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When it comes to their health, people have distinctive ways of making decisions, understanding their individual risks, and carrying out recommended screening, treatment and follow-up regimens. Behavioral scientists are learning that in order to overcome the cognitive, emotional, and practical barriers to effective healthcare, doctors need to recognize their patients’ individual information-processing styles and adjust their communication styles accordingly.

To find out more about this emerging field, Benchmarks interviewed Suzanne M. Miller, Ph.D, a leader in the field of behavioral science and cancer. Miller’s approach recognizes the need to develop “information prescriptions” to personalize messages about cancer risk, prevention, and treatment options. She uses her skills as a clinical psychologist to extend basic methods and findings in cognitive and social science to benefit cancer patients and at-risk individuals, and has created the Monitor-Blunter Style Scale to distinguish between these patterns of response. She is a senior member in the Division of Population Science and Director of the Psychosocial and Behavioral Medicine Program at Fox Chase Cancer Center, Philadelphia, Pa.

What is the difference between a “blunter” and a “monitor”?

Blunters and monitors are terms we have coined to describe how people differ in handling and processing information. A monitor describes the type of person who has turned up the volume so that while the doctor may be saying "abnormal pap test result," they might hear "cervical cancer, with endless days and nights of treatment and suffering." They're very attuned to information – they will often amplify or exaggerate it, particularly when they're under stress, and they will surf the Web and read everything they can get their hands on. They're happy to discuss details of their illness, and take in all the comfort and reassurance offered.

In contrast, blunters tend to distract from information--they tune it out and de-emphasize it. It's almost like a doctor has to turn up the volume if they want to be heard. If the doctor says, “abnormal pap smear," the patient thinks to themselves, “I have no symptoms, I feel fine – there’s probably no real problem.” They don't want to dwell on their illness, and would rather be distracted and let life go on.

How do you determine whether someone is a blunter or a monitor?

We have developed a survey that asks people how they would act in certain situations. For example, if you ask them about what they do when they’re in the dentist's chair and having some unpleasant dental work done, some monitors say things like, “I want the dentist to tell me exactly what they are going to do, I listen for the dentist's drills, I pay attention to the dentist's fingers and instruments, and I look at the bowl for blood from my mouth.” Blunters will say things like, “I daydream, I think about pleasant memories, I focus on what I did last summer,” and that sort of thing.

Do people fall into one extreme or the other, or is there a continuum?

It is a scale, and people fall along a normal distribution, from very extreme monitoring to very extreme blunting, and along the whole continuum. We tend to talk in terms of two types, but there is also a group in the middle who probably do a little of each.

Do you think that monitors and blunters experience equal distress in these situations?

No, I don't think so. Virtually across the board from finding out that you're at risk for a disease, right through to undergoing treatment and its after-effects, monitors tend to experience more distress than blunters. They're paying more attention and are more likely to ask the "what if" questions; “What if this goes wrong, what does this mean and what if this happens, and what will happen to me?” And for them, every neutral cue is read negatively; whereas a blunter attempts to read neutral information more positively. If you're not getting test results back and you have to wait for them, there's no information there. But monitors can make the situation much more stressful by thinking way ahead; “What if the results come back this way, what if it comes back that way, what will I do if it turns out to be cancer…how can I live with this, what will happen to me?” Whereas blunters say to themselves, “There's nothing I can do right now.” They're not asking every day, “Are the test results back?” They're not focusing on it; they're turning their attention to other things.

How can clinicians do a better job of communicating with their patients based on this behavior model?

You have to respect the patient's style and let that be your guide. Follow their lead. The aim of this kind of research is to develop interventions and management strategies that are tailored to the specific needs of monitors and blunters and matched to their style. We need to do a better job of sensitizing clinicians to the different types of coping styles of their patients. Some clinicians have an intuitive sense that if a patient is asking a lot of questions--they want to know more and they should be told more. If they make a statement and the patient says, “Can you tell me more about that?”-- they know that this is a monitoring type of patient to whom one should impart more detailed information and spend more time on all of the specifics of the diagnosis, treatment or its after-effects.

With the blunting type of patient, when a doctor says something and the patient doesn't ask anything further, they get a sense that the patient doesn't want to know more. We need to train physicians to have their psychological antennae up – that it really matters how you package this information depending on the patient’s needs. With typical office visit times getting shorter, if a physician can be prepared and know if the patient is a monitoring or blunting type, less time may often be appropriate with a blunter type of patient.

Are there different approaches to communication based on the type of disease one is dealing with? Is there a difference between how a patient would deal with breast cancer or lung cancer?

I think that the way one deals with information tends to be part of a person's style. It's how they tend to approach the most threatening situations--especially threatening health care situations. However, how well that style serves them in a particular instance can depend on variations in any medical condition. For example, it isn't so much that it's breast cancer vs. another kind of cancer, but that breast cancer often involves a lot of conflicting medical advice and decision making on the part of the patient. We know that for early-stage breast cancer, lumpectomy with radiation is as effective as mastectomy. But some women--especially monitors--end up opting for mastectomy even when it’s not medically necessary, because they can’t deal with the anxiety of possible recurrence if they don’t have the entire breast removed. These decisions then become very anxiety-driven, rather than driven by rational, evidence-based, medical considerations.

Is there a gender breakdown between monitors and blunters? What is the best approach to take with delivering messages to each type?

There is a slight tendency for women to be more likely to be monitors--particularly when it comes to the health care setting; they tend to be more focused and tuned in. And monitors are more likely to take better care of themselves, go to routine appointments, and follow recommendations that the physician makes.

And the blunter, because they're not attentive to threat, is less likely to do that--doesn't pay attention, isn't focused on it, may have to be reminded several times to get a pap smear, mammogram or an annual checkup. We need to find ways of turning up the volume for blunters so that they hear the message--and the message is, “You need to come in and get screening, and if you don't, it will not be good for your health.” But monitors are already more attentive, so they don't need such loud messages blaring at them. In fact, because of their tendency to feel more vulnerable, it's better to give the message in a softer, more reassuring manner; for example, “It's time for your annual pap test-- remember that you can reduce your risk of cervical cancer if you come in.” So the emphasis for monitors needs to be around reassuring messages--that they're getting the situation under control with a lot of detailed information about what's going to happen and when, so they're not worrying about uncertainty. Monitors fare better when you give them all the information, when you speak to all the “what-ifs,” because they're on their mind anyway, and whatever they imagine tends to be worse and over-exaggerated and amplified in relation to what is likely to be the actual case.

For the blunter, the doctor may have to say, “You need to realize that you will increase your risk if you don't come in.” Blunters need shorter messages, but ones that are stronger and are aimed at making them pay attention to the need for routine care and follow-up. The idea is not to force a lot of information and details on blunters – that just makes them more anxious than if you just allow them to distract and to use other techniques for coping.

So the ideal outcome is that the person is well taken care of, makes informed medical decisions, and also experiences the least amount of distress?

Yes, because distressed people not only feel bad, but they also get confused. We know that stress increases perceptions of pain; increases recovery time, increases blood pressure, and ultimately people who are stressed can get very avoidant. So if a monitor has a medical encounter where they're not getting the right amount of information, and they don't feel that their need for support and reassurance is being heard and met, their stress levels tend to increase. Then they may start to avoid the whole situation because they don't want to deal with any additional stress.

For example, if a monitor gets a call from the doctor’s office asking them to come back in to redo a biopsy, you may find that they become non-adherent because can’t deal with the anxiety. They may cancel the appointment and tell themselves that they are too stressed right now, that they’ll do it next week, and then cancel that appointment. I think in terms of the real impact on behavior and health, ultimately, an ounce of prevention is worth a pound of cure in terms of matching what we do to those different kinds of patients.

I like to think of this as providing “information prescriptions,” just as we prescribe doses of medicine based on an individual’s unique needs. We need to build systems that deal with people’s informational needs, but also recognize that what goes along with that is different levels of anxiety, different levels of perceived vulnerability, different values and goals.

If you're a very anxious person, your values and goals about your care are going to be quite different than if you're not an anxious person and you think you can live with uncertainty. One goal of our research is to help doctors and patients with the skills and strategies they need for managing that anxiety. Sometimes the best option is watchful waiting--for example, when it comes to prostate cancer. So it is part of our job to help patients with the tools to get their anxiety under control so that they can make the best possible medical decisions.

Where is the state of the cancer communication field right now?

I think that the message is getting out—and that more physicians are aware that communicating information is a critical component of quality of care. Research shows that people have difficulty processing information even when they're not stressed – that what is read to them or said to them, particularly when it involves numbers, probabilities, unfamiliar terms and procedures, can lead to confusion. People don't hear exactly what's being said and they edit the information in their heads. Particularly when it comes to cancer prevention, screening and treatment, one health care interaction often leads to future health interactions. So it’s important that the initial visits be of very high quality. We need to continue to find ways to bridge that gap between all the information available to us and provide it to individuals in ways that serve their particular needs.

For more information, go to the Behavioral Research Core Facility at Fox Chase Cancer Center at http://www.fccc.edu/research/facilities/behavioral/BRCF.html.

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