Effective communication between health-care professionals and patients is essential for the delivery of high-quality health care. Communication issues are often a critical factor in litigation. Research has suggested that effective communication during medical encounters positively influences patient recovery, pain control, adherence to treatment, satisfaction, and psychological functioning.[3,35] Due to the threat of mortality from the diagnosis of cancer, uncertainty of therapy efficacy, and the physical and emotional stress of undergoing chemotherapy, patients must obtain a high level of complex information during communications with their treating physician.[36,37]
Older adults diagnosed with cancer are the population group considered to be at highest risk for poor communication with health professionals. The older patient is less likely to be assertive and ask in-depth questions. Overall physician responsiveness (ie, the quality of questions, informing, and support) is better with younger patients than with older patients, and there is less concordance on the major goals and topics of the visit between physicians and older patients than between physicians and younger patients.[38,39]
Physician-Patient Communication and Oral Literacy Demand The underpinning of effective verbal communication in the medical encounter is the interaction between a patient’s health literacy level and the quality of dialogue between patient and physician. “Oral literacy demand” can be defined as the aspects of dialogue that challenge patients with low literacy skills. During conversations, the general language complexity increases with the greater number of sentences in the passive voice and faster dialogue pacing, both of which have negative effects on comprehension.
The use of technical terminology is an important component of oral literacy demand. Research done on adult literacy of genetic information presented during genetic counseling sessions suggests that literacy demand was proportional to the use of technical terms. A doctor’s choice of vocabulary can affect patient satisfaction immediately after a general practice consultation, and if the doctor uses the same vocabulary as the patient, patient outcomes improve. In addition, studies have found increased “dialogue density”—or the duration of uninterrupted speech by a physician—correlates with greater oral literacy demand. A review 152 prenatal and cancer pretest genetic counseling sessions with simulated clients found that the higher use of technical terms, and the more dense and less interactive the dialogue, the less satisfied the simulated clients were and the lower their ratings were of counselors’ nonverbal effectiveness.
In addition, patients with low health literacy are less likely to ask their physician to slow down the dialogue and repeat information when their understanding is compromised. Interventions to modify health-care provider use of technical terms, general language complexity, and structural characteristics of dialogue can enhance overall communication by decreasing patient oral literacy demand.
Communication Barriers in the Elderly
The literature suggests that evaluating such factors as memory decline and sensory deficits are essential in geriatric patient medical visits. These common age-related communication barriers are often overlooked in the oncology consultation and frequently compromise the quality of communications. There is a broad range of cognitive loss among individuals with dementia, and unless the physician is trained to uncover this problem, it can be missed in patients with mild or even moderate loss. For example, the 1999–2001 National Health Interview Surveys (NHIS) indicate that 2.3 million (7.1%) community dwelling people aged 65 and over are limited by memory impairment or confusion, while 800,000 (2.4%) are limited by senility and dementia.
In addition to cognition, hearing and vision are important components of communication. Presbycusis, or decreased hearing of higher frequency sounds, is one of the most common and significant sensory changes that affect elderly people. The incidence of sensorineural hearing loss increases each decade so that by the 7th and 8th decades, 35% to 50% of older adults have hearing impairment. Vision loss also has a significant impact on physician-patient interaction because visual cues are vital in interaction. After age 65 there is a decrease in visual acuity, contrast sensitivity, glare intolerance, and visual fields. Based on the 1997–2002 NHIS, 15% to 25% of older adults had visual impairment. The combination of both hearing and visual impairment among elders aged 65 to 79 was 7% and increased to 17% for individuals aged 80 and over.
Physician visits for elderly patients with these functional impairments may be so difficult to coordinate that they result in frequently missed appointments. When these frail older patients finally do see the physician, the visits may be emotionally and physically stressful for them, limiting effective communication.[10,39]
Low levels of health literacy present challenges to any decision-making paradigm,[48,49] especially in the case of complex cancer treatment decisions in the elderly. Complexity in the cancer treatment decision process originates from the fact that selection of therapy is unique to every patient. Typically, several treatment options are possible and the oncologist and patient must together carefully weigh the risk of toxicity against potential benefit. Patient preferences, quality of life, and social responsibilities must be considered along with the stage of disease, biologic characteristics of the tumor, and comorbid illnesses.
Cancer Treatment Decisions and Self-Efficacy One important factor in decision-making is “self-efficacy,” or confidence in one’s ability to understand and communicate with physicians. Patients with high self-efficacy have been found to have fewer episodes of depression and develop more realistic goals. An important aspect of self-efficacy is the sense of control and involvement in the treatment, which has been associated with several desirable outcomes including greater patient satisfaction, increased adherence to treatment, and positive treatment outcomes in elderly patients. Evidence suggests that cancer patients who report greater self-efficacy are better adjusted and experience greater quality of life than those with low self-efficacy.