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Context: Gender and personality may individually impact end-of-life care. Men often receive more aggressive treatments than women near death, and personality - particularly openness - may be associated with increased care utilization when it diverges from traditional treatment norms. However, research has not examined the interaction of these variables in a dyadic context., Objectives: This study examined the dyadic effects of patient gender and caregiver personality on end-of-life care., Methods: Using data from the VOICE randomized clinical trial, the present sample consisted of patient-caregiver dyads receiving outpatient care for advanced cancer in Sacramento and Western New York. Analyses assessed whether caregiver personality was associated with gender-based differences in patient chemotherapy or emergency department/inpatient visits in the 30 days before death. Logistic regression examined the interaction between caregivers' Big Five personality dimensions and patient gender while accounting for patient and caregiver demographic and health characteristics., Results: Of a total of 134 patient-caregiver dyads, 19.4% (n = 26) of patients received chemotherapy and 47.8% (n = 64) had an emergency department/inpatient visit in the 30 days before death. Results demonstrated a significant interaction between caregiver openness and patient gender on receipt of chemotherapy (odds ratio = 0.07, p = 0.006). When caregivers were less open, men were more likely to receive chemotherapy near death, whereas when caregivers were more open, women were more likely to receive chemotherapy near death., Conclusion: Results suggest caregiver personality characteristics, particularly openness, might disrupt gender-based treatment norms at end-of-life. Findings demonstrate that patient and caregiver factors can interact to explain patient healthcare utilization., Competing Interests: Disclosures and Acknowledgments The authors have declared no conflicts of interest. This research was supported by funds from the National Institute of General Medical Sciences (U54GM104940). Laura M. Perry was supported by the NIH/NCI training grant T32CA193193., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Patients highly value being listened to, taken seriously, heard, and understood; indeed, listening to patients is essential to alleviate suffering. Yet listening as a clinical skill has been virtually ignored in the training of physicians. In this paper, we synthesize literature related to listening in medicine and explore the internal and external challenges and complexity of listening - including the need to listen with a diagnostic as well as a relational ear to take in physical symptoms, emotions, and contexts - often in chaotic and time-pressured environments. We suggest physicians focus on the development of "deep listening" skills, involving cultivating curiosity, openness, reflective self-questioning, and epistemic reciprocity; we also suggest how to ensure patients know they are being listened to., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objectives: Explore how older patients utilize their social networks to inform prognostic understanding., Methods: In a pilot study of adults (≥65 years old) with advanced cancer, 16 patients completed surveys, social network maps, and semi-structured interviews exploring with whom they preferred to communicate about their illness. Interviews were analyzed using open-coding, and codes were categorized into emergent themes. Social network maps and themes were analyzed via mixed-methods social network analysis (MMSNA). Three case examples with diverse network characteristics and communication patterns were selected for further analysis., Results: Three overarching themes (i.e., prognostic understanding, social support, and therapeutic alliance) revealed that patients' prognostic understanding was strongly influenced by the quality of the social support patients perceived from members of their social networks. Patients demonstrated prognostic understanding when they reported close relationships and open communication with their network members. Case examples revealed some ways that patients sought information and had better sense of their prognosis when they had supportive social networks., Conclusion: Findings illustrate how understanding social networks may provide information on how older adults with cancer seek, share, and process prognostic information., Competing Interests: Conflict of Interest None., (Copyright © 2022. Published by Elsevier B.V.)

Background: Little is known about how older adults (OA) with advanced cancer interact with social network members (NM), and the nature of communication. This qualitative study aimed to characterize the processes by which OAs with cancer engage with NMs regarding their illness., Methods: OAs 65 + with advanced cancer and considering treatment (n = 29) and NMs (n = 18) underwent semi-structured interviews asking 1) about their illness understanding; 2) to identify NMs with whom OAs discuss health-related matters; and 3) to describe the content, process, and impact of those illness-related conversations. Three coders analyzed transcribed interviews. Codes were categorized and emergent themes were identified to generate hypotheses., Results: OAs seek NMs with medical backgrounds for cancer-related information and NMs with personal experience of a serious illness for emotional support. Patients characterize geographical location, frequency of communication, and length of NM relationship as factors that influence the nature of support the NM provides. Additionally, differences emerged between OA and NM perspectives on the depth of conversations and decision-making., Conclusions: A better characterization of how OAs' seek and share information and support may improve medical communication, disease understanding, and support goals-concordant care., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Epistemic uncertainty refers to situations in which available evidence is insufficient or unreliable, often accompanied by complexity due to novel contexts, multifactorial causation, and emerging options (the "unknowable unknown"). It stands in contrast to aleatory uncertainty where probabilities are known, and potential benefits and harms can be calculated and presented graphically (the "knowable unknown")., Discussion: Epistemic uncertainty is common, and encompasses uncertainty about the nature of the illness, whom to entrust with one's care, and one's ability to adapt and cope. Communication about the "unknowable unknown" occurs infrequently and ineffectively, and there is little research on improving communication in the face of epistemic and complex uncertainty. Terror Management Theory (TMT) predicts that in encountering serious illness, people engage in "worldview defense" - suppressing death-related thoughts, affiliating with like-minded others, and developing cognitive rigidity and intolerance of information that challenges their worldview. Mindfulness is associated with diminished defensive worldview reactions and cognitive rigidity, and greater tolerance of ambiguity. Shared mind encompasses shared understanding and affective attunement., Conclusion: For clinicians and seriously ill patients facing epistemic uncertainty, psychologically-informed interventions that promote mindfulness and shared mind offer promise in promoting open discussions regarding prognostic uncertainty, advance care planning, and treatment decision-making., Competing Interests: Competing interests Author reports no competing interests., (Copyright © 2021 Elsevier B.V. All rights reserved.)

The COVID-19 pandemic has heightened interest in how physician mental health can be protected and optimised, but uncertainty and misinformation remain about some key issues. In this Review, we discuss the current literature, which shows that despite what might be inferred during training, physicians are not immune to mental illness, with between a quarter and a third reporting increased symptoms of mental ill health. Physicians, particularly female physicians, are at an increased risk of suicide. An emerging consensus exists that some aspects of physician training, working conditions, and organisational support are unacceptable. Changes in medical training and health systems, and the additional strain of working through a pandemic, might have amplified these problems. A new evidence-informed framework for how individual and organisational interventions can be used in an integrated manner in medical schools, in health-care settings, and by professional colleagues is proposed. New initiatives are required at each of these levels, with an urgent need for organisational-level interventions, to better protect the mental health and wellbeing of physicians., Competing Interests: Declaration of interests SBH and KP reports grant income from iCare Foundation and NSW Health. MH was a consultant psychiatrist at the Practitioner Health Programme between 2010 and 2015. All other authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

Context: Older adults with advanced cancer face uncertainty related to their disease and treatment., Objectives: To evaluate the associations of uncertainty with psychological health and quality of life (QoL) in older adults with advanced cancer., Methods: Secondary cross-sectional analysis of baseline data from a national clustered geriatric assessment trial. Patients 70 years and older with advanced cancer considering a new line of chemotherapy were recruited. We measured uncertainty using the modified nine-item Mishel Uncertainty in Illness Scale. Dependent variables included anxiety (Generalized Anxiety Disorder-7), depression (Generalized Depression Scale-15), distress (distress thermometer), QoL (Functional Assessment of Cancer Therapy-General), and emotional well-being (Functional Assessment of Cancer Therapy-General subscale). We used multivariate linear regression analyses to evaluate the association of uncertainty with each dependent variable. We conducted a partial least squares analysis with a variable importance in projection (VIP) plot to assess the contribution of individual variables to the model. Variables with a VIP <0.8 were considered less influential., Results: We included 527 patients (median age 76 years; range 70-96). In multivariate analyses, higher levels of uncertainty were significantly associated with greater anxiety (β = 0.11; SE = 0.04), depression (β = 0.09; SE = 0.02), distress (β = 0.12; SE = 0.02), as well as lower QoL (β = -1.08; SE = 0.11) and emotional well-being (β = -0.29; SE = 0.03); the effect sizes were considered small. Uncertainty items related to disease and treatment were most strongly associated with psychological health and QoL scores (all VIP >0.8)., Conclusion: Uncertainty among older patients with advanced cancer is associated with worse psychological health and QoL. Tailored uncertainty management strategies are warranted., (Copyright © 2020 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Context: Previous studies from the U.S. and Canada report deficiencies in informed decision making and a need to improve end-of-life (EoL) care in patients undergoing dialysis. However, there is a paucity of literature on these issues in Pakistani dialysis patients, who differ from Western patients in culture, religion, and available health care services., Objectives: To study informed dialysis decision-making and EoL attitudes and beliefs in Pakistani patients receiving dialysis., Methods: We used convenience sampling to collect 522 surveys (90% response rate) from patients in seven different dialysis units in Pakistan. We used an existing dialysis survey tool, translated into Urdu, and backtranslated to English. A facilitator distributed the survey, explained questions, and orally administered it to patients unable to read., Results: Less than one-fourth of the respondents (23%) felt informed about their medical condition, and 45% were hopeful that their condition would improve in the future. More than half (54%) wished to know their prognosis, and 80% reported having no prognostic discussion. Almost 63% deemed EoL planning important, but only 5% recalled discussing EoL decisions with a doctor during the last 12 months. Nearly 62% of the patients regretted their decision to start dialysis. Patients' self-reported knowledge of hospice (5%) and palliative care (7.9%) services was very limited, yet 46% preferred a treatment plan focused on comfort and symptom management rather than life extension., Conclusion: Pakistani patients reported a need for better informed dialysis decision making and EoL care and better access to palliative care services. These findings underscore the need for palliative care training of Pakistani physicians and in other developing countries to help address communication and EoL needs of their dialysis patients., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Context: Discordance in prognostic understanding between caregivers of adults with advanced cancer and the oncologist may shape caregivers' views of the oncologist and bereavement outcomes., Objectives: We examined prospective associations of caregiver-oncologist discordance with caregiver-oncologist therapeutic alliance and caregiver anxiety after patient death., Methods: We conducted a secondary analysis of data collected in a cluster randomized controlled trial from August 2012 to June 2014 in Western New York and California. At enrollment, caregivers and oncologists used a seven-point scale to rate their beliefs about the patient's curability and living two years or more: 100%, about 90%, about 75%, about 50 of 50, about 25%, about 10%, and 0%. Discordance was defined as a difference of two points or more. Outcomes at seven months after patient death included caregiver-oncologist therapeutic alliance (The Human Connection scale, modified into five items) and caregiver anxiety (Generalized Anxiety Disorder-7). We conducted multivariable linear regression models to assess the independent associations of discordance with alliance and anxiety., Results: We included 97 caregivers (mean age 63) and 38 oncologists; 41% of caregiver-oncologist dyads had discordant beliefs about the patient's curability, and 63% of caregiver-oncologist dyads had discordant beliefs about living two years or more. On multivariate analysis, discordance in beliefs about curability was associated with lower anxiety (β = -2.20; SE 0.77; P = 0.005). Discordance in beliefs about length of life was associated with a weaker alliance (β = -5.87; SE = 2.56; P = 0.02)., Conclusion: A better understanding of how caregivers understand and come to terms with poor prognoses will guide interventions to improve cancer care delivery and outcomes of cancer treatment., (Copyright © 2020 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Context: There has been surprisingly little attention to conceptual and methodological issues that influence the measurement of discretionary utilization at the end of life (DIAL), an indicator of quality care., Objective: The objectives of this study were to examine how DIALs have been operationally defined and identify areas where evidence is biased or inadequate to inform practice., Methods: We conducted a scoping review of the English language literature published from 1/1/04 to 6/30/17. Articles were eligible if they reported data on ≥2 DIALs within 100 days of the deaths of adults aged ≥18 years. We explored the influence of research design on how researchers measure DIALs and whether they examine demographic correlates of DIALs. Other potential biases and influences were explored., Results: We extracted data from 254 articles published in 79 journals covering research conducted in 29 countries, mostly focused on cancer care (69.1%). More than 100 DIALs have been examined. Relatively crude, simple variables (e.g., intensive care unit admissions [56.9% of studies], chemotherapy [50.8%], palliative care [40.0%]) have been studied more frequently than complex variables (e.g., burdensome transitions; 7.3%). We found considerable variation in the assessment of DIALs, illustrating the role of research design, professional norms and disciplinary habit. Variables are typically chosen with little input from the public (including patients or caregivers) and clinicians. Fewer than half of the studies examined age (44.6%), gender (37.3%), race (26.5%), or socioeconomic (18.5%) correlates of DIALs., Conclusion: Unwarranted variation in DIAL assessments raises difficult questions concerning how DIALs are defined, by whom, and why. We recommend several strategies for improving DIAL assessments. Improved metrics could be used by the public, patients, caregivers, clinicians, researchers, hospitals, health systems, payers, governments, and others to evaluate and improve end-of-life care., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Context: Although patient and physician characteristics are thought to be predictive of discretionary interventions at the end of life (EoL), few studies have data on both parties., Objective: To test the hypothesis that patient preferences and physician attitudes are both independently associated with discretionary interventions at the EoL., Methods: We report secondary analyses of data collected prospectively from physicians (n = 38) and patients with advanced cancer (n = 265) in the Values and Options in Cancer Care study. Predictor variables were patient attitudes toward EoL care and physician-reported comfort with medical paternalism, assessed indirectly using a modified version of the Control Preference Scale. We explored whether the magnitude of the physician variable was influenced by the inclusion of particular patient treatment-preference variables (i.e., effect modification). Outcomes were a chemotherapy use score (≤14 days before death [scored 2], 15-31 days before death [scored 1], and >31 days [scored 0]) and an emergency department visit/inpatient admission score (two or more admissions in the last 31 days [scored 2], one admission [1], and 0 admissions [0]) in the last month of life., Results: Chemotherapy scores were nearly 0.25 points higher if patients expressed a preference for experimental treatments with unknown benefit at study entry (0.238 points, 95% CI = 0.047-0.429) or reported an unfavorable attitude toward palliative care (0.247 points, 95% CI = 0.047-0.450). A two-standard deviation difference in physician comfort with medical paternalism corresponded to standardized effects of 0.35 (95% CI = 0.03-0.66) for chemotherapy and 0.33 (95% CI = 0.04-0.61) for emergency department visits/inpatient admissions. There was no evidence of effect modification., Conclusion: Patient treatment preferences and physician attitudes are independently associated with higher levels of treatment intensity before death. Greater research, clinical, and policy attention to patient treatment preferences and physician comfort with medical paternalism might lead to improvements in care of patients with advanced disease., (Copyright © 2019 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: We examined whether conversations involving Black or Latino patients with advanced cancer differ in the presence or characteristics of prognosis communication., Methods: We audio-recorded initial consultations between 54 palliative care clinicians and 231 hospitalized people with advanced cancer. We coded for the presence and characteristics of prognosis communication. We examined whether the presence or characteristics of prognosis communication differed by patients' self-reported race/ethnicity., Results: In 231 consultations, 75.7% contained prognosis communication. Prognosis communication was less than half as likely to occur during conversations with Black or Latino patients (N = 48) compared to others. Among consultations in which prognosis was addressed, those involving Black or Latino patients were more than 8 times less likely to contain optimistically cued prognoses compared to others., Conclusion: Prognosis communication occurred less frequently for Black and Latino patients and included fewer optimistic cues than conversations with other patients. More work is needed to better understand these observed patterns of prognosis communication that vary by race and ethnicity., Practice Implications: Growing evidence supports prognosis communication being important for end-of-life decision-making and disproportionately rare among non-White populations. Therefore, our findings identify a potentially salient target for clinical interventions that are focused on ameliorating disparities in end-of-life care., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To explore family caregivers' emotional experiences while caring for patients with advanced cancer and navigating distressing information, awareness of dying, and difficult decisions., Methods: Qualitative descriptive study of semi-structured interviews with 92 bereaved caregivers of patients with advanced cancer. Interviews explored caregivers' experiences as patients transitioned out of active cancer treatment and neared the end of life., Results: Included in caregivers' characterization of this transition time were three particularly emotionally charged experiences. The first occurred when caregivers felt jolted into awareness that patients were dying.They were startled to realize that patients would die sooner than expected; some expressed frustration that they had not been adequately warned. In the second, caregivers felt conflicted when involved in decisions that pitted patients' preferences against what caregivers felt patients needed, resulting in ambivalence, guilt, and grief. Thirdly, caregivers who felt they did their best for patients expressed fulfillment and gratitude., Conclusion: Caregivers of patients with advanced cancer face unique, emotionally charged experiences that can lead to distress and affect care at the end of life., Practice Implications: Awareness of these situations may help oncology teams to provide sufficient guidance and support, partner with caregivers to clarify patients' needs, and deliver higher quality care., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Context: Men and those with low educational attainment are less likely to receive palliative care. Understanding these disparities is a high priority issue., Objectives: In this study of advanced cancer patients, we hypothesized that men and those with lower levels of educational attainment would have less favorable attitudes toward palliative care., Methods: We performed a cross-sectional analysis of data collected from 383 patients at study entry in the Values and Options in Cancer Care (VOICE) clinical trial. Patients were asked about their preferences for palliative care if their oncologist informed them that further treatment would not be helpful. Palliative care was defined as "comfort care" that focuses on "quality of life, but not a cure." Response options were definitely no, possibly no, unsure, possibly yes, and definitely yes. Those preferring palliative care (definitely or possibly yes) were compared to all others. Predictors were patient gender and education level. Covariates included age, race, disease aggressiveness, and financial strain., Results: Women were more likely [odds ratio (95% CI)] than men to prefer palliative care [3.07 (1.80-5.23)]. The effect of education on preferences for palliative care was not statistically significant [0.85 (0.48-1.48)]., Conclusion: Significant gender differences in patients' preferences for palliative care could partially account for gender disparities in end-of-life care. Interventions to promote palliative care among men could reduce these disparities., (Copyright © 2018 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Clinician discomfort with death may affect care of patients but has not been well-studied. This study explores oncology clinicians' attitudes surrounding their own death and how these attitudes both affect and are affected by their care of dying patients and their communication with them., Methods: Qualitative interviews with physicians (n=25), nurse practitioners (n=7), and physician assistants (n=1) in medical or hematologic oncology clinical practices about communication styles, care of terminally ill patients, and personal perspectives about mortality., Results: Clinicians described three communication styles used with patients about death and dying: direct, indirect, or selectively direct. Most reported an acceptance of their mortality that was "conditional," meaning that that they could not fully know how they would respond if actually terminally ill. For many clinicians, caring for dying patients affected their outlook on life and death, and their own perspectives on life and death affected their approach to caring for dying patients., Conclusion: An awareness of personal mortality may help clinicians to discuss death more openly with patients and to provide better care., Practice Implications: Efforts to promote self-awareness and communication training are key to facilitating clear communication with and compassionate care of terminally ill patients., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: The objective of this study was to provide insight into how advanced cancer patients and their caregivers use a Question Prompt List (QPL) during a consultation and for preparation for future consultations., Methods: Audiotaped consultations and follow-up phone calls of 28 advanced cancer patients were coded and content analyzed. Questions asked and concerns expressed in consultations were coded for initiator, content, inclusion in the QPL and exact wording. Patients' reported and future use of the QPL were coded from the phone calls., Results: The majority of patients reported that they used the QPL. Questions asked by patients and caregivers predominately coincided with questions from the prognosis section of the QPL. Questions were rarely asked literally from the QPL, instead questions were tailored to patients' own circumstances., Conclusion: QPLs are useful to stimulate discussion on prognosis among advanced cancer patients and caregivers. Patients tailored questions from the QPL to their own circumstances which may suggest high involvement and engagement. The development of more specific tailored communication interventions for advanced cancer patients is warranted., Practice Implications: Implementation of QPLs in the advanced cancer setting may be beneficial for patients, caregivers and healthcare providers to facilitate discussion of topics such as prognosis., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: To examine using audio-recorded encounters the extent and process of companion participation when discussing treatment choices and prognosis in the context of a life-limiting cancer diagnosis., Methods: Qualitative analysis of transcribed outpatient visits between 17 oncologists, 49 patients with advanced cancer, and 34 companions., Results: 46 qualifying companion statements were collected from a total of 28 conversations about treatment choices or prognosis. We identified a range of companion positions, from "pseudo-surrogacy" (companion speaking as if the patient were not able to speak for himself), "hearsay", "conflation of thoughts", "co-experiencing", "observation as an outsider", and "facilitation". Statements made by companions were infrequently directly validated by the patient., Conclusion: Companions often spoke on behalf of patients during discussions of prognosis and treatment choices, even when the patient was present and capable of speaking on his or her own behalf., Practice Implications: The conversational role of companions as well as whether the physician checks with the patient can determine whether a companion facilitates or inhibits patient autonomy and involvement. Physicians can reduce ambiguity and encourage patient participation by being aware of when and how companions may speak on behalf of patients and by corroborating the companion's statement with the patient., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: To assess the effect of a pilot intervention to promote clinician-patient communication about physical activity on patient ratings of their perceived competence for physical activity and their clinicians' autonomy-supportiveness., Methods: Family medicine clinicians (n=13) at two urban community health centers were randomized to early or delayed (8 months later) communication training groups. The goal of the training was to teach the 5As (Ask, Advise, Agree, Assist, Arrange) for physical activity counseling. Outcome measures were changes in patient perceptions of autonomy support (modified Health Care Climate Questionnaire, mHCCQ) and perceived competence (Perceived Competence Scale for physical activity, PCS) completed via surveys at baseline, post-intervention and six-month follow-up., Results: Patients (n=326) were mostly female (70%) and low income. Using a generalized estimating equations model (GEE) with patients nested within clinician, patient perceived autonomy support increased at post-intervention compared to baseline (mean HCCQ scores 3.68-4.06, p=0.03). There was no significant change in patient perceived competence for physical activity., Conclusions: A clinician-directed intervention increased patient perceptions of clinician autonomy support but not patient perceived competence for physical activity., Practice Implications: Clinicians working with underserved populations can be taught to improve their autonomy supportiveness, according to patient assessments of their clinicians., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: To explore patients' perspectives across two cultures (Australia and USA) regarding communication about prognosis and end-of-life care issues and to consider the ways in which these discussions can be optimised., Methods: Fifteen Australian and 11 US patients completed individual semi-structured qualitative interviews. A further 8 US patients participated in a focus group. Interviews and focus group recordings were transcribed verbatim and interpreted using thematic text analysis with an inductive, data-driven approach., Results: Global themes identified included readiness for and outcomes of discussions of prognosis and end-of-life issues. Contributing to readiness were sub themes including patients' adjustment to and acceptance of their condition (together with seven factors promoting this), doctor and patient communication skills, mutual understandings and therapeutic relationship elements. Outcomes included sub themes of achievement of control and ability to move on. A model of the relationships between these factors, emergent cross cultural differences, and how factors may help to optimise these discussions are presented., Conclusion: Identified optimising factors illustrate Australian and US patients' perspectives regarding how prognosis and end-of-life issues can be discussed with minimised negative impact., Practice Implications: Recognition of factors promoting adjustment, acceptance and readiness and use of the communication skills and therapeutic relationship elements identified may assist in optimising discussions and help patients plan care, achieve more control of their situation and enjoy an optimal quality-of-life., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Commercial advertising and patient education have separate theoretical underpinnings, approaches, and practitioners. This paper aims to describe a collaboration between academic researchers and a marketing firm working to produce demographically targeted public service anouncements (PSAs) designed to enhance depression care-seeking in primary care., Methods: An interdisciplinary group of academic researchers contracted with a marketing firm in Rochester, NY to produce PSAs that would help patients with depressive symptoms engage more effectively with their primary care physicians (PCPs). The researchers brought perspectives derived from clinical experience and the social sciences and conducted empirical research using focus groups, conjoint analysis, and a population-based survey. Results were shared with the marketing firm, which produced four PSA variants targeted to gender and socioeconomic position., Results: There was no simple, one-to-one relationship between research results and the form, content, or style of the PSAs. Instead, empirical findings served as a springboard for discussion and kept the creative process tethered to the experiences, attitudes, and opinions of actual patients. Reflecting research findings highlighting patients' struggles to recognize, label, and disclose depressive symptoms, the marketing firm generated communication objectives that emphasized: (a) educating the patient to consider and investigate the possibility of depression; (b) creating the belief that the PCP is interested in discussing depression and capable of offering helpful treatment; and (c) modelling different ways of communicating with physicians about depression. Before production, PSA prototypes were vetted with additional focus groups. The winning prototype, "Faces," involved a multi-ethnic montage of formerly depressed persons talking about how depression affected them and how they improved with treatment, punctuated by a physician who provided clinical information. A member of the academic team was present and consulted closely during production. Challenges included reconciling the marketing tradition of audience segmentation with the overall project goal of reaching as broad an audience as possible; integrating research findings across dimensions of words, images, music, and tone; and dealing with misunderstandings related to project scope and budget., Conclusion: Mixed methods research can usefully inform PSAs that incorporate patient perspectives and are produced to professional standards. However, tensions between the academic and commercial worlds exist and must be addressed., Practice Implications: While rewarding, academic-marketing collaborations introduce tensions which must be addressed., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Conflict and chaos are prevalent in health care, and perhaps especially in palliative care. Typically, our point of entry into our patients' lives is often at the moment of conflict, discord, or intense suffering. Despite this, little in our formal training as clinicians teaches us how to be present for this suffering. Much has been written about the process of communication with regard to giving bad news, handling family meeting conflicts, and negotiating shifting goals of care, but little has been addressed about how to train the clinician to be present with the dissonance and suffering. In this paper, we explore how music, art, and literature teach us how to stay in moments of tension. In turn, lessons on how to learn to lean into the dissonance of many palliative care encounters are extrapolated., (Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Objective: To test the effect of three questions (what are my options? what are the benefits and harms? and how likely are these?), on information provided by physicians about treatment options., Methods: We used a cross-over trial using two unannounced standardized patients (SPs) simulating a presentation of mild-moderate depression. One SP was assigned the intervention role (asking the questions), the other the control role. An intervention and control SP visited each physician, order allocated randomly. The study was conducted in family practices in Sydney, Australia, during 2008-09. Data were obtained from consultation audio-recordings. Information about treatment options and patient involvement were analyzed using the Assessing Communication about Evidence and Patient Preferences (ACEPP) tool and the OPTION tool., Results: Thirty-six SP visits were completed (18 intervention, 18 control). Scores were higher in intervention consultations than controls: ACEPP scores 21.4 vs. 16.6, p<0.001, difference 4.7 (95% CI 2.3-7.0) and OPTION scores 36 vs. 25, p=0.001, difference 11.5 (95% CI 5.1-17.8), indicating greater information provision and behavior supporting patient involvement., Conclusion: Asking these three questions improved information given by family physicians and increased physician facilitation of patient involvement. Practice implications. These questions can drive evidence-based practice, strengthen patient-physician communication, and improve safety and quality., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: Patient navigation for cancer care assesses and alleviates barriers to health care services. We examined paired perspectives of cancer patients and their navigators to examine the process of patient navigation. We explored the strengths, limitations, and our own lessons learned about adopting the novel methodology of multiperspective analysis., Methods: As part of a larger RCT, patients and navigators were interviewed separately. We reviewed interviews with 18 patient-navigator dyads. Dyad summaries were created that explicitly incorporated both patient and navigator perspectives. Emerging themes and verbatim quotations were reflected in the summaries., Results: Paired perspectives were valuable in identifying struggles that arose during navigation. These were represented as imbalanced investment and relational amelioration. Patients and navigators had general consensus about important patient needs for cancer care, but characterized these needs differently., Conclusion: Our experience with multiperspective analysis revealed a methodology that delivers novel relational findings, but is best conducted de novo rather than as part of a larger study., Practice Implications: Multiperspective analysis should be more widely adopted with clear aims and analytic strategy that strengthen the ability to reveal relational dynamics. Navigation training programs should anticipate navigator struggles and provide navigators with tools to manage them., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: To identify attitudinal and interpersonal barriers to depression care-seeking and disclosure in primary care and in so doing, evaluate the primary care paradigm for depression care in the United States., Methods: Fifteen qualitative focus group interviews in three cities. Study participants were English-speaking men and women aged 25-64 with first-hand knowledge of depression. Transcripts were analyzed iteratively for recurring themes., Results: Participants expressed reservations about the ability of primary care physicians (PCPs) to meet their mental health needs. Specific barriers included problems with PCP competence and openness as well as patient-physician trust. While many reflected positively on their primary care experiences, some doubted PCPs' knowledge of mental health disorders and believed mental health concerns fell outside the bounds of primary care. Low-income participants in particular shared stories about the essentiality, and ultimate fragility, of patient-PCP trust., Conclusion: Patients with depression may be deterred from care-seeking or disclosure by relational barriers including perceptions of PCPs' mental health-related capabilities and interests., Practice Implications: PCPs should continue to develop their depression management skills while supporting vigorous efforts to inform the public that primary care is a safe and appropriate venue for treatment of common mental health conditions., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: We examined how navigation, defined as the assessment and alleviation of barriers to adequate health care, influences patients' perspectives on the quality of their cancer care., Methods: We conducted post-study patient interviews from a randomized controlled trial (usual care vs. patient navigation services) from cancer diagnosis through treatment completion. Patients were recruited from 11 primary care, hospital and community oncology practices in New York. We interviewed patients about their expectations and experience of patient navigation or, for non-navigated patients, other sources of assistance., Results: Thirty-five patients newly diagnosed with breast or colorectal cancer. Valued aspects of navigation included emotional support, assistance with information needs and problem-solving, and logistical coordination of cancer care. Unmet cancer care needs expressed by patients randomized to usual care consisted of lack of assistance or support with childcare, household responsibilities, coordination of care, and emotional support., Conclusion: Cancer patients value navigation. Instrumental benefits were the most important expectations for navigation from navigated and non-navigated patients. Navigated patients received emotional support and assistance with information needs, problem-solving, and logistical aspects of cancer care coordination., Practice Implications: Navigation services may help improve cancer care outcomes important to patients by addressing fragmented, confusing, uncoordinated, or inefficient care., (Copyright 2009 Elsevier Ireland Ltd. All rights reserved.)

Objective: To assess the message preferences of individuals affected by depression as part of a project that will evaluate interventions to encourage at-risk patients to talk to their physicians about depression., Methods: Adaptive Conjoint Analysis (ACA) of 32 messages defined by 10 message attributes. Messages were developed based on input from three focus groups comprised of individuals with a personal and/or family history of depression, then tested using volunteers from an Internet health community. In an online conjoint survey, 249 respondents with depression rated their liking of the messages constructed for each attribute. They were then presented with two message sets and rated their preferences. Preference utilities were generated using hierarchical Bayes estimation., Results: The optimal communication approach described both psychological and physical symptoms of depression, recognized multiple treatment options, offered lifetime prevalence data, noted that depression can affect anyone, and acknowledged that finding an effective treatment can take time., Conclusion: Individuals with depression respond differently to depression care messages, underscoring the need for careful message development and evaluation., Practice Implications: ACA, used in conjunction with focus groups, is a promising approach for developing and testing messages in the formative research stage of intervention development., (Copyright 2009 Elsevier Ireland Ltd. All rights reserved.)

Objective: To examine physician communication associated with prognosis discussion with cancer patients., Methods: We conducted a study of physician-patient communication using trained actors. Thirty-nine physicians, including 19 oncologists and 20 family physicians participated in the study. Actors carried two hidden digital recorders to unannounced visits. We coded recordings for eliciting and validating patient concerns, attentive voice tone, and prognosis talk., Results: Actor adherence to role averaged 92% and the suspected detection rate was 14%. In a multiple regression, eliciting and validating patient concerns (beta=.40, C.I.=0.11-0.68) attentiveness (beta=.32, C.I.=0.06-0.58) and being an oncologist vs. a family physician (beta=.33, C.I.=0.33-1.36) accounted for 46% of the variance in prognosis communication., Conclusion: Eliciting and validating patient concerns and attentiveness voice tone is associated with increased discussion of cancer patient prognosis as is physician specialty., Practice Implications: Eliciting and validating patient concerns and attentive voice tone may be markers of physician willingness to discuss emotionally difficult topics. Educating physicians about mindful practice may increase their ability to collect important information and to attend to patient concerns.

Objective: Although prior research indicates that features of clinician-patient communication can predict health outcomes weeks and months after the consultation, the mechanisms accounting for these findings are poorly understood. While talk itself can be therapeutic (e.g., lessening the patient's anxiety, providing comfort), more often clinician-patient communication influences health outcomes via a more indirect route. Proximal outcomes of the interaction include patient understanding, trust, and clinician-patient agreement. These affect intermediate outcomes (e.g., increased adherence, better self-care skills) which, in turn, affect health and well-being. Seven pathways through which communication can lead to better health include increased access to care, greater patient knowledge and shared understanding, higher quality medical decisions, enhanced therapeutic alliances, increased social support, patient agency and empowerment, and better management of emotions., Conclusion: Future research should hypothesize pathways connecting communication to health outcomes and select measures specific to that pathway., Practice Implications: Clinicians and patients should maximize the therapeutic effects of communication by explicitly orienting communication to achieve intermediate outcomes (e.g., trust, mutual understanding, adherence, social support, self-efficacy) associated with improved health.

Objective: There is considerable interest in the influences on patients' ratings of physicians., Methods: In this cross-sectional study, patients (n = 4616; age range: 18-65 years) rated their level of satisfaction with their primary care physicians (n = 96). Patients and physicians were recruited from primary care practices in the Rochester, NY metropolitan area. For analytic purposes, length of the patient-physician relationship was stratified (< or =1, 1-4, > or =5 years). Principal components factor analysis of items from the Health Care Climate Questionnaire, the Primary Care Assessment Survey and the Patient Satisfaction Questionnaire yielded a single factor labeled "Satisfaction" that served as the sole dependent variable. Higher scores mean greater satisfaction. Predictors of interest were patient demographics and morbidity as well as physician demographics and personality, assessed with items from the NEO-FFI., Results: Patients treated by a physician for 1 year or less rated male physicians higher than female physicians. This gender difference disappeared after 1 year, but two physician personality traits, Openness and Conscientiousness, were associated with patients' ratings in lengthier patient-physician relationships. Patients report being more satisfied with physicians who are relatively high in Openness and average in Conscientiousness. Older patients provide higher ratings than younger patients, and those with greater medical burden rated their physicians higher., Conclusion: Patients' ratings of physicians are multidetermined. Future research on patient satisfaction and the doctor-patient relationship would benefit from a consideration of physician personality. Identifying physician personality traits that facilitate or undermine communication, trust, patient-centeredness, and patient adherence to prescribed treatments is an important priority., Practice Implications: Learning environments could be created to reinforce certain traits and corresponding habits of mind that enhance patient satisfaction. Such a shift in the culture of medical education and practice could have implications for patient care.

Objective: To explore limitations of current communication theory by considering different perspectives of researchers, clinicians, patients and teachers of communication., Method: Theory development based on limitations of the current communication research literature due to inconsistencies between patient reports and observed communication behavior., Results: While researchers focus on the mechanics and techniques of communication, patients seek relationships in which they experience trust, the right amount of autonomy, caring, and expertise. Patients', physicians', and communication experts' perspectives do not always define the same problems and often point to different solutions., Conclusions: In addition to studying clinician behaviors and patient perceptions of care, communication research should focus on five additional factors: what patients notice, want and need, and how their perspectives differ from those of physicians and researchers; the context, including illness severity and type and family influences; how complex health systems facilitate and impede communication; patients' influences on physician communication behavior; and habits of mind that promote attentive care.

Objectives: To develop a reliable and valid computer coded measure to assess emotional expression from transcripts of physician-patient interactions., Methods: Physician encounters with two standardized patients (SPs) were audiotaped. Fifty patients from each physician (n = 100 primary care physicians) completed surveys that assessed patients' perceptions of their relationships with physicians. Audio-recordings of 193 patient-physician encounters were transcribed and computer-coded to derive a percent emotion words, and research assistants completed the Measure of Patient-Centered Communication (MPCC)., Results: After adjustment for potential confounders, regression analyses revealed physicians' use of emotion words and the MPCC contribute independently to patients' and SPs' perceptions of their relationship with physicians., Conclusions: The computerized coding of emotion words shows promise as a reliable, valid, and simple method to code transcript data of physician-patient interactions. This method may be expanded to examine other aspects of physician language and does not require coder training.