Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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The time of diagnosis is important but so too is the time before and after
- Christine M Habgood (12 April 2004)
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Communication training for doctors
- Debra Nestel (15 April 2004)
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Communication - the needs of all kinds of people should be explored
- Joyce M Carter (15 April 2004)
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Thanks for the lecture about patient needs.
- Lesley J Fallowfield (16 April 2004)
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Re: Thanks for the lecture about patient needs.
- Elizabeth Cockerell (19 April 2004)
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It takes two to make a therapeutic relationship work
- June Jones, Derek Willis, GP and Graduate Entry Moderator, University of Birmingham (20 April 2004)
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Communication - information and choice are vital
- Joanne Rule (21 April 2004)
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Here we go again!
- Rosetta Manaszewicz (22 April 2004)
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Trust and respect require effective communication
- Amanda J Ramirez, Michael Richards, Alison Prescott (23 April 2004)
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What a muddled paper!
- Angela Coulter (27 April 2004)
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what patients want in their doctors
- heather j emmett (27 April 2004)
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clinicians need a varied repetoire of communication skills
- Susan M Wearne (28 April 2004)
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sad misconception
- Amanda C Howe (10 May 2004)
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Overheated correspondence is unhelpful
- Klim McPherson (12 May 2004)
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Essentials of good communication to patients.
- Sukumaran Srikumar, Balasubrahmanyam Nirmal Kumar, Consulatant Otolaryngologist. (17 May 2004)
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A comment of academic principles and qualitative research
- Geraldine M Leydon, Clare Moynihan, Institute of Cancer Research, Sutton, Surrey. (20 May 2004)
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Just as valid without the patient interviews...?
- Ben Riley (20 June 2004)
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Christine M Habgood, General practitioner Mile Oak Clinic, Brighton BN41 2WF
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How doctors communicate with their patients around the time of a cancer diagnosis and whilst treatment is being planned is important and Burkitt Wright and her colleagues findings agree with other studies. For example Leydon et al summarised patients’ requirements of their doctors as “faith, hope and charity”. It is more difficult to study whether patients' previous contacts with the medical profession set the scene for their relationships with doctors when they become unwell. It may be that a previous good experience of a known medical attachment figure, for example the general practitioner, is significant. All GPs will recognise the experience of having a patient coming to check out what they have heard in the surgeon's consulting room before there is any chance of a clinic letter having arrived. It may also be that a patient's needs change over the course of the cancer journey. Study recruitment in surgical and oncology clinics biases towards patients who are living the “recovery plot” but communication which at the time of diagnosis appeared to be optimistic, may at the time of relapse be perceived retrospectively to have been lacking in realism. This study finds that patients require professional expertise, a relationship with the doctor and an ability to demonstrate respectfulness of the patient as an individual. It may be that we need to add other qualities to the list; in the longer term patients may need doctors who are good at truth-telling in sensitive and appropriate ways and in helping patients make sense of their current situation within their own life story. Tailoring communication skills training to these needs may be one part of the solution; good teamwork may be more pragmatic. Leydon GM, Boulton M, Moynihan C, Jones A, Mossman J, Boudioni M, McPherson K. Cancer patients’ information seeking behaviour: in depth interview study. BMJ 2000: 320: 909-3 The A-M, Hak T, Koeter G, van der Wal G. Collusion in doctor-patient communication about imminent death: an ethnographic study. BMJ 2000;321:1376-81 Competing interests: None declared |
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Debra Nestel, Senior Lecturer Centre for Medical & Health Sciences Education, Monash University, Australia, 3800
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Definitions of patient-centred care from patients’ perspectives have been reported in the literature (1,2). Further, there are many patient- centred interviewing models that are largely evidence-based and provide valuable information about communication skills that practitioners can use to deliver high quality patient care (3-7). Although these models often focus on consultations, the notion of building a relationship is also important. Burkitt et al provide evidence of patients’ needs from their relationships with doctors (8). Patients in their study valued doctors who are perceived to be technically expert, form individual relationships with them and show respect while patients did not intrinsically value provision of information and choice. Definitions of patient-centred care and interviewing models already incorporate these values. What the authors argue is that the emphasis of current communication training is misplaced. The benefit of Burkitt et al’s paper is that it again raises the issue of quality and quantity of communication training for doctors. Cegala and Broz identify several difficulties with such training of which the absence of a sound theoretical framework is core (9). Incorporating patient-centred interviewing models into training would provide structure and an evidence base on which clinicians can further develop their skills. The methodology adopted by the researchers demonstrates the value they place on identifying patients’ needs. Further research of this nature is important. However, this study is limited by the patients’ experiences of the doctors whom they have consulted. We know nothing of the communication training that these doctors have undertaken or of the doctors’ perceptions as to whether they believe they are communicating effectively especially in relation to trust, care and respect. The authors also argue that the starting point for training in clinical communication should be “patients’ vulnerability and dependence on doctors.” However, doctors’ self-awareness may be an equally important place to start. References 1.Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, Ferrier K, Payne S. (2001) Preferences of patients for patient-centred approach to consultation in primary care: observational study. BMJ. 322;1- 7. 2. Stewart M. (2001). Towards a global definition of patient-centred care. BMJ. 322;444-5. 3. Cole S, Bird J. (2000).The Medical Interview: The Three-Function Approach. 2nd Edition. Mosby: St Louis. 4. Lazare A, Putnam S, Lipkin M. Three functions of the medical interview, In. Lipkin M, Putnam S, Lazare A. The Medical Interview: Clinical Care, Education and Research. 1995, Springer-Verlag: Ann-Arbour. pp 3-19. 5. Pendleton D, Schofield T, Tate P, Havelock P. (1984). The Consultation: An Approach to Learning and Teaching. Oxford University Press: Oxford. 6. Silverman J, Kurtz S, Draper J. (1998). Skills for Communicating with Patients. Radcliffe Medical Press: Oxford. 7. Lloyd M, Bor R. (2004) Communication Skills for Medicine. Churchill Livingstone: London. 2nd edition. 8. Burkitt Wright E, Holcombe C, Salmon P. Doctors’ communication of trust, care, and respect in breast cancer: qualitative study. BMJ,doi:10.1136/bmj.38046.771308.7C (published 30 March 2004) 9. Cegala DJ, Broz SL. Physician communication skills training: a review of theoretical backgrounds, objectives and skills. Medical Education. 2002;36:1004-1016. Competing interests: None declared |
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Joyce M Carter, Consultant in Public Health Medicine Central Liverpool Primary Care Trust, 24 Pall Mall, Liverpool L3 6AL
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I agree with Smith (1) that it is arguable that the results of the paper from Burkitt Wright et al (2) can be generalised and that patients with breast cancer are likely to be radically different from patients with conditions that are not life threatening (1). Breast cancer is a common cancer (many women will know of someone who has had it and recovered), there is a lot of information available about it through the media, it is a relatively easy to diagnose, and the prognosis is good compared with many other cancers and chronic diseases. The treatment for early breast cancer may be unpleasant but the bulk of it is likely to be over within a year; the patient can then resume normal life. Therefore consultations about breast cancer are likely to be more straightforward than with many other diseases, including other cancers and chronic diseases. So it is easier for a doctor to be positive and honest. But for many chronic diseases the natural history varies considerably and that in itself can make diagnosis and prognosis problematic. The patient can face a lifetime of uncertainty with the prospect of continuing pain and increasing and variable impairments. Doctors are experts in medical or surgical means of managing a disease, but if patients rely solely on doctors, they might not learn of other ways of maintaining their lifestyle (3). In this study patients were excluded if they had acute distress, cognitive impairment, or insufficient English (2), so the opinions of people in those groups are not known. This is another reason why the results cannot be generalised. As communication training is developed I hope that account will be taken of the need for doctors to be able to communicate with everyone, or at least for them to acknowledge that they will need communication support if they do not have the skills to communicate with some people. People with learning disabilities, for example, face inequalities of access to health care. Uptake rates for breast and cervical screening are especially poor for this sector of the population (4)– obviously relevant to Burkitt Wright et al`s paper (2). Excluding marginalised groups from being subjects of research perpetuates their marginalisation (5). Communication research and teaching should be based on “what patients need rather than on what professionals think they need” (2), but we must make sure that the process is fully inclusive. References 1. Smith R. The teaching of communication skills may be misguided. British Medical Journal 2002; 324:1101 2. Burkitt Wright E, Holcombe C, Salmon P, Doctors' communication of trust, care, and respect in breast cancer: qualitative study. British Medical Journal 2004;328:864 (10 April), doi:10.1136/bmj.38046.771308.7C (published 30 March 2004) 3. Carter JM. Removing barriers for disabled people would be giant leap. British Medical Journal 2001; 323:340 4. Department of Health. Valuing people. A new strategy for learning disability for the 21st century. London:The Stationery Office, 2001 (Cm 5086) 5. Carter JM, Ghebrehewet S. Women's attitudes to false positive mammography results. Findings may not apply to the UK. British Medical Journal 2000; 321:1409 Competing interests: I have breast cancer and rheumatoid arthritis |
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Lesley J Fallowfield, Director Cr-UK Psychosocial Oncology Group Brighton & Sussex Medical SchoolTeaching
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Dear Sir, To my knowledge none of the authors of the specious article "Doctors communication of trust, care,and respect in breast cancer:qualitative study" have ever attended one of my own group's communication skills courses; yet that doesn't stop them from making comments such as "They (patients) valued forms of communication that are currently not emphasised in training and research and did not intrinsically value others that are currently thought important, including provision of information and choice". Apart from the breath-takingly absurd suggestion that the qualitative analysis of the views of 39 women with breast cancer should over-turn the copious and painstaking reseach and survey findings gathered by many not just ourselves, the assertions made are factually incorrect. 1) we ALWAYs ensure that patient needs inform the content of our communication skills courses by:- involvement of patient groups including the NCRN consumer liaison group and from empirical research findings 2) any doctor or nurse who has actually participated in one of our courses will confirm that patient-centredness is a core component which involves learning how to tailor information giving, providing choice if wanted, responding appropriately to patient led cues, expressing empathy and respect. 3) Just ask CancerBACUP how many calls they receive each day from distressed patients and relatives who are anxious and distraught by the lack of information they've received. Sure we need trust, care and respect but there is no convincing evidence that I am aware offer suggesting that those things in themselves are enough. I am indignant and affronted that the work done by my own group and that of others whom I respect and admire including Tattersall and Butow in Australia receives such short shrift from Burkitt Wright et al. The efficacy of our most recent training courses (Fallowfield et al Lancet, 2002, BJC, 2003) was demonstated by improving doctors skills in all the key areas that the authors seem to feel that only they have ever thought about. Furthermore more than 3,000 real patients in cancer clinics throught the UK commented in detail about the communication they received in exit interviews and via questionnaire. Thanks for the offer but I think that we'll use that research to "help focus communication research and teaching on what patients need rather than what professionals think they need". Shame on the BMJ and its reviewers for publishing a paper likely to help undo all the work many of us have been engaged with when trying to produce a sensible framework for communication skills teaching. Yours,
Competing interests: My research team have been funded for the past 15 years developing ways to improve communication skills training for healthcare professionals |
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Elizabeth Cockerell, none Suffolk
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Please may I agree with Lesley Fallowfield's comments here about BACUP. The website was initially annoying, because surely all patients should be getting that from their own G.P. or the hospital unit? But then it dawned on me that in over 50 years the NHS hasn't come anywhere near providing the sort of service that BACUP provides. Elizabeth Cockerell.
Competing interests: none |
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June Jones, Lecturer in Biomedical Ethics University of Birmingham, Derek Willis, GP and Graduate Entry Moderator, University of Birmingham
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Salmon et al (1) provide much that is useful for both practitioner and teacher to think and act on with regards to communicating and functioning well as a health care professional. However we would argue that any from of relationship, therapeutic or otherwise, has by necessity to involve more than one person. Therefore the responsibility for this relationship to function cannot solely rest on one person’s shoulders. To look at a doctor’s or health care professional’s responsibility in isolation therefore has the potential to deny that the patient has any responsibility in forming the type of relationship valued by the study patients. We do not claim that the relationship between doctor and patient does not have an inherent power imbalance. The doctor is often more knowledgeable concerning the condition being discussed and is often less intimidated in the surroundings where the relationship is formed. However this still does not mean that the patient should or cannot have a role in this relationship. It would be interesting to perform a follow-up study on the same group of doctors at the breast cancer clinic, comparing doctors attitudes with the patients’ attitudes as to what made a better therapeutic relationship. It maybe that a doctor acts in a particularly useful way in response to a way a patient consults or presents. Salmon et al cite evidence that many patients prefer to be directed about treatment rather than given choice, but this leaves the doctor in a dilemma. Such patients may then bring a complaint or commence legal action against a doctor. Patients may claim that the ‘direction’ they accepted was one they wouldn’t have chosen had they received fuller information about alternatives. By placing the emphasis on a doctor delivering the relationship a patient wants, we are leaving doctors in a vulnerable position. We are not advocating that defensive medicine drives the therapeutic relationship, but to ignore the vulnerabilities of health care professionals does them a disservice. Whilst it is vital to discover what patients want out of consultations, we must also be mindful of doctors needs, and how we can best prepare medical students and qualified doctors to practice in the complex world of healthcare. (1) Wright E.B, Holcombe C, Salmon P, BMJ 2004; 328;864-867 Competing interests: None declared |
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Joanne Rule, Chief Executive CancerBACUP EC2A 3JR
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April 21, 2004 Dear Sir, As an information charity we were particularly interested in the study carried out by Burkitt Wright. (Doctors’ communication of trust, care and respect in breast cancer: qualitative study) CancerBACUP’s helpline receives hundreds of calls a day from distressed patients and relatives in search of more information following a cancer diagnosis or during and after their cancer treatment. Each one is desperate to receive clear, accurate information about their individual case conveyed in a calm, sensitive, skilled manner. While we acknowledge the importance of qualitative research, we have some concerns about the Burkitt Wright study. The stated objective of the study was to determine how a small group of patients with breast cancer wanted their doctors to communicate with them. When this aim was addressed through a structured questionnaire, its findings “concurred with the current emphasis on information, choice and emotional discussion.” This should come as no surprise as this is the result of solid and substantial research showing how highly these three factors are valued by patients. The aim of the study seems to have then shifted from an examination of communication, of which the imparting of information is an integral part, to an analysis of doctors’ characteristics and behaviour, and how doctors communicate trust, care and respect. No one could be surprised by the finding that technical expertise, the ability to form individual relationships and respect for the patient were highly valued. To conclude from this, however, that the provision of information and choice were therefore not valued seems odd, especially when many of the comments made under these three broad headings focus on how well the doctor communicated accurate information. (ie: “She answers questions with no hesitation”; “He lied, or fibbed, or spared your feelings”). Patients clearly linked trust to feeling they had been “given the facts”. The comments patients made about choice are already widely understood and acknowledged. What patients generally regard as choice is clear information, communicated in a sensitive, respectful manner, about the various merits of different treatments, and why their doctor is recommending one over another. To conclude that the study shows that patients “are not well served by some forms of communication that are currently thought important, including information, choice and emotional discussion”, and to suggest that “patients do not generally seek information to be better informed but to maintain hope and trust”, is plain wrong. This study makes some interesting points about a patient’s natural desire for attachment, trust and respect in their relationship with their doctor. It is one thing, however, to focus on how these attributes contribute to good communication but quite another to use these findings to denigrate the provision of information, choice and emotional discussion. To draw such conclusions from this study is misguided. The recently-published NICE Guidance on Supportive and Palliative care for Adults with Cancer gives clear advice on all aspects of cancer care, including face to face communication and information provision and is backed by substantial amounts of research. It is also the result of an extremely wide consultation which included cancer patients. CancerBACUP contributed to and supports this guidance. Information and choice are an intrinsic part of building attachment, trust and respect and they are highly valued in themselves. Extensive research and the experiences of the thousands of people who use our services clearly demonstrate this. Information and choice is what people say they want. Yours sincerely Joanne Rule Chief Executive CancerBACUP Competing interests: None declared |
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Rosetta Manaszewicz, Steering Committee Member, Breast Cancer Action Group (Vic.) PO.BOX 381 Fairfield, Vic. Australia
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Thank God for the articulate, commonsense expertise of people such as Lesley Fallowfield and Joanne Rule. Their reactions to the Burkitt Wright study has gone a long way in restoring my faith in the efficacy of psychosocial research which is fully grounded in the human lives and experiences which the Burkitt Wright paper so inadequately professes to represent. Time and again the issue of honest, timely and relevant information provision is derailed by the ‘red herrings’ integral to the above paper and to previous papers such as the Leydon et. el. ‘expose’. As I’ve written before, can’t we please move beyond the point of arguing whether or not patients really want information? Can’t we accept the proposition that such terms as ‘hope’, for instance, may have a multitude of meanings to each individual which is entirely different to the medical profession’s presumed and simple definition of survival? And as Lesley Fallowfield has written before, why must information provision be predicated on the assumption that a patient’s desire for understanding is tantamount to a desire for ‘shared decision making’? Yes, patients do want information – they want the verbal, the written, the whizz bang multimedia miracles of Flash, and lately, DVD. They want it in both the brief layman’s terms AND possibly even the best ‘scientific’ papers the BMJ has to offer. And they may want this simultaneously - depending on their disease stage, their preferred learning styles, and their current situation. The role of the clinician and the system is to respect this diversity and the individual preferences and values which lie at the core. To therefore perceive the patient’s desire for information simply as the need to ‘maintain hope and trust’ is not only to diminish the ‘delicious fecundity’ of human experience, but to undermine the very principle of ‘patient centred medicine’. Competing interests: None declared |
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Amanda J Ramirez, Director, Cancer Research UK London Psychosocial Group Adamson Centre, St Thomas' Hosptial, Michael Richards, Alison Prescott
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Editor Burkitt Wright et al and Richard Smith have collectively missed the point! Effective communication between doctors and patients is one of the key factors that promotes both trust in doctors and the sense of being treated with dignity and respect by them. These are not simply specious observations; they are based on a recently available analysis of the National Cancer Patient Survey (National Surveys of NHS Patients: Cancer- Analysing Themes), which involved responses from more than 65,000 patients with cancer. Analysis of individual items from the questionnaire indicates that multiple items are significant covariates with 'having trust in doctors' and being 'treated with respect and dignity by doctors, nurses and other hospital staff'. Several of these positive associations are directly relevant to the provision of information and to the quality of communication (see below). The data also shows that both 'trust' and 'dignity' are related to other variables, including privacy, cleanliness and helping to ease patients' pain. Questionnaire Items Information and communication items Not easy to understand doctor's explanation: Trust in doctors, odds ratio – 1.46 Doctor's response not easily understood: Trust in doctors, odds ratio – 1.87, Respect and dignity, odds ratio – 1.16 Doctor's withholding information: Trust in doctors, odds ratio – 1.47, Respect and dignity, odds ratio – 1.29 Staff talk about patient as if patient were not around: Trust in doctors, odds ratio – 1.38, Respect and dignity, odds ratio – 1.63 Doctors/nurses not consistent with providing information: Trust in doctors, odds ratio – 2.44, Respect and dignity, odds ratio – 1.42 Patient not involved with decision about treatment: Trust in doctors, odds ratio – 1.41, Respect and dignity, odds ratio – 1.41 Doctors didn't involve family in decision about treatment: Trust in doctors, odds ratio – 1.21, Respect and dignity, odds ratio – 1.10 Patient not told of possible side effects from treatment: Trust in doctors, odds ratio – 1.16, Respect and dignity, odds ratio – 1.15 Patient not aware of treatment outcome: Trust in doctors, odds ratio – 1.32, Respect and dignity, odds ratio – 1.22 Not the right amount of information given on outcome of treatment: Trust in doctors, odds ratio – 1.13 Other items Not enough privacy during discussion with doctor/nurse: Trust in doctors, odds ratio – 1.52, Respect and dignity, odds ratio – 1.92 Not enough privacy during examination: Trust in doctors, odds ratio – 1.36, Respect and dignity, odds ratio – 1.86 Hospital ward not clean enough: Trust in doctors, odds ratio - 1.44, Respect and dignity, odds ratio – 1.72 Hospital staff didn't do enough to help ease patient's pain/discomfort: Trust in doctors, odds ratio - 1.73, Respect and dignity, odds ratio – 2.78 It is clear from these data that coherent and effective communication and information giving by doctors are central to patients' sense of trust, and feeling that they being treated with dignity and respect, though, of course, they are not the whole story. Amanda Ramirez, Professor of Liaison Psychiatry Cancer Research UK London Psychosocial Group Michael Richards, National Cancer Director Department Of Health Alison Prescott, Health Statistician National Centre for Social Research Competing interests: Amanda Ramirez and Michael Richards are involved in the NHSU Advanced Communication Skills Programme |
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Angela Coulter, Chief Executive, Picker Institute Europe Oxford OX1 1RX
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The discussion section of Wright et al's paper is extraordinarily muddled. The first paragraph appears to suggest that communication style is not of particular concern to patients, but then goes on to emphasise the importance of trust, empathy and autonomy - all of which depend on effective communication. After asserting that their analysis is more sensitive to patients' needs than everyone else's, the authors make several sweeping and paternalistic generalisations about patients, refering the reader to a set of equally paternalistic, and at times positively misleading, communication rules (boxes 1-3). They even imply that fostering blind faith is more desirable than imparting honest information. In the sixth paragraph - the most confusing of all - they say that giving patients "the option" (what option?) is better than giving them choice (what on earth do they mean?) but suggest this has nothing to do with empowerment or shared decision making. They speak approvingly of patient autonomy, but not of determining role preferences, sharing reliable information, discussing more than one option, being open about uncertainties, clarifying values, or any other facets of a mature approach to clinical decision-making. How did this one slip through? Competing interests: None declared |
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heather j emmett, lecturer university of tasmania hobart 7004
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I remember many years ago a General Practitioner friend told me about a study into what patients valued in their doctors. I do not know any details about the study but the findings were very interesting. He said they were the three As that patients wanted in physicians and this was the order the patients valued them in: 1 Availability 2 Affability 3 Ability. This seems to fit with what Wright, Holcombe and Salmon report and could also be applied to any health care professional. Competing interests: None declared |
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Susan M Wearne, GP Educator Centre for Remote Health, Alice Springs, Northern Territory, Australia
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Dear Sir, Well done Burkitt Wright, Holcombe and Salmon for adding to our knowledge about doctor-patient communication (1). The accompanying Editors Choice concludes this study shows that current teaching on communication may be misguided. I disagree. Firstly the paper highlights the importance of professional values. This is a separate but complementary aspect of the curriculum to communication skills teaching. Secondly it is not surprising that patients with a life threatening disorder do not wish to share decision- making. This does not mean that teaching doctors how to share decision making with patients and their families is misguided. My clinical experience is that patients prefer different levels of input to decisions depending on the problem and their current situation. I have had several patients with chronic conditions who have taken the lead role in their care, for example adjusting their dose of rheumatoid medication. However, at times these same self-managing patients have asked me to make the decisions for them, either because the stakes were so high, for example, deciding on surgery for a cervical disc lesion or because of personal situation, recent bereavement. I teach doctors and nurse practitioners that an effective health professional has a wide repertoire of communications skills. The art of professional practice is to assess in each clinical situation, which skill and style is going to be most effective. Even in the same consult it may be appropriate to be both directive and to share decision-making. One style does not suit all: vive la difference in communication skills teaching! Yours sincerely Dr Susan Wearne, GP Educator Centre for Remote Health, Alice Springs Reference: 1 Burkitt Wright E, Holcombe C, Salmon P. Doctors’ communication of trust, care, and respect in breast cancer: qualitative study. BMJ 2004; 328:864- 7 Competing interests: None declared |
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Amanda C Howe, professor of Primary Care University of East Anglia, NR4 7TJ
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Sir Following others I cannot easily distinguish between the behaviours that engender patients to feel individually appropriate trust, respect and empathy and the modern evidence based teaching of these behaviours to health professionals(collectively known as consultation skills teaching), so Burkitt et al. appear to have built their article on rather shifting sands. Methodological biases aside, none of your correspondents appear to have mentioned the patient's reason for being critical in situations where communicative issues may or may not be at stake - sheer sorrow, anger and grief. A case of seeing neither wood nor tree perhaps, and a lesson to all of us in academe. Competing interests: None declared |
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Klim McPherson, Visiting professor of public health epidemiology Nuffield dept of obstetrics and gynaecology, Oxford OX3 7LJ
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These discussions in the journals about patient information become overheated remarkably quickly. Just reading the headings of the responses to Burkitt Wright and colleagues leaves one jaundiced, and to read the contents is much worse. Surely what patients want is appropriate care– which must involve proper respect, information as required and above all high medical competence with proper facilities. Very little is said about what competent doctors know (and indeed don’t know), but they do have the responsibility of knowing as much as is known about how to care for patients with disease. Clearly such responsibility can be exploited and sometimes to the clear detriment of patient health. There are millions of examples. Much of this comes from the US and other health systems where personal profit impinges on the manner and content of consultation – mostly indirectly. Thus the informed decision-making ‘movement’ derives from an over provided system in which much of health care is exploitative, and often contrary to patients better informed wishes. Given unmet priorities here, how much of that sensibly transmits to a highly rationed system,? Good medical practice is about understanding that patients differ markedly, between each other and during the disease course, in what they want and what they want to know. Dogma does not help much, even if based on massive surveys asking largely hypothetical questions. I must say that I found Burkitt Wright’s analysis quite sensible and incidentally not inconsistent with our own findings (Leyden et al – already cited) among cancer patients. Richard Smith’s source of interest is central. How do patients distinguish between ignorance (not knowing what is already known) and uncertainty (not knowing what is not known) in their doctor? Experts naturally find professing uncertainty difficult, for fear of appearing ignorant. To know what one can’t know requires extraordinary knowledge. Responding to interrogation from patients requires data of varying reliability and very quickly any expert assessment (possibly appearing satisfactory) will be misleading – indeed will be largely predicated on the doctor’s preferences. Isn’t this where we started? Will professional advocates do better ? So we need measures for ensuring the most appropriate clinical expertise, which deliberately encourages meaningful respect for patients– and I think we are getting there. Plus, of course, a research agenda properly addressing the main areas of uncertainty; light not heat! Yours truly, Klim McPherson FFPH FMedSci Visiting Professor of Public Health Epidemiology Nuffield Dept of Obstetrics & Gynaecology Oxford University Competing interests: None declared |
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Sukumaran Srikumar, Senior House Officer in ENT Royal Albert Edward Infirmary. Wigan WN1 2NN, Balasubrahmanyam Nirmal Kumar, Consulatant Otolaryngologist.
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Doctors’ communication of trust, care, and respect in breast cancer: qualitative study. EDITOR – This paper from Liverpool has highlighted aspects of communication that are currently not emphasised in training (1). In this study patients valued the enduring relationship with the doctors, their expertise and preferred optional informed decision making for their treatments. Simple ways of communicating respect has also been a major factor. Though this study was performed among breast cancer patients the results could be generalised. We observed similar results in an audit of patient satisfaction after outpatient patient consultation in an ENT department. Patients were asked to fill in anonymised questionnaires at the end of each clinical consultation. These questionnaires have been validated as efficient tools to assess communication skills of clinicians and also aspects of humanistic qualities as stressed in the paper (2). An arbitrary value of more than 80% satisfaction to be achieved was set. There were 70 patients in the first cycle. Consultant ratings were high (>95%) but that of junior doctors fell below the standard. Corrective measures were suggested to individual clinicians after constructive dialogue. In the second cycle 138 new patient rating forms were again analysed. The rating of the junior doctors improved to 90% and the consultant rating remained the same. The consistently high consultant ratings could reflect patients increased trust in them and their expertise. In our audit a simple tool was used to assess not only the communication skills but also included aspects of humanistic qualities of the clinicians. Good communication skills are the cornerstone of medical practice as already known. Aspects of training as suggested in the paper and shown in our audit need to be included in training of doctors to provide high quality care to our patients. Srikumar Sukumaran, Senior House Officer in ENT
1. Emma Burkitt Wright, Christopher Holcombe, Peter Salmon. Doctors’ communication of trust, care, and respect in breast cancer: qualitative study. BMJ 2004;328:864-7(10 April) 2. Webster GD. (1989) Final report of the patient satisfaction questionnaire study. American Board of Internal Medicine. Competing interests: None declared |
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Geraldine M Leydon, Lecturer and MRC Fellow London School of Hygiene and Tropical Medicine, Keppel Street, WC1, Clare Moynihan, Institute of Cancer Research, Sutton, Surrey.
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A comment on academic principles and qualitative research We write as two of the authors of the paper ‘Cancer patients’ information seeking behaviour: in depth interview study’ (2000) with two aims in mind. First, we offer, albeit briefly, some thoughts on Burkitt-Wright et al’s paper. Second, we offer a few thoughts on the rapid responses to their paper. Rather than take each in turn, we merge these issues throughout, as the two are interrelated. We applaud the paper by Burkitt-Wright et al. for demonstrating some important differences among breast cancer patients. In their paper, they coherently begin to unpack the very complexity we too referred to in our paper four years ago. The diverse and shifting ways in which people respond to information and decision making through communication, are not yet fully explicated (nor, we suspect, will they ever be) and the aspects that are well described, are not yet fully understood in terms of their various functions in naturally occurring interaction. The authors cite patient perspectives that resonate with our data. For example, we demonstrated that in one particular context, some cancer patients (of all disease types, not just breast cancer) did not want or require all information, all of the time as some survey research (only) suggests. For some participants, the importance of preserving hope constrained their attempts to seek information, while others sought information in order to retain and build hope. Both papers have shown that the concept of ‘good communicative practice’ in cancer care is ambiguous and continues to require a critical eye. It is surely the job of those in the world of academia (with no less commitment to influencing and improving practice) to problematize that which is often taken-for-granted or seen to be written in stone. Without such effort we risk not deepening our understanding or even missing the point. We are by no means the first to introduce this idea and it is surprising that alternative and (often complementary) modes of investigation are greeted with such ‘force’. Burkitt-Wright et al’s paper highlights the ways in which information, communication and shared decision-making bind together; how difficult they are to unravel, both in the context of being a researcher and, more importantly, a patient. Conceptually, they are mutually exclusive and yet inextricably entwined. It is as simple and as complicated as that! We think that Burkitt-Wright et al. are saying, that however well doctors share information with (or communicate) with patients, ‘options’ that are given to patients do not always equate with choice ‘as it is usually understood’. This is interesting for not only does it demonstrate that we may be ‘missing’ some of the ways in which some patients may wish to handle their cancer care, it also begins to question the knotty concept of ‘choice’. While some of the commentators agree that the paper allows for a wider perspective, others appear to be less convinced and are vitriolic in their responses. Central to some of the comments made seems to be the negation of how a patient-centred medicine must take into account that people may have needs that are surprising, diverse, and often outside of the mainstream way of thinking about cancer. Indeed, it may convincingly be argued that one sign of ‘sound’ research is to find surprises (Silverman). This can only be done by ‘allowing’ patients to speak for themselves. Questionnaires cannot ‘pick up’ these nuances. (Cicourel A. (1964)). ‘Oddness’ or ‘deviant’ and contrasting cases are part and parcel of everyday life and highlights diversity. ‘Plain wrong’ is a misnomer when patients speak about their needs. Denying that such diversity exists, or dismissing patient views as unimportant because they are essentially outliers or sit uncomfortably with the mainstream, is tantamount to or at least suggestive of a less than perfect approach to research. It is neither inconceivable, nor contentious for that matter, that some patients may not seek information to be better informed, but instead to maintain hope and trust. Moreover, if Burkitt-Wright et al’s patient’s utterances hark back to paternalism, perhaps that is what some people want! Mike Michaels (1996) elegantly summarized that ‘ignorance’ might be a deliberate choice. Some might feel that ‘good communication’ or ‘information’ is peripheral at points on their illness trajectory and consequentially they might not frame responses or accounts in this way during an interview; this is worth knowing. It is the case that the paper published verbatim responses. They did not fall from the sky. Why, therefore, we might sensibly ask, are these responses viewed to be so treacherous? ‘Good communication’, information provision / sharing and ‘choice’ is what the majority of people say they want. This is not in doubt. So too, every patient has a right to have all these. But people may define, experience and later reconstruct all of these factors in differing ways. We are beginning to see this through work that uses different methodologies from the mainstream quantitative approach, as valuable as the latter may be. Wilkinson and Kitzinger (2000) using a discursive approach have skilfully shown how the concept of ‘fighting spirit’ might not so simply be a psychological approach to coping with cancer, but also an idiomatic expression with a range of conversational and moral functions . Some (e.g. Ramirez (2004)) have cogently begun to show how there are many ‘other’ factors that lend themselves to effective communication (however defined). The ways in which those ‘other’ factors promote trust in doctors and a sense of being treated with dignity and respect by them is of interest. Burkitt-Wright et al. and Richard Smith do not portray others and their work as ‘missing the point’. Rather, they expand on that work. But they do diverge in that they make a sensible suggestion; that is, trust, a sense of dignity and respect do not always rely on ‘good communication’. We all know this to be the case in our everyday relationships and this need not be questioned. Their study participants speak of something that transcends the hitherto, ‘right’ way to communicate. It is a way of being a doctor that is mercurial and cannot be easily defined or measured, and certainly not by surveys in isolation or at all. Communication is personal, idiosyncratic and, importantly, a two-way phenomenon. Patients communicate too; they bring knowledge of their own to a medical meeting and influence how the trajectory of any one encounter comes to be played out, sequentially speaking. Burkitt-Wright et al. simply provide one insight into how that two-way process might come to be conceived of and reported by some patients. This does not negate the validity or sense of other work that is being done in the field of communication studies. Rather, it has the potential to augment it. It should be plain that when research demonstrates divergence from the mainstream, the first point of call is not to dismiss it as unreliable, invalid and essentially ‘made up’. The work should be interrogated for its sense, reasons for difference explored and, perhaps even discussed, collaboratively, to establish whether and how the pieces of the jigsaw puzzle fit together. Difference is not to be feared, but should excite ones intellectual interest and provide grounds for systematic questioning of current concepts or how current practices and theories might be reassessed in the light of new proposals. It is of huge concern that some of the rapid respondents have reacted to the Burkitt Wright et al. paper in such a way. Such ire is reminiscent of the ways in which some of the very same voices reacted to our ‘Faith, Hope and Charity’ paper. Is it not possible to accept a different way of looking at the cancer world? As an aside many patients and academics with a cancer experience) continue to react extremely positively to our paper and in the fullness of time Burkitt-Wright et al. might receive the same accolade, if indeed they have not already (not what research is about, but reassuring and important in the face of such harsh criticism). Ours appeared at a time when information seemed to be construed as a panacea. We wanted to flag that those who chose (we emphasize choice here) not to seek further information can be exercising a choice as rational agents in their own cancer care, choosing one way over another and not ‘besieged by misunderstanding’ (see Mike Michaels 1996). The Burkitt-Wright paper uses an entirely appropriate methodology, well deployed, in a particular context and has been peer reviewed (not by either of us). While it would have been illuminating to combine patient reports with a detailed analysis of the actual communication process, which is an approach the authors have employed elsewhere (and well), the rapid responses belie the interest value of a paper such as theirs. Disagreements and conflict are permitted and it is this that signals a healthy expansion, testing and reformulation of intricate problems. However, disagreement and criticism must be based on rational grounds and the proposals that agitate be properly refuted, based on thoughtful questioning of the methodological approach. As it stands, the responses go against sound academic principles and give anybody working in this field a very bad name indeed. Cicourel A (1964) Fixed choice questionnaires. In Method and Measurement in Sociology. Pp105-120. Free Press, New York. Silverman D. (1999) Doing Qualitative Research A Practical Handbook. London: Sage. Wilkinson S and Kitzinger C. (2000) Thinking differently about thinking positive: a discursive approach to cancer patients’ talk. Social Science and Medicine 50: 797-811 Michael M. Knowing ignorance and ignoring knowledge: discourses of ignorance in the public understanding of science. In: Irwin A, Wynne B (eds). Misunderstanding Science? The Public Reconstruction of Science and Technology. Cambridge University Press, 1996. 107-126. Leydon G.M., Boulton M., Moynihan C., Jones A., Mossman J., Boudioni M., McPherson K. Cancer patients’ information seeking behaviour: in depth interview study (BMJ, 2000:320:909-3) . Competing interests: None declared |
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Ben Riley, GP Registrar (Aylesbury VTS) Poplar Grove Practice, Aylesbury, HP20 1XB
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The paper by Burkitt, Wright et al.(1) is remarkable in both its outspoken conclusions and dodgy methodology, and as a result is well worth studying in a Journal Club. It demonstrates some of the difficulties in qualitative research, not least the effects of selection, observer and recall bias, that have lead the Authors to reach conclusions that are not justified by their data.(2) Although the Abstract states that “women with breast cancer seek to regard their doctors as attachment figures who will care for them”, the Authors do not appear to consider the effect that this relationship might have on their data. The interviews were all performed post-operatively, many within 16 days of potentially life-saving surgery; a time when most patients might be expected to hold their doctor in particularly high regard. They observed how their patients often dismissed examples of poor communication skills, and generalise from this that patients do not perceive such communication skills to be important. This is not a valid generalisation. It is equally possible that patients rationalise or dismiss their doctor’s poor communication skills at times they are feeling both vulnerable and grateful, in order to preserve a positive view of their doctor. After recent breast cancer surgery patients may feel positively towards their doctor for a variety of reasons. Some may feel (rightly or wrongly) that they owe them their life, and as a result could be less likely to perceive their doctor’s communication behaviour negatively. It would be wrong to assume that the same applies to a patient's perception of a first consultation when the doctor is a stranger. The most curious conclusion made by the Authors is that patients value “being given the option” but not “provision of information and choice”. How this conclusion is reached is not clear from the data or discussion, but rather appears to have been based on the Authors’ beliefs about communication skills training, although the experience of training received by the doctors involved in the study is not described. In dismissing the work of Fallowfield(3) and others that supports shared-decision making, and criticising the current emphasis on patient empowerment, the Authors claim a new understanding of how patient autonomy might best be respected. In concluding that “patients identified a role for surgeons that equated neither to direction nor choice, but meant respecting patients’ autonomy,” the Authors appear to have discovered the ‘third way’ in doctor-patient communication - not a bad result for a study of just 39 patients! 1 Wright E.B, Holcombe C, Salmon P, BMJ 2004; 328;864-867. 2 See Rapid Responses to Wright E.B, Holcombe C, Salmon P, BMJ 2004; 328;864-867. 3 Fallowfield L, Jenkins V. Effective communication skills are the key to good cancer care. Eur J Cancer 1999;35: 1592-7. Competing interests: None declared |
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