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Perceived difficulties in consulting with patients and families: a survey of Australian cancer specialists

Aneta Dimoska, Afaf Girgis, Vibeke Hansen, Phyllis N Butow and Martin H N Tattersall
Med J Aust 2008; 189 (11): 612-615.
Published online: 1 December 2008

Abstract

Objective: To determine what aspects of communicating and consulting with cancer patients are viewed as difficult and stressful by cancer specialists in Australia.

Design, participants and setting: Anonymous, cross-sectional, Internet-based survey completed by 134 cancer specialists between June and August 2007. Participants, who were all members of the Clinical Oncological Society of Australia, included oncologists and palliative care specialists.

Main outcome measures: Degree of difficulty perceived for various consultation tasks; level of stress reported during various practice-related situations.

Results: Doctors had the most difficulty discussing high-cost drugs with patients they knew could not afford them, followed by topics relating to treatment failure. They had the least difficulty telling patients they had cancer or being honest about prognosis. The most stressful practice situations included having incomplete patient information to conduct the consultation and having a long line of patients waiting for a consultation. At least 62% of respondents reported experiencing some degree of stress in all the practice situations presented. There were differences in difficulty and stress experienced as a function of the doctor’s sex, age and clinical experience.

Conclusions: Targeted, evidence-based guidelines and communication courses are required to better equip cancer specialists for providing non-directive advice about unsubsidised high-cost drugs and for offering different forms of hope in the context of treatment failure. Implementing small organisational changes — such as reducing interruptions during consultations and informing patients of the duration of their allocated consultation — may also help reduce stressful practice situations.

“Burnout”, the end result of repeated exposure to stress, is characterised by apathy, depression, health problems and the eventual inability to work.1 Cancer specialists are at particular risk of burnout because of the nature of their work, with 28%–56% reportedly suffering at least one episode of burnout in their career.1,2 Communicating with patients has been identified as a significant source of stress for these doctors,2,3 particularly when it involves breaking bad news4,5 and if they feel inadequately trained for the task.2 With cancer specialists conducting an average of 35 bad-news discussions per month,5 the accumulated effect of these events can have an impact on the doctor’s health and the quality of care provided to patients.6

Baile and colleagues5 surveyed 167 cancer specialists attending the 1999 Annual Meeting of the American Society of Clinical Oncology. The most difficult communication tasks reported were those dealing with a lack of curative treatment options for a patient, euthanasia, cancer recurrence, treatment failure, and do-not-resuscitate (DNR) orders. Doctors reported feeling unable to deal with emotional reactions to bad news5 and having a fear of eroding all hope in the patient.7

Practice-related stressors place further strain on doctors and their interactions with patients. In a study of Australian general practitioners, time constraints and phone interruptions during patient consultations were rated among the top three most frequent stressors.8 Cancer specialists have reported that time constraints are a major barrier to providing adequate information to patients9 and to involving them in treatment decisions.10

Our aim in this study was to determine what aspects of consulting with cancer patients are perceived by Australian cancer specialists as difficult and stressful.

Methods

Our survey was part of a larger study on stress and burnout among members of the Clinical Oncological Society of Australia (COSA).11 In May 2007, members of COSA (n = 1322) were informed about an upcoming survey on stress and burnout. Of these, 1157 agreed to receive further information. After receiving the invitation, 165 declined further contact and nine reported that they no longer worked in cancer care. Of the 740 respondents to the larger survey, 151 identified themselves as oncologists or palliative care specialists (the remainder were nurses, psychologists, social workers and members of other non-medical specialties). The 151 cancer specialists were asked to complete an Internet-based “consultation stress questionnaire”.

Questionnaire design

The consultation stress questionnaire was a modified version of that used by Baile et al.5 A shorter questionnaire was piloted among eight COSA members. The final questionnaire contained 11 items measuring the difficulty experienced when conducting various consultation tasks and eight items measuring stress experienced in relation to various practice factors. Responses were reported on a four-point Likert scale (“not at all”, “somewhat”, “quite a bit” or “a lot”). Participants also provided demographic information (age, sex, education level) and practice information (cancer specialty, number of years in current position, geographical region of work).

Procedure

Participants received the survey invitation either via email or by post (if requested). Invitations provided a web address for accessing the questionnaire and personal log-in details. Three reminders were sent to non-responders 2, 3 and 6 weeks after the initial invitation. For participants who received the postal invitation, the second reminder also included a printed copy of the survey.

Analyses

Responses were cross-tabulated for each item across the four response categories. Subsequently, differences in age (median, 49 years) and number of years in current position (median, 17 years) were examined by dividing the sample into two groups using median splits and using χtests. To ensure adequate numbers in each cell for between-group analyses, the response categories “somewhat”, “quite a bit” and “a lot” were subsumed into one category (“stress”) and compared with “not at all” (“no stress”).

Ethics approval

The questionnaire and protocol were approved by the University of Sydney and University of Newcastle human research ethics committees.

Results

Of the 151 eligible participants identified, 134 completed the questionnaire (89% response rate). Of the 17 non-respondents, 16 were surgical oncologists and one was a radiation oncologist. Based on figures from the Royal Australasian College of Physicians and the Royal Australasian College of Surgeons, our sample represented about 20% of practising oncologists and 4% of palliative care specialists in Australia.

Demographic characteristics of the sample were as follows: 70% male; 91% working in metropolitan areas; 63% medical oncologists, 20% radiation oncologists, 11% surgical oncologists and 6% palliative care specialists; mean age, 49.1 years (SD, 10.1 years; range, 31–76 years); and mean length of experience in current position, 17.6 years (SD, 10.6 years; range, 1–40 years).

Self-reported levels of difficulty in conducting particular consultation tasks are summarised in Box 1. Discussing high-cost drugs with patients who doctors believe cannot afford them caused the greatest difficulty, with 78% of doctors reporting at least some difficulty. Other difficult discussions were about treatment failure (67%), DNR orders (63%), transition from curative to supportive care (62%), and cancer recurrence (62%).

Self-reported levels of stress experienced during different practice situations are presented in Box 2. Almost all doctors reported being at least somewhat stressed when there was a long line of patients waiting to see them (97%) and when they had inadequate patient information (93%). Other sources of stress included interruptions during consultations (86%), seeing patients when doctors were unwell themselves (85%), and managing office staff (79%).

Sex

More male doctors than female doctors had difficulty responding to patients’ emotions (65% v 46%; χ2 = 4.1; P < 0.05). More female than male doctors had difficulty discussing complementary therapies (59% v 37%; χ2 = 5.6; P < 0.05) and found the following situations stressful: having inadequate patient information (100% v 90%; χ2 = 3.9; P < 0.05), interruptions (97% v 82%; χ2 = 5.5; P < 0.05), seeing patients when they were unwell themselves (97% v 81%; χ2 = 6.1; P < 0.01), and disagreeing with colleagues in multidisciplinary meetings (76% v 59%; χ2 = 3.5; P < 0.05).

Age

Younger doctors (aged < 49 years) had greater difficulty discussing complementary therapies than older doctors (57% v 28%; χ2 = 11.5; P < 0.01) and were more stressed by consultation interruptions (93% v 80%; χ2 = 4.7; P < 0.05).

Years in current position

Compared with more experienced colleagues, doctors who had been less than 17 years in their current position were more likely to report difficulty in discussing high-cost drugs (85% v 69%; χ2 = 4.4; P < 0.05) or complementary therapies (55% v 29%; χ2 = 9.0; P < 0.01), and in seeing patients when they themselves had problems at home (67% v 44%; χ2 = 6.7; P < 0.01). They also reported being more stressed by consultation interruptions (93% v 78%; χ2 = 6.4; P < 0.05) and disagreements in multidisciplinary meetings (72% v 54%; χ2 = 4.6; P < 0.05).

Discussion

Our study revealed that most Australian cancer specialists have particular difficulty discussing high-cost drugs with patients they believe cannot afford them. The second most difficult topic was treatment failure. Practice-related factors, affecting interactions with patients, also caused stress in over 60% of our respondents.

Although anti-cancer drugs are the most rapidly growing group of drugs within the Pharmaceutical Benefits Scheme (PBS),12 a large number of effective drugs are listed only for particular indications. Our findings echo those of a survey by Thomson and colleagues of 184 Australian medical oncologists, which revealed that only a third of oncologists would discuss a new drug with a patient if the drug was not PBS-subsidised.13 However, doctors have an ethical, and most likely legal,14 duty to inform patients about any clinically relevant treatment options and side effects.13 These findings suggest that cancer specialists would benefit from guidelines on how to discuss unfunded high-cost drugs. We support the view of Thomson and colleagues that such discussions could follow the initial presentation of standard options,13 and add that doctors should outline differences between treatment options in costs versus the likelihood of benefits.

The fact that the doctors in our survey reported the least difficulty with disclosing cancer diagnosis or being honest about a patient’s prognosis is an improvement on the findings of a decade ago, suggesting that training in these topics has reduced discomfort.5,15 However, given that two-thirds reported difficulty with topics surrounding treatment failure, doctors may need targeted communication skills training on moving the emphasis to symptom control, exploring realistic goals and other forms of “hope”, and providing psychosocial support.16 Similarly, discussions about DNR orders could be an opportunity to identify and reaffirm the patient’s values about hoping for a peaceful death.17 We recommend that cancer specialists read the recently released guidelines on how to best discuss these and other end-of-life issues.18

Discussing complementary therapies caused particular difficulty for female doctors, younger doctors and less experienced doctors in our survey. This contrasts with a study that showed female and younger doctors had a more favourable attitude towards complementary therapies.19 Our results may reflect a lack of confidence in such discussions due to gaps in knowledge.20 Currently, complementary medicine is not acknowledged in the Australian medical curriculum.21

While some stressors cannot easily be ameliorated in busy cancer clinics, the incidence of others can be reduced by small organisational changes. For example, long appointment lists that do not allow sufficient time for each patient to be seen should be curtailed. Is it reasonable that newly referred cancer patients be seen within a 15-minute consultation? It may be helpful to inform patients before their appointment of how much time they have been allocated.22 Communication aids that allow cancer patients to identify questions to ask their doctor before their appointment may also reduce consultation times.23 Prohibiting phone and staff interruptions, which reportedly consume 4% of oncology consultations,24 is a relatively simple strategy.

Cancer care often involves meetings of a multidisciplinary team, making maintenance of complete patient records and sharing of information difficult. Having electronically accessible records can minimise problems of inadequate patient information25 and help reduce phone and staff interruptions.

However, the attitudes and habits of staff at all levels can be barriers to changing practices. Education of, and consultation with, medical, management and administration staff about specific stressors, together with a policy of promoting a stress-free environment championed by senior staff, will aid in the successful adoption of changes.26

A limitation of our study was that participants were self-selected members of COSA. Surveying a larger and more random sample would strengthen our findings, as would the inclusion of a more representative sample of palliative care specialists. Furthermore, use of a structured survey may have excluded analysis of other relevant stressors that might be elicited by a qualitative approach. Finally, as we did not measure doctors’ level of exposure to different practice situations, we cannot rule out the possibility that low scores reflect a lack of exposure, rather than better coping skills.

Although ameliorating the difficulties experienced by cancer specialists in dealing with patients is not simple, our findings highlight areas to target in evidence-based training. Small organisational changes, such as reducing phone and staff interruptions during consultations and informing patients how much time is allocated for their consultation, may have immediate effects on reducing doctors’ stress levels.

1 Level of difficulty reported by cancer specialists for various consultation tasks

Number of respondents (%)


I find it difficult to:

Not at all

Somewhat

Quite a bit

A lot


Tell patients they have cancer

91 (68%)

38 (28%)

5 (4%)

0

Tell patients they have a cancer recurrence

51 (38%)

66 (49%)

15 (11%)

2 (2%)

Discuss bad test results with a patient

55 (41%)

68 (51%)

11 (8%)

0

Discuss treatment failure

44 (33%)

74 (56%)

14 (11%)

1 (1%)

Discuss transition from curative to supportive care with patients

50 (38%)

68 (51%)

12 (9%)

3 (2%)

Bring up the topic of do-not-resuscitate orders

49 (37%)

61 (46%)

19 (14%)

4 (3%)

Respond to patients when they are emotional

53 (41%)

63 (48%)

13 (10%)

2 (2%)

Be completely honest about a patient’s prognosis

81 (61%)

45 (34%)

5 (4%)

2 (2%)

Discuss high-cost drugs with patients I know cannot afford them

28 (22%)

56 (44%)

26 (21%)

17 (13%)

Discuss complementary therapies with patients

75 (57%)

44 (33%)

11 (8%)

2 (2%)

Deal with patients when I have problems at home

57 (44%)

62 (47%)

10 (7%)

2 (2%)

2 Level of stress reported by cancer specialists for various practice-related situations

Number of respondents (%)


It is stressful for me when:

Not at all

Somewhat

Quite a bit

A lot


Patients or their families ask too many questions

50 (38%)

75 (57%)

5 (4%)

2 (2%)

I have to handle my own negative feelings when interacting with patients

44 (33%)

78 (59%)

10 (8%)

0

I don’t have all the relevant information about a patient that I need to conduct the consultation

9 (7%)

47 (36%)

53 (40%)

23 (17%)

There is a long line of patients waiting to see me

4 (3%)

52 (39%)

52 (39%)

24 (18%)

I am interrupted during the consultation (eg, by the phone ringing)

18 (14%)

71 (54%)

33 (25%)

10 (8%)

I am unwell myself and I have to see patients

19 (15%)

75 (57%)

28 (21%)

9 (7%)

I have the additional responsibility of managing staff in the office

28 (21%)

78 (60%)

21 (16%)

4 (3%)

I conflict with a colleague in a multidisciplinary meeting regarding a decision about a patient

47 (36%)

65 (50%)

14 (11%)

5 (4%)

  • Aneta Dimoska1
  • Afaf Girgis2
  • Vibeke Hansen2
  • Phyllis N Butow1,3
  • Martin H N Tattersall1,3

  • 1 Centre for Medical Psychology and Evidence-based Decision Making, University of Sydney, Sydney, NSW.
  • 2 Centre for Health Research and Psycho-oncology, The Cancer Council NSW, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW.
  • 3 University of Sydney, Sydney, NSW.

Correspondence: adimoska@psy.unsw.edu.au

Acknowledgements: 

Our data were collected as part of a larger study commissioned by COSA and funded by Cancer Australia. The assistance of both organisations is gratefully acknowledged. We also thank Margaret McJannett and her team for facilitating contact with COSA members; the University of Newcastle’s Corporate Information Unit for online survey administration; and the members of COSA who completed the survey.

Competing interests:

Afaf Girgis was paid by COSA as a consultant to undertake the research project within which our survey questions were nested. Neither COSA nor Cancer Australia was involved in the study design, data collection, analysis or interpretation, or in the writing of this article.

  • 1. Whippen DA, Canellos GP. Burnout syndrome in the practice of oncology: results of a random survey of 1000 oncologists. J Clin Oncol 1991; 9: 1916-1920.
  • 2. Ramirez AJ, Graham J, Richards MA, et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer 1995; 71: 1263-1269.
  • 3. Graham J, Ramirez AJ, Cull A, et al. Job stress and satisfaction among palliative physicians. Palliat Med 1996; 10: 185-194.
  • 4. Tattersall MH, Butow PN, Clayton JM. Insights from cancer patient communication research. Hematol Oncol Clin North Am 2002; 16: 731-743.
  • 5. Baile WF, Lenzi R, Parker PA, et al. Oncologists’ attitudes toward and practices in giving bad news: an exploratory study. J Clin Oncol 2002; 20: 2189-2196.
  • 6. Shanafelt TD, Novotny P, Johnson ME, et al. The well-being and personal wellness promotion strategies of medical oncologists in the North Central Cancer Treatment Group. Oncology 2005; 68: 23-32.
  • 7. Buckman R. Breaking bad news: why is it still so difficult? Br Med J (Clin Res Ed) 1984; 288: 1597-1599.
  • 8. Schattner PL, Coman GJ. The stress of metropolitan general practice. Med J Aust 1998; 169: 133-137. <MJA full text>
  • 9. Graham J, Ramirez AJ. Improving the working lives of cancer clinicians. Eur J Cancer Care (Engl) 2002; 11: 188-192.
  • 10. Shepherd HL, Tattersall MH, Butow PN. Physician-identified factors affecting patient participation in reaching treatment decisions. J Clin Oncol 2008; 26: 1724-1731.
  • 11. Girgis A, Hansen V, Goldstein D. Are Australian oncology health professionals burning out? A view from the trenches. Eur J Cancer 2008. In press.
  • 12. Sweeny K. Trends in the use and cost of pharmaceuticals under the Pharmaceutical Benefits Scheme. Melbourne: Centre for Strategic Economic Studies, 2002: 1-28. (Pharmaceutical Industry Project: Equity, Sustainability and Industry Development. Working Paper No. 5.) http://www.cfses.com/documents/pharma/05-Trends_in_Pharmaceuticals_PBS.PDF (accessed Oct 2008).
  • 13. Thomson J, Schofield P, Mileshkin L, et al. Do oncologists discuss expensive anti-cancer drugs with their patients? Ann Oncol 2006; 17: 702-708.
  • 14. Chappel v Hart (1998) 156 ALR 517.
  • 15. Butow PN, Kazemi JN, Beeney LJ, et al. When the diagnosis is cancer: patient communication experiences and preferences. Cancer 1996; 77: 2630-2637.
  • 16. Clayton JM, Butow PN, Arnold RM, Tattersall MH. Fostering coping and nurturing hope when discussing the future with terminally ill cancer patients and their caregivers. Cancer 2005; 103: 1965-1975.
  • 17. Crampton J. DNR or PEACE? BMJ 2008; 336: 1015.
  • 18. Clayton JM, Hancock KM, Butow PN, et al. Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers. Med J Aust 2007; 186 (12 Suppl): S77-S108. <MJA full text>
  • 19. Ernst E, Resch KL, White AR. Complementary medicine. What physicians think of it: a meta-analysis. Arch Intern Med 1995; 155: 2405-2408.
  • 20. Newell S, Sanson-Fisher RW. Australian oncologists’ self-reported knowledge and attitudes about non-traditional therapies used by cancer patients. Med J Aust 2000; 172: 110-113. <MJA full text>
  • 21. Owen D, Lewith GT. Teaching integrated care: CAM familiarisation courses. Med J Aust 2004; 181: 276-278. <MJA full text>
  • 22. Dugdale DC, Epstein R, Pantilat SZ. Time and the patient–physician relationship. J Gen Intern Med 1999; 14 Suppl 1: S34-S40.
  • 23. Brown RF, Butow PN, Dunn SM, Tattersall MH. Promoting patient participation and shortening cancer consultations: a randomised trial. Br J Cancer 2001; 85: 1273-1279.
  • 24. Dimoska A, Butow PN, Dent E, et al. An examination of the initial cancer consultation of medical and radiation oncologists using the Cancode interaction analysis system. Br J Cancer 2008; 98: 1508-1514.
  • 25. Sicotte C, Paré G, Moreault M-P, Paccioni A. A risk assessment of two interorganizational clinical information systems. J Am Med Inform Assoc 2006; 13: 557-566.
  • 26. Rycroft-Malone J, Harvey G, Seers K, et al. An exploration of the factors that influence the implementation of evidence into practice. J Clin Nurs 2004; 13: 913-924.

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