Patients’ reflections on communication in the second-opinion hematology–oncology consultation

Abstract

Objective

The nature of communication between patients and their second-opinion hematology consultants may be very different in these one-time consultations than for those that are within long-term relationships. This study explored patients’ perceptions of their second-opinion hematology–oncology consultation to investigate physician–patient communication in malignant disease at a critical juncture in cancer patients’ care and decision-making.

Methods

In-depth telephone interviews with a subset of 20 patients from a larger study, following their subspecialty hematology consultations.

Results

Most patients wanted to contribute to the consultation agenda, but were unable to do so. Patients sought expert and honest advice delivered with empathy, though most did not expect the consultant to directly address their emotions. They wanted the physician to apply his/her knowledge to the specifics of their individual cases, and were disappointed and distrustful when physicians cited only general prognostic statistics. In contrast, physicians’ consideration of the unique elements of patients’ cases, and demonstrations of empathy and respect made patients’ feel positively about the encounter, regardless of the prognosis.

Conclusions

Patients provided concrete recommendations for physician and patient behaviors to enhance the consultation.

Practice implications

Consideration of these recommendations may result in more effective communication and increased patient satisfaction with medical visits.

Introduction

Hematologic malignancies account for 9% of new cancer diagnoses annually in the United States [1]. The percentage of patients who seek hematology consultations for second opinions is unknown, but such encounters are common at tertiary care institutions. The quantity and content of what patients seek from their consultations change over time, even within the first few visits [2], [3], [4], and communication may be very different for one-time consultations than for long-term patient–oncologist relationships [5]. When patients’ desired levels of information have been met during a consultation, they are more satisfied and less distressed [6]. Gauging how much, and, possibly more importantly, what kind of information a patient is seeking during the visit is essential, though challenging to physicians who must consider multiple factors in their assessments, including patients’ verbal and nonverbal behaviors, and demographic, contextual, and medical factors [7], [8], [9], [10]. Asking patients to contribute to the visit agenda is a logical place to start [11], [12], though cancer consultation visits have been found to be predominantly physician-dominated [3], [7]. Physicians have been found to have difficulty accurately assessing patients’ anxiety [13], [14], [15], and oncologists may be more reluctant to respond to patients’ emotional cues than patients’ information requests [16], [17].

Patient-centeredness is essential to quality cancer care, and employing communication styles that actively engage patients in their care is an increasingly recognized core clinical skill [12]. A study in primary care settings emphasized that individual patient characteristics contribute greatly to patients’ expectations for the visit and their assessment of patient-centeredness [19]. And studies of chronic disease care have shown that when parents’ worries about their children's asthma are relieved and their concerns attended to, parents are more likely to feel that physicians listened to them and were interactive during the encounter [20], [21]. In contract to primary or chronic care, however, second-opinion hematology consultation visits may be the only time the cancer patient and the consulting physician meet, despite the profound nature of the discussions. Accurately assessing patient characteristics or providing relief from worries may present increased challenges. This creates a complex medical encounter where the physicians’ need to convey expertise and provide information may eclipse patient-centered communication and the specific pressing needs of patients and their support people, though this may remain unacknowledged in the encounter [12], [22]. The second-opinion consultation therefore offers the opportunity to study physician–patient communication in malignant disease at a critical juncture in cancer patients’ care and decision-making.

As part of a larger observational study of physician–patient communication in hematology consultations, a medical anthropologist (REG) conducted in-depth, qualitative interviews with a subset of the patients seeing hematology consultants. This paper reports the results of those interviews to elucidate the patient experience of communication involved in the second-opinion hematology consultation.