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10.1245/ASO.2006.07.026
Annals of Surgical Oncology 13:788-793 (2006)
© 2006 Society of Surgical Oncology
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Original Article

The Surgeon-Patient Interaction in Older Women With Breast Cancer: What Are the Determinants of a Helpful Discussion?

Amardeep Thind, MD, PhD1 and Rose Maly, MD, MSPH2

1 Departments of Family Medicine and Epidemiology and Biostatistics, Schulich School of Medicine, University of Western Ontario, 245-100 Collip Circle, London, Ontario N6G 4X8, Canada
2 Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, Box 957087, 10880 Wilshire Boulevard, Suite 1800, Los Angeles, California 90095-7087

Correspondence: Address correspondence and reprint requests to: Amardeep Thind, MD, PhD; E-mail: athind2{at}uwo.ca.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: Surgery is a key modality in the treatment of breast cancer. The patient-physician interaction is a key determinant of a range of outcomes, but there is little work examining the surgeon–breast cancer patient interaction. We analyzed data from 240 women with a new breast cancer diagnosis to better understand this interaction and to delineate the patient, surgeon, and surgeon-patient interaction-level characteristics affecting this interaction.

Methods: A cross-sectional survey was conducted in Los Angeles County of 240 women with a new breast cancer diagnosis aged ≥55 years. Women were asked to rate on a scale of 0 to 10 how helpful overall the way their surgeon discussed their breast cancer with them was. Logistic regression models were constructed to assess the relationship of patient, surgeon, and surgeon-patient interaction characteristics to the outcome variable.

Results: Forty-four percent of women said that they found the way their surgeon discussed their breast cancer with them extremely helpful. Women with a higher level of perceived self-efficacy, a longer consultation time with the surgeon, a higher interactive information-giving score, and a higher participatory decision-making score had significantly higher odds of reporting the discussion to be "extremely helpful."

Conclusions: Our results indicate that strategies to improve the patient’s perceived self-efficacy (preparing questions beforehand, practicing, watching a role model, and so on) will improve the surgeon-patient discussion. At a systems level, adequate time should be budgeted for the consultation, and we must ensure that adequate communication skills are imparted to surgeons during their educational training.

Key Words: Breast cancer • Surgeon-patient interaction • Helpful discussion • Older women


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Breast cancer is one of the most common cancers, and for most patients with this condition, surgery is a key modality in their overall treatment plan. There is a large body of evidence attesting to the importance of the patient-physician interaction as a determinant of a range of outcomes,1–5 but there is a paucity of work examining the interaction between the surgeon and the breast cancer patient.

Medical practice today is focused on the paradigm of shared decision making between the physician and patient.6,7 A key component of this approach is the provision of information on the disease, treatment options, and possible outcomes by the physician. In this study, we attempt to elucidate the patient, surgeon, and surgeon-patient interaction-level characteristics among women who reported that the way the surgeon discussed their breast cancer with them was "extremely helpful."


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Research Questions
In a sample of elderly women who underwent lumpectomy or mastectomy for their breast cancer, what are the patient, surgeon, and surgeon-patient interaction-level characteristics of women who reported that the way the surgeon discussed their breast cancer with them was extremely helpful?

Study Design and Data Source
The study was a cross-sectional survey of 240 women with a new breast cancer diagnosis aged ≥55 years in Los Angeles County, CA. The patients’ surgeons (n = 155) were also surveyed about their sociodemographic and practice characteristics, and patients’ medical records were abstracted for breast carcinoma stage and treatment type. Further details of the survey, including patient identification and recruitment, are available elsewhere.8

Variable Specification
Dependent Variable
Women were asked to rate on a scale of 0 to 10 (0 being not helpful at all and 10 being extremely helpful) how helpful overall the way that their surgeon discussed their breast cancer with them was. Because we were interested in ascertaining the characteristics associated with an "extremely helpful" discussion with a surgeon, we dichotomized the responses to create a binary dependent variable.

Independent Variables
We grouped the independent variables into three categories: patient level, surgeon level, and surgeon-patient interaction level. Among patient-level variables, age was continuous and measured in years, and race/ethnicity included white, black, and Latina. Education (high school or below and some college or more) and income (≤$30,000/year and > $30,000/year) were binary variables. Breast cancer stage was dichotomized as stage 1 versus stage ≥2, and the presence of health maintenance organization insurance was noted by a binary variable. The time from biopsy to surgery (lumpectomy or mastectomy) was continuous and measured in days. The Short-Form 36 was used to measure the patients’ general health perception, and a validated scale was used to assess racial and medical mistrust; the internal consistency (as measured by Cronbach’s {alpha}) for the scales in our sample was .81 for racial and .66 for medical mistrust, respectively.9 Patients’ perceived self efficacy in physician-patient interactions was measured by using the validated Patient-Physician Interaction Questionnaire (PEPPI).10 The PEPPI scale score can range from 0 to 50, with higher scores indicating stronger perceived self-efficacy in physician-patient interactions; Cronbach’s {alpha} for this in the sample was .94.

Surgeon-level characteristics included years in practice. The surgeon-patient interaction was delineated by three variables. Consultation time was a binary variable (≤15 or <15 minutes). Interactive information giving was a score from 0 to 15, obtained by summing patient responses on whether 15 individual topics had been discussed by their surgeon. Topics included the aggressiveness of the cancer, chance of recurrence, spread of disease, and so on; details of this scale are reported elsewhere.8 A higher score indicates more interactive information giving. Cronbach’s {alpha} for this scale was .71.

The participatory decision-making style of the surgeons (i.e., their propensity to involve patients in diagnostic and treatment decisions) was measured by using the Participatory Decision Making Style Scale from the Medical Outcomes Study.11 The scale has a range from 0 to 100, with higher scores indicating a higher participatory decision-making style. Cronbach’s {alpha} for the scale in the sample was .98.

Data Analysis
Data analysis was performed by using Stata/SE version 8.2 (College Station, TX). The unit of analysis was a woman who had undergone lumpectomy or mastectomy. Bivariate associations were checked by using the t- and {chi}2 tests. Multiple logistic regression modeling was used to estimate the parameters, and we adjusted the standard errors for clustering at the surgeon level. The overall fit of the model to the data was assessed with the maximum log likelihood ratio {chi}2 statistic.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Descriptive Analyses
Less than half of the women (44%) reported that they found the way their surgeon discussed their breast cancer with them "extremely helpful." Descriptive statistics are listed in Table 1Go. There was no difference in the mean age or stage of disease between the women who found the discussion extremely helpful and those who did not. A preponderance of black women (62%) and most Latinas (58%) did not find the discussion extremely helpful. Women who had some college education or more and those reporting higher incomes were significantly more likely to find the discussion extremely helpful, as were women who reported better general health and those who had higher perceived self-efficacy scores. Women who had higher scores on the racial and medical mistrust scales were significantly less likely to report finding the discussion extremely helpful. There were no statistically significant differences between the two groups in health maintenance organization insurance status and time from biopsy to surgery.


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  		TABLE 1. Descriptive results of women (undergoing lumpectomy or mastectomy) who reported that the way the surgeon discussed their breast cancer was "extremely helpful"
 
Surgeons’ length of time in practice was not associated with patients finding the discussion extremely helpful. A longer consultation time, more interactive information giving, and greater participatory decision making were positively associated with a woman finding the discussion extremely helpful.

Multivariate Analyses
Table 2Go presents the results of the logistic regression model for finding the surgeon discussion of breast cancer to be extremely helpful. Among patient level variables, a patient with a higher PEPPI score was more likely to find the discussion extremely helpful (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.05–1.14). In terms of surgeon-patient interaction-level variables, women whose consultation was longer than 15 minutes had more than twice the odds of reporting the discussion to be extremely helpful compared with women with a shorter consultation (OR, 2.25; 95% CI, 1.04–4.88). Every additional topic discussed by the surgeon resulted in a 20% increase in the odds of reporting the discussion to be extremely helpful (OR, 1.20; 95% CI, 1.04–1.38), and a unit increase in the participatory decision-making score was associated with a 2% increase in the odds of reporting the discussion to be extremely helpful (OR, 1.02; 95% CI, 1.01–1.03). Stated in terms of predicted probabilities, these results indicate that a 1-SD increase in the interactive information-giving score and the participatory decision-making score results in a 40% and 31% increase, respectively, in the predicted probability of the consultation being reported as extremely helpful.


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  		TABLE 2. Odds ratios from logistic regression model for reporting that the way surgeons discussed breast cancer was "extremely helpful"
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Surgeons are key members of the team treating a woman with breast cancer, and studies show that women choose their surgeons most frequently as the single most helpful source of information, followed by books, the general practitioner, and other women with breast cancer.12 Slightly less than half of women (44%) reported that they found the way their surgeon discussed their breast cancer with them extremely helpful. Even though women were asked to rate their responses on a scale of 0 to 10, almost half rated the discussion as a 10. Such a skewed distribution has been recognized in the literature,13 and this may occur because women are unwilling to criticize their doctors; alternatively, they may lack a point of comparison.14

One of the strongest determinants of a woman finding the discussion extremely helpful was her perceived self-efficacy in communicating with her surgeon. Women with a maximum PEPPI scale score were more likely than their counterparts to rate the discussion extremely helpful, even after controlling for other patient-, surgeon-, and patient-surgeon interaction-level factors. Having high perceived self-efficacy may lead women to ask focused questions and process information in a manner that satisfies their informational and decision-making needs, thus allowing them to extract maximum benefit from the consultation. Other studies have also shown the positive effect of self-efficacy on outcomes in breast cancer patients.15,16

In today’s era of time-constrained consultations, it is a challenge to establish rapport with cancer patients, address their stigmas and fears, discuss emotional issues, and present complex medical information and treatment options, all in a manner that patients can comprehend. It is, therefore, not surprising that patients’ negative perceptions of a general surgery consultation have been found to be affected by the consultation time17; our research corroborates this finding for consultations between elderly women with breast cancer and their surgeons. The average physician visit is just over 17 minutes,18 and previous studies have shown that physicians tend to spend less time with, and provide poorer information to, older patients compared with younger patients.19–21 However, evidence suggests that surgeon–breast cancer patient interactions are longer than the average ambulatory visit; a recent study reported that this encounter was approximately 20 minutes.15 This finding suggests that surgeons seem to be balancing significant pressures in their practices to see patients quicker with the unique needs of their breast cancer patients.

An essential component of the surgeon-patient interaction has to be informational exchange. The Institute of Medicine has stated that one of the hallmarks for excellence in cancer care is patient awareness of all treatment options and of the risks and benefits associated with each of them.22 This comprehensive understanding is especially important in early-stage breast cancer, when women could choose between one of two treatments: breast-conserving surgery and mastectomy.23,24 In this situation, presenting information about treatment and outcomes and eliciting patient treatment preferences become vital. Numerous studies have reported that cancer patients desire detailed information about their disease from their providers.12,16,25 Our research additionally documents an important association between increased information giving and the patient finding the discussion helpful, thereby linking the increased provision of information with an important dimension of patient satisfaction.

Nonetheless, surgeons should keep in mind not only the provision of information, but also the context. Research has documented that physicians overestimate their own informativeness, use medical terms difficult for a layperson to understand, and overestimate the patient’s understanding of such information.4,26,27 In addition, patients receiving bad news during a consultation may have difficulty processing and recalling information given during the consultation.28 The time taken to convey relevant information is also critical: some studies suggest that in a 20-minute consultation, doctors spend little more than 1 minute in information giving.29 Surgeons need to be cognizant of these points when dealing with a breast cancer patient; additionally, these issues should also be stressed in the medical education curriculum. From the perspective of the consultation, a useful starting point would be for surgeons to first encourage their patients to discuss their main concerns without interruption.30

Our research also suggests that surgeons adopt a more participatory decision-making style when interacting with elderly breast cancer patients. Although this recommendation would suggest that surgeons offer a menu of treatment choices to patients and be willing to share responsibility and control with them, it presupposes that (1) patients want to share in this process, (2) the surgeon has correctly identified the patient’s decision-making style, and (3) the surgeon offers to share the decision-making process. Research suggests that these three conditions are often not met in clinical practice and that cancer patients vary substantially in their styles and preferences.31–33 Our recommendation would be for the surgeon to assess the patient’s preferred decision-making style and proceed accordingly, because such concordance is associated with positive patient outcomes.31,33,34

There are several caveats that should be noted when our findings are interpreted. First, the sample was limited to elderly women with breast cancer from Los Angeles County. Second, our data are cross-sectional, thus precluding any cause-and-effect relationships. For example, it is not clear whether the patient’s rating of the discussion as extremely helpful is the cause or result of the interaction with the surgeon. Third, we were not able to stratify on the basis of the specialty of the surgeon, i.e., surgical oncologist versus general surgeon. Surgical oncologists may have tools at their disposal that help patients better communicate their questions and concerns. Finally, we relied on self-reported information, which may be subject to recall bias. Patients’ self-report of communication with surgeons is not an unbiased measure (unlike video or audio tapes) of what truly transpired during the encounter, and recollection of the encounter may be flawed. However, women in the sample reported a high level of confidence in their memory of the encounter, a finding that is consistent with other research involving cancer patients.35 This confidence on the part of patients could perhaps be due to the phenomenon of a "flashbulb" memory, wherein people tend to better remember traumatic or emotional events in their lives.36

Despite the study limitations, we believe that our findings support several recommendations to help improve the surgeon–breast cancer patient interaction. On the patient side of the surgeon-patient interaction, providing strategies to better communicate with the surgeon (such as preparing questions beforehand, practicing, and watching a role model) via books, nurse counseling, or videotapes can be effective.37,38 Other patient-focused strategies that could be used to inform and enrich the surgeon–breast cancer patient interaction include interactive shared decision-making tools or tools to ensure that patients fully understand their options,39,40 use of illustrated decision-making role cards,41 computer-assisted programs,42 coaching in verbal behavior techniques,43 or decision boards.44 From the surgeon’s perspective, brief postvisit surveys of a patient’s perceptions of the encounter can provide valuable feedback information.45,46

Over the longer term, two systemic changes are recommended. First, at the systems level, we need to ensure that there are minimal time constraints on the consultation, thus allowing the surgeon to completely address all patient concerns. Second, we must ensure that adequate communication skills are imparted to surgeons during their educational training. While it is known that communication skills such as active listening, open questioning, showing empathy, summarizing information, and assessing patient understanding can be learned, physicians generally receive little training in these areas.47 Future surgeons need to learn clinical and communication skills side by side.48

Received for publication July 22, 2005. Accepted for publication November 22, 2005.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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