Effect of a Skills Training for Oncologists and a Patient Communication Aid on Shared Decision Making About Palliative Systemic Treatment: A Randomized Clinical Trial.

BACKGROUND: Palliative systematic treatment offers uncertain and often limited benefits, and the burden can be high. Hence, treatment decisions require shared decision making (SDM). This trial examined the independent and combined effect of an oncologist training and a patient communication aid on SDM. METHODS: In this multicenter randomized controlled trial with four parallel arms (2016-2018), oncologists (n = 31) were randomized to receive SDM communication skills training or not. The training consisted of a reader, two group sessions, a booster session, and a consultation room tool (10 hours). Patients (n = 194) with advanced cancer were randomized to receive a patient communication aid or not. The aid consisted of education on SDM, a question prompt list, and a value clarification exercise. The primary outcome was observed SDM as rated by blinded observers from audio-recorded consultations. Secondary outcomes included patient-reported SDM, patient and oncologist satisfaction, patients' decisional conflict, patient quality of life 3 months after consultation, consultation duration, and the decision made. RESULTS: The oncologist training had a large positive effect on observed SDM (Cohen's d = 1.12) and on patient-reported SDM (d = 0.73). The patient communication aid did not improve SDM. The combination of interventions did not add to the effect of training oncologists only. The interventions affected neither patient nor oncologist satisfaction with the consultation nor patients' decisional conflict, quality of life, consultation duration, or the decision made. CONCLUSION: Training medical oncologists in SDM about palliative systemic treatment improves both observed and patient-reported SDM. A patient communication aid does not. The incorporation of skills training in (continuing) educational programs for medical oncologists is likely to stimulate the widely advocated uptake of shared decision making in clinical practice. TRIAL REGISTRATION: Netherlands Trial Registry NTR 5489. IMPLICATIONS FOR PRACTICE: Treatment for advanced cancer offers uncertain and often small benefits, and the burden can be high. Hence, treatment decisions require shared decision making (SDM). SDM is increasingly advocated for ethical reasons and for its beneficial effect on patient outcomes. Few initiatives to stimulate SDM are evaluated in robust designs. This randomized controlled trial shows that training medical oncologists improves both observed and patient-reported SDM in clinical encounters (n = 194). A preconsultation communication aid for patients did not add to the effect of training oncologists. SDM training effectively changes oncologists' practice and should be implemented in (continuing) educational programs.

Risk factors of unmet needs among women with breast cancer in the post-treatment phase.

OBJECTIVE: Unmet health care needs require additional care resources to achieve optimal patient well-being. In this nationwide study we examined associations between a number of risk factors and unmet needs after treatment among women with breast cancer, while taking into account their health care practices. We expected that more care use would be associated with lower levels of unmet needs. METHODS: A multicenter, prospective, observational design was employed. Women with primary breast cancer completed questionnaires 6 and 15 months post-diagnosis. Medical data were retrieved from medical records. Direct and indirect associations between sociodemographic and clinical risk factors, distress, care use, and unmet needs were investigated with structural equation modeling. RESULTS: Seven hundred forty-six participants completed both questionnaires (response rate 73.7%). The care services received were not negatively associated with the reported levels of unmet needs after treatment. Comorbidity was associated with higher physical and daily living needs. Higher age was associated with higher health system-related and informational needs. Having had chemotherapy and a mastectomy were associated with higher sexuality needs and breast cancer-specific issues, respectively. A higher level of distress was associated with higher levels of unmet need in all domains. CONCLUSIONS: Clinicians may use these results to timely identify which women are at risk of developing specific unmet needs after treatment. Evidence-based, cost-effective (online) interventions that target distress, the most influential risk factor, should be further implemented and disseminated among patients and clinicians.

Promoting shared decision making in advanced cancer: Development and piloting of a patient communication aid.

OBJECTIVE: To learn how to configure a patient communication aid (PCA) to facilitate shared decision-making (SDM) about treatment for advanced cancer. METHODS: The PCA consists of education about SDM, a question prompt list, and values clarification methods. Study 1. A first version was presented to 13 patients, 8 relatives and 14 bereaved relatives in interviews. Study 2. A second version was used by 18 patients in a pilot study. Patients and oncologists were interviewed, patients were surveyed, and consultations were audio-recorded. RESULTS: Respondents reported that the aid facilitated patient control over information, raised choice awareness and promoted elaboration. Risks were identified, most importantly that the aid might upset patients. Also, some respondents reported that the PCA did not, or would not support decision making because they felt sufficiently competent, did not perceive a role for themselves, or did not perceive that the decision required elaboration. CONCLUSIONS: Opinions on the usefulness of the PCA varied. It was challenging to raise awareness about the presence of a choice, and to find a balance between comprehensive information and sensitivity. PRACTICE IMPLICATIONS: A future study should demonstrate whether the PCA can improve SDM, and whether this effect is stronger when oncologists receive training.

Training for Medical Oncologists on Shared Decision-Making About Palliative Chemotherapy: A Randomized Controlled Trial.

BACKGROUND: Systemic treatment for advanced cancer offers uncertain and sometimes limited benefit, while the burden can be high. This study examines the effect of shared decision-making (SDM) training for medical oncologists on observed SDM in standardized patient assessments. MATERIALS AND METHODS: A randomized controlled trial comparing training with standard practice was conducted. Medical oncologists and oncologists-in-training (n = 31) participated in a video-recorded, standardized patient assessment at baseline (T0) and after 4 months (T1, after training). The training was based on a four-stage SDM model and consisted of a reader, two group sessions (3.5 hours each), a booster session (1.5 hours), and a consultation card. The primary outcome was observed SDM as assessed with the Observing Patient Involvement scale (OPTION12) coded by observers blinded for arm. Secondary outcomes were observed SDM per stage, communication skills, and oncologists' satisfaction with communication. RESULTS: The training had a significant and large effect on observed SDM in the simulated consultations (Cohen's f = 0.62) and improved observed SDM behavior in all four SDM stages (f = 0.39-0.72). The training improved oncologists' information provision skills (f = 0.77), skills related to anticipating/responding to emotions (f = 0.42), and their satisfaction with the consultation (f = 0.53). CONCLUSION: Training medical oncologists in SDM about palliative systemic treatment improves their performance in simulated consultations. The next step is to examine the effect of such training on SDM in clinical practice and on patient outcomes. IMPLICATIONS FOR PRACTICE: Systemic treatment for advanced cancer offers uncertain and sometimes limited benefit, while the burden can be high. Hence, applying the premises of shared decision-making (SDM) is recommended. SDM is increasingly advocated based on the ethical imperative to provide patient-centered care and the increasing evidence for beneficial patient outcomes. Few studies examined the effectiveness of SDM training in robust designs. This randomized controlled trial demonstrated that SDM training (10 hours) improves oncologists' performance in consultations with standardized patients. The next step is to examine the effect of training on oncologists' performance and patient outcomes in clinical practice.

Does silence speak louder than words? The impact of oncologists' emotion-oriented communication on analogue patients' information recall and emotional stress.

OBJECTIVE: The impact of two types of oncologists' emotion-oriented communication on participants' recall of medical information was investigated, and the potential mediation by a reduction in emotional stress. Additionally, moderation effects by personal characteristics were explored. METHODS: An oncologist's communication in response to a patient's emotional expressions was manipulated during a videotaped, scripted bad-news consultation. Three conditions were created: 1) standard communication, 2) emotion-oriented silence, and 3) emotion-oriented speech. Participants (N = 217) were randomly allocated to one of the three conditions. Measurements included information recall (free recall and recognition), emotional stress (self-reported and physiological), and personal characteristics. RESULTS: Emotion-oriented silence (p = .002) and speech (p = .019) enhanced information recognition compared to standard communication. No differences in free recall were found. Emotional stress did not mediate these relations. Poorer functional health literacy predicted poorer recognition, but this was counteracted by emotion-oriented communication. CONCLUSIONS: By means of acknowledging, exploring, empathic and supportive statements, and attentive silence, the oncologist's communication resulted in better information recognition. How oncologists' communication impacts patients' information recall warrants further investigation, as this could not be explained by reducing emotional stress. PRACTICE IMPLICATIONS: These insights will help educators to validate the relevance of emotion-oriented strategies, and encourage oncologists to adopt them.

How to support cancer genetics counselees in informing at-risk relatives? Lessons from a randomized controlled trial.

OBJECTIVE: In hereditary and familial cancer, counselees are requested to inform their at-risk relatives. We developed an intervention to support counselees in this task. METHODS: A randomized controlled trial was conducted aimed at improving cancer genetic counselees' i) knowledge, ii) motivation to disclose information, and ii) self-efficacy in this regard. Eligible participants were randomized to telephonic counseling (n = 148), or standard care (n = 157) and assessed at baseline, 1 week post-intervention, and 4 months after study enrolment. RESULTS: No between-group differences were found in participants' knowledge, motivation, and self-efficacy. Knowledge concerning which second-degree relatives to inform was lower compared to first-degree relatives. About 60% of the participants was of the opinion that they needed to inform more relatives than stated in their summary letter and only about 50% were correctly aware of which information to disclose. Of note, at baseline, almost 80% of the participants had already correctly informed their at-risk relatives. CONCLUSIONS: Since, unexpectedly, counselees already informed most of their relatives before the intervention was offered, efficacy of the intervention could not convincingly be determined. Counselees' knowledge about whom to inform about what is suboptimal. PRACTICE IMPLICATIONS: Future interventions should target a more homogeneous sample and address counselees' understanding and recall.

Patients' and oncologists' views on how oncologists may best address patients' emotions during consultations: An interview study.

OBJECTIVE: This qualitative study examines patients' and oncologists' views on how to best address emotions during consultations, and explores oncologists' opinions on their own communication and on strategies to improve oncologists' response to patients' emotions. METHODS: Semi-structured interviews were conducted with 16 cancer patients and 13 oncologists, after watching videotaped consultations illustrating three communication strategies for addressing emotions. RESULTS: Many participants preferred emotion-oriented speech to address patients' emotions; this strategy was assumed to (positively) affect a broad range of outcomes. Nevertheless, some preferred attentive silence or no emotion-oriented talk at all. Oncologists and patients had similar views on factors that may hinder oncologists to address emotions. Generally, oncologists mentioned that their response to emotions could be improved; for this, various (educational) strategies were suggested. CONCLUSION: Patients and oncologists generally agree that patients' emotions can best be addressed by empathic, explorative, acknowledging, and supportive statements. Still, differences in preferences exist, thus oncologists need to attune their communication to the individual patient. PRACTICE IMPLICATIONS: The findings can inform medical communication training and encourage oncologists to improve their communication. The regular videotaping of consultations might be a promising method to provide feedback and reflect, thereby improving oncologists' response to patients' emotions.

Studying medical communication with video vignettes: a randomized study on how variations in video-vignette introduction format and camera focus influence analogue patients' engagement.

BACKGROUND: Video vignettes are used to test the effects of physicians' communication on patient outcomes. Methodological choices in video-vignette development may have far-stretching consequences for participants' engagement with the video, and thus the ecological validity of this design. To supplement the scant evidence in this field, this study tested how variations in video-vignette introduction format and camera focus influence participants' engagement with a video vignette showing a bad news consultation. METHODS: Introduction format (A = audiovisual vs. B = written) and camera focus (1 = the physician only, 2 = the physician and the patient at neutral moments alternately, 3 = the physician and the patient at emotional moments alternately) were varied in a randomized 2 × 3 between-subjects design. One hundred eighty-one students were randomly assigned to watch one of the six resulting video-vignette conditions as so-called analogue patients, i.e., they were instructed to imagine themselves being in the video patient's situation. Four dimensions of self-reported engagement were assessed retrospectively. Emotional engagement was additionally measured by recording participants' electrodermal and cardiovascular activity continuously while watching. Analyses of variance were used to test the effects of introduction format, camera focus and their interaction. RESULTS: The audiovisual introduction induced a stronger blood pressure response during watching the introduction (p = 0.048, [Formula: see text]= 0.05) and the consultation part of the vignette (p = 0.051, [Formula: see text]= 0.05), when compared to the written introduction. With respect to camera focus, results revealed that the variant focusing on the patient at emotional moments evoked a higher level of electrodermal activity (p = 0.003, [Formula: see text]= 0.06), when compared to the other two variants. Furthermore, an interaction effect was shown on self-reported emotional engagement (p = 0.045, [Formula: see text]= 0.04): the physician-only variant resulted in lower emotional engagement if the vignette was preceded by the audiovisual introduction. No effects were shown on the other dimensions of self-reported engagement. CONCLUSIONS: Our findings imply that using an audiovisual introduction combined with alternating camera focus depicting patient's emotions results in the highest levels of emotional engagement in analogue patients. This evidence can inform methodological decisions during the development of video vignettes, and thereby enhance the ecological validity of future video-vignettes studies.

Older Patients' Recall of Online Cancer Information: Do Ability and Motivation Matter More than Chronological Age?

This study proposes and tests a model to provide a more comprehensive understanding of the contribution of chronological age versus age-related ability and motivation factors in explaining recall of online cancer information among older patients (n = 197). Results revealed that recall is not a matter of chronological age per se, but rather a matter of ability and motivation. Age-related ability and motivation factors explained 37.9% of the variance in recall. Health literacy, involvement with the webpage, and satisfaction with the emotional support were positively associated with recall. Furthermore, recall was negatively related to frailty, anger, future time perspective, and perceived cognitive load. The findings pose relevant opportunities for tailoring interventions to improve online information provision for older cancer patients.

Trust and Perceptions of Physicians' Nonverbal Behavior Among Women with Immigrant Backgrounds.

Previous findings suggest immigrant patients have lower trust in their physicians, and perceive nonverbal communication differently compared to non-immigrant patients. We tested discrepancies in trust and the impact of non-verbal behavior between immigrants and non-immigrants in The Netherlands. Nonverbal communication of an oncologist was systematically varied in an experimental video vignettes design. Breast cancer patients (n = 34) and healthy women (n = 34) viewed one of eight video versions and evaluated trust and perceived friendliness of the oncologist. In a matched control design, women with immigrant and non-immigrant backgrounds were paired. Immigrant women reported stronger trust. Nonverbal communication by the oncologist did not influence trust differently for immigrants compared to for non-immigrants. However, smiling strongly enhanced perceived friendliness for non-immigrants, but not for immigrants. Immigrant patients' strong trust levels may be formed a priori, instead of based on physicians' communication. Physicians may need to make extra efforts to optimize their communication.

The value of physicians' affect-oriented communication for patients' recall of information.

OBJECTIVE: The aim of this paper is to discuss experimental research investigating the effect of physicians' affect-oriented communication on patients' recall of information provided during medical consultations, with a special focus on the mediating role of emotional stress in that relation. METHODS & RESULTS: A search of experimental research literature was conducted, resulting in six research articles experimentally investigating the relations of interest, all using a video-vignettes design. A summary of results is provided and discussed. CONCLUSIONS: The research reviewed in this paper provides evidence for the causal and mostly positive influence of several forms of affect-oriented communication on patients' recall of medical information. Results indicate that reducing emotional stress may not be the underlying mechanism through which physicians' communication influences patients' recall. PRACTICE IMPLICATIONS: The obtained insights will help educators to teach evidence-based medical communication skills and to scientifically validate the importance of these skills for patients' recall of information. Advancing physicians' communication skills with evidence-based training will contribute to the professionalism that is the hallmark of good quality of care.

Are psychophysiological arousal and self-reported emotional stress during an oncological consultation related to memory of medical information? An experimental study.

Patients forget 20-80% of information provided during medical consultations. The emotional stress often experienced by patients during consultations could be one of the mechanisms that lead to limited recall. The current experimental study therefore investigated the associations between (analog) patients' psychophysiological arousal, self-reported emotional stress and their (long term) memory of information provided by the physician. One hundred and eighty one cancer-naïve individuals acted as so-called analog patients (APs), i.e. they were instructed to watch a scripted video-recoding of an oncological bad news consultation while imagining themselves being in the patient's situation. Electrodermal and cardiovascular activity (e.g. skin conductance level and heart rate) were recorded during watching. Self-reported emotional stress was assessed before and after watching, using the STAI-State and seven Visual Analog Scales. Memory, both free recall and recognition, was assessed after 24-28 h. Watching the consultation evoked significant psychophysiological and self-reported stress responses. However, investigating the associations between 24 psychophysiological arousal measures, eight self-reported stress measures and free recall and recognition of information resulted in one significant, small (partial) correlation (r = 0.19). Considering multiple testing, this significant result was probably due to chance. Alternative analytical methods yielded identical results, strengthening our conclusion that no evidence was found for relationships between variables of interest. These null-findings are highly relevant, as they may be considered to refute the long-standing, but yet untested assumption that a relationship between stress and memory exists within this context. Moreover, these findings suggest that lowering patients' stress levels during the consultation would probably not be sufficient to raise memory of information to an optimal level. Alternative explanations for these findings are discussed.

Disclosing the Uncertainty Associated with Prognostic Estimates in Breast Cancer.

BACKGROUND: Treatment decision making is often guided by evidence-based probabilities, which may be presented to patients during consultations. These probabilities are intrinsically imperfect and embody 2 types of uncertainties: aleatory uncertainty arising from the unpredictability of future events and epistemic uncertainty arising from limitations in the reliability and accuracy of probability estimates. Risk communication experts have recommended disclosing uncertainty. We examined whether uncertainty was discussed during cancer consultations and whether and how patients perceived uncertainty. METHODS: Consecutive patient consultations with medical oncologists discussing adjuvant treatment in early-stage breast cancer were audiotaped, transcribed, and coded. Patients were interviewed after the consultation to gain insight into their perceptions of uncertainty. RESULTS: In total, 198 patients were included by 27 oncologists. Uncertainty was disclosed in 49% (97/197) of consultations. In those 97 consultations, 23 allusions to epistemic uncertainty were made and 84 allusions to aleatory uncertainty. Overall, the allusions to the precision of the probabilities were somewhat ambiguous. Interviewed patients mainly referred to aleatory uncertainty if not prompted about epistemic uncertainty. Even when specifically asked about epistemic uncertainty, 1 in 4 utterances referred to aleatory uncertainty. When talking about epistemic uncertainty, many patients contradicted themselves. In addition, 1 in 10 patients seemed not to realize that the probabilities communicated during the consultation are imperfect. CONCLUSIONS: Uncertainty is conveyed in only half of patient consultations. When uncertainty is communicated, oncologists mainly refer to aleatory uncertainty. This is also the type of uncertainty that most patients perceive and seem comfortable discussing. Given that it is increasingly common for clinicians to discuss outcome probabilities with their patients, guidance on whether and how to best communicate uncertainty is urgently needed.

Don't forget the dentist: Dental care use and needs of women with breast cancer.

PURPOSE: Patients with breast cancer may develop dental problems due to treatment. We examined the prevalence of their dental care use and needs, compared the prevalence of use with that of the general population, and examined which factors predict patients' dental care use. METHODS: Patients with primary breast cancer completed a questionnaire at 6 and 15 months post-diagnosis. Medical data were retrieved from medical records. The prevalence of dental care use and needs was examined with descriptive analyses. Associations between predictors and dental care use were examined with multivariate analyses. RESULTS: Twenty-one percent of 746 participants visited their dentist at least once in the past three months at 6 months, and 23% at 15 months post-diagnosis. The estimated percentage of women with at least one contact with their dentist in 12 months was low compared to the general female population (31.9% versus 79.5%). One to two percent of the respondents wanted more contact. Having dental care insurance (odds ratio 1.80; 95% CI, 1.08-3.00), chemotherapy (odds ratio 1.93; 95% CI, 1.21-3.06), and clinical distress 6 months post-diagnosis (odds ratio 2.53; 95% CI, 1.70-3.79) predicted use of dental care 9 months later. CONCLUSIONS: Up to 15 months post-diagnosis, breast cancer patients' dental care use is lower than warranted. Oncologists and cancer nurses are recommended to inform patients about dental risks, and to encourage them - particularly those without insurance - to visit their dentist. Occurrence of dental problems should be monitored, especially in patients who receive chemotherapy or who are clinically distressed.

Predictors of enduring clinical distress in women with breast cancer.

To date, little is known about enduring clinical distress as measured with the commonly used distress thermometer. We therefore used the distress thermometer to examine: (a) the prevalence of enduring clinical distress, distress-related problems, and subsequent wish for referral of women with breast cancer, and (b) sociodemographic, clinical, and psychosocial predictors of enduring clinical distress. The study had a multicenter, prospective, observational design. Patients with primary breast cancer completed a questionnaire at 6 and 15 months postdiagnosis. Medical data were retrieved from chart reviews. Enduring clinical distress was defined as heightened distress levels over time. The prevalence of enduring clinical distress, problems, and wish for referral was examined with descriptive analyses. Associations between predictors and enduring clinical distress were examined with multivariate analyses. One hundred sixty-four of 746 patients (22 %) reported having enduring clinical distress at 6 and 15 months postdiagnosis. Of these, 10 % wanted to be referred for care. Fatigue was the most frequently reported problem by patients with and without clinical distress, at both time points. Lack of muscle strength (OR = 1.82, 95 % CI 1.12-2.98), experience of a low level of life satisfaction (OR = 0.77, 95 % CI 0.67-0.89), more frequent cancer worry (OR = 1.40, 95 % CI 1.05-1.89), and neuroticism (OR = 1.09, 95 % CI 1.00-1.18) were predictors of enduring clinical distress. In conclusion, one in five women with breast cancer develops enduring clinical distress. Oncologists, nurse practitioners, and cancer nurses are advised to use single-item questions about distress and distress-related problems to ensure timely detection of high-risk patients. Providers should also routinely assess fatigue and its causes, as fatigue is the most frequently reported distress-related problem over time.

Analogue patients' self-reported engagement and psychophysiological arousal in a video-vignettes design: Patients versus disease-naïve individuals.

OBJECTIVES: The ecological validity of video-vignettes design investigating patient-provider communication hinges on the engagement of analogue patients (APs) with the vignette. The present study aimed to compare engagement in two commonly utilized groups of APs, patients and disease-naïve individuals. Engagement was assessed by self-report and in the form of physiological arousal. METHODS: Cancer patients (N=22) and disease-naïve individuals (N=24) were recruited as APs. APs completed the Video Engagement Scale after watching a vignette of a oncologic bad news consultation. Electrodermal and cardiovascular activity were assessed continuously during watching the vignette, and cortisol levels were assessed in four saliva samples. RESULTS: Patients reported higher engagement with the vignette than disease-naïve individuals (t=2.46, p<0.05) and showed a larger blood pressure response (systolic: F=5.87, p<0.01 and diastolic: F=4.00, p<0.05). However, these differences disappeared after adjusting for age. No group differences were found on other psychophysiological parameters. CONCLUSIONS: Our results suggest that patients and disease-naïve individuals are equally engaged when viewing video vignettes. When group differences were found, older age turned out to be a more prominent predictor of engagement. PRACTICE IMPLICATIONS: Researchers may consider other arguments besides APs' disease history when selecting an AP group.

Design and Feasibility of an Intervention to Support Cancer Genetic Counselees in Informing their At-Risk Relatives.

Cancer genetic counselees receive individualized information regarding heightened risks and medical recommendations which is also relevant for their at-risk relatives. Unfortunately, counselees often insufficiently inform these relatives. We designed an intervention aimed at improving counselees' knowledge regarding which at-risk relatives to inform and what information to disclose, their motivation to disclose, and their self-efficacy. The intervention, offered by telephone by trained psychosocial workers, is based on the principles of Motivational Interviewing. Phase 1 of the intervention covers agenda setting, exploration, and evaluation, and phase 2 includes information provision, enhancing motivation and self-efficacy, and brainstorming for solutions to disseminate information within the family. Fidelity and acceptability of the intervention were assessed using recordings of intervention sessions and by counselee self-report. A total of 144 counselees participated. Psychosocial workers (n = 5) delivered the intervention largely as intended. Counselees highly appreciated the content of the intervention and the psychosocial workers who delivered the intervention. In the sessions, psychosocial workers provided additional and/or corrective information, and brainstorming for solutions was performed in 70 %. These results indicate that this intervention is feasible and warrants testing in clinical practice. For this, a randomized controlled trial is currently in progress to test the intervention's efficacy.

Oncologists' non-verbal behavior and analog patients' recall of information.

Background Information in oncological consultations is often excessive. Those patients who better recall information are more satisfied, less anxious and more adherent. Optimal recall may be enhanced by the oncologist's non-verbal communication. We tested the influence of three non-verbal behaviors, i.e. eye contact, body posture and smiling, on patients' recall of information and perceived friendliness of the oncologist. Moreover, the influence of patient characteristics on recall was examined, both directly or as a moderator of non-verbal communication. Material and methods Non-verbal communication of an oncologist was experimentally varied using video vignettes. In total 194 breast cancer patients/survivors and healthy women participated as 'analog patients', viewing a randomly selected video version while imagining themselves in the role of the patient. Directly after viewing, they evaluated the oncologist. From 24 to 48 hours later, participants' passive recall, i.e. recognition, and free recall of information provided by the oncologist were assessed. Results Participants' recognition was higher if the oncologist maintained more consistent eye contact (ß = 0.17). More eye contact and smiling led to a perception of the oncologist as more friendly. Body posture and smiling did not significantly influence recall. Older age predicted significantly worse recognition (ß = -0.28) and free recall (ß = -0.34) of information. Conclusion Oncologists may be able to facilitate their patients' recall functioning through consistent eye contact. This seems particularly relevant for older patients, whose recall is significantly worse. These findings can be used in training, focused on how to maintain eye contact while managing computer tasks.

Assessing engagement while viewing video vignettes; validation of the Video Engagement Scale (VES).

OBJECTIVES: In health communication research using video vignettes, it is important to assess viewers' engagement. Engagement scores can indicate ecological validity of the design, and help distinguish between different engagement types. Therefore, we aimed to develop and validate a scale assessing viewers' engagement with video vignettes. METHODS: Based on an existing question set, the 15-item, five-dimensional Video Engagement Scale (VES) was developed. The VES was validated in two video-vignettes studies to investigate patient-physician communication. In addition to engagement, we assessed its presumed correlates, e.g., perceived realism of the video and identification with the patient. RESULTS: Internal consistency and test-retest reliability were adequate in both studies (N=181 and N=228). Positive correlations between the VES and perceived realism of the video, credibility of and identification with the patient suggested good content validity. Confirmatory factor analysis suggested a four-dimensional model fit, largely resembling our hypothesized model. CONCLUSIONS: The VES reliably and validly measures viewers' engagement in health communication research using video vignettes. It can be employed to assess ecological validity of this design. Further testing of the scale is needed to more solidly establish its dimensionality. PRACTICE IMPLICATIONS: We recommend that researchers use the VES, to ensure ecological validity of future video-vignettes studies.

All eyes on the patient: the influence of oncologists' nonverbal communication on breast cancer patients' trust.

Trust in the oncologist is crucial for breast cancer patients. It reduces worry, enhances decision making, and stimulates adherence. Optimal nonverbal communication by the oncologist, particularly eye contact, body posture, and smiling, presumably benefits patients' trust. We were the first to experimentally examine (1) how the oncologist's nonverbal behavior influences trust, and (2) individual differences in breast cancer patients' trust. Analogue patients (APs) viewed one out of eight versions of a video vignette displaying a consultation about chemotherapy treatment. All eight versions varied only in the oncologist's amount of eye contact (consistent vs. inconsistent), body posture (forward leaning vs. varying), and smiling (occasional smiling vs. no smiling). Primary outcome was trust in the observed oncologist (Trust in Oncologist Scale). 214 APs participated. Consistent eye contact led to stronger trust (ß = -.13, p = .04). This effect was largely explained by lower educated patients, for whom the effect of consistent eye contact was stronger than for higher educated patients (ß = .18, p = .01). A forward leaning body posture did not influence trust, nor did smiling. However, if the oncologist smiled more, he was perceived as more friendly (rs = .31, p < .001) and caring (rs = .18, p = .01). Older (ß = .17, p = .01) and lower educated APs (ß = -.25, p < .001) were more trusting. Trust was weaker for more avoidantly attached APs (ß = -.16, p = .03). We experimentally demonstrated the importance of maintaining consistent eye contact for breast cancer patients' trust, especially among lower educated patients. These findings need to be translated into training for oncologists in how to optimize their nonverbal communication with breast cancer patients while simultaneously managing increased time pressure and computer use during the consultation.