We are delighted to review the article by Dr. Tony Back on communication with cancer patients. We applaud his effort to provide recommendations for enhanced communication with patients and families based on findings from the literature. We agree that using the cancer trajectory to identify key communication tasks provides a useful heuristic model because, by matching communication tasks to "high-stakes" clinical encounters, this approach intuitively appeals to practicing clinicians. As clearly described by Dr. Back, the vast majority of recommendations for communication among oncologist, patient, and family are not derived from evidence-based research. This underscores the importance of conducting additional research to use as a basis for guiding clinicians in how to handle these challenging communication tasks.
Available Evidence
One area of research for which there seems to be more evidence is in identifying patients' information needs and how best to give information to patients. These studies have shown that patients generally want a great deal of information about their disease and that they are able to identify clear preferences for one type of message delivery over another.[1-3]
The existing research on educational interventions suggests that it is possible to teach communication skills and that these skills can be transferred to the clinic and bedside with sufficient practice.[4,5] In this regard, we find Dr. Back's recommendations for specific behaviors (eg, ask patients what type of information and level of detail they would like to have) and for what not to do (eg, avoid stating that "there is nothing more that can be done") to be very useful and practical. We would like to also bring up the importance of very basic skills such as asking openended questions, effective listening, and allowing patients to express feelings. By the nature of this review, these skills are not covered extensively, but there is some evidence in the literature as to their impact.[6]
Emotional Distress
Dr. Back's discussion of emotional distress touches on several issues. One is the normal emotion that occurs in patients in response to, for example, hearing bad news. Responding to patient sadness or anxiety in these situations is a core skill addressed in most communication skills training programs. The detection of specific patient concerns such as side effects of treatment or family problems and their associated distress, however, may be of a second order of difficulty and not as easily mastered. The literature suggests that this task may be assisted by the use of screening instruments for clinical depression or anxiety disorders as well as distress-detection instruments.[7]
Conclusions
The dearth of empirically based data to guide teaching and clinical communication skills raises important issues about the use of current clinical guidelines to guide our teaching and practice of communication skills. The literature on interpersonal psychology, the sociology of illness, and the role of the physician as healer argues for kindness toward and respect for the medically ill, recognizes the power inherent in the position of the doctor, and acknowledges the ethical responsibilities toward patients and families.[8,9] This body of knowledge plays an important role in current "best practice" recommendations[10] for using and teaching key interpersonal and communication skills in oncology. Finding ways to empirically evaluate these recommendations remains a significant challenge that, heretofore, has not been taken up to a great extent by researchers in communication skills.
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