Leitlinienprogramm OnkologiePsycho-oncology

11. Patient-centered Communication – Psycho-oncology

Version 2.0 · May 2023 · AWMF 032-051OL
Leitlinienprogramm Onkologie · Deutsche Krebsgesellschaft · Deutsche Krebshilfe · AWMF

11.1 · Consensus-based Statement · modified 2023

Patient-centered communication refers to an approach in communicating that perceives the patient in their current physical, emotional and social situation, takes into account their personal values, needs and preferences, and promotes their self-competence, ability to act and make decisions.

Consensus
Strong consensus (100%)
Change note11.5 Patient-centered communication refers to communicative behavior that perceives the patient in his or her current physical and emotional state, takes into account his or her personal values, needs, and preferences, and promotes his or her self-competence, ability to act, and decision-making skills.
11.2 · Consensus-based Recommendation · modified 2023

All professional groups working in oncology shall communicate with cancer patients and their relatives in a patient-centered manner, i.e. oriented towards the individual concerns, needs, values and preferences of patients and relatives with regard to information, education and participation in decision-making.

Consensus
Strong consensus (100%)
Change note11.6 Communication with cancer patients and their relatives should be patient-centered by all professional groups working in oncology. It should be oriented to their individual concerns, needs and preferences with regard to information, education and participation in decision-making. These should be asked repeatedly during the course of the disease, especially in critical phases (diagnosis, relapse/progression).
11.3 · Consensus-based Recommendation · modified 2023

The communicative preferences of cancer patients and their relatives shall be assessed regularly during the course of the disease, especially in critical phases (diagnosis, progression/recurrence).

Consensus
Consent (88%)
Change noteThe original recommendation (11.6) is divided into two parts (new 11.2 + 11.3)

11.1 Basic Principles and Use of Patient-centered Communication

11.4 · Consensus-based Recommendation · modified 2023

Patient-centered communication shall be guided by the following basic principles:

  • Creating an appropriate, undisturbed environment for conversation
  • Sufficient time
  • Establishing a sustainable, supportive relationship with the patient and family members
  • Conducting the conversation on the basis of active listening
  • Exploration of the patient's subjective level of information
  • Direct and empathetic addressing of emotionally stressful topics
  • Conveying important information in a comprehensible language that is as simple as possible
  • Honest communication of risk and prognosis, leaving room for realistic hope
  • Using strategies to ensure patient understanding and retention of information
  • Encouragement to ask questions
  • Encouragement to express feelings
  • Expressing emotional support
  • Reassurance that the patient has understood the relevant information in the intended way
  • Involving relatives or caregivers depending on the patient's wishes.
  • Offering further psychological and social services
Consensus
Consent (94%)
Change notePatient-centered communication should be guided by the following basic principles: Ensuring an atmospherically appropriate and undisturbed environment without interruptions Establishing a sustainable relationship with the patient Conducting the conversation on the basis of active listening Addressing difficult topics directly and empathetically Conveying significant information in language that is close to the patient, avoiding medical vocabulary, explaining technical terms if necessary. It should be sincere and at the same time leave room for realistic hope Use of strategies to improve understanding (repetition, summary of important information, use of graphics, etc.) Encouragement to ask questions as well as to express feelings Involvement of relatives or caregivers depending on the patient's wishes Offer of further assistance
11.5 · Consensus-based Recommendation · new 2023

To promote patient-centered communication, empirically proven tools such as lists of questions, information brochures, fact boxes, or decision aids can be used during a consultation.

Consensus
Consent (94%)
11.6 · Consensus-based Statement · new 2023

In the context of the digitalization of the health care system, digital media are being used more frequently for communication between practitioners and patients. Interaction via digital media has some special features. These include, for example, the tendency to use short, concise sentence fragments and the frequent use of abbreviations. These peculiarities can limit the quality of patient-centered communication. Patient-centered communication via digital media thus requires a reflective attitude and approach.

Consensus
Strong consensus (100%)
11.7 · Consensus-based Recommendation · new 2023

Breaking bad news shall not take place on the phone or via digital media, rather through in a personal contact.

Consensus
Strong consensus (100%)
11.8 · Consensus-based Recommendation · new 2023

In special justified situations or at the explicit request of the patient, telemedicine media can be used to convey bad news.

Consensus
Strong consensus (100%)

The implementation of patient-centered communication is a central task of all professional groups working in oncology. In view of the described functions of patient-centered communication, it is obvious that this is relevant in all phases of patient care, from diagnosis to follow-up care. The basic core competencies of patient-centered communication are [1031]; [1032], [1033]:

  • Before the interview: viewing available medical information; creating goals for the interview; anticipating the needs and reactions of the patient and family members
  • Exploration of the patient's level of knowledge; collaborative topic setting; building trust and confidence in the practitioner's skills; establishing a partnership approach
  • Communicate current information based on the patient's concerns and preferences for information.
  • Check patient's understanding; document important issues that were discussed
  • Provide opportunities for follow-up questions; repeat and summarize important information
  • Respond empathically to the patient's verbal and nonverbal emotional expressions; express respect and sympathy; convey hope; use language that is universally understood

Gilligan et al. [1034] identify the following as important clinically relevant situations: discussing treatment goals and prognosis; discussing treatment options, including participation in clinical trials; discussing end-of-life care; incorporating family members in care; dealing with barriers to communication (e.g., foreign language patients, use of interpreters, patients with minimal health literacy); discussing the cost of treatment; and providing needs-based care to underserved, marginalized groups (minorities).
Current developments in personalized oncology/precision oncology also create clinically relevant situations that present a great challenge in terms of communication. Patients consenting to molecular diagnostics and possibly receiving novel immunotherapy have a high need for information, often a limited understanding of the goal of the diagnostics, unrealistic expectations of therapy, and a sense of uncertainty [1035], [1036], [1037], [1038], [1039]. Establishing informed consent, participatory decision-making, consideration of patient autonomy, and communicating a prognosis fraught with uncertainty represent typcial tasks of physician communication in this situation. In addition, the patient's reactions to the results of the diagnosis and the resulting options must be addressed in the conversation [1040][1041]. According to Kaphingst et al. [1042], there are still significant research gaps on the effects of communication between practitioner and patient.
Various recommendations for a structured approach (heuristic models) are available to help practitioners structure the patient consulatation and overcome communicative challenges. They are based on empirical findings, clinical experience and expert consensus. The best-known model is SPIKES, which was developed for the communication of bad news [1043]. Other examples of such heuristic models are: REMAP, for talking about treatment goals [1044]; the 3-step Model for addressing emotional distress of patients [1045]; or AEGIS, which can be used for communicating prognosis [1046]. In addition to such heuristic models, numerous works provide concrete formulation suggestions for statements made by practitioners in relation to specific communicative challenges [1034], [1033], [1040], [1043], [1044], [1047], [1046], [1048], [1049].

In the face of ongoing globalization and continuous migration, practitioners will encounter increasing numbers of patients who have language barriers or low health literacy. Especially in such situations, it is necessary to use simple, clear language that is free of technical terms that are difficult to understand [1050].
In the conversation between practitioner and patient, various tools can be used to support patient-centered communication. If patients use a list of keywords or questions in the conversation, they typically ask more questions and retain more information from the consultation than if no list is used. However, the use of a cue list has no effect on patients' mental well-being or satisfaction [1051], [1052], [1053], [1054]. Similar results are shown when patients receive an audio recording of the conversation with the practitioner [1053]. Positive effects in terms of patient knowledge and satisfaction are also shown for patient brochures that are handed out as part of the practitioner-patient consultation. Furthermore, there are indications that handing out information brochures can have a positive effect on therapy adherence [1055].

Conveying risks presents a particular challenge in terms of communication. Comprehension of risk is influenced by health literacy and numeracy [1056], [1057]. Furthermore, the way risks are presented has an influence on the understanding of risks and on subsequent decisions (framing effect) [1056], [1058], [1059], as well as on the emotional reaction of the recipient [1060]. The communication of risks should be presented numerically rather than textual [1061]; [1059] and supported by graphical aids such as tables and bar charts [1057], [1059], [1058], [1062], [1063], [1064], which helps to improve comprehension – even by those practitioners who have difficulty understanding them [1065]. Probabilities should be expressed as natural frequencies [1063], [1064], for which fact boxes are suitable tabular aids [1061], [1066]. However, the assessment of future risks is also subject to subjective concepts of risks and probabilities as well as affective influences [354], [1067], [1060], which need to be taken into account when making decisions [1068] and require an individualized approach to risk communication and decision making.


Regarding the effect of decision aids for patients with a wide range of diseases, a Cochrane review found that decision aids for screening, treatment, or prevention increase the level of knowledge and accuracy of risk assessment, reduce decision conflicts, increase awareness of one's own values, lead to a higher congruence between personal values and the decision made, and also lead to higher patient satisfaction [1069]. A subgroup analysis for patients with cancer yielded almost identical results [1070]. This confirms the results of a previous meta-analysis, which showed positive effects with regard to knowledge and decision conflict [O'Brien, Mary Ann et al. 2009]. Regarding specific diagnostic groups, a review of breast cancer patients showed that decision aids for screening or treatment had a positive effect on reducing decision conflict, but no effect on knowledge and satisfaction [1072]. Reviews that examined decision aids exclusively for treatment decisions (not screening) found positive effect for decision conflict, knowledge level, informedness, perceived involvement in decision, and satisfaction [1073], [1074], [1075]. Comparably, positive effects of decision support were found for the question of genetic testing for patients with breast cancer. Here a positive effect could be determined regarding knowledge level and satisfaction [1076]. Reviews of decision aids for therapy decisions in patients with prostate carcinoma [1077], [1078], [1079], colorectal carcinoma, and lung carcinoma [1080] show overall contradictory results regarding knowledge level, decision conflict, satisfaction and treatment decision. The influence of decision aids on the psychological well-being of patients is estimated as being rather low [O'Brien, Mary Ann et al. 2009]; [1074]; [1081]; [1076]. Overall, it should be noted that there is considerable heterogeneity in the quality of the decision aids used [1077], [1078], [1082], [1083], [1084], [1085], [1086].


As a result of increasing digitalization in the healthcare sector, communication between healthcare professionals and patients is increasingly taking place via digital media. The digital exchange of messages via protected patient portals is appealing to both practitioners and patients. This form of communication is seen as being convenient, and patients also see it as a way of requesting information, communicating changes in health status at short notice, and thus receiving support quickly [1087], [1088]. In digital communication via a patient portal, health care providers primarily express themselves in a factual manner; the content is often lacking in affective, supporting and participatory communication [1089], [1090]. However, patients also want patient-centered communication in digital channels. If this is not the case, it is registered and negatively evaluated by patients, which can have an impact on the perceived quality of care [1087].
The transmission of "bad news" (breaking bad news) is a particularly challenging situation. Action protocols for this situation (e.g., SPIKES) stipulate that the conveyance take place face-to-face in a quiet, undisturbed setting. In one study, 85% of patients surveyed said that this was important to them [1091]. Cancer patients prefer to have bad news delivered in person rather than over the phone [1092]. However, a survey of U.S. breast cancer patients found that nearly 60% learned of their diagnosis during a telephone conversation. Some patients had explicitly expressed the wish to be contacted by telephone. The results also showed that telephone communication has increasingly become the norm and that the proportion of patients who received a diagnosis communicated by telephone has increased over the years [1093]. Detailed results on the psychosocial effects of communicating bad news over the telephone are scarce. In a randomized-controlled trial, Bodtger et al. [1094] examined the psychosocial effects of diagnosis messaging over the telephone versus messaging in a face-to-face consultation. The results yielded no difference in psychosocial adjustment between the two groups after transmission of the diagnosis. However, if the telephone call took place at the end of a longer diagnostic clarification process, care was taken to ensure that, whenever possible, a physician already known to the patient made the telephone call. The telephone conversation followed the principles of the SPIKES protocol.


Exceptional situations can lead to a situation in which even the conveyance of bad news has to, for a certain period of time, take place via telephone or video call. The Covid-19 pandemic is such a situation, whereby contact restrictions meant that even patient consultations did not always take place in person [1095], [1096]. In an Australian study, 85% of the physicians surveyed said they had used the telephone or video to talk to patients during the pandemic; 22% said that telecommunication was an appropriate manner to convey bad news. Potentially problematic aspects of delivering bad news via video include connection instability and operating difficulties, lack of clarity about what specific social situation the patient is in, limited assessability of nonverbal cues, and limited ability to create a comfortable atmosphere and show emotional support [1095]. Some of these problematic aspects can be minimized, e.g. by informing patients beforehand about what constitutes an appropriate setting for this conversation and including relatives in the video conference. Practitioners should, among other things, choose an appropriate setting with a simple background, interact intentionally with the camera, explicitly name emotional aspects, as nonverbal signals are more difficult to judge, speak more slowly than in a face-to-face contact and, in case of connection problems, do not speculate about content but ask for what was said to be repeated again [1097]. First studies report training courses for delivering bad news through digital media [1098], [1099], [1100]. In the study by Rivet et al. [1099], over half of the participants expressed positive views regarding the future delivery of bad news via telemedicine channels. There is a great need for research on the psychosocial effects of the conveyance of bad news via telemedicine channels.

11.1.1 Communicative Preferences of Cancer Patients

Patient-centered communication should be based on the needs and values of patients. To this end, it is relevant to know the communication preferences of the patient. Important dimensions of communication preferences are patient participation and patient orientation, effective and open communication, emotionally supportive communication [1101], as well as comprehensive information, clarity/directness in conversation and documentation of subjective information needs [1102], [1103].

Specific communicative behaviors rated as particularly important are "determining the therapeutic measures in a joint conversation", "communicate how the treatment of the disease will proceed", "project calm in the conversation" [1101] as well as "give full attention", "schedule enough time for the conversation", "explain in detail all treatment options", and in a "personal contact" [1102][1104].

Similar preferences are found in relation to the conveyance of bad news. Patients want the information to be communicated clearly and honestly, to be informed about all treatment options and to have clarity about the progression of the condition, for the practitioner to speak calmly, to offer emotional support and to inspire hope, and to allow the patient to ask questions and express feelings [1105], [1106]. However, there is certainly a broad spectrum in terms of the desire for completeness and detail of information about symptoms and prognosis, so it is necessary to elicit individual patient preferences [1105], [1107]. If communication preferences are not taken into account, this is accompanied by an increase in mental distress [1103].

Over the last 30 years, it has been observed that more and more patients want to be actively involved in medical decisions [1108], although the preference for a passive role that leaves the decision-making authority to those treating them certainly still occurs [1109], [1110]. A study from Germany showed that in each case, approximately one third of cancer patients preferred participatory, patient-led or practitioner-led decision making [1111]. Between 20% and 70% of patients report a discordance between desired and experienced participation in medical decisions, i.e. they are less actively involved than they would like to be [1112], [1113], [1114].

11.2 Definition of Patient-centered Communication

Patient-centered medicine, which is oriented towards the needs, values, and preferences of patients, is nowadays considered a characteristic of high-quality medical care. The Integrative Model of Patient-Centeredness by Scholl et al. [1115] defines three domains, each with several dimensions, to describe patient-centered care. The three domains are: basic principles, such as basic characteristics of the practitioner; actions and measures, such as patient participation in care; and facilitating factors, such as communication between practitioner and patient. From the point of view of experts from the health care system, communication between practitioners and patients is one of the five most important characteristics of patient-centeredness, along with the other characteristics of the patient as an individual, patient participation in care processes, patient information, and empowerment [1116].
Patient-centered communication refers to a communicative approach that takes into account the patient's physical, emotional and social situation, their personal values, needs and preferences; and promotes their self-competence and ability to act [1117], [1118]. Adapted to the special needs of people with cancer, Epstein and Street [1117] define goals and tasks of patient-centered communication based on six interrelated functions:

  • Fostering a helpful, "healing" relationship between practitioner and patient.
  • Exchange of information
  • Responding to emotions
  • Dealing with uncertainty
  • Making decisions
  • Promoting self-management

The functions listed, which are oriented to concrete communicative goals and needs for cancer patients, imply a basic communicative competence or mindset that is not limited to defined rules or conversation techniques, so-called‚ „skills", [1117], [1119].

 

11.3 Effectiveness of Patient-centered Communication

11.9 · Consensus-based Statement · new 2023

Patient-centered communication has a positive effect on patient retention and informedness. It is associated with higher patient satisfaction and better therapy adherence. In addition, there is a correlation between good patient-centered communication and improved mental well-being, higher self-efficacy, lower decision conflict, and better quality of life for patients.

Consensus
Strong consensus (100%)

According to Epstein and Street [1117], the effectiveness of patient-centered communication can be described by means of proximal, intermediate, and distal outcomes. Possible proximal outcomes include an appropriate understanding of the patient with regard to the information received or the establishment of trust and respect. Intermediate outcomes include patient satisfaction and patient adherence. Distal outcomes include, for example, improved quality of life, reduced health care costs, or improved survival. The various outcomes differ in terms of the available and established evidence. Patient-centered communication can have a direct effect on health-related outcomes, but indirect effects mediated by variables such as treatment adherence are more likely [1120].

Reviews examined different outcome domains across disorders and settings conclude that the implementation of patient-centered communication is associated with higher patient satisfaction, better retention and recall of information, and positive effects on mental health complaints and physiological outcome measures [1121], [1122], [1123], [1124], [1125], [1126]. Similarly, reviews in oncology have concluded that empathy and open, honest, and hopeful communication are associated with higher patient satisfaction and better psychological well-being [1127]. More recent evidence on selected outcomes and on two specific communicative tasks (participatory decision making and prognosis communication) is presented below.

11.3.1 Retention of Information

Studies with cancer patients and observed physician behavior [1128], [1129] as well as experimental, vignette-based studies with healthy individuals ("analog patients") [1130], [1131], [1132], [1133] suggest that emotion-related communication on the part of the practitioner is associated with better retention performance on the part of (analog) patients. This included building trust, communicating empathically, observing pauses, and validating emotional expressions. Experimental studies with analog patients show contradictory results for a conversational approach that primarily aims at structuring information [1134], [1135].

11.3.2 Patient Satisfaction

Studies on observed behavior in doctor-patient conversations show that higher levels of emotion-related communicative behaviors (e.g., encouragement, empathy, expression of concern, optimism, expression of hope) as well as higher levels of instrumental behaviors (e.g., exploration, counseling) are related to patient satisfaction after the consultation [1118], [1136]. Emotion-related behaviors show a stronger relationship with patient's satisfaction than instrumental behavior [1118]. Similarly, patients who rate the practitioner's communication as being more patient-centered report higher patient satisfaction [1137], [1125], [1138], [1139]. Patients who rate the communicative skills of the practitioners as excellent subjectively perceive their care as very good [1140].

11.3.3 Patient Adherence

Patient-centered communication is associated with higher patient adherence [1141], [1142]. According to a meta-analysis, practitioners with good communication skills achieve 19% higher patient adherence compared to practitioners whose communication skills were rated low [1142]. In the field of oncology, results indicate that patient-centered communication is associated with higher adherence to adjuvant endocrine therapy for breast cancer [1143].

11.3.4 Mental Well-being, Psychological Factors, and Quality of Life

Attentive, empathic, responsive communicative behavior by practitioners – both objectively observed and subjectively perceived by the patient – is associated with a decrease in distress and hopelessness following the conversation between doctor and patient [1136], [1139]. Similarly, an experimental study showed that strong patient-centered behavior when communicating a diagnosis was associated with less anxiety on the part of patients [1144]. Furthermore, associations were found between the high quality of patient-centered communication perceived by patients and better mental and physical health [1145], higher self-efficacy [1117], [1037], [1052], [1146] lower decision conflict [1139] and higher quality of life [1147], [1148].

11.3.5 Effects of Participatory Decision Making

Authors of systematic reviews on participatory decision making from the entire field of medicine conclude that there is clear evidence for a positive effect especially in relation to affective-cognitive outcomes. Thus, participatory decision making is primarily associated with patient satisfaction, understanding, and trust in the practitioner [1149], [1150], [1151]. This correlation is primarily evident when the quality of participatory decision-making is assessed from the perspective of the patient. The association is empirically less certain when observers assessed the quality of participatory decision making, and there was no association in studies in which the participating practitioners assessed the quality of participatory decision making [1151]. Positive effects on behavioral outcomes, e.g., adherence, and health-related outcomes, e.g., symptom reduction and quality of life, have been less consistently observed [1149], [1150], [1151]. In oncology, systematic reviews show weak evidence of a positive effect of participatory decision making on anxiety, depression, quality of life, and utilization of the health care system [1152], [1153]. Participatory decision making about screening and treatment options in patients with prostate cancer is associated with higher levels of knowledge and feelings of informedness, but no evidence is available for an effect on treatment adherence or health status [1154], [1155]. A systematic review in patients with glioma does not allow a firm conclusion on the effect of participatory decision making [1156].
Regardless of the effect of participatory decision making, studies show that the majority of patients want to be involved in decisions. When decisions are strongly dominated by the caregiver, patients are less likely to report having received excellent care, regardless of their preferred level of participation [1157].

11.3.6 Effects of Communicating the Prognosis

Patients with cancer want open and honest communication about their disease situation. This also includes the question of prognosis. Appropriate information is necessary so that patients can make an informed, carefully weighed decision about treatment. However, treatment providers are often reluctant to make a prognostic statement. This is related to the difficulty of making a concrete, correct prediction in the face of a complex medical situation, but also the fear of harming the relationship between the practitioner and the patient as well as the patient's mental state [1158]. However, the results of a systematic review show that information about prognosis was associated with a better understanding of the patient's prognosis and a more correct subjective estimation of survival time. Communication of prognosis leads to a physiological distress response. A negative effect of the information about the prognosis on the mental state is rather not shown, on the contrary, positive effect results are more convincing. There is also no evidence for a negative effect of the prognosis information on the relationship between the practitioner and the patient. Furthermore, there is evidence for a relationship between prognosis communication and the discussion of treatment preferences in the terminal phase of the disease [1158]. Regarding the specific form of prognosis communication, the authors conclude from the present results that the combination of unambiguous and affective communication explaining multiple scenarios of survival (see Mori et al. [1159]), combined with collaborative behavior that recognizes the practitioner as the subject matter expert, is particularly favorable. This promotes retention, the patient's mental well-being, and the relationship between the practitioner and the patient [1158]. The conveyance of the prognosis is typically a stressful situation for patients. Stress has effects on memory and behavior, among other things. Patients who show a high degree of psychological impairment in the situation show poorer retention performance for transmitted information and they participate less in the practitioner-patient conversation [1160]. Therefore, it is useful to be empathetic when communicating the prognosis and to check at the end of the conversation whether the patient has correctly understood and retained the most important facts. In the case of mentally distressed patients, it is advisable to address the emotional situation first and to arrange another appointment for communicating the prognosis [1160], [1161].

11.4 Improving Communicative Competences

11.10 · Consensus-based Statement · new 2023

In order to achieve a high standard in patient-centered communication, the continuous improvement of communication skills of all professionals working in oncology should be strived for.

Consensus
Strong consensus (100%)
11.11 · Consensus-based Statement · modified 2023

Communication skills training that meets essential quality standards improves patient-centered communicative behaviors of oncology practitioners.

Consensus
Strong consensus (100%)
Change noteQualified training ('communication training', 'communication skills training') has been shown to improve the objective communicative behavior of physicians and nurses.
11.12 · Consensus-based Recommendation · modified 2023

Physicians and other professionals working in oncology should participate in a quality-assured communication skills training to improve their communication skills.

Consensus
Strong consensus (97%)
Change notePhysicians and other professional groups working in oncology should undergo further education and training measures to improve their communication skills.

Given the importance of patient-centered communication within the framework of patient-centered care, there are worldwide efforts to train communicative skills in order to achieve a high standard of patient-centered communication. Today, practicing communication skills is a given standard in medical school [1162] [1163]. Furthermore, there are international efforts to establish communication training as routine in institutions or certain areas of the medical care system [1164]. In Switzerland, it is mandatory for physicians to take part in communication training during their specialized training to become an ‘Oncologist’ [1165].
There are consensus recommendations available that define formal and content-related quality standards[1034]; [1165][1166]. The standards include, among other things, that communication skills be practiced actively through role-play and that participants receive feedback on their communicative behavior. More and more, there is an emphasis that the focus should not be placed on the mere technical practice of skills. Additionally, the practice of communicative skills should also be used to promote self-reflection, to train awareness of situational characteristics of practitioner-patient communication, and to achieve individual training goals [1034]; [868][1167][1165].
Health care professionals who participated in communication training typically express high satisfaction with the training [1168], [1169], [1168]. Studies found no significant differences in satisfaction with communication training between treatment providers who participated in the training on a voluntary basis and treatment providers for whom participation was a mandatory part of their continuing education.
The realization of defined quality communication training standards and institutional implementation encounter numerous barriers, primarily structural and resource related. Accordingly, there is a wide variance in the formal and content aspects of communication trainings [1164], [1170]. Many of the described communication trainings for treatment providers deviate in numerous aspects from the quality standards that were defined in a consensus meeting in 2008 [1170]. This high variance makes it difficult to generate strong empirical evidence for the effectiveness of communication training. Nevertheless, there are numerous studies with positive results on the effectiveness of communication training.

11.4.1 Effectiveness of Communication Trainings

Results of a systematic review and a Cochrane review, both supplemented by meta-analytical evaluations, show that practitioners who have undergone communication training use more patient-centered communicative behavior in conversations with real patients or standardized patients than practitioners who have not participated in such training. The effects are small to moderate [1171], [1172]. Specifically, Moore et al. [1172] found a positive effect of communication training on three of seven behaviors considered. According to these findings, communication training resulted in practitioners being more likely to exhibit empathic behaviors and less likely to "simply" communicate facts without paying attention to the patient's emotional response or offering support. Furthermore, practitioners used open-ended questions more often after training than practitioners who had not participated in training. The analyses also provided evidence that these positive effects persisted in the medium term (i.e., several months after training was completed) [1172]. According to Moore et al. [1172], the analyses showed no benefit of communication training with respect to the behaviors of summarizing, inquiring about concerns, conveying appropriate information, and negotiating/agreement-making. The analysis by Barth and Lannen [1173] also revealed a pattern of results that, while not statistically significant throughout, was consistently observed. They found that communication trainings that lasted less than 24 hours produced smaller effects than trainings that lasted more than 24 hours. Considering the quality of the studies, the overall evidence is of low to moderate quality [1174], [1172].

Both studies found no convincing evidence for an effect from communication training on patient-sided outcomes [1171], [1172]. However, Haskard, Zolnierek and DiMatteo [1142] report that physicians who had participated in a communication training achieved 12% higher treatment adherence from their patients than did physicians who had not participated in such training.

Other systematic reviews conclude that communication trainings improve the communication skills of practitioners, but it is unclear what time frame, format, and content are best for this [1175]. Selman et al. [1176] found that communication training resulted in practitioners expressing more empathy and talking about emotions. This was a medium effect, but it only applied to interactions with standardized patients, not to conversations between training participants and real patients. This work also found no effect of communication training on patient-related outcomes [1176].

Furthermore, systematic reviews suggest that communication trainings lead to an increase in the self-assessed quality of communication skills and to higher self-efficacy. However, the authors also note that the quality of evidence is low [1177], [1178], [1179].

Furthermore, systematic reviews are available on the effects of communication trainings with non-physician practitioners. Consistent with other work, Kerr et al. [1180] found a positive effect of communication training on nurses' communicative behavior; the authors rated the quality of evidence as moderate. A systematic review on communication training with team members in radiation oncology (including physicians, nurses, medical physicists, medical technical radiology assistants) showed positive effects regarding some communication skills, especially empathic communication and the use of emotion words, but also inconsistent results regarding other communicative behaviors, e.g., the use of open-ended questions. Regarding patient-reported outcomes, inconsistent results were also evident [1181].

Current RCTs support the main conclusions of the aforementioned systematic reviews. Bylund et al. [1169] report an increase in the scope of patient-centered conversation techniques used by participants in communication training. Furthermore, positive effects were shown for the specific conversational techniques of structuring topics, checking for understanding, and organizing the delivery of information. This gain in communicative skills occurred primarily in the group of practitioners who initially demonstrated low values in their communicative behavior. Moreover, these positive effects were only evident in conversations with standardized patients. The transfer of the gain in competencies into the clinical setting could not be demonstrated; in conversations with real patients there was no difference in patient-centered communication between trained and non-trained practitioners. In contrast, Epstein et al. [1182] found that communication training with physicians (combined with an intervention for patients with advanced cancer) resulted in higher levels of patient-centered communication with real patients. However, there were no effects on secondary outcomes such as the quality of the patient-physician relationship, quality of life, or consensus on the prognosis. A positive effect of training was also reported by Henselmans et al. [1183]. It was shown here that oncologists who had participated in skills training were more likely to implement participatory decision-making in their conversations with patients with advanced cancer than oncologists who had not participated in the training.

In view of the findings presented here, research efforts are particularly indicated to investigate how the success of a communication training can be transferred to clinical practice and what the minimum scope of communication training should be in order to achieve clinically significant effects.

References

[1031] Rodin, Gary, Mackay, Jean A., Zimmermann, Camilla, Mayer, Carole, Howell, Doris, Katz, Mark, et.al. Clinician-patient communication: a systematic review, Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 2009. 17(6): p. 627-644., https://pubmed.ncbi.nlm.nih.gov/19259706/

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