Patient Satisfaction
Informed Consent
Malpractice Claims

Patient Satisfaction

Patient satisfaction reflects how well patient health care needs, expectations, or preferences are met. The measurement of satisfaction with patient care is complicated by a patient bias to skew responses in favor of high satisfaction scores. In oncology, some studies support the concept that communication skills are related to patient satisfaction in several areas. Specifically, several studies relate patient satisfaction to psychological adjustment, including patient satisfaction with the amount and kind of information provided at the time of diagnosis;[1] clinician willingness to discuss treatment options;[2] patient perception of the oncologist as caring, attentive, or emotionally supportive;[3-5] and patient rating of communication with the physician. Basic communication skills have also been related to satisfaction in other studies,[6,7] which have demonstrated that among gynecology and medical oncology patients, satisfaction was associated with attentiveness, interest, and friendliness and with providing information. These findings among oncology patients parallel those found in other medical specialties.

Informed decision making is an essential component of the ethical practice of prescribing cancer treatments and conducting research. However, fully involving patients in clinical decision making is a challenging task for physicians, who nonetheless have been urged in recent years to take a less legalistic and more interactive approach with patients in explaining treatments.[8,9] The aim of informed consent is to emphasize more effective communication between patients and physicians, where information disclosure and patient participation in decision making are the goals rather than the notions of an administrative requirement to have patients sign a document or to protect a physician from legal liability.[10] A dialogue would also allow the clinician to determine how much information a patient actually desires and would respect the patient’s right to shun information that might be unwanted.[10,11]

There are few data to describe how oncologists practice informed consent, and there are inadequate guidelines for communicating with patients about treatment decisions.[12] The best information comes from studies of communication in clinical trials, which show that oncologists scored poorly on measures of the quality of the content of information provided to the patient and explanation of randomization, implicitly expressing favoritism of one treatment over another;[13] that physicians overestimate patient satisfaction with specific treatment information;[14] and that not all patients understand the unproven nature of the treatment.[15] Inflexibility in the timing of information may represent a physician barrier to clinical trial recruitment. For example, treatment of breast cancer for patients on clinical trials cannot begin until the patient has signed the informed consent form. This requirement effectively compels physicians to reveal information to patients soon after the diagnosis is confirmed. Sixty-one percent of the physicians in one study [16] explained that they would have preferred to tell patients about their diagnosis and prognosis in small increments. They argued that patients need time to absorb the shock of the diagnosis before hearing a detailed description of the uncertainty of treatment options, but that the need to obtain informed consent constrained their schedule for disclosure to patients.[16]

The reason that eligible patients decline participation in clinical trials has been explored in several studies, which reflect many of the issues surrounding inadequate communication. In one study, patients were found more likely to participate in clinical trials when their physicians were cordial, able to establish trust and rapport with the patient, and attentive to patient concerns.[17] Other than increasing monetary incentives to the investigators conducting the studies, few interventions have been successful at finding ways to improve accrual to clinical trials in oncology, including an intervention study to improve communication about randomized clinical trials [18] and an intervention program designed to increase the enrollment of rural American patients who have cancer.[19] A pilot study that examined barriers to the participation of African American patients with cancer in clinical trials concluded that factors associated with religion, education, and income rather than race may be major barriers to clinical trial participation.[20] The authors of the study concluded that interventions that target education and income could increase the recruitment of African American oncology patients onto clinical trials.[20] More work in this area is needed to increase the participation of all oncology patients in clinical trials, regardless of race or educational and income level.

Interventions to improve the informed consent process also show that having a study team member or educator spend more time talking one-on-one with the patient to improve understanding of clinical trials are more successful than the use of multimedia or enhanced consent forms.[21] One study using a staged approach in which parents or guardians consented to more limited segments of treatment showed promise.[22]

A small number of physicians appears to generate a disproportionate number of lawsuits.[23] Although there are a number of risk factors for malpractice claims—including physician specialty, number of patients seen, and physician characteristics—they do not seem to be predicted by the characteristics of a physician’s patients, the technical aspects of care, or the complexity of care.[24] Rather, patient dissatisfaction—especially with the interpersonal aspects of care—seems to be an important determining factor. These interpersonal aspects include time spent with the patient, ability of the physician to meet patient expectations for care, ability of the physician to convey information to the patient, physician concern for patient worries, and the friendliness and courteousness of the physician.[25]

Other but more scarce research has suggested that communication skills are also related to patient retention, compliance with treatment, practitioner burnout,[26] collaboration among oncology teams,[27] and increased difficulty in transitioning to palliative care.[28]

References

1. Fallowfield LJ, Hall A, Maguire GP, et al.: Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial. BMJ 301 (6752): 575-80, 1990.  [PUBMED Abstract]
   
   
2. Butow PN, Kazemi JN, Beeney LJ, et al.: When the diagnosis is cancer: patient communication experiences and preferences. Cancer 77 (12): 2630-7, 1996.  [PUBMED Abstract]
   
   
3. Roberts CA, Aruguete MS: Task and socioemotional behaviors of physicians: a test of reciprocity and social interaction theories in analogue physician-patient encounters. Soc Sci Med 50 (3): 309-15, 2000.  [PUBMED Abstract]
   
   
4. Takayama T, Yamazaki Y, Katsumata N: Relationship between outpatients' perceptions of physicians' communication styles and patients' anxiety levels in a Japanese oncology setting. Soc Sci Med 53 (10): 1335-50, 2001.  [PUBMED Abstract]
   
   
5. Zachariae R, Pedersen CG, Jensen AB, et al.: Association of perceived physician communication style with patient satisfaction, distress, cancer-related self-efficacy, and perceived control over the disease. Br J Cancer 88 (5): 658-65, 2003.  [PUBMED Abstract]
   
   
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7. Silliman RA, Dukes KA, Sullivan LM, et al.: Breast cancer care in older women: sources of information, social support, and emotional health outcomes. Cancer 83 (4): 706-11, 1998.  [PUBMED Abstract]
   
   
8. Braddock CH 3rd, Edwards KA, Hasenberg NM, et al.: Informed decision making in outpatient practice: time to get back to basics. JAMA 282 (24): 2313-20, 1999 Dec 22-29.  [PUBMED Abstract]
   
   
9. American Society of Clinical Oncology.: American Society of Clinical Oncology policy statement: oversight of clinical research. J Clin Oncol 21 (12): 2377-86, 2003.  [PUBMED Abstract]
   
   
10. Gattellari M, Voigt KJ, Butow PN, et al.: When the treatment goal is not cure: are cancer patients equipped to make informed decisions? J Clin Oncol 20 (2): 503-13, 2002.  [PUBMED Abstract]
    
    
11. Baile WF, Beale EA: Giving bad news to cancer patients: matching process and content. J Clin Oncol 19 (9): 2575-7, 2001.  [PUBMED Abstract]
    
    
12. Albrecht TL, Franks MM, Ruckdeschel JC: Communication and informed consent. Curr Opin Oncol 17 (4): 336-9, 2005.  [PUBMED Abstract]
    
    
13. Brown RF, Butow PN, Ellis P, et al.: Seeking informed consent to cancer clinical trials: describing current practice. Soc Sci Med 58 (12): 2445-57, 2004.  [PUBMED Abstract]
    
    
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15. Joffe S, Cook EF, Cleary PD, et al.: Quality of informed consent in cancer clinical trials: a cross-sectional survey. Lancet 358 (9295): 1772-7, 2001.  [PUBMED Abstract]
    
    
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17. Albrecht TL, Blanchard C, Ruckdeschel JC, et al.: Strategic physician communication and oncology clinical trials. J Clin Oncol 17 (10): 3324-32, 1999.  [PUBMED Abstract]
    
    
18. Fleissig A, Jenkins V, Fallowfield L: Results of an intervention study to improve communication about randomised clinical trials of cancer therapy. Eur J Cancer 37 (3): 322-31, 2001.  [PUBMED Abstract]
    
    
19. Paskett ED, Cooper MR, Stark N, et al.: Clinical trial enrollment of rural patients with cancer. Cancer Pract 10 (1): 28-35, 2002 Jan-Feb.  [PUBMED Abstract]
    
    
20. Advani AS, Atkeson B, Brown CL, et al.: Barriers to the participation of African-American patients with cancer in clinical trials: a pilot study. Cancer 97 (6): 1499-506, 2003.  [PUBMED Abstract]
    
    
21. Flory J, Emanuel E: Interventions to improve research participants' understanding in informed consent for research: a systematic review. JAMA 292 (13): 1593-601, 2004.  [PUBMED Abstract]
    
    
22. Angiolillo AL, Simon C, Kodish E, et al.: Staged informed consent for a randomized clinical trial in childhood leukemia: impact on the consent process. Pediatr Blood Cancer 42 (5): 433-7, 2004.  [PUBMED Abstract]
    
    
23. May ML, Stengel DB: Who sues their doctors? How patients handle medical grievances. Law Soc Rev 24 (1): 105-20, 1990. 
    
    
24. Stelfox HT, Gandhi TK, Orav EJ, et al.: The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. Am J Med 118 (10): 1126-33, 2005.  [PUBMED Abstract]
    
    
25. Hickson GB, Federspiel CF, Pichert JW, et al.: Patient complaints and malpractice risk. JAMA 287 (22): 2951-7, 2002.  [PUBMED Abstract]
    
    
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27. Catt S, Fallowfield L, Jenkins V, et al.: The informational roles and psychological health of members of 10 oncology multidisciplinary teams in the UK. Br J Cancer 93 (10): 1092-7, 2005.  [PUBMED Abstract]
    
    
28. Emanuel EJ: Care for dying patients. Lancet 349 (9067): 1714, 1997.  [PUBMED Abstract]
    
    

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