Introduction
Being diagnosed with a life-threatening but benign neurosurgical condition such as a benign brain tumor is a major life event that brings with it complex and constantly evolving information and support needs. Given the risk of morbidity and/or mortality, not surprisingly the communication between doctors and their patients tends to focus on the immediate future with an emphasis on treatment options and risk. In the current climate of full disclosure, patients are often overwhelmed with statistical information that they are ill equipped to interpret and which may not address their real concerns. When such conversations take place between surgeons and patients who face possible morbidity after surgical intervention, it can be especially challenging to ensure that all the patient’s information needs are met.
There are few studies [
1‐
6] dealing with what patients want to know in the context of informed consent, but none address the information needs of patients undergoing major life-saving surgery. In addition, there has been little in-depth work exploring the totality of patient experience from early signs and symptoms, through treatment, the post-operative period, and longer-term recovery. For patients, the lived experience of diagnosis, treatment, and recovery resonates well beyond the limited encounters they have with their surgeon. In order to map the currently uncharted territory of their information needs, a more detailed and comprehensive understanding of the patient journey is needed.
This study was conducted to explore the information needs of neurosurgical patients with non-malignant but potentially life-threatening conditions, and to provide evidence to support the development of more patient-centered approaches to doctor–patient communication by neurosurgeons.
Methodology
Study design
This was a qualitative research study using in-depth semi-structured interviews with patients who had undergone craniotomy for a non-malignant but life-threatening intracranial lesion. Patients with malignant tumors were excluded as it was felt that their post-operative experience would be dominated by larger issues related to further adjuvant treatment and concerns about survival. Also, these patients have in-depth, regular, and consistent contact with health care providers for years after their surgery.
Setting and participants
Participants were patients recruited from the practices of five neurosurgeons specializing in brain tumors and cerebrovascular disease in a tertiary referral hospital. This is a teaching hospital with Acute Care Nurse Practitioners, residents, and fellows who take part in the patients’ clinical management and also play some role in addressing patients’ information needs. In addition, patients are provided with written pre- and post-operative information booklets addressing common concerns and questions.
The participants were ambulatory adult patients age 18 or older, proficient in English, who underwent surgery between April 2006 and February 2008. Recruitment of participants was led by a dedicated recruiter (SO) who attended the neurosurgical clinic for a 2-month-period. Patients were approached in a non-consecutive manner, attempting to provide a representative blend of patients vis a vis age, gender, specific benign diagnosis, and all five participating surgeons’ practices. Prospective participants were identified and approached by the recruiter who explained the study and provided them with printed information that they could consider at their leisure. The information included a reply slip that they could return to indicate an interest in participating in the study. Those who returned the reply slips were subsequently contacted by an experienced qualitative researcher and interviewer (LR).
Sample size
Twenty-five interviews were sought as it was anticipated that this would be sufficient to achieve data saturation. “Saturation” is a concept in qualitative research describing the situation wherein no new concepts arise during successive interviews, beyond those that have already emerged [
7].
Data collection
Twenty-five semi-structured interviews were conducted over a period of 2 months on patients who fulfilled the inclusion criteria. The semi-structured format following an interview guide (Appendix A) allows for both directed questions from the interviewer and freer exploration of unanticipated issues raised by the participants. All interviews were digitally audio recorded for verbatim transcription. Demographic data including age, sex, ethnicity, occupation, and diagnosis were collected.
Data analysis
Verbatim transcripts of all interviews were prepared by a professional transcriptionist, checked for accuracy against the sound files by the interviewer, and corrected where necessary. Transcripts were entered into HyperResearch software for qualitative data analysis and coded for both anticipated and emergent themes. A coding framework was developed in discussion with the principal investigator. For the analysis, the method of constant comparison was used and included searches for disconfirming evidence to ensure that all perspectives were represented. The process of constant comparison is part of a grounded theory approach to qualitative data analysis. Grounded theory is inductive, allowing analytical categories to emerge from the data “rather than defining them a priori.” Constant comparison is a process by which data are compared with each other to define the integrity of these analytic categories [
7,
8].
Research ethics
Participation was entirely voluntary and informed consent was obtained. All data were kept confidential. Audiotapes and anonymized transcripts were held in a secure location. The study was approved by the Research Ethics Board of the University Health Network.
Discussion
Although qualitative research is unfamiliar to most quantitatively oriented physicians, it is a powerful tool for gaining insight into patient perspectives and answering questions that cannot be answered by quantitative research methodology [
10]. Qualitative findings are not generalizable; rather, they are indicative of a range of common experiences.
It is widely accepted that adequate information before a therapeutic procedure is fundamental to giving informed consent, and there is literature attesting to this [
1‐
5,
11,
12]. However, information needs vary from patient to patient, and for many, the amount and type of information they seek exceeds that required to secure informed consent.
Some postulate that providing information about risks and complications causes undue and unnecessary anxiety, whereas others report that improving patient’s knowledge about treatment reduces anxiety [
11]. Beresford et al. [
13] identified three groups of patients in terms of their information needs: (1) those requiring little or no risk information; (2) those requiring information about major risks; and (3) those requiring full risk disclosure. Because of this heterogeneity, patient preferences should be discussed before risk disclosure. Similarly, Bridson et al. [
14] advocate a more patient-centered method in which the clinician should ask patients their goals for treatment even before treatment options are discussed, in order to tailor the information to fit the context of the patient’s objectives. Fraser [
15] suggests that doctors should neither insist on gaining fully informed consent from anxious patients nor deny detailed information to inquiring ones.
A few studies have been conducted to assess the effect of demographic factors on patient preference, and it was shown that younger individuals with a higher level of education require more information [
6,
12]. In our study subgroup analysis was not possible due to the small numbers in each group.
In terms of the amount of pre-operative information, most of the participants felt that what they received was sufficient to make a decision regarding surgery, but was lacking in other aspects of their illness. Other studies report a wide range in patient satisfaction with the amount of information they received, with the number of satisfied respondents ranging from 48% to 96% [
1,
3,
11]. Rankinen et al. [
6] conclude that the amount of information surgical patients receive is less than they expected.
What do patients want to know? The list includes information about surgical risks [
1‐
5], the nature of the disease and indications for surgery [
3], surgical technique [
2,
3], information about the surgeon [
2], alternative treatment options [
2,
4,
5], outcome, and quality and quantity of life [
5]. Aside from information that would help them decide whether or not they will accept surgery, patients also value information about what to expect post-operatively. Specifically, information about recovery time, future management, and long-term effect on work are highly desired [
2‐
4]. This is consistent with the finding in this study that patients’ information needs are greater post-operatively. This can be explained by an increased demand on the part of the patient and a decreased supply on the part of the surgeon. Pre-operatively, thoughts about the surgery and its possible complications occupy the patient’s mind; it is only after the surgery is over that they allow themselves to think about the recovery period and long term sequelae of their illness. Also, surgeons generally focus on the large task, not the “smaller” issues that are of concern to patients.
There is also an understandable tendency for surgeons to focus on the treatment itself and the events preceding it rather than those following it, resulting in a mismatch in information needs and delivery for patients. This results in significant information deficits around treatment outcomes, expectations of recovery, and the return to health, with some participants feeling that they were simply cut adrift as soon as they were “off the table.” Ironically, patients with more serious diagnoses, like malignancy, are probably less likely to experience what patients with benign tumors do, likely because of the intensity and frequency of monitoring, doctor contact, and ongoing communication in this group of patients.
Inadequate post-operative information has been observed in other settings. Henderson and Phillips [
16] reported that only 55% of patients routinely received discharge information, and the 45% had to ask for information if they wanted it. Information about their illness and recovery helps people cope better, enabling them to comply with the post-treatment constraints and to recognize and act appropriately should there be any complications [
3]. In addition, pre-operative knowledge reduces anxiety, pain, and stress, the need for physiotherapy and occupational therapy, and the length of hospital stay [
6].
Could a long interval between surgery and the interview introduce “recall bias”? Since qualitative interviews are not tests of recall, the concept of recall bias is not relevant. Qualitative research seeks to address questions that cannot be answered by counting or measuring things or, indeed, testing them against objective markers. What people remember and how they remember it provides important and useful information about how they experienced illness and healthcare. While narrative accounts of experience are undoubtedly shaped and re-shaped over time, this is seen as adding depth and insight rather than detracting from the value of the information.
The need for information begins when the illness starts [
12], which does not necessarily correspond to when the patient meets the surgeon. As a result, several patients take it upon themselves to self-advocate and do their own research. Others do the same even after they have spoken with the surgeon. While this behavior is a feature of the information age in which we live, it is also an expression of the vulnerability people feel at having to rely on health care providers for information and the low expectations they have of their information needs being met.
Regarding the use of the internet, some patients access credible resources such as the website of the treating hospital and organizations such as the acoustic neuroma association, while others get their information from less reliable sources such as patients’ blogs and online patient chat rooms. Several participants who found themselves alarmed at information they felt unable to assess adequately stopped themselves from looking any further for this reason.
The findings from this study emphasize the need for improved communication with all patients, so they can effectively participate in their recovery process and move on with their lives. Many of these information needs can be met by the involvement of allied health care providers (e.g. nurses, social workers), and thorough but easy to read written materials. These adjuncts should be optimally used to help busy practitioners better serve their patients. However, neurosurgeons (along with some help from other allied health care personnel) must carry the responsibility to avoid information gaps and optimize communication with their patients.
Acknowledgment
The authors thank Chris Wallace, MD, MSc, FRCSC, FACS and Michael Tymianski, MD, PhD, FRCSC at the Toronto Western Hospital for allowing us to study their patients, and to all the patients for their generosity and grace. We also acknowledge two grants: (1) Canadian Institutes of Health Research, MOP 77670, Therapeutic Hopes and Ethical Concerns: Clinical Research in the Neurosciences; and (2) Canadian Institutes of Health Research, NNF 80045, States of Mind: Emerging Issues in Neuroethics for help supporting this work.