A new paradigm for clinical communication: critical review of literature in cancer care

Abstract

ObjectivesTo: (i) identify key assumptions of the scientific ‘paradigm’ that shapes clinical communication research and education in cancer care; (ii) show that, as general rules, these do not match patients’ own priorities for communication; and (iii) suggest how the paradigm might change to reflect evidence better and thereby serve patients better.MethodsA critical review, focusing on cancer care. We identified assumptions about patients’ and clinicians’ roles in recent position and policy statements. We examined these in light of research evidence, focusing on inductive research that has not itself been constrained by those assumptions, and considering the institutionalised interests that the assumptions might serve.ResultsThe current paradigm constructs patients simultaneously as needy (requiring clinicians’ explicit emotional support) and robust (seeking information and autonomy in decision making). Evidence indicates, however, that patients generally value clinicians who emphasise expert clinical care rather than counselling, and who lead decision making. In denoting communication as a technical skill, the paradigm constructs clinicians as technicians; however, communication cannot be reduced to technical skills, and teaching clinicians ‘communication skills’ has not clearly benefited patients. The current paradigm is therefore defined by assumptions that that have not arisen from evidence. A paradigm for clinical communication that makes its starting point the roles that mortal illness gives patients and clinicians would emphasise patients’ vulnerability and clinicians’ goal‐directed expertise. Attachment theory provides a knowledge base to inform both research and education.ConclusionsResearchers will need to be alert to political interests that seek to mould patients into ‘consumers’, and to professional interests that seek to add explicit psychological dimensions to clinicians’ roles. New approaches to education will be needed to support clinicians’ curiosity and goal‐directed judgement in applying this knowledge. The test for the new paradigm will be whether the research and education it promotes benefit patients.

Perspectives of patients with haematological cancer on how clinicians meet their information needs: “Managing” information versus “giving” it

“…Indeed, only one “variant” patient took this stance, and she was unusual in the sense of medical authority she felt. The responsibility is, though, consistent with suggestions that clinical relationships in cancer resemble attachment relationships . That is, patients attribute to practitioners the expertise and authority to look after them and to know what they need—including what information they need.…”

Greater than the sum of its parts: patient-clinician communication education

“…In their critical review of clinical communication specific to cancer care, published in this issue, Salmon and Young identify two such underlying assumptions in current research and education. Firstly, patients are self‐determining and hence the clinician's role is to give information for use in joint decision making and to ensure patient autonomy.…”

A new paradigm or a misrepresentation of current communication research and teaching?

“…1 However, we believe they have presented a highly biased discussion of current research and teaching which cherry-picks the evidence and produces a description that those working in the field simply do not recognise. Their analysis fails to take into account the realities of the evidence base and the actual practice of communication scholarship and education.…”

“…In fact, communication teaching stresses the importance of flexibility and envisages the skills of communication as components of a toolkit to be selected and used appropriately for the task in hand in order to achieve the goals of both clinician and patient. Salmon and Young's paper 1 To justify the position that patients are both vulnerable and dependent, the authors 1 selectively cite data indicating that patients prefer to avoid emotional talk with practitioners and prefer doctors who prioritise the provision of clinical care over counselling. Their claims, 1 based primarily on their own qualitative studies in cancer, contradict other substantial research noting the negative impact on patients' satisfaction and well-being when clinicians fail to recognise and make room for patients' ideas, concerns, emotional expressions and desire for participation in decision making.…”