Table 3.

Suggestions to Improve Patient-Clinician Communication Regarding Pulmonary Nodules

Patient as person

Recognize that identifying a pulmonary nodule is often distressful although frequently underreported

Discuss the nodule directly with the patient and provide a written summary  Examples •Schedule an office or telephone visit to discuss the nodule • A written summary should: ○ Provide information about the nodule and address common concerns ○ Avoid medical jargon or sending the CT report without further explanation ○ See e-Appendix 1 for an example of a patient-centered notification letter

Actively elicit patient feelings  Examples •“It’s common to be distressed after learning you have a pulmonary nodule; how are you feeling?” •“What’s on your mind?” •“Some people with a nodule worry they have lung cancer… what have you been thinking?”

Provide reassurance and resources to decrease distress

Make it easy for patients with persistent concerns to contact a knowledgeable clinician  Examples •Provide telephone number for nurse coordinator/manager •Clarify ability to message clinician through the electronic health record

Recognize that the nodule may be an important concern for patients and allow time for discussion of the patient’s questions. Avoid minimizing or dismissive language

Information exchange

Patient-level suggestions

Provide information about the causes of nodules, rationale for active surveillance rather than immediate biopsy, and follow-up plan details, including benefits and harms

Report the semi-quantitative risk of lung cancer and relevant nodule information that relates to risk prediction (eg, lack of growth decreases malignancy risk)

Describe the follow-up plan in detail, including possible steps if the nodules change (eg, biopsy or surgery for growing nodule)

Use pictures, summary tables, and plain, simple language

Provide list of signs and symptoms that should prompt contact

Outline key imaging dates and subsequent office visits or telephone calls and provide a copy

Provide written and/or online educational resources for obtaining further information  Examples •Nodule risk calculator: http://reference.medscape.com/calculator/solitary-pulmonary-nodule-risk •Nodule patient education: http://www.thoracic.org/patients/patient-resources/resources/lung-nodules-online.pdf

Provide smoking cessation guidance if applicable, framed as a “teachable moment”

System-level suggestions

Health-care systems can develop system-wide tools to increase patients’ knowledge and understanding of the lung cancer evaluation process

Health-care systems should develop tools to monitor and ensure adherence to follow-up recommendations

Shared decision-making

Clarify that active surveillance is a decision that the patient can discuss and question  Example •“Let’s talk together about what to do about your nodule”

Ask what role the patient prefers in the decision-making process  Example •“When we make this decision about what to do about your nodule, some patients want to make the decision on their own, some just want me to decide, and many want something in the middle. How about you?”

If the patient is comfortable with a shared approach, actively engage patients in decisions regarding the follow-up evaluation

Take the patient’s values and preferences into account before making a final decision  Examples •“Some people are worried about getting lung cancer when thinking about nodule follow-up; what do you think?” •“I know you have worried about radiation exposure in the past, so let’s talk about that before we decide on a plan.” •“Most of the time, the right decision is to watch the nodule over time, when we get another CT scan. But some people want to have an answer right away. How do you feel about waiting?” •“How would you like to get the results of your next CT scan?”

Therapeutic alliance

Ask patients what they expect at the outset of the encounter to help define roles and prevent assumptions

Evaluate patients’ understanding of the concepts presented  Examples •“To make sure I didn’t forget to tell you anything, can you repeat back to me when you’re going to get your next CT scan? And what are you going to do if you have more questions or start to feel distressed?”