Interviewee

Dr Geraldine Leydon, Senior Postdoctoral Research Fellow and Medical Sociologist, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom

Article

Leydon, GM. (2008) 'Yours is potentially serious but most of these are cured': optimistic communication in UK outpatient oncology consultations, Psycho-Oncology, 17(11): 1081-88

Summary

Research shows that cancer patients want honesty, as well as, optimism from their doctors, when discussing their illness prognosis. They do not want to hear bad news delivered bluntly. Doctors struggle to strike a balance between uncertainty and certainty, realism versus optimism, and hope versus fear. This week Michael Bouwman talks with Dr Geraldine Leydon about her UK-based research into the communication patterns of oncologists and their patients during consultations. Geraldine found that oncologists use communication patterns, known as the 'power of proximateness' and give the 'bad' news first, followed by 'better' news, known as the 'pairing phenomenon'. Communication studies show that people respond to the last thing said in a conversation; so in cancer consultations patients are more likely to pick up and comment on the 'good' information and move on from the 'bad'. Doctors invoked optimism in pre-treatment meetings, which meant patients were more likely to participate in treatments such as chemotherapy and radiotherapy. Geraldine says that while the practice of proximate pairing may be a useful and time-saving resource for practitioners, it also poses a serious ethical dilemma: it can limit the length of a conversation, resulting in doctors failing to further discuss the serious aspects of the news just delivered.

Transcript

Michael Bouwman: I’m Michael Bouwman and today I’m talking with Dr. Geraldine Leydon, Senior Post Doctoral Research Fellow and Medical Sociologist in The University of Southhampton, Aldermoor Health Centre, Southhampton, UK. I’m speaking with Geraldine about her study and article: ‘Yours is potentially serious but most of these are cured: optimistic communication in UK outpatient oncology consultations’, published in Psycho-Oncology. Welcome, would you provide a background for the discussion, in the form of a short overview, of what we know about doctor-patient communication and the delivery of bad news?

Geraldine Leydon: Okay, well basically from the literature, we know that the way in which doctors communicate can actually influence a number of things. So, for instance, it can influence patient understanding of their own illness—in this case cancer. It can influence their health behaviours and their outcomes as well, such as satisfaction. We also know interesting that the way doctors communicate can actually impact on their own health as well. Now, in terms of patient preference for how information ought to be communicated, there’s literature which has shown that patients really do value hope and optimism in the cancer consultation. They do want information and they want that information to be shared honestly, but they actually don’t want that to be delivered bluntly; so they want some kind of light at the end of the tunnel, if you like. So the art of reassurance is really perceived to be quite critical in these cancer meetings. I think this really is quite interesting because it really provides a bit of a communication challenge for health care professionals. They have to design their information so that when speaking with these cancer patients, they strike a balance between such things as uncertainty and certainty, realism versus optimism, and hope versus fear. Now, we know that from the literature doctors can actually struggle to strike this balance. There was a fairly large survey—conducted by Bale and colleagues in America—which showed that oncologists found that how to be honest with a patient, but not destroy hope, was actually one of the most difficult and stressful challenges faced when communicating with cancer patients, and it was this kind of conundrum, if you like, that inspired me to do some research in this area.

Michael Bouwman: Ok, yes.

Geraldine Leydon: So what I did was I audio-recorded doctors in three hospitals in the UK and I basically wanted to analyse their consultations with their patients, and look at how they might try to strike a balance or actually may not strike a balance between good, bad and uncertain tidings. I, very quickly, identified a fairly robust doctor-initiated communication strategy, and all I mean by that is a way that they sort of conveyed information to their patients. Now I’ve called this the pairing phenomenon, it’s a fairly simple concept really: all the pairing phenomenon refers to is how doctors are very unlikely to just produce bad news in a consultation. They’ll often work quite hard to mitigate or soften bad news with some relatively good news. So I can give you an example from my data corpus, one particular doctor, when talking with a patient with cancer, and talking about radiotherapy, announced as follows, he said: ‘Obviously we can’t guarantee that it will work, but there’s a very good chance that it will’. Now the interesting thing there is the doctor doesn’t end his term with the ‘obviously we can’t guarantee radiotherapy will work’ rather he works to soften that and make it a bit sweeter I suppose by saying that ‘there’s actually a very good chance that it will work’. Now as well as the pairing phenomenon, doctors sort of use of words or their lexical choice also work to convey an optimistic tone in these consultations.

Michael Bouwman: And you also note that patients tend to collaborate in this construction of optimism. Could you talk about that?

Geraldine Leydon: Yes, sure—so when I was inspecting these paired news deliveries, i.e. paired, good and bad information, I noticed that patients tended to respond to the positive news components and actually passed up the opportunity to comment on the negatively balanced news. So I wanted to really sort of interrogate the pairing phenomenon in a bit more detail; and I identified something called, ‘the power of proximateness’ and I have Professor Paul Drew from York University to thank for that term, and again this is a really simple concept: all the power of proximateness refers to is how doctors routinely organised their information in a particular way. So they didn’t just do it in any way, they always gave the bad news first and then followed it with some relatively better news. Now, you might have wondered why that’s important and actually the importance of that lies in the work of the late Harvey Sacks who also conducted detailed analysis like that in my study. And Harvey Sacks found that next speakers in conversation, the next speakers here are patients, routinely respond to the last thing said by the person they’re talking with, in this case the doctor. So, by designing information in this proximately paired way, doctors actually enhance the chance that a patient will pick up on the good information and move on from the bad. And indeed, in my data corpus, this is exactly what patients did—they would comment on the optimistic tidings and pass by the negative news.

Michael Bouwman: Right—and then they’d fail to discuss the more serious news that’s being delivered.

Geraldine Leydon: Exactly, yes. I mean this is one of the sort of ethical dilemmas I suppose of treating information in this way. There is a real danger that in proximately pairing information, patients will be encouraged to focus on the optimistic news and in turn, you know, disregard the uncertain news as you said. So while the practice of proximate pairing may actually be a useful resource for practitioners, they really must be mindful of its potential to limit the discussion as negatively balanced news.

Michael Bouwman: And—Geraldine, what are the practical implications of your study?

Geraldine Leydon: There is some evidence within my data corpus but also in the literature out there, especially the conversation analytic literature looking at medical meetings, that being optimistic in a treatment meeting can actually help construct and sustain the therapeutic rationale, which is really critical in these, you know, clinically focused pre-treatment meetings; and also we know that optimism can boost the patients’ motivation to participate in treatment and improve treatment adherence; and Ruth Parry in Nottingham has done some nice work showing this. In terms of how doctors pursue the consultation agenda, positive statements like those we’ve discussed that turn endings have been shown to enable a particular outcome of topic transition and all I mean by that is, basically if it’s upbeat at the end of the turn then it’s actually easier for a doctor to move on and continue going through the agenda which actually is quite critical; these are very much agenda focused meetings.

Michael Bouwman: I suppose it saves some time.

Geraldine Leydon: Exactly, I mean there is basically a cost, a time benefit, associated with this practice which again you know, you might consider to be a practical benefit derived from this way of communicating.

Michael Bouwman: Thanks for speaking with IPP-SHR Podcasts. It’s been a pleasure speaking with you today on this very interesting topic.

Geraldine Leydon: Thank you for inviting me.