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Factors that influence physicians' detection of distress in patients with cancer†
Can a communication skills training program improve physicians' detection?
Article first published online: 10 JUN 2005
Copyright © 2005 American Cancer Society
Volume 104, Issue 2, pages 411–421, 15 July 2005
How to Cite
Merckaert, I., Libert, Y., Delvaux, N., Marchal, S., Boniver, J., Etienne, A.-M., Klastersky, J., Reynaert, C., Scalliet, P., Slachmuylder, J.-L. and Razavi, D. (2005), Factors that influence physicians' detection of distress in patients with cancer. Cancer, 104: 411–421. doi: 10.1002/cncr.21172
Contributors: Darius Razavi, Nicole Delvaux, and Christine Reynaert conceived this study, wrote the protocol, obtained funding, and supervised data collection and analysis. Darius Razavi, Nicole Delvaux, and Serge Marchal conducted the training courses. Serge Marchal supervised data collection. Jacques Boniver, Jean Klastersky, and Pierre Scalliet participated to the writing of the protocol and obtained funding. Anne-Marie Etienne supervised data collection. Isabelle Merckaert contributed to data collection and to the rating of the interviews, participated in the data analysis, and wrote the first drafts of the report. Yves Libert contributed to data collection, coordinated day-to-day management of the project, participated in preparation of data analysis, and contributed to the writing of the first drafts of the report. Jean-Louis Slachmuylder designed the data base and contributed to data collection and final analysis. All investigators contributed to the writing of the final report.
- Issue published online: 29 JUN 2005
- Article first published online: 10 JUN 2005
- Manuscript Accepted: 8 MAR 2005
- Manuscript Revised: 18 JAN 2005
- Manuscript Received: 8 NOV 2004
- “Fonds National de la Recherche Scientifique-Section Télévie” of Belgium
- “Fonds d'Encouragement à la Recherche de l'Université Libre de Bruxelles” (Brussels, Belgium)
- C.A.M. Training and Research Group (Brussels, Belgium)
- communication skills;
No study to date has assessed the impact of skills acquisition after a communication skills training program on physicians' ability to detect distress in patients with cancer.
First, the authors used a randomized design to assess the impact, on physicians' ability to detect patients' distress, of a 1-hour theoretical information course followed by 2 communication skills training programs: a 2.5-day basic training program and the same training program consolidated by 6 3-hour consolidation workshops. Then, theinvestigate contextual, patient, and communication variables or factors associated with physicians' detection of patients' distress were investigated. After they attended the basic communication skills training program, physicians were assigned randomly to consolidation workshops or to a waiting list. Interviews with a cancer patient were recorded before training, after consolidation workshops for the group that attended consolidation workshops, and ≈ 5 months after basic training for the group that attended basic training without the consolidation workshops. Patient distress was recorded with the Hospital Anxiety and Depression Scale before the interviews. Physicians rated their patients' distress on a visual analog scale after the interviews. Physicians' ability to detect patients' distress was measured through computing differences between physicians' ratings of patients' distress and patients' self-reported distress. Communication skills were analyzed according to the Cancer Research Campaign Workshop Evaluation Manual.
Fifty-eight physicians were evaluable. Repeated-measures analysis of variance showed no statistically significant changes over time and between groups in physicians' ability to assess patient distress. Mixed-effects modeling showed that physicians' detection of patients' distress was associated negatively with patients' educational level (P = 0.042) and with patients' self-reported distress (P < 0.000). Mixed-effects modeling also showed that physicians' detection of patient distress was associated positively with physicians breaking bad news (P = 0.022) and using assessment skills (P = 0.015) and supportive skills (P = 0.045).
Contrary to what was expected, no change was observed in physicians' ability to detect distress in patients with cancer after a communication skills training programs, regardless of whether physicians attended the basic training program or the basic training program followed by the consolidation workshops. The results indicated a need for further improvements in physicians' detection skills through specific training modules, including theoretical information about factors that interfere with physicians' detection and through role-playing exercises that focus on assessment and supportive skills that facilitate detection. Cancer 2005. © 2005 American Cancer Society.
Between 10% and 50% of patients with malignancies experience high levels of distress.1–3 Emotional distress is a normal response to cancer diagnosis, treatment, and prognosis that needs to be recognized and treated when it becomes an impairment. Untreated, distress can have long-term, detrimental consequences on a patient's compliance with treatment,4, 5 chance of survival,6 desire for hastened death,7 and quality of life for both patients and their relatives.8, 9 It is thus important to detect distress as early as possible in the course of the disease and to refer patients for appropriate interventions. Physicians have an important role to play in this regard. Unfortunately, several studies have shown that oncologists often fail to recognize distress in their patients and tend to underestimate the level of distress that they experience.10–14 Underestimation of distress has been reported as more frequent in older patients,15 in patients with lower socioeconomic status,11 in patients who are diagnosed with head and neck carcinoma or with lung carcinoma,11 and in patients with higher performance status scores.14
This may be explained by the fact that physicians lack knowledge about symptoms of distress or rely on superficial signs to assess patients' distress. Moreover, patients sometimes are reluctant to disclose their psychological concerns spontaneously, and they leave the initiative of discussing these topics to their physician.16 It has been reported that distress in older patients is more difficult to detect, because elderly patients tend to show less overt symptoms of distress and often are more reluctant to talk explicitly about problems with emotional functioning.17
Therefore, physicians need to be able to investigate those concerns explicitly by eliciting patients' disclosure and by clarifying expressed concerns. In a study of primary care involving standardized patients, the investigators reported that, in fact, physicians who recognized depression in their patients asked twice as many questions about feelings and affects compared with physicians who did not recognize depression.17, 18 In another study of general practitioners in primary care, moreover, it was found that physicians who failed to recognize their patients' distress somehow inhibited their patients' expression of verbal and vocal cues of distress.15 Assessment skills, thus, are important for detecting patients' distress. Unfortunately, due to fears that they will not be able to handle patients' distress adequately or that they will have a detrimental effect on their patients, physicians often are as reluctant to discuss emotional functioning as patients.19
A recent study showed the interest of providing physicians with theoretical information about distress to improve their identification of cues of distress. In that study, it was found that oncologists, after a brief, 1-hour didactic training on depressive disorders in cancer patients, were able to identify depressive symptoms better in cancer patients on videotaped interviews.20 In that study, physicians were not trained on how to elicit patients' concerns or on how to assess emotional functioning. A randomized, controlled study in primary care found that a training program for physicians that coupled 1.5 hours of theoretical information about psychosocial problems with a communication skills training course increased the number of patients who were identified accurately as showing signs of distress.21 This emphasizes the usefulness of communication skills training programs for improving physicians' detection of patients' distress. An increased body of evidence in cancer care shows that communication skills of physicians can be improved after well designed, skill-focused, practice-oriented, and learnercentered communication skills training programs.22–24 However, to date, no study of cancer care has assessed the impact of skills acquisition after a communication skills training program on physicians' detection of cancer patients' distress.
The results from the studies described above showed that, to improve their detection of patients' distress, physicians need to be able to use assessment skills. Due to a fear that they will not be able to handle patient distress adequately, physicians also probably need to use supportive skills to respond adequately to a patient's distress once it has been expressed. The use of both assessment skills and supportive skills may help physicians to detect and handle patient distress. These skills may be acquired through communication skills training programs.
Therefore, in the current study, our objective was to assess, in a randomized design, the impact, on physicians' ability to detect patients' distress, of a 1-hour theoretical information course followed by two communication skills training programs: a 2.5-day basic training program and the same training program consolidated by 6 3-hour consolidation workshops. The second objective of this study was to investigate contextual, patient, and communication variables or factors associated positively or negatively with physicians' detection of patients' distress. Previously reported results of this study23 showed that, after both training programs, physicians used more assessment skills (elicited and clarified patients' concerns more often). Moreover, the results showed that physicians who had attended consolidation workshops after the basic training program used more supportive skills (that is, used more empathy and more educated guesses). Figure 1 shows the relation between the phase of training and relevant development of knowledge and skills. The basic training program was designed to increase physicians' knowledge about symptoms and prevalence of distress in cancer care and to initiate improvements in physicians' assessment skills. The consolidation workshops were designed to improve physicians' supportive skills, which are needed to handle patients' distress and to pursue the assessment of perceived cues of distress to allow detection of distress. Thus, we hypothesized that consolidation workshops would be required to reach the level of improvement in physicians' assessment and supportive skills needed to improve the detection of distress.
MATERIALS AND METHODS
To be included in the study, physicians had to be specialists and to be working with cancer patients (part time or full time). First, all Belgian French-speaking physicians were invited by mail to take part in the study, and all institutions that specialized in cancer care were asked to deliver an internal letter of invitation. Second, heads of medical units who were working in cancer care were informed about the study (by mail or by telephone). They were invited to take part and were asked to allow us to contact specialist physicians who were working in their units to invite them to take part in the study. Consequently, individual and group information sessions were organized.
Study Design and Assessment Procedure
The efficacy of the consolidation workshops was assessed in a study that assigned physicians randomly, after a basic training program, either to attend the consolidation workshops or to a waiting list (Fig 2). The study was approved by the local ethics committee. The basic training program was spread over 1 month. The consolidation workshops started 2 months later for participants who were assigned immediately to the workshops. The bimonthly workshops were spread over 3 months. Physicians who were assigned to the waiting list were invited to take part in the consolidation workshops 6 months after the end of the basic training program.
Assessments were scheduled before basic training program (T1), just after this program, and either after consolidation workshops (for the consolidation-workshop group) or approximately 5 months after the end of basic training (for the basic-training-without-consolidation-workshops group) (T2). The assessment procedure included, at each assessment time, two simulated interviews and two interviews with a cancer patient (one with and one without the presence of a relative), and a set of questionnaires. In this article, we report the results concerning interviews with cancer patients at T1 and T2. Results regarding the impact of consolidation workshop attendance on the use of communication skills by physicians have been published elsewhere.23
Basic Training Program
The 19-hour basic training program consisted of 2 8-hour day sessions and 1 3-hour evening session. The program included a 2-hour plenary session focusing on theoretical information in the form of 2 lectures and 17 hours of small group role-playing sessions. The first lecture covered the aims, functions, and specificity of physician-patient communication in cancer care. The second lecture focused on how to handle distress in cancer patients. In addition, two handbooks that discussed these topics were offered to each participant.25, 26 Physicians were then split into small training groups (limited to six participants) to practice the communication tasks discussed in the lectures through predefined role plays, and immediate feedback was offered by experienced facilitators. The next sessions focused on role plays based on the clinical problems that were brought up by the participants. The role plays also led to case discussions. The topics discussed were breaking bad news, coping with patients' uncertainties and distress, and detecting psychopathologic reactions to diagnosis and prognosis. Sessions also focused on how to interact when patients' relatives are present. The basic training program ended with a plenary session at which participants were invited to give feedback on the training.
Each of the 6 consolidation workshops consisted of a 3-hour evening training workshop (limited to 6 participants). Each workshop was led by an experienced facilitator and was based on role plays, with systematic feedback based on the clinical problems brought up by the participants. Workshops were spread over 3 months to allow physicians to practice the communication skills they learned during the basic training program. These workshops also were aimed at evaluating the difficulties of transferring newly acquired skills to the workplace and at stimulating the use of those skills.
Interviews with Patients
An interview with a cancer patient was audiotaped at each assessment time. Patients were chosen by physicians. Inclusion criteria for patients included breaking news (bad, neutral, or good), age > 18 years, ability to speak French, absence of cognitive dysfunction, and written informed consent. Patients were different at the T1 and T2 assessment times.
Interview Rating System
All audiotapes were transcribed, and the transcripts were assessed for their quality and then rated by trained psychologists. Rating was based on the French translation and adaptation of the Cancer Research Campaign Workshop Evaluation Manual.27 Raters were blind to the training condition of participants and to assessment time. The Cancer Research Campaign Workshop Evaluation Manual was used to assess the function and emotional level of each utterance.
Interviews were rated by 14 intensively trained psychologists. Training included reading the manual, doing rating exercises, and supervision by the rater coordinator. Before beginning to rate, raters had to reach at least the following concordance rate with a validating test: 67% for the functions and 71% for the emotional level. Moreover, to ensure a quality control and to avoid rating conflicts, raters were supervised systematically by the rater coordinator on a week-to-week basis to check the accuracy of their ratings. Finally, all ratings were checked throughout the process for inconsistencies by means of a computer program.
Before the interviews, each patient completed a sociodemographic questionnaire, the Hospital Anxiety and Depression Scale (HADS),28, 29 and the Ways of Coping Checklist.30, 31 Each physician completed a sociodemographic and socioprofessional questionnaire. After the interviews, each physician assessed his or her patient's distress on a visual analogue scale (VAS). Physicians also had to report cancer-related information about patients and information about context characteristics.
Patients' sociodemographic questionnaire
Each patient provided demographic information, including age, gender, marital and family status, occupational status, and educational level.
The HADS28 is a 4-point, 14-item, self-report instrument that assesses anxiety and depression in physically ill respondents. This scale was translated into French and was validated in a sample of inpatients with cancer.29 The use of the HADS total score is recommended to assess psychological distress.29
Physicians' ratings of patients' distress
Physicians rated their patient's distress on a 10-point VAS immediately after the interview. Ratings ranged from 0 (extremely distressed) to 10 (not at all distressed). Scores were inverted to enhance readability. A VAS was used, because other authors have used similar scales in previous studies to assess physicians' ability to detect patients' distress.10, 13 Moreover, it has been shown that the VAS is a valid tool for measuring a patient's level of distress.32–35
Physician's sociodemographic and socioprofessional data
Data were collected about physician's age, gender, marital status, medical specialty, number of years of practice in medicine and in oncology, number of cancer patients seen in the week before the assessment procedure, their type of medical practice, and whether or not they had had some previous communication skills training in the last year.
Statistical analyses of the data consisted of a comparative analysis of both groups of physicians at baseline using parametric and nonparametric tests, as appropriate (t tests and chi-square tests). Patients' characteristics at baseline and after the intervention were compared using repeated-measures analyses of variance (MANOVAs) and chi-square tests, as appropriate. Correlation coefficients were computed first between patients' HADS scores and physicians' ratings of patients' distress (VAS) and the use of assessment and supportive skills for each group of physicians at baseline and after the interventions. Moreover, to assess the impact of the two communication skills training programs on physicians' detection of patients' distress, a new variable was computed to measure physicians' ability to detect patients' distress. Patients' HADS scores and physicians' VAS ratings were brought up to a maximal score of 100. Then, the modified HADS scores were subtracted from the modified VAS ratings. Next, time and group-by-time changes in this new variable, which we called physicians' detection of patients' distress, were processed using MANOVAs. All tests were 2-tailed, and the α was set at 0.05.
Mixed-effects modeling was employed to investigate factors associated with physicians' detection of patients' distress. An exploratory analysis was used to identify important covariates. Variables that were tested on the univariate level (using Pearson correlations and t tests, as appropriate) included physician's age, gender, group allocation, assessment time, and use of assessment and supportive skills and patient's gender, educational level, self-reported distress, prognosis, months since diagnosis; type of news given, and type of physician-patient relationship. Factors were entered in the multivariate model only if they satisfied the inclusion criterion (i.e., P > 0.05). Group (P = 0.38) and time (P = 0.94), although they were not significant at the univariate level, were retained in the model. A linear mixed-effects model with fixed effects was used. The analyses were performed with SPSS software (version 11.0 for MAC OS X; SPSS Inc., Chicago, IL).
Role of the Funding Source
The study sponsor had no role in study design, data collection, data analysis, or data interpretation or in the writing of this report.
Physician and Patient Sociodemographic Data
All Belgian French-speaking specialists physicians were invited by mail to take part in the training program (n = 3706 physicians), and all institutions that specialized in cancer care were asked to diffuse an internal letter of invitation (n = 2741 invitations). Figure 2 shows that, due to the low response rate to the recruitment procedure (only 90 potentially interested physicians responded to the mailing), 214 physicians, including the 90 potentially interested physicians, were contacted actively by telephone, and 163 of them were met individually. Twenty-one information sessions also were organized in institutions that specialized in cancer care. In total, 173 physicians were met during those sessions. After this process, 113 physicians registered to the training program, and 72 attended the first training day. Barriers to participation were personal and institutional reasons, time limitations, training duration, and time-consuming assessment procedures. Four physicians who attended < 15 hours of basic training (including 1 physician who dropped out) and 6 physicians who took part in < 4 workshops were not considered assessable. Sixty-two physicians completed the program. Three physicians were not able to accrue a patient for the interview with a cancer patient. One audiotape recording was lost because of a technical failure. Therefore, 58 physicians who completed the interviews with a cancer patient were assessable. Comparison of included and excluded physicians showed no statistically significant differences with regard to age, gender, or the number of years in practice. With regard to physicians' demographic and socioprofessional characteristics, no statistically significant differences were found at baseline between physicians who participated in the consolidation workshops and physicians who were assigned to the waiting list (Table 1).
|Characteristic||No. of patients (%)|
|Basic training without CW (n = 30)||Basic training with CW (n = 28)|
|At baseline||Five mos after basic training||At baseline||Five mos after basic training|
|Patient sociodemographic characteristics|
|Mean ± SD age (yrs)||56.3 ± 11.2||59.8 ± 14.0||56.6 ± 15.8||61.5 ± 15.4|
|Male||10 (33.3)||10 (33.3)||10 (35.7)||9 (32.1)|
|Female||20 (66.7)||20 (66.7)||18 (64.3)||19 (67.9)|
|Single, separated, divorced, or widowed||11 (36.7)||13 (43.3)||16 (57.1)||16 (57.1)|
|Married or living with partner||19 (63.3)||17 (56.7)||12 (42.9)||12 (42.9)|
|Yes||26 (86.7)||20 (66.7)||22 (78.6)||19 (67.9)|
|No||24 (13.3)||10 (33.3)||6 (21.4)||9 (32.1)|
|Working part or full time||9 (30.0)||9 (30.0)||7 (25.0)||6 (21.4)|
|Invalid, incapacitated, unemployed, homemaker, or retired||21 (70.0)||21 (70.0)||21 (75.0)||22 (78.6)|
|≤ High school graduation||18 (60.0)||15 (50.0)||16 (57.1)||15 (53.6)|
|College or university graduation||12 (40.0)||15 (50.0)||12 (42.9)||13 (46.4)|
|≥ 80||25 (83.3)||29 (96.7)||21 (75.0)||26 (92.9)|
|< 80||5 (16.7)||1 (3.3)||7 (25.0)||2 (7.1)|
|Type of diseaseb|
|Solid tumor||27 (90.0)||24 (80.0)||21 (75.0)||22 (78.6)|
|Hematologic malignancy||3 (10.0)||6 (20.0)||7 (25.0)||6 (21.4)|
|In remission, no change, or too early to assess||22 (73.3)||25 (83.3)||19 (67.9)||22 (78.6)|
|In progression||8 (26.7)||5 (16.7)||9 (32.1)||6 (21.4)|
|< 1 yr||7 (23.3)||3 (10.0)||8 (28.6)||7 (25.0)|
|≥ 1 yr||23 (76.7)||27 (90.0)||20 (71.4)||21 (75.0)|
|Previous cancer treatment|
|Yes||23 (76.7)||21 (70.0)||23 (82.1)||19 (67.9)|
|No||7 (23.3)||9 (30.0)||5 (17.9)||9 (32.1)|
|Current cancer treatment|
|Yes||15 (50.0)||13 (43.3)||19 (67.9)||19 (67.9)|
|No||15 (50.0)||17 (56.7)||9 (32.1)||9 (32.1)|
|Mean ± SD mos since diagnosis||31.5 ± 36.2||32.2 ± 42.0||31.3 ± 40.2||27.7 ± 30.7|
|Type of news|
|Bad||10 (33.3)||5 (16.7)||11 (39.3)||7 (25.0)|
|Neutral and/or poor||19 (66.7)||25 (80.3)||17 (60.1)||21 (75.0)|
|Type of physician-patient relationshipb|
|First encounter||4 (13.3)||3 (10.0)||3 (10.7)||3 (10.7)|
|Seen previously||26 (86.7)||27 (90.0)||25 (89.3)||25 (89.3)|
Physicians in the consolidation-workshops group were a mean ± standard deviation (SD) age of 41.0 years ± 6.1 years, 46% were female, and 11% lived alone. They had a mean ± SD of 16.0 years ± 6.0 years of medical practice and 13.0 years ± 6.1 years of practice in oncology. Thirty-nine percent of the physicians worked in oncology and radiotherapy. Ten percent of the physicians worked with outpatients only. The mean ± SD number of cancer patients seen during the week before the assessment procedure was 29 ± 25 patients. None of the physicians had attended communication skills training workshops in the last year. Physicians in the basic-training-without-consolidation-workshops group were a mean ± SD age of 44.0 years ± 8.0 years, 43% were female, and 18% lived alone. They had a mean ± SD of 18.0 years ± 7.6 years of medical practice and 15.5 years ± 8.2 years of practice in oncology. Forty-seven percent of the physicians worked in oncology and radiotherapy. Thirteen percent of the physicians worked with outpatients only. The mean ± SD number of cancer patients seen during the week before the assessment procedure was 27 ± 19 patients. Seven percent of the physicians had attended a communication skills training program in the last year. Table 1 shows that no statistically significant differences were found in patients, disease, and interview characteristics over time or between the consolidation-workshop group and the basic-training-without-consolidation-workshops group when comparison was possible.
The Influence of Attendance at the Basic Training Program and to the Consolidation Workshops on Intercorrelations between Physicians' VAS Ratings, Patients' HADS Scores, and Physicians' Communication Skills
Table 2 shows that no significant correlations were observed at baseline between physicians' VAS ratings, patients' HADS scores, and physicians' assessment skills (that is, utterances eliciting and clarifying psychological information) or supportive skills (that is, making educated guesses, empathy, alerting to reality, or confronting) both in the consolidation-workshop group and the basic-training-without-consolidation-workshops group. Six months later, physicians' VAS ratings of patients' distress were correlated significantly with patients' HADS scores, both in the basic-training-without-consolidation-workshops group (correlation coefficient [r] = 0.49; P ≤ 0.01) and in the consolidation-workshop group (r = 0.64; P ≤ 0.001).
|Characteristic||Basic training without CW group (n = 30)||Basic training with CW (n = 28)|
|HADS||VAS||Assessment skills||Supportive skills||HADS||VAS||Assessment skills||Supportive skills|
|HADS||1.00||0.29||0.19||− 0.05||1.00||0.17||0.24||− 0.31|
|VAS||N||1.00||0.03||− 0.10||N||1.00||0.10||− 0.10|
|Assessment skills||N||N||1.00||0.12||N||N||1.00||− 0.07|
|Six mos after baselinea|
Six months later, physicians' VAS ratings of patients' distress also were correlated significantly with physicians' assessment and supportive skills. In the basic-training-without-consolidation-workshops group, 5 months after basic training, physicians' VAS ratings of patients' distress had a significant positive association with physicians' use of assessment skills (that is, with utterances eliciting and clarifying psychological information; r = 0.56; P ≤ 0.001). Their use of supportive skills also became correlated with their use of assessment skills (r = 0.43; P ≤ 0.01). However, the use of assessment and supportive skills by those physicians did not become correlated with patients' HADS scores. After attendance at the consolidation workshops, physicians' VAS ratings of patients' distress had a significant, positive association with physicians' use of assessment skills (r = 0.53; P ≤ 0.01) and supportive skills (r = 0.65; P ≤ 0.001). Moreover, physicians' use of assessment skills (that is, utterances eliciting and clarifying psychological information) had a significant, positive correlation with patients' HADS scores (r = 0.64; P ≤ 0.001).
The Influence of Attendance at the Basic Training Program and the Consolidation Workshops on Physicians' Detection of Patients' Distress
Table 3 shows the results of the MANOVAs, which indicated no significant changes over time or between groups in physicians' VAS ratings of patients' distress or in patients' HADS scores. Before training, 25 of 58 patients (43.1%) scored above the threshold score of 13 on the HADS, indicating probable adjustment disorder or major depressive disorder (12 patients in the basic-training-without-consolidation-workshops group and 13 patients in the consolidation-workshops group). Six months later, 27 of 58 patients (46.6%) scored above threshold on the HADS (16 patients in the basic-training-without-consolidation-workshops group and 11 patients in the consolidation-workshops group). No significant MANOVA time or group-by-time changes were noted in physicians' ability to detect patients' distress, as computed through differences between physicians' VAS ratings of patients' distress and patients' HADS scores.
|Distress rating||Mean ± SD||MANOVA|
|Basic training without CW (n = 30)||Basic training with CW (n = 28)||Time||Group × time|
|At baseline||Five mos after basic training||At baseline||Five mos after basic training||F1.56||P value||F1.56||P value|
|Physician's ratings of patients' distress (VAS)||3.3 ± 2.1||3.5 ± 2.1||4.0 ± 2.0||3.9 ± 2.8||0.00||0.85||0.08||0.77|
|Patients' self-reported distress (HADS total score)||10.4 ± 6.1||12.6 ± 7.1||13.2 ± 6.8||11.8 ± 8.1||0.12||0.73||2.10||0.16|
|Physicians' detection of patients' distressa||7.9 ± 21.5||4.7 ± 19.8||8.3 ± 23.6||11.1 ± 21.5||0.00||0.96||0.58||0.45|
Factors Associated with Physicians' Detection of Patients' Distress
Group (P = 0.38) and time (P = 0.94), although they were not significant, were retained in the model. Patient's educational level (P = 0.003), the type of news given (P = 0.015), patient's self-reported distress (P < 0.000), and physicians' use of assessment skills (P = 0.044) and supportive skills (P = 0.002) were identified as possible predictors and also were retained in the multivariate model. The physician's age and gender; the patient's gender, prognosis, and number of months since diagnosis; and the type of physician-patient relationship did not satisfy the inclusion criterion (i.e., P < 0.05).
The mixed-effects model showed that physician's detection of patients' distress was associated negatively with an educational status of high school graduate or less versus an educational status of college or university graduate (P = 0.042) and with patients' self-reported distress (P < 0.000) (Table 4). Mixed-effects modeling also showed that physicians' detection of patients' distress was associated positively with physicians breaking bad news (P = 0.022) and with physicians using assessment skills (P = 0.015) and supportive skills (P = 0.045).
|Variables in order entered into model||Estimates of effects||Standard error||95%CI||P value|
|Physicians' detection of patients' distress (intercept)a||16.42||5.08||6.33–26.51||0.002|
|Group (BP with CW/BW without CW)||3.41||5.36||− 7.34–14.15||0.528|
|Time (6 mos after baseline/baseline)||− 1.61||5.00||− 11.53–8.31||0.748|
|Group × time||− 2.45||7.16||− 16.65–11.75||0.733|
|Patient educational level (≤ high school/≥ college)||− 7.31||3.55||− 14.35–0.27||0.042|
|Type of news given by physicians (bad news vs. good or neutral news)||9.51||3.94||1.35–16.96||0.022|
|Patients' self-reported distressb||− 1.05||0.27||− 1.57–0.52||< 0.000|
|Physicians' assessment skills||1.55||0.62||0.31–2.78||0.015|
|Physicians' supportive skills||3.27||1.61||0.01–6.47||0.045|
At baseline, physicians' ratings of patients' distress were not correlated significantly with patients' self-reported distress. Results at baseline, thus, confirmed the findings of previous studies that physicians often failed to detect their patients' distress accurately.10–14 It is important to emphasize that the association between physicians' ratings of patients' distress and patients' self-reported distress improved over time. Physicians' ratings of patients' distress were correlated highly with patients' self-reported distress in both groups after training (that is, 5 months after the basic training program for the basic-training-without-consolidation-workshops group and immediately after the consolidation workshops for the consolidation-workshops group). However, contrary to what was expected, no change was observed in physicians' detection of patients' distress (measured by subtracting patients' HADS scores brought up to 100 from physicians' VAS ratings of patients' distress brought up to 100) after the communication skills training programs whether physicians attended the basic training program or the basic training program followed by the consolidation workshops.
The absence of significant improvement in physicians' ability to detect patients' distress after both training programs confirms the fact that improving physicians' ability to detect cancer patients' distress is a complex task. It was hypothesized that an improvement in physicians' use of assessment and supportive skills, in parallel with an increased knowledge about distress in cancer patients, would lead to an improvement in physicians' ability to detect patients' distress. Apparently, this was not the case. The 1-hour theoretical lecture on how to handle patients' distress may not have been sufficient to help physicians identify cues of distress in their patients. The fact that the communication skills training programs tested in the current study, contrary to what was observed after a shorter training program that was conducted in primary care,21 did not lead to significant changes in physicians' detection of patients' distress could be explained by physicians' multiple, competing agendas in cancer care, such as assessing patients' physical functioning, providing information, detecting patients' distress, and so on.
The results also showed that, before training, physicians did not adjust the use of their assessment or supportive skills to the level of distress they perceived in their patients (assessed in this study with a VAS) and to the level of distress experienced by their patients (assessed in this study with the HADS). After both training programs, however, physicians used more assessment skills (that is, they elicited and clarified their patients' psychological concerns more often) when they perceived their patients as more distressed (as assessed with a VAS).
Most important with regard to the focus of the current study, it appeared that, after training, only assessment skills of the physicians who attended the consolidation workshops were correlated with patients' level of distress (assessed with the HADS). The more distressed the patients, the more physicians used assessment skills. Moreover, the use of assessment skills and supportive skills was correlated highly only for these physicians.
After a basic training program, thus, physicians start adjusting their communication skills to the distress that they have perceived. After a basic training program, physicians may not be confident enough in their skills. They may interrupt the assessment of patients' distress or concerns too soon, which may lead them to maintain an imprecise impression of their patients' level of distress. Thus, a basic training program initiates the adjustment of physicians' assessment skills to perceived cues of distress. Consolidation workshops probably allow physicians to adjust their assessment skills further by using supportive skills to pursue their assessment of perceived cues of distress. The hypothesis that physicians' detection of patients' distress may be facilitated by an increased use of supportive skills was confirmed by results from the mixed-effects modeling, which showed that physicians' detection of patients' distress is facilitated by the use of both assessment skills and supportive skills.
Our finding that the acquisition of assessment and supportive skills did not lead to a significant improvement in physicians' ability to detect their patients' distress could be explained by the fact that physicians still may not be confident enough in their skills and/or may not have the needed theoretical knowledge. The lack of significant improvement in physicians' detection of patients' distress, thus, may be explained by the fact that physicians' use of assessment and supportive skills still is not sufficient to allow them to investigate patients' concerns further. This lack of significant improvement also may be explained by the fact that physicians' theoretical knowledge about distress is not sufficient to allow them to generate the needed hypotheses about patients' distress and concerns or to verify their adequacy (by means of checking and making appropriate educated guesses). Results of the mixed-effects modeling that showed the influence of contextual and patient-related variables (such as the type of news given by physicians and patient educational level) confirmed this hypothesis. To improve this assessment, physicians should be aware of those influences when they assess patients. Thus, better detection of patients' distress also may require the use of skills like checking and educated guesses, which may be helpful for getting a more precise picture and a more accurate assessment of a patient's level of distress. The fact that, for the purpose of this study, only one patient was considered for each physician and that the physicians selected the patients also may explain the limited effect observed.
The fact that physicians were enrolled voluntarily and mainly were experienced clinicians may limit the generalizability of our results. It could be argued that the motivation of those physicians was high, and that this may have an impact on the changes observed. The fact that the physicians were experienced also may mean that the way they assessed their patients' distress was rooted more in habits and that improvements in this context may be more difficult to achieve.
The results of this study provide important information for designing the methods of future studies dealing with the issue of improving distress detection. First, the current results showed that physicians differ greatly in their ability to detect their patients' distress (as demonstrated by the important standard deviation). This has implications with regard to the sample size needed to offer sufficient power to detect improvements in physicians' ability to detect distress. Thus, future studies should involve a larger sample of physicians and should include more patients from participating physicians. Future studies also could consider using simulated patients, allowing a reduction in the diversities that may derive from the wide range of patients' reactions and of interview characteristics, which may mask an improvement in physicians' ability to detect patient distress.36
To our knowledge, this is the first study that used a randomized design to assess the impact of two communication skills training programs (a basic training program and a basic training program consolidated by 6 3-hour workshops) on physicians' detection of distress in patients with cancer. Contrary to what was expected, no significant change was observed in physicians' ability to detect the distress of patients after either of the communication skills training programs. However, the training programs allowed physicians to tailor their communication skills to the patient's level of distress by adjusting their assessment and supportive skills to that level. This was observed mostly after physicians attended the consolidation workshops. The results of this study indicate a need for further improvements in physicians' detection skills. Improving physicians' detection of distress in patients may require a specific training module. On one hand, this specific training module should focus on knowledge about cues of distress that need to be identified, on knowledge about the factors that interfere with detection, and on knowledge about emotional regulation and dysregulation. On the other hand, the training should also focus on the practice of assessment (that is, eliciting, clarifying, and checking) and supportive skills (that is, making educated guesses, empathy, alerting to reality, and confronting). Our results also may emphasize the usefulness of using screening tools not only to assess patient distress29, 37 but also to increase patients' spontaneous disclosure of concerns and distress.38 The efficacy of such training and screening efforts with or without consolidation workshops certainly should be assessed to reduce the number of patients with distress that is left unrecognized.
The authors thank all of the physicians and patients who participated in the study.
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