Positive Communication Yields Positive Results For Cancer Patients

According to the American Cancer Society, each week there are about 200-300 San Diegans diagnosed with cancer. Studies show that patient-centered care yields an increase in patient satisfaction as well as recovery rates. We will discuss the importance of positive communication between cancer patients and doctors.

Guests

Dr. Wayne Beach, professor of communication at SDSU and a member of the Cancer Center in the School of Medicine at the University of California, San Diego. His research focuses on conversational and institutional interactions and their convergence, including medical interviewing and how families talk through cancer diagnosis and treatment.

Dr. William Stanton, medical director of the Scripps Cancer Center at Scripps Mercy Hospital's San Diego campus. A general oncologist, he provides care for people with lung, colorectal, prostate, skin, blood and breast cancer.

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CAVANAUGH: According to the American cancer society, each week there are about 2 to 300 San Diegans diagnosed with cancer. When that diagnosis is made, and as treatment begins, it's essential that anxious patients fully understand their disease and their options. Next semester San Diego state university will be the first university in California to introduce a health communication major. It's part of a movement within the medical community to find ways to improve communication between healthcare workers and patients. I'd like to welcome my guests, doctor William Stanton is medical director of the Scripps cancer center at Scripps mercy hospital San Diego campus. Doctor Stanton, welcome.

STANTON: Thank you very much, Maureen.

CAVANAUGH: And doctor Wayne Beach is professor of communications at SDSU and a member of the Morris cancer school at the school of medicine at the university of California San Diego. Doctor beach, good morning.

BEACH: Good morning.

CAVANAUGH: Now, let me start but, doctor beach, when someone hears the word cancer, fear might be a first reaction. Is there a right way or a wrong way to tell someone that diagnosis?

BEACH: You start off with the difficult question. Clearly it's the number one health fear in America for a reason. Patients can go on-line to the American cancer society or the National Cancer Institute and read the statistics which basically are one out of every two men are diagnosed with cancer in the course of a life span, one out of every three women, and if you are diagnosed, 50 percent of those people do die because of cancer, and so that is a normal lay understanding in public. Patients have spoken with other people, with other family members, and so when they go into the clinic, there is a lot of anxiety and fear. And so there are various ways to deliver bad news to patients of one common way is to ask patients what they think is going on first. And to solicit that point of view. And then when that happens to be able to accommodate that point of view by the doctor to inform them of what the diagnosis might be. But, you know, obviously doctor Stanton has done it thousands of times. And I think that there's a whole large body on bad news, but the stereotype of just bad news in the cancer clinic is actually a false stereotype. It's much more about life affirmation and hope than it is despair.

CAVANAUGH: Well, let me ask you then, doctor Stanton, have you in your years of delivering this kind of information to patients come up with a way that is the best way to let someone know they have a diagnosis of cancer?

STANTON: Well, I think there are two different settings, Maureen, first is when the patient first learns issue usually from a furthermore physician that they have cancer, and the second scenario is when they meet the cancer specialist. For the primary care physician, the best technique that works is to be open and honest and have a plan, immediately, as to how to manage this new news. Usually it's a referral. And hopefully a referral that is timely and quick. And the second thing for the primary physician is to maintain availability, please call me if you have any needs or concerns, and please have your family call me and we'll have a conference. Because tomorrow, you'll have a hundred questions. So call us back and we'll arrange to answer. And the other thing the primary care physician often does is does the hand off well, he calls, he or she calls the oncologist, explains the family dynamics and the situation and whether there's any nervousness or anxiousness that needs immediate discharge.

CAVANAUGH: As professor of communication at SDSU, doctor beach, what do you see as some of the common communication problems that come up between doctors and patients with patients who have serious illness?

BEACH: Patients come in and have been planning coming to this doctor for a long time. For the doctor, it's one of a number of individuals every day, and there's a major difference there, so patients come in with an agenda too, they come in with questions, but especially in the case of cancer, they come in with a lot of fears and a lot of anxiety, and a lot of hopes, as we were discussing. So one [CHECK] bid emotional support from doctors, and in response, the question is, how do doctors acknowledge and address that emotional concern or -- and or do they switch to quickly what we call a biomedical agenda, which is the concern with the body and the system, and the diagnosis and treatment? And so that's a primary problem that we're seeing in analyses of recorded interviews or how patients bid for emotional support, and whether or not doctors respond directly to that or not.

CAVANAUGH: I understand. And I would imagine that there's some difference in the way communication works best, depending on whether you have a teenager in front of you or an elderly patient. All that makes a defense in the way you want to talk to that patient.

BEACH: Well, I think so. In fact in a new study that doctor Stanton and I are going to be collaborating on, it's going to be submitted to the initial cancer institute, we are going to be including direct analyses of family members contributions to better understand the impact that they have. [CHECK] oftentimes as advocates for patients who speak as much, if not more than the patients in the clinic.

CAVANAUGH: I'm speaking with doctor weapon beach, he's [CHECK] and also a member of the Morris cancer center at UCSD, and doctor William Stanton is medical director of the [CHECK] Scripps mercy hospital San Diego campus, and we're talking about ways to improve communication between healthcare workers, and patients, doctors and patients and about the fact that SDSU is the first university in California later this year to introduce a health communication major. Before we get to that, doctor Stanton, I wonder if you could describe to us, what's known as patient center care?

STANTON: Well, I think patient center care is based upon, first, a certain amount of transparency, you know, there was a time in America in the mid-20th century when patients had cancer and they were not told. This lid to enormous amounts of unnecessary anxiety because when [CHECK] already knew. Things were different, the family dynamics were different, and they didn't feel well. And they didn't have any explanation and they usually fear what they regarded was the worst. And so transparency means the patient and the family are informed. Doctor beach mentioned our new study. One of the reasons it's important to direct it at the physicians and other healthcare providers is that sometimes wee faced with a whole family in the room to discuss this with, and as was earlier mentioned, the pitch, the level of the conversation may be different if there's a teenager present or even child present or the patient. This makes it extremely hard for physicians and care givers and they need training in how to approach these multidimensional conversations.

CAVANAUGH: I just want to remind our audience, if they would lick to join this conversation, we welcome your calls at 1-888-895-5727. That's 1-888-895-KPBS. As did beach mentioned, doctor Stanton, a patient comes in, and they have been looking forward or dreading or anticipating this confrontation with the doctor, and this conversation for quite some time. And yet doctors as we know have somewhat limited time to spend with each individual patient. So how is it that you make the most of your team with your patients when you're with them?

STANTON: Well, surprisingly enough, the first rule is not to talk but to listen more. Because patient centered care involves not only transparency but recognizing and identifying and sometimes forcing or causing the patient to identify their own goals. And where they are. And so these are techniques that you learn over time, but you do need to learn them. They don't come naturally. And in today's environment with healthcare reform causing shorter and shorter patient visits, you have become very good at it, and very efficient at it, and that's why we think, especially, this project that we're embarking on will be useful to physicians. We hope to show physicians videos of depend performances and bad performances. And these are learning opportunities.

CAVANAUGH: Doctor beach, you make the -- you make the case too that it's more than just simply what's being said at these meetings. Body language enters into these interactions as well. Tell us a little bit about that.

BEACH: [CHECK] and only 13 percent of the time are patients direct about what they're feeling. And for example.

A. About their hopes or their fears or their uncertainties. And so the rest of the time, they're being indirect. And a lot of the indirectness is the embodies of the talk, and that is gaze, gesture, talk, the use of bodies, how they watch doctors looking at medical charts and how they try to get the doctor's attention from the medical charts. So to train physicians to be more effective, you can't just focus on the utterance or the talk, you have to focus on the full environment which includes the use of the body. And there are actually a lot of studies going on worldwide on the impact of gaze, touch, etc. [CHECK] explicitly bid for hope from doctor, they will not electric the doctor in the eye when they do that. And I think what they're doing is they're avoiding the possibility of rejection of that bid, and what we call the averted gaze is it a way to draw attention to the penalty that the bid that they're making will not be confirmed by the doctor.

CAVANAUGH: I word, I want to ask both of you this, how to you answer a question that a patient might have if a patient, him or herself doesn't even know that they have this conversation? Do you know what I mean? If indeed someone is sitting there and is really being somewhat noncommunicative? How do you draw someone out to get them to actually ask the questions and express the fears that they might have?

STANTON: Well I think a direct interaction would be to ask the patient what they believe is the problem, why they are here, and if they have any questions because we would like to address any concerns that they have that they might be reluctant to express. The table is open for any question, no question is too dumb. It's a common occurrence that patients come to physicians really kind of embarrassed by their lack of knowledge, and you have to reassure them that that's perfectly okay. That cancer is a very very far complicated ills, and they shouldn't be embarrassed by not knowing everything about it.

CAVANAUGH: Now, I said at the beginning that one of the reasons we're talking here today is because in the fall of this year, [CHECK] health communication major. Now, I know when people have serious ill business, and they're going to the doctor, it's always first degree to bring someone along with you so that that person will be able to articulate a little bit better the questions, remember the answers, you know, that sometimes you can't when you're obsessed with your own disease, and your own feelings about that. But -- so is this health communication major -- is that supposed to lead to people who will intercede and be that kind of person to sit with a patient and with a doctor and have that kind of communication?

BEACH: Well, what you're referring to is patient advocacy.

CAVANAUGH: Yes.

BEACH: Could very well be one tentacle that would come on the of a health communication major like that. I think that for example someone with a master's degree in health communication could well want to speak for and on behalf of patients. And part of that -- like breast navigator patients for instance, who would introduce women who were diagnosed with breast cancer into the system, and personally walk with them, through the system with them, and be mentors, you could see a scenario where a person trained in communication could focus on helping to train communication skills for patient advocates that would perhaps be conduits and patients and family members, I think the reason for the health communication degree is that communication is everywhere, it's critically important. If it's poor, it leads to bad health outcomes, it leads to poor satisfaction, it leads to increased malpractice, it leads to patients not complying with the regiments that doctors have asked them to do, like take pills or exercise and diet in particular ways. So it's clear that it's about trust and relationships. And it's not just true in the clinic, it's true, I think, in all healthcare. So we're dealing here with counselors and with nurses and with administrators and staff. Anyone dealing with any healthcare branch is effective or not depending on the quality of their communication?

CAVANAUGH: I wonder specifically besides patient advocate, what kind of career choices might students have who took a health communication major?

BEACH: Well, I think increasingly, you're going to see hospitals, medical groups, centers, explicitly taking communication as a specialty, and feting it into what's typically called human resources, which has, of course, connections with marketing and sales, and with word of mouth about the quality of the medical system. So you're going to have people being able to be trainers, people coming out and pursuing their doctorates to do basic research, and I think health communication is a classic place where you can do basic research like I've done [CHECK] and then collaborating with the medical experts such as doctor Stanton, and it takes both. And what that does is bring different disciplines together, did brings different institutions together, for example UCSD and [CHECK] to be able to blend together basic research with applied value, and both are optimized that way, I think the university and the community can be brought together in a stronger way in a very systematic way, if you treat that as an agenda.

CAVANAUGH: And doctor Stanton, you wanted to comment?

STANTON: Yes, thank you Maureen. I wanted to say a special word about the patient navigator, which is another goal I would have for doctor beach's health communication program of the navigator is a role that is increasingly being espoused by the American cancer society, and the National Cancer Institute. The navigator is sometimes even a nurse or a nurse practitioner who is very knowledgeable about cancer. And up, we talked about explaining the diagnosis to the patient, that pales in comparison with explain the treatment options. [CHECK] treatments of 1 or 2 or 3 different modalities, and to organize the consultations and to interdigitate them in an appropriate manner, and to [CHECK] contact with questions about the sheer mechanic system what the navigator does. Now, doctor Harold freeman, professor at Columbia University introduced this concept at Harlem hospital a decade ago, and he was able to show that the five years survival in that demographic was doubled by the use of the navigator. That's a remarkable improvement. And so by investing in communications, we can sometimes accomplish as much or more as the treatments we give ourselves.

CAVANAUGH: That's fascinating. We have time for a quick call. Lisa is calling from Clairemont. Lisa, good morning, and we're gonna have to make it fast. Thank you.

NEW SPEAKER: Okay. I'll make it fast. My son, he was at nine at the time, he was diagnosed with bone cancer in 2009, and I think the way our pediatrician, and the way our oncologist worked together, specifically the first time our oncologist spoke to us, [CHECK] this is happening to your family, but I'm looking forward to getting to know you. And it really did make you feel like she cared about your child, and that there was hope in the situation. And our pediatrician was just like you said, the primary doctor being completely accessible, I stopped in the [CHECK] and sat down with us, and like you said, the body language, our oncologist would sit on our son's bed in the hospital and just made you feel like she was actually available it talk and not in and out, and you were interrupting her day.

CAVANAUGH: And did that help you with the fear that you were experiencing, Lisa?

NEW SPEAKER: It really did. It helped us feel like we had someone -- that she was a part of our team, and she wanted the best for our child, and like we had access to her. She even -- the first time we met her, gave us her cellphone number so that we could call her if we had any questions. So that available, to feel like you're not in this alone, that you have someone who has the answers and is upon willing to be there for you, really took a lot of the -- for us.

CAVANAUGH: Well, lessa, thank you for sharing this. Thanks for your phone call very much. So do you think that things are turning around, doctor beach, that indeed the idea that there's -- you know, the doctor that you can't speak with or can't communicate very well, and they're the patient who's basically incapable of asking the correct questions, is that scenario sort of going away?

BEACH: I don't know if it's going away. But I know that more and more interventions are designed to get in the middle of it, find out how it's organized, and translate that in collaboration with medical experts into training modules to improve communication skills. I don't think it'll ever go away because our primary human condition when faced with threats and cancer clearly is something that people are risk ark versive about, is to be fearful and anxious and doctors are not grief therapists or counselors, so it is not about having them [CHECK] providing that kind of care, but patients who hear that they're heard and understood and that those emotions are being acknowledged, will participate more in the medical visitation, and will work and collaborate with doctors better. The history quickly is doctor centered care to patient centered care. But it's moved now to what's called relationship centered care, because obviously it's not patients or doctors working independently, it's a dance. And then the next move, which is what we're promoting is the close examination of human interaction, that you can video record, that you can transcribe and study the patterns of. And all of that is I think a wonderful, [CHECK] but to intervene in more effective ways.

CAVANAUGH: Doctor wane beach, and doctor William Stanton, thank you so much for speaking with us today.

STANTON: Thank you Maureen.

BEACH: Thank you.

CAVANAUGH: If you would like to comment, please go on-line, KPBS.org/These Days.