needs or problems refers to the assumption that early interventions' could have therapeutic results superior to those of delayed support, both for quality of life and survival. Thirdly, restorative interventions refer to actions used when a cure is likely, the aim being the control or elimination of residual cancer disability. Fourthly, supportive rehabilitation is planned to lessen disability related to chronic disease, characterised by cancer illness remission and progression, and to active treatment. Fifthly, palliation is required when curative treatments are likely to no longer be effective, and when maintaining or improving comfort becomes the main goal. Psychological interventions are often multidisciplinary, with a variety of content. The type of psychological intervention ranges from information and education to more sophisticated support programmes including directive (behavioural or cognitive) therapies, or non-directive (dynamic or supportive) therapies. Social interventions usually include financial, household, equipment, and transport assistance depending on individual and family needs and resources. These interventions may be combined with the prescription of pharmacological (psychotropic, analgesic), physical, speech or occupational therapies, especially in rehabilitation programmes. Health care services devoted to delivery of these interventions are hospital, hospice or home-based and organised very differently depending on already available community resources and local practice.

Professional rehabilitation of lymphoma patients: a study of psychosocial factors associated with return to work.

During the last ten years a substantial reduction in mortality has been obtained for Hodgkin's and non-Hodgkin's lymphoma. Since lymphoma treatment is often accompanied by side effects and long-term sequelae, however, patients often have problems with rehabilitation. It is thus very important that these problems and needs be identified. Going back to work is one of the main objectives of rehabilitation and can be taken as a valuable indicator of the problems and needs of such patients. We therefore conducted a study at the Jules Bordet Institute between December 1989 and December 1990. Of the patients in remission and able to go back to work, only 54% of them have done so. Anxiety, depression, and treatment toxicity interfere with return to work, and the likelihood of job reentry increases with the time lapse since the end of treatment. Rehabilitation programs must focus on alleviating illness and treatment sequelae as soon as treatment ends.