RESUMEN
CONTEXT: Communication education has become integral to pre- and post-qualification clinical curricula, but it is not informed by research into how practitioners think that good communication arises. OBJECTIVES: This study was conducted to explore how surgeons conceptualise their communication with patients with breast cancer in order to inform the design and delivery of communication curricula. METHODS: We carried out 19 interviews with eight breast surgeons. Each interview centred on a specific consultation with a different patient. We analysed the transcripts of the surgeons' interviews qualitatively using a constant comparative approach. RESULTS: All of the surgeons described communication as central to their role. Communication could be learned to some extent, not from formal training, but by selectively incorporating practices they observed in other practitioners and by being mindful in consultations. Surgeons explained that their own values and character shaped how they communicated and what they wanted to achieve, and constrained what could be learned. CONCLUSIONS: These surgeons' understanding of communication is consistent with recent suggestions that communication education: (i) should place practitioners' goals at its centre, and (ii) might be enhanced by approaches that support 'mindful' practice. By contrast, surgeons' understanding diverged markedly from the current emphasis on 'communication skills'. Research that explores practitioners' perspectives might help educators to design communication curricula that engage practitioners by seeking to enhance their own ways of learning about communication.
Asunto(s)
Comunicación , Relaciones Médico-Paciente , Cirujanos/psicología , Neoplasias de la Mama , Teoría Fundamentada , Humanos , Aprendizaje , Atención Plena , Investigación CualitativaRESUMEN
OBJECTIVE: Cancer clinicians are routinely criticised for communicating information poorly to patients, but expert guidance is sometimes contradictory or impractical. We wanted to understand how, and how well, breast cancer surgeons in their normal practice balanced the competing tasks of informing patients while keeping them hopeful. METHOD: In a post-operative surgical outpatient clinic in a UK breast unit, we recruited 9 surgeons and 20 breast cancer patients with whom they consulted. We audio recorded and interviewed both patients and surgeons about their consultations, then analysed data qualitatively within and across cases taking a constant comparative approach. RESULTS: Every consultation contained biomedical factually explicit information, but the information that was most significant for patients was factually less explicit. Progressively less explicit forms, along a 'spectrum' of information, included: judgments about treatment implications; judgments about prognosis; evaluative comments; and clues about what information signified. Surgeons used the less explicit types of information to communicate hope. Where prognosis was poor, communication was confined to more explicit information. Surgeons' practice was closely aligned with what patients sought. CONCLUSION: Common criticisms of cancer clinicians for giving 'too little' information belie the complexity of their task in simultaneously managing information needs and hope. The 'information spectrum' could help educators and clinicians to understand this task.
Asunto(s)
Neoplasias de la Mama/psicología , Carcinoma/psicología , Comunicación , Educación del Paciente como Asunto , Relaciones Médico-Paciente , Cirujanos , Revelación de la Verdad , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/cirugía , Carcinoma/cirugía , Carcinoma Intraductal no Infiltrante/psicología , Carcinoma Intraductal no Infiltrante/cirugía , Femenino , Humanos , Persona de Mediana Edad , Investigación CualitativaRESUMEN
BACKGROUND: Although clinicians are often criticized for giving inadequate information to patients with cancer, current recommendations to "provide full information" or "all the information patients want" are impractical. We therefore examined how surgeons manage information-giving to patients with breast cancer in practice, and how their approach compared with what patients wanted. STUDY DESIGN: We interviewed 20 patients consulting after surgery in a specialist breast unit, and the eight surgeons whom they consulted. Qualitative analysis examined surgeon and patient perspectives on the purposes of information. RESULTS: Surgeons and patients both stated the importance of "honesty" and "telling everything" but surgeons did not want to tell everything they could and patients did not want to hear it. Patients wanted information mainly to maintain hope, demonstrate the surgeon's expertise, and sustain a personal clinical relationship. Surgeons shaped their information-giving for the same reasons while providing necessary information about histology and treatment. CONCLUSIONS: Surgeons and patients agreed strikingly about the purposes of information and indicated that giving information is a more complex task than current recommendations imply. We suggest that expert recommendations should catch up with practice rather than the reverse. That is, if recommendations are to reflect patients' real rather than assumed needs, and be realistic about how surgeons can meet these needs, the recommendations should be informed by knowledge of how patients and surgeons already reconcile these needs in clinical practice.
Asunto(s)
Neoplasias de la Mama , Cirugía General , Pautas de la Práctica en Medicina , Revelación de la Verdad , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/diagnóstico , Femenino , Humanos , Persona de Mediana EdadRESUMEN
OBJECTIVE: We developed a method whereby relationships can be studied simultaneously from the perspectives of each party and researchers' observations of their dialogue. Then we used this method to study how to recognise authentic, caring clinical relationships. METHODS: Participants were 20 patients who had recently received surgery for breast cancer and nine surgeons with whom they had a post-operative consultation. We audiorecorded consultations, before interviewing patients and surgeons about their perceptions of the consultation and each other. Cross-case qualitative analyses (analysing consultations and surgeon and patient interviews, respectively) were supplemented by integrative, within-case analysis. RESULTS: Surgeons and patients described their relationship as personal and emotional, but emotional talk was absent from consultations. For patients and surgeons, their relationship depended, instead, on surgeons' expertise and character. CONCLUSION: Our integrative approach suggested that authentic caring in these relationships lay in practitioners' conscientious execution of their role and, contrary to currently influential views, not in an explicit emotional engagement. PRACTICE IMPLICATIONS: Relationships between patients and practitioners cannot be described adequately using analyses of interactions between them. Researchers will need to triangulate between these observations and the patient and practitioner perspectives in order to understand what makes for authentically caring relationships.
Asunto(s)
Comunicación , Satisfacción del Paciente , Percepción , Relaciones Médico-Paciente , Derivación y Consulta/estadística & datos numéricos , Neoplasias de la Mama/psicología , Neoplasias de la Mama/cirugía , Atención a la Salud/métodos , Femenino , Humanos , Entrevistas como Asunto , Masculino , Médicos , Periodo Posoperatorio , Investigación Cualitativa , Grabación en CintaRESUMEN
OBJECTIVE: We examined to what extent variability in breast cancer patients' sense of relationship with their surgeons was attributable to patient vs surgeon variation and we examined the role of one patient characteristic: attachment style. METHODS: Women (N=133) due to undergo surgery for breast cancer with one of six surgeons self-rated their relationship with the surgeon, using the Working Alliance Inventory, and indicated their adult attachment style (secure vs insecure). Multilevel analysis of alliance scores quantified variance components at patient and surgeon levels and tested the relationship with attachment. RESULTS: Variability in alliance was overwhelmingly at the patient level. Alliance was greater in securely than non-securely attached patients, although this influence was small. CONCLUSION: Variability in quality of clinical relationships after breast cancer diagnosis largely reflects variation between individual patients, not surgeons. Although patients' attachment style is significant, its role is modest. More influential patient characteristics need to be identified. PRACTICE IMPLICATIONS: Breast cancer patients report a strong relationship with their surgeons. Because differences between surgeons make only a small contribution to variability in relationship, it should be a priority to identify and address the characteristics or behaviours at the level of individual patients that are associated with poorer relationships.
Asunto(s)
Neoplasias de la Mama/cirugía , Comunicación , Apego a Objetos , Participación del Paciente , Relaciones Médico-Paciente , Adulto , Anciano , Actitud del Personal de Salud , Femenino , Humanos , Relaciones Interpersonales , Mastectomía , Persona de Mediana Edad , Médicos , Especialidades QuirúrgicasRESUMEN
Doctors are widely encouraged to share decision-making with patients. However, the assumption that responsibility for decisions is an objective quantity that can be apportioned between doctors and patients is problematic. We studied treatment decisions from three perspectives simultaneously - observing consultations and exploring patients' and doctors' perspectives on these - to understand how decision-making that we observed related to participants' subjective experience of responsibility. We audio-recorded post-operative consultations in which 20 patients who had undergone initial surgery for breast cancer discussed further treatment with one of eight surgeons in a general hospital serving a socioeconomically diverse urban population in England. We separately interviewed each patient and their surgeon within seven days of consultation to explore their perspectives on decisions that had been made. Qualitative analysis distinguished procedurally different types of decision-making and explored surgeons' and patients' perspectives on each. Surgeons made most decisions for patients, and only explicitly offered choices where treatment options were clinically equivocal. Procedurally, therefore, shared decision-making was absent and surgeons might be regarded as having neglected patients' autonomy. Nevertheless, patients generally felt ownership of decisions that surgeons made for them because surgeons provided justifying reasons and because patients knew that they could refuse. Conversely, faced with choice, patients generally lacked trust in their own decisions and usually sought surgeons' guidance. Therefore, from the perspective of ethical frameworks that conceptualise patient autonomy as relational and subjective, the surgeons were protecting patient autonomy. Studying subjective as well as procedural elements of decision-making can provide a broader perspective from which to evaluate practitioners' decision-making behaviour.