Annals of Oncology Advance Access originally published online on June 26, 2006
Annals of Oncology 2006 17(9):1450-1458; doi:10.1093/annonc/mdl142
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© 2006 European Society for Medical Oncology
oncology practice |
Factors that influence cancer patients' anxiety following a medical consultation: impact of a communication skills training programme for physicians
1 Université Libre de Bruxelles, Faculté des Sciences Psychologiques et de l'Éducation, Brussels
2 Université Libre de Bruxelles, Institut Jules Bordet, Brussels
3 Université Catholique de Louvain, Faculté de Psychologie et des Sciences de l'Éducation, Louvain-la-Neuve
4 C.A.M. (Training and Research Group), Brussels
5 Hôpital Universitaire Erasme, Service de Psychologie, Brussels
6 Université de Liège, Faculté de Médecine, Liège
7 Université de Liège, Faculté de Psychologie, Liège
8 Université Catholique de Louvain, Faculté de Médecine, Brussels, Belgium
*Correspondence to: Prof. D. Razavi, Université Libre de Bruxelles, Av. F. Roosevelt, 50 – CP 191, B-1050 Bruxelles, Belgium. Tel: +32-2-650-36-16; Fax: +32-2-650-22-09; E-mail: drazavi{at}ulb.ac.be
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Abstract |
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 Top Abstract introductionpatients and methodsresultsdiscussionAcknowledgementsReferences |
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Background: No study has yet assessed the impact of physicians' skills acquisition after a communication skills training programme on the evolution of patients' anxiety following a medical consultation. This study aimed to compare the impact, on patients' anxiety, of a basic communication skills training programme (BT) and the same programme consolidated by consolidation workshops (CW), and to investigate physicians' communication variables associated with patients' anxiety.
Patients and methods: Physicians, after attending the BT, were randomly assigned to CW or to a waiting list. The control group was not a non-intervention group. Consultations with a cancer patient were recorded. Patients' anxiety was assessed with the State Trait Anxiety Inventory before and after a consultation. Communication skills were analysed according to the Cancer Research Campaign Workshop Evaluation Manual.
Results: No statistically significant change over time and between groups was observed. Mixed-effects modelling showed that a decrease in patients' anxiety was linked with screening questions (P = 0.045), physicians' satisfaction about support given (P = 0.004) and with patients' distress (P < 0.001). An increase in anxiety was linked with breaking bad news (P = 0.050) and with supportive skills (P = 0.013). No impact of the training programme was observed.
Conclusions: This study shows the influence of some communication skills on the evolution of patients' anxiety. Physicians should be aware of these influences.
Key words: cancer, anxiety, medical consultation, communication skills, training
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introduction |
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TopAbstractintroductionpatients and methodsresultsdiscussionAcknowledgementsReferences |
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Anxiety is a frequent response to cancer diagnosis, treatment, remission and relapse. Prevalence of high anxiety in cancer patients varies from 10% to 50% [1]. Reducing the level of patients' anxiety is important because anxiety may lead to emotional distress and functioning disturbances [2, 3], and may interfere with patients' compliance [4]. It has been suggested that patients' anxiety during the initial consultation might undermine physician–patient relationship and that reducing anxiety during the consultation may lead to better patient understanding of information, stronger physician–patient relationship and, ultimately, enhanced patient well-being [5]. Studies have shown that physicians' communication during the first consultation was related to better long-term adjustment [6, 7]. Moreover non-effective physician–patient communication skills may lead to psychological distress including increased anxiety and depression and poorer psychological adjustment to cancer [4, 8, 9]. Physicians are thus in a key position to help reduce cancer patients' anxiety.
Some studies have investigated the impact of physicians' use of information on patients' anxiety (following a consultation). Physicians' transmission of adequate levels of information and the use of videotaped or written support, do not increase patients' anxiety [10–14] and in some cases even reduce patients' anxiety [13, 15–17]. Inadequate transmission of information [18, 19] or lack of information [7, 20, 21] on the contrary have been shown to increase patients' anxiety. In particular, one study has shown that 33% of patients were not reassured about their breast symptoms just after the medical consultation, despite having being told a benign diagnosis [22]. Another study has demonstrated that information disclosure was not predictive of patients' anxiety immediately after a first consultation where treatment options were discussed [20].
As regard supportive skills, two studies report that skills such as simple reassurance do not reduce anxiety (in particular for the most anxious patients) [23, 24]. Some specific forms of reassurance have even been shown to lead to an increase in patients' anxiety immediately after the medical consultation: this is particularly true for reassurance made before patients' concerns have been elicited [23]. It has been suggested that a key to successful reassurance might be the ability to assess patients' concerns before trying to reassure them [25]. This suggests that to reduce patients' anxiety after a consultation, physicians need to be able to use effective communication skills: an effective use of assessment, information and supportive skills can probably reduce patients' anxiety.
To acquire these skills physicians need to be trained. Physicians' communication skills can be improved following well-designed, skill-focused, practice-oriented and learner-centred communication skills training programmes [4, 26–29]. Workshops encouraging open questioning, eliciting of psychological concerns, empathy and summarising, while discouraging premature reassurance, ‘advice mode’, and leading questions have led to enduring changes and greater disclosure of patients' psychosocial problems [30]. Previously reported results of this study showed that, following a 20-h basic training, physicians used more assessment skills (eliciting and clarifying patients' concerns) [29]. Moreover, results showed that physicians who attended consolidation workshops following the basic training programme used more supportive skills (that is, used more empathy and more educated guesses) [29].
No study has yet assessed the impact of skills acquisition after a communication skills training programme on the pre–post consultation evolution of patients' anxiety. Moreover, at this point not enough studies have investigated the impact of communication variables and contextual factors on the pre–post consultation evolution of patients' anxiety.
The first aim of this study was to assess in a randomised design the impact of two communication skills training programmes (a basic training programme and a basic training programme consolidated by six 3-h workshops) on the pre–post consultation evolution of patients' anxiety. Training included a 1-h theoretical information course followed by two communication skills training programmes: a 2.5-day basic training programme and the same training programme consolidated by six 3-h consolidation workshops. It was hypothesised that consolidation workshops would be required in order to improve physicians' communication skills, which may reduce patients' anxiety (Figure 1). The second aim of this study was to investigate communication variables and contextual factors associated with the pre-post consultation evolution of patients' anxiety.
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patients and methods |
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study design and assessment procedure
To be included in the study, physicians had to be specialists and to be working with cancer patients (part time or full time). The efficacy of the consolidation workshops was assessed in a study randomly allocating physicians, after a basic training programme, to consolidation workshops or to a waiting list (Figure 2). The study was approved by the local ethics committee. The basic training programme was spread over a 1-month period. The consolidation workshops started 2 months later for participants who were immediately assigned to the workshops. The bimonthly workshops were spread over a 3-month period. Subjects assigned to the waiting list were invited to take part in the consolidation workshops 6 months after the end of the basic training programme. Detailed descriptions of the training programmes have been published previously [27, 29, 31].
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Assessments were scheduled before basic training programme (T1) and after consolidation workshops for the consolidation-workshop group and approximately 5 months after the end of basic training for the basic-training-without-consolidation-workshops group (T2). A consultation with a cancer patient was audiotaped at each assessment time. Patients were chosen by physicians. Inclusion criteria for patients included breaking news (bad, neutral or good), age older than 18 years, ability to speak French, absence of cognitive dysfunction and written informed consent. Patients were different at T1 and T2.
consultation rating system
All audiotapes were transcribed. Transcripts were assessed for their quality and then rated by trained psychologists. Rating was based on the French translation and adapted from the Cancer Research Campaign Workshop Evaluation Manual [32]. The Cancer Research Campaign Workshop Evaluation Manual was used to assess the form and function of each utterance. Eliciting and clarifying psychological information are considered as assessment skills, giving appropriate information, summarising, introducing and closing as information skills and educated guesses, empathy, alerting to reality and confronting as supportive skills. The construction of these categories has been tested in previous studies [29, 31, 33].
questionnaires
Before the consultations, each patient completed a sociodemographic questionnaire, the Hospital Anxiety and Depression Scale [34, 35] and the State Trait Anxiety Inventory [36]. Each physician completed a sociodemographic and socioprofessional questionnaire. After the consultations, each patient completed the State Trait Anxiety Inventory again and physicians had to report cancer-related information about patients. Physicians also filled in the Perception of Interview Questionnaire [29].
State Trait Anxiety Inventory – State (STAI-S) [36].
The 20-item STAI-S questionnaire measures general anxiety at the time of completion. Items have four response categories from ‘not at all’ to ‘very much so’, giving scores from 20 to 80. This scale has been translated into French and validated [37]. Each patient completed the STAI-S just before and just after the medical consultation.
Pre-post consultation evolution of patients' anxiety (evolution of patients' anxiety).
To assess the evolution of cancer patients' anxiety levels following the medical consultation a new variable was computed through a difference between patients' self-reported ratings of anxiety (STAI-S) after the medical consultation and patients' self-reported ratings of anxiety (STAI-S) before the medical consultation.
Hospital Anxiety and Depression Scale (HADS) [34].
The HADS is a four-point 14-item self-report instrument assessing anxiety and depression in physically ill subjects. This scale was translated into French, and validated in a sample of cancer in-patients [35]. Each patient completed the HADS just before the medical consultation.
Perception of the Interview Questionnaire [29, 33].
The Perception of the Interview Questionnaire is a 14-item, four-point scale ranging from 1 (not at all) to 4 (a lot). This questionnaire evaluates patients' and physicians' perceptions of physicians' behaviour in the consultation. Physicians completed their version of this questionnaire after the consultation. Items could be analysed separately.
statistical analyses
Statistical analyses of the data consisted of a comparative analysis of both groups of physicians at baseline using parametric tests and non-parametric tests as appropriate (t-tests and 
2 tests). Patients' characteristics at baseline and after intervention were compared using repeated measures analysis of variance (MANOVA) and 2 tests as appropriate. Correlation coefficients were first computed between the pre–post consultation evolution of patients' anxiety and the use of assessment, informative and supportive skills for each group of physicians at baseline and after the interventions. Time and group-by-time changes in the pre–post consultation evolution of patients' anxiety were then processed using repeated measures analysis of variance (MANOVA). All tests were two-tailed and the alpha was set at 0.05. Mixed-effects modelling was employed to investigate factors associated with the pre-post consultation evolution of patients' anxiety. An exploratory analysis was used to identify important covariates. Factors were entered in a multivariate model only if they satisfied the inclusion criterion (i.e. P < 0.10). A linear mixed-effects model with fixed effects was used.
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physician and patient sociodemographic data
The description of the recruitment procedure is summarised in Figure 2. Comparison of included and excluded physicians showed no statistically significant differences for age, gender and number of years of practice. Physicians demographic and socioprofessional characteristics are described in Table 1. No statistically significant differences were found at baseline between physicians who participated in the consolidation workshops and those randomised to the waiting list.
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As displayed in Table 2, no statistically significant differences were found in patients, disease and consultation characteristics over time and between the consolidation-workshop and the basic-training-without-consolidation-workshops groups when comparison was possible.
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influence of the training programs on intercorrelations between the pre-post consultation evolution of patients' anxiety and physicians' communication skills
As shown in Table 3, no significant correlations were observed at baseline between pre-post consultation evolution of patients' anxiety and physicians' assessment (i.e. utterances eliciting and clarifying psychological information), information (i.e. utterances giving appropriate information, summarising, introducing and closing) and supportive skills (i.e. making educated guesses, empathy, alerting to reality or confronting) both in the consolidation-workshop and the basic-training-without-consolidation-workshops groups.
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Six months after baseline, the pre-post consultation evolution of patients' anxiety became significantly positively correlated with physicians' use of supportive skills only in the consolidation-workshop group (r = 0.59, P
0.001).
Six months after baseline, physicians' use of supportive skills became correlated with their use of assessment skills in both groups (r = 0.43, P 0.05 in the basic-training-without-consolidation-workshops group and r = 0.67, P 0.001 in the consolidation-workshop group).
influence of the training programs on the pre-post consultation evolution of patients' anxiety
As shown in Table 4, repeated measures analysis of variance (MANOVA) showed no significant changes, over time and between groups, in pre-consultation anxiety levels (STAI-S), in post-consultation anxiety levels (STAI-S) and in the pre–post consultation evolution of patients' anxiety. The pre–post consultation evolution of patients' anxiety is negative at both assessment time and for both groups: on average, anxiety decreases after the consultation (mean = –2.9, SD = 14.0; P = 0.028, two tailed paired t-test).
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factors associated with the pre–post consultation evolution of patients' anxiety
Group (P = 0.987) and time (P = 0.572), although not significant, were retained in the model. The type of news given (P = 0.059), physicians' use of screening questions (P = 0.033), physicians' use of supportive skills (that is making educated guesses, empathy, alerting to reality or confronting) (P = 0.003), patients' self-reported distress (P < 0.001) and physicians' satisfaction about support given (P = 0.007) were identified as possible predictors and were retained in the multivariate model.
As shown in Table 5, mixed-effects modelling showed that the pre–post consultation evolution of patients' anxiety was negatively correlated with physicians' use of screening questions (P = 0.045), physicians' satisfaction about support given (P = 0.004) and with patients' self-reported distress (P < 0.001). Mixed-effects modelling also showed that the evolution of patients' anxiety was positively associated with physicians' breaking bad news (P = 0.050) and physicians' use of supportive skills (P = 0.013).
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discussion |
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TopAbstractintroductionpatients and methodsresultsdiscussionAcknowledgementsReferences |
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This is the first study assessing in a randomised design the impact of two communication skills training programmes (a basic training programme and a basic training programme consolidated by six 3-h workshops) on the pre–post consultation evolution of patients' anxiety (the evolution of patients' anxiety). The evolution of patients' anxiety was measured through a difference between patients' self-reported ratings of anxiety after the medical consultation and patients' self-reported ratings of anxiety before the medical consultation. The second aim of this study was to investigate communication variables and contextual factors associated positively or negatively with the evolution of patients' anxiety.
First of all, it should be underlined that, on average, patients' anxiety decreased following the consultation both at baseline and following training (which means 5 months after the basic training programme for the basic-training-without-consolidation-workshops group and immediately after the consolidation workshops for the consolidation-workshops group). This confirms results of studies that have shown that patients' anxiety often decreases following a consultation with a physician [13, 23, 38]. This can be explained by the fact that patients often experience anticipatory anxiety before their consultation with a physician and that after the consultation their anxiety generally decreases.
Contrary to what was expected, no statistically significant difference was observed in the pre-post consultation evolution of patients' anxiety following the communication skills training programmes whether physicians attended the basic training programme alone or the basic training programme followed by the consolidation workshops. It was hypothesised that an improvement in physicians' use of assessment, information and supportive skills would lead to an added decrease in patients' anxiety following the consultation. This has not been the case: learned assessment, information and supportive skills may not have been sufficient to further reduce patients' anxiety.
With regard to communication factors, mixed-effect modelling showed the influence of two types of communication skills on the evolution of patients' anxiety. First, the use of supportive skills (educated guesses, empathy and alerting to reality) was correlated positively with the evolution of patients' anxiety: supportive skills are counter-productive by generating anxiety. Secondly, the mixed-effects modelling showed that the more physicians used screening questions like ‘What else?’ or ‘Have you any other concerns or questions?’, the more patients' anxiety decreased following the consultation: screening questions thus reduce patients' anxiety.
Moreover, before training, the use of assessment, information and supportive skills by physicians was not correlated with the evolution of patients' anxiety. After training, for the physicians who were randomised to the consolidation workshops, supportive skills were correlated with an increase in patients' anxiety following the consultation: these results indicate that supportive skills acquired after training may produce anxiety. It should be noted also that for these physicians, the use of supportive skills was positively correlated with the use of assessment skills. It should finally be recalled that previously reported results of this study have shown that using assessment skills and supportive skills are factors that facilitate patients' distress detection by physicians [31].
What are the hypotheses which may explain all these results? On the one hand, it could be hypothesised that eliciting concerns is inherently linked to an increase of anxiety. On the other hand, it could be hypothesised that eliciting concerns produces anxiety only if during the consultation all concerns have not been assessed adequately. In other words, the increase in anxiety could be explained by the fact that physicians may interrupt the assessment of patients' concerns too soon. To reduce patients' anxiety physicians may need to have a precise picture of all patients' concerns. Although eliciting patients' concerns may at some point increase their anxiety, eliciting their whole range of concerns may reduce their anxiety level by giving patients the feeling they have been understood. This may be done by using screening questions that facilitate the identification of the whole range of patients' concerns. This study showed that the use of this type of question is associated with a decrease in anxiety. In this study, meanwhile, the use of assessment skills had no influence on the evolution of patients' anxiety. The reason for this may be that a simple increase in the use of assessment skills is not sufficient to elicit the whole range of patients' concerns and is, therefore, not sufficient to give patients the feeling that they have been understood. Screening questions like ‘What else?’ or ‘Have you any other concerns or questions?’ may generate this feeling.
The mixed-effects modelling also showed the influence of context variables on the evolution of patients' anxiety. The more the patients were anxious during the week before the consultation (measured by the Hospital Anxiety Depression Scale), the more their anxiety decreased following the consultation. This could be explained by the fact that patients experiencing anticipatory anxiety before a medical consultation are generally reassured by meeting the physician. Moreover, the mixed-effects modelling showed, as expected, that breaking bad news led to an increase in patients' anxiety following the consultation. Finally, the mixed-effects modelling showed that a decrease in patients' anxiety after the consultation was associated with physicians' satisfaction with provided reassurance. This confirms the result of a study that suggested that physicians are able to feel when they have been able to ease patients' anxiety [39].
This study did not take into account many other potential factors which may increase or reduce patients' anxiety level. One factor could be, for example, the use of specific terms: a recent study about patient–provider interactions during invasive procedures suggested that information-giving and sympathising with the patient with negative terms like pain or undesirable experience were associated with an increase in patients' anxiety [40]. Another factor could also be the physicians' non-verbal behaviours: eye contacts, speech tone, etc. Studies are needed to specify the impact of these potential factors on the evolution of patients' anxiety.
Our finding that the training programme had no impact on the evolution of patients' anxiety could also be explained by the fact that the measurement used here may not have been adapted for the context of this study. In other words, an assessment of ‘anxieties’ related directly to the different aspects/contents of a medical consultation could perhaps be more sensitive. Another hypothesis may be that the consultations in this study were heterogeneous and may thus not have been similar enough to produce the same type/intensity of contextual anxiety.
To our knowledge, this is the first study assessing in a randomised design the impact of two communication skills training programmes (a basic training programme and a basic training programme consolidated by six 3-h workshops) on the evolution of patients' anxiety. Contrary to what was expected, no significant difference was observed in the evolution of patients' anxiety following a communication skills training programme whether physicians attended the basic training programme alone or the basic training programme followed by consolidation workshops.
Results of this study confirm results of previous studies that have shown that some reassurance may produce anxiety and have suggested that communication skills are probably efficient if physicians elicit all their patients' concerns in depth by using screening questions [23]. Teaching physicians to address the whole range of patients' concerns with appropriate assessment, information and supportive skills could be useful to reduce anxiety.
Results of this study indicate the need to improve communication skills further which may reduce patients' anxiety. Helping physicians improve the way they deal with patients' anxiety during a medical consultation requires specific training modules. These training modules should include a theoretical lecture on general and situational factors that generate anxiety in order to focus physicians' attention on this issue. It could also be necessary to focus physicians learning on the practice of assessment skills (especially on screening questions tagging all patients' concerns), on the practice of supportive skills (that is making educated guesses, empathy, alerting to reality or confronting when appropriate) and on the practice of informative skills (that is responding adequately to patients' concerns).
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Acknowledgements |
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This research programme was supported by the ‘Fonds National de la Recherche Scientifique—Section Télévie’ of Belgium, by the ‘Fonds d'Encouragement à la Recherche de l'Université Libre de Bruxelles’ and by the C.A.M. training and research group (Brussels, Belgium). We are grateful to all the physicians and patients who participated in the study.
Received for publication February 23, 2006. Revision received April 12, 2006. Accepted for publication May 5, 2006.
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