The patient-doctor communication/decision process in Europe


An interesting but underpowered study just reported as a “mini-review” in BJU International gives us some (but not much) new information from Europe about the comparative expectations of urologists and prostate cancer patients around the discussion of new diagnosis and the the choice between appropriate treatment options.

The sad thing about this paper is that while the authors (Dennis et al.) generated information from 303 physicians, they got input from 48 patients — most of them in Belgium and all diagnosed at least 5 years previously.

Those who subscribe to the UroToday web site will be able to read the full text of the paper. Others will be limited to accessing only the abstract (which, also sadly, doesn’t mention the levels of participation by physicians or patients in this study).

The study was based on two linked surveys carried out in 2011. One was focused primarily on urologists (291/303 physicians) who treat prostate cancer, about half of whom practised at academic medical centers. The other was directed to patients with prostate cancer but limited (perhaps not intentionally) to men diagnosed at least 5 years earlier, which seems like a serious lack of commitment to gaining good, current patient input. Results from the two surveys are complemented with published data from other sources.

According to the published results:

  • Most specialists spent 15-29 min telling the patient about his diagnosis.
    • About 50 percent of the specialists felt “very comfortable” during this conversation.
    • About 67 percent of the patients reported feeling uncomfortable
    • About 40 percent of the patients stated that their physician was insufficiently supportive or sensitive
    • 65 percent of the patients considered this time insufficient.
  • Most specialists spent another 15-29 min explaining treatment options.
    • 52 percent of patients considered this to be insufficient.
    • Physician and patient opinions about the prognostic and therapeutic information provided were very different.
    • “Nearly all” physicians reported providing patients with information about effectiveness/prognosis and side effects of different treatments
    • Only 56.3 percent of patients remembered being given information about effectiveness/prognosis
    • Only 29.2 percent of patients remembered being given information about side effects.
    • About 67 percent of patients were dissatisfied with the amount of information provided.
  • Only 10 percent of patients were provided with any printed information that they could read and absorb in a less stressful situation.
  • A shared decision-making process was (supposedly) preferred by both patients and specialists.
  • Both the physicians and the patients considered treatment efficacy to be the key factor determining treatment choice. However, …
  • Physician opinion and/or experience had a significant impact on patient choice regarding treatment. 
  • The supportive role of partners/relatives was more appreciated when discussing treatment options than during diagnosis.

In their conclusions the authors state that physicians can (and arguably should) seek to improve quality of care by

  • Taking adequate time to inform and educate their patients
  • Using simple terminology and straightforward language that is easily understood by patients
  • Encouraging a shared decision-making process.
  • Ensuring that the individual patient’s needs and preferences are the clinical priority

While these are all laudable conclusions, the lack of large-scale patient input into the databases on which the report is built demonstrates that the research team itself completely failed to acknowledge the importance of gathering such input with accuracy from a large and well-characterized cohort. (Within the report, for example, they describe a separate but similar patient survey with data from 75 patients as “extensive.”) The authors do, however, acknowledge that the high proportion of academic urologists in the physician sample may also mean that the physician input was not entirely reflective of widespread community practice.

The “New” Prostate Cancer InfoLink is of the opinion that research into the communication process between physicians and patients is still not being taken seriously by most funding bodies. This report, which includes the leader of a European advocacy organization (a retired urologist) as the primary author, appears to confirm our opinion. It is to be hoped that the Patient-Centered Outcomes Research Institute (PCORI) here in the USA will be willing to fund much better research in this area and encourage a greater appreciation of the importance of this issue.

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