Abstract
Background
Despite the clinical importance of assessing smoking history and advising patients who smoke to quit, patients with lung cancer often experience feelings of blame and stigma during clinical encounters with their oncology care providers (OCPs). Promoting empathic communication during these encounters may help reduce patients’ experience of stigma and improve related clinical outcomes. This paper presents the evaluation of OCP- and patient-reported data on the usefulness of an OCP-targeted empathic communication skills (ECS) training to reduce the stigma of lung cancer and improve communication.
Research Question
What is the impact of the ECS intervention on OCPs’ communication skills uptake and patient-reported outcomes (lung cancer stigma, satisfaction with communication, and perceived OCP empathy)?
Methods
Study subjects included 30 multidisciplinary OCPs treating patients with lung cancer who participated in a 2.25 h ECS training. Standardized Patient Assessments were conducted prior to and following training to assess ECS uptake among OCPs. In addition, of a planned 180 patients who currently or formerly smoked (six unique patients per OCP [three pretraining, three posttraining]), 175 patients (89 pretraining, 86 posttraining) completed post-OCP visit surveys eliciting feedback on the quality of their interaction with their OCP.
Results
OCPs exhibited an overall increase in use of empathic communication skills [t(28) = –2.37; P < .05], stigma-mitigating skills [t(28) = –3.88; P < .001], and breadth of communication skill use [t(28) = –2.91; P < .01]. Patients reported significantly higher overall satisfaction with communication post-ECS training, compared with pretraining [t(121) = 2.15; P = .034; Cohen d = 0.35]. There were no significant differences from pretraining to posttraining for patient-reported stigma or perceived OCP empathy.
Interpretation
Empathy-based, stigma-reducing communication may lead to improved assessments of tobacco use and smoking cessation for patients with smoking-related cancers. These findings support the dissemination and further testing of a new ECS model for training OCPs in best practices for assessment of smoking history and engagement of patients who currently smoke in tobacco treatment delivery.
Key Words: communication skills training, empathic communication, lung cancer, oncology, satisfaction with communication, smoking, standardized patient assessment, stigma
Abbreviations: ECS, empathic communication skills; MSK, Memorial Sloan Kettering Cancer Center; OCP, oncology care provider; SPA, standardized patient assessment
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Stigma, the experience and internalization of negative appraisal and devaluation from others, is increasingly recognized as a threat to the delivery of high-quality care for patients diagnosed with lung cancer.1,2 The prominent social scientist Erving Goffman defined stigma as a “characteristic that designates an individual as socially devalued.”3 Stigma evokes different emotions (eg, disgust, fear, anger) and may motivate people to form or bolster stigma attitudes.4 Due to the association between lung cancer and smoking, patients diagnosed with lung cancer often face stigmatizing societal attitudes1; this is particularly true for those who currently or formerly smoked.5 The majority of patients with lung cancer report experiencing stigma,2 and nearly one-half (48%) report having experienced stigma during clinical encounters with their oncology care providers (OCPs), particularly during discussions about smoking.2
Practice guidelines for smoking cessation recommend routine assessment of smoking status, cessation advice, and referral or assistance to tobacco treatment.6 However, adoption of these practices in oncology care has been inconsistent, and patient engagement has been low.7 Despite the clinical importance of promoting smoking cessation in the context of cancer care,8,9 there is a growing concern that routine assessment of smoking and providing cessation advice may elicit perceived and internalized lung cancer stigma, resulting in the unintended consequence of patient avoidance of seeking tobacco cessation support.1,10 Lung cancer stigma may also be triggered when clinicians miss or ignore patient-initiated statements that provide an opportunity for the clinician to respond empathically.11, 12, 13, 14
Among different types of empathic opportunities, the following three types are particularly relevant to smoking-related conversations between OCPs and patients with lung cancer who currently or formerly smoked: (1) emotion (statement of an affective state; for example, “I am scared about this diagnosis”); (2) challenge (statement of barriers related/unrelated to cancer; for example, “I have tried but haven’t been able to quit smoking”); and (3) progress (statement of improvement in condition/quality of life or positive event; for example, “I have not touched a cigarette in 4 months”).14, 15, 16
Each of these provides an opportunity for the OCP to respond empathically. For instance, when patients with lung cancer express negative emotions (eg, guilt, self-blame), OCPs can respond empathically by normalizing nicotine addiction (eg, “You started smoking when you were a teenager without full appreciation for nicotine addiction and the harms of smoking. It was also a different time when smoking was much more widespread and acceptable”). They can also validate patient struggle with tobacco dependence (eg, “Nicotine is a powerful addiction, and I understand quitting smoking is not easy”), while providing a clear recommendation for quitting (eg, “I recommend that you meet with a counselor to help with quitting”), emphasizing the benefits of quitting (eg, “Quitting smoking can improve your cancer treatment and outcomes”), and expressing a willingness to help (eg, “I will put in a referral for you to see a counselor, and they will help you through this process of quitting”). Responses such as these can help provide empathy to patients who currently or formerly smoked.
Our earlier work described the critical need for OCPs to be trained in communicating empathically with patients who have lung cancer.1,12,16 Facilitating greater empathic communication may be particularly important for improving clinical care, given that patients with lung cancer frequently experience feelings of blame, shame, and guilt when OCPs adhere to clinical practice guidelines6 for routine assessment of smoking history.1,2,11
Communicating empathically with patients is beneficial for promoting patients’ health17 and engagement with care.18 Pehrson et al19 defined the goal of empathic communication as “to recognize or elicit and respond to patients’ empathic opportunities to communicate understanding, alleviate distress, and provide support.” Although several definitions of empathy exist, we chose this definition because it is most pertinent to the clinical encounter. Neumann et al20 proposed that empathic communication leads patients to disclose more information, which results in two pathways to better outcomes: affective-oriented effects and cognitive/behavioral-oriented effects. Although the cognitive/behavioral-intended effects are likely, we focused on affective-oriented effects as they are relevant for examining patient-reported stigma. The model theorizes that the affective-oriented effects of clinical empathy lead to short-term and intermediate outcomes related to feeling listened to, valued, understood, and accepted; that their experiences are valid and normal; and that the isolation of the illness is bridged.
In an effort to develop an OCP-focused intervention to reduce stigma, we created an Empathic Communication Skills (ECS) training module that focuses on the communication challenges present in OCPs’ discussions of smoking history with lung cancer patients.21 The ECS training module was adapted from prior work19 and was based on focus groups with lung cancer survivors, recruited via the Go2 Foundation for Lung Cancer. The focus groups revealed that stigmatizing interactions with OCPs were common, and patients provided detailed narrative descriptions of stigmatizing interactions.22 These descriptions included repeated unexplained questioning about smoking behavior (different medical professionals questioning the patients about smoking; for example, “…you’re constantly asked the question, ‘Did you smoke?’ by every medical professional you come in contact with”), disbelieving the patient (not believing the patient is telling the truth; for example, “Well, you’re still smoking, right? You’re sneaking some cigarettes”), and blaming statements about smoking behavior (critical, judgmental presumptions; for example, “Well, you wouldn’t get lung cancer if you didn’t smoke”). Participants also suggested communication preferences based on their experiences with OCPs. These suggestions helped guide the development of effective empathic communication strategies for reducing lung cancer stigma.21
Additional details about ECS training module development and OCP-reported training appraisal and self-efficacy have been published elsewhere, with the results showing that the ECS training was feasible and acceptable.21 The current study examined the efficacy of the ECS intervention on OCPs’ communication skills uptake and patient-reported outcomes (lung cancer stigma, satisfaction with communication, and perceived OCP empathy).
Subjects and Methods
Study Design
The study design was a single-arm, pre-post intervention.23 All study procedures were reviewed and approved by the Institutional Review Board at Memorial Sloan Kettering Cancer Center (MSK). Several ECS training modules were offered from December 2017 to April 2019.
Participants and Recruitment
OCP subjects were eligible to participate if they: (1) were physicians (ie, attending physicians or fellows from radiology, thoracic oncology, thoracic surgery, or pulmonary medicine), advanced practice providers (ie, nurse practitioners, physician assistants), or other clinical nurses (ie, clinical nurse specialist, clinical registered nurse) from the MSK Thoracic Disease Management Team; and (2) routinely conducted individual clinical consultations, including an assessment of patients’ smoking history. The OCPs provided informed consent, and participation was voluntary.
We attempted to recruit six unique patients per OCP (ie, three patients prior to ECS training, three patients following ECS training). Ultimately, 175 (180 planned) patients were consented for study participation. Patients were eligible if they: (1) were recently diagnosed with and receiving medical treatment for lung cancer (any stage, any type) by one of 30 OCPs enrolled in the study; (2) currently or formerly (ie, quit within the past 10 years) smoked cigarettes; and (3) were within their first three visits with the OCP.
ECS Training
The goal of this 2.25 h ECS training was to enhance clinician recognition and responsiveness to empathic opportunities with patients with lung cancer by communicating understanding, alleviating stigma and distress, and providing support. ECS training was guided by an established communication skills training model24 developed at MSK with seven recommended communication strategies: agenda setting, history taking, recognizing or eliciting a patient’s empathic opportunity, shared understanding of the patient’s emotion/experience, empathic responding, coping and connection to social support, and closing the conversation. The didactic training content was followed by experiential role-play exercises with standardized patients (trained actors). In addition, all OCP participants completed Standardized Patient Assessments (SPAs), one prior to and one following training. An SPA involved video-recording of an interaction (up to 12 mins) between the OCP and the standardized patient portraying two distinct clinical scenarios; standardized scripts were used.
Coding
Two trained coders (T. J. W. and C. M. M.), blinded to the prestatus or poststatus of the SPA, coded all the SPA videos using the Comskil Coding System24 adapted within the context of taking a smoking history. Intercoder agreement was assessed at the beginning of coding and at the midpoint by double coding 10% of data. Due to the large number of possible codes for any interaction and the variable units of analyses, a time-chunk method24 was used to determine intercoder agreement; we assessed coders’ percent agreement on 15 s blocks of a 12 min interaction. Following each intercoder agreement, we assessed for percent agreement, resolved all disagreements via a third coder (S. C. B.), and continued with coding only when ≥ 75% agreement was achieved.
Measures
Our evaluation included both OCP and patient-reported outcomes. The primary outcome was ECS training skill uptake for participating OCPs (based on SPAs). Secondary outcomes included patient-reported OCP empathy, satisfaction with communication, and lung cancer stigma (Table 1). All pretraining data were collected within 2 months prior to the training, ECS training skill uptake (ie, posttraining SPA) data were collected immediately following training, and posttraining patient-reported data were collected within 6 months of training.
Table 1.
OCP and Patient Characteristics, Overall and According to Group
| Characteristic | Group | All | Pretraining Group | Posttraining Group |
|---|---|---|---|---|
| OCP (N = 30) | ||||
| OCP type | MD | 8 (27%) | NA | NA |
| APP (NP/PA) | 11 (37%) | NA | NA | |
| RN | 11 (37%) | NA | NA | |
| Sex | Female | 25 (83%) | NA | NA |
| Male | 5 (17%) | NA | NA | |
| Patient (N = 175) | ||||
| Sex | Female | 81 (46%) | 48 (54%) | 33 (38%) |
| Male | 94 (54%) | 41 (46%) | 53 (62%) | |
| Race | White | 155 (89%) | 80 (90%) | 75 (87%) |
| Black/African American | 9 (5%) | 6 (7%) | 3 (3%) | |
| Asian/Pacific Islander | 3 (2%) | 0 (0%) | 3 (3%) | |
| Other | 8 (5%) | 3 (3%) | 5 (6%) | |
| Hispanic | Missing | 1 (1%) | 0 (0%) | 1 (1%) |
| No | 161 (92%) | 83 (93%) | 78 (91%) | |
| Yes | 13 (7%) | 6 (7%) | 7 (8%) | |
| Marital status | Missing | 2 (1%) | 1 (1%) | 1 (1%) |
| Married/living with partner | 119 (68%) | 57 (64%) | 62 (72%) | |
| Single | 19 (11%) | 13 (15%) | 6 (7%) | |
| Divorced/separated | 23 (13%) | 13 (15%) | 10 (12%) | |
| Widowed | 12 (7%) | 5 (6%) | 7 (8%) | |
| Education | Missing | 1 (1%) | 1 (1%) | 0 (0%) |
| Less than 7th grade | 1 (1%) | 0 (0%) | 1 (1%) | |
| 7th-9th grade | 1 (1%) | 1 (1%) | 0 (0%) | |
| 10th-11th grade | 7 (4%) | 4 (4%) | 3 (3%) | |
| High school graduate/GED | 51 (29%) | 25 (28%) | 26 (30%) | |
| Partial college (at least 1 year) or vocational training | 37 (21%) | 21 (24%) | 16 (19%) | |
| College graduate | 33 (19%) | 16 (18%) | 17 (20%) | |
| Graduate degree or professional training | 44 (25%) | 21 (24%) | 23 (27%) | |
| Employment status | Employed | 61 (35%) | 32 (36%) | 29 (34%) |
| On leave | 2 (1%) | 1 (1%) | 1 (1%) | |
| Homemaker | 1 (1%) | 1 (1%) | 0 (0%) | |
| Disabled | 10 (6%) | 4 (4%) | 6 (7%) | |
| Retired | 94 (54%) | 47 (53%) | 47 (55%) | |
| Unemployed | 7 (4%) | 4 (4%) | 3 (3%) | |
| Smoking status | Currently smoke | 15 (8%) | 6 (7%) | 9 (11%) |
| Formerly smoked | 159 (91%) | 83 (93%) | 76 (88%) | |
| Do not know | 1 (1%) | 0 (0%) | 1 (1%) | |
| Type of lung cancer | NSCLC | 118 (67%) | 57 (64%) | 61 (71%) |
| SCLC | 11 (6%) | 8)9%) | 3 (3%) | |
| Suspicious lung massa | 46 (26%) | 24 (27%) | 22 (26%) | |
| Stage of lung cancer | Missing | 54 (31%) | 28 (31%) | 26 (30%) |
| I | 67 (38%) | 35 (39%) | 32 (37%) | |
| II | 14 (8%) | 4 (4%) | 10 (12%) | |
| III | 16 (9%) | 10 (11%) | 6 (7%) | |
| IV | 24 (14%) | 12 (13%) | 12 (14%) | |
| Observed Range | Mean ± SD | Mean ± SD | Mean ± SD | |
| Age, y | 42-85 | 68.1 ± 8.8 | 67.8 ± 8.1 | 68.3 ± 9.5 |
| Perceived SES | 1-10 | 7.0 ± 1.7 | 7.0 ± 1.5 | 7.0 ± 2.0 |
APP = advanced practice provider; GED = general equivalency diploma; MD = medical doctor; NA = not applicable; NP = nurse practitioner; PA = physician assistant; NSCLC = non-small cell lung cancer; OCP = oncology care provider; RN = registered nurse; SCLC = small cell lung cancer; SES = socioeconomic status.
Suspicious mass, waiting for confirmatory diagnosis.
ECS Training Skill Uptake
The quality of communication skills demonstrated was evaluated based on the presence or absence of 20 communication skills from the Comskil Coding System,24 and it was adapted to evaluate empathy and stigma mitigation. The adapted Comskil Coding System included 23 skills, grouped under six communication skills categories: agenda setting, checking, questioning, information organization, empathic communication, and stigma-mitigating skills. The use of skills was scored dichotomously (absence/presence), and a sum score was computed for the six skill categories and a total sum score to represent breadth of skills used (possible range, 0-23).
Perceived OCP Empathy
Perceived OCP empathy was measured by using the Consultation and Relational Empathy Questionnaire, a well-validated, 10-item self-report scale that measures patients’ perception of how empathic their OCP was during a specific encounter.25 This measure is rated on a six-point Likert response scale (0 = poor, 5 = excellent). Items were summed, and a higher score indicated greater OCP empathy (pretraining, mean = 49.3, SD = 2.0, Cronbach α = 0.79; posttraining, mean = 49.6, SD = 1.6, Cronbach α = 0.89).
Satisfaction With OCP Communication
Satisfaction with communication was measured by using the Consumer Assessment of Health Care Providers and Systems Program.26 Patients responded to six items focused around satisfaction with different aspects of OCP-patient communication on a four-point Likert response scale (1 = never, 4 = always). Items were summed, and a higher score indicated greater satisfaction with OCP communication (pretraining, mean = 23.5, SD = 1.4, Cronbach α = 0.87; posttraining, mean = 23.9; SD = 0.40; Cronbach α = 0.50).
Lung Cancer Stigma
Lung cancer stigma was measured by using the Lung Cancer Stigma Inventory.27 This 25-item scale includes three subscales, creating by summing respective scores: internalized stigma (pretraining, mean = 24.3, SD = 10.5, Cronbach α = 0.74; posttraining, mean = 24.2, SD = 11.3, Cronbach α = 0.66), perceived stigma (pretraining, mean = 16.8, SD = 6.6, Cronbach α = 0.89; posttraining, mean = 15.8, SD = 5.1, Cronbach α = 0.92), and constrained disclosure (pretraining, mean = 11.6, SD = 5.2, Cronbach α = 0.75; posttraining, mean = 10.5, SD = 5.4, Cronbach α = 0.78). Items are rated on a five-point Likert scale (1 = not at all, 5 = extremely), and a total score was created by summing all items.
Data Analysis
Because the skills used for SPAs were scored dichotomously (absence/presence), we assessed change in use of individual skills by conducting McNemar tests. We also conducted paired samples Student t tests to assess change in use of skill categories (agenda setting, checking, questioning, information organization, empathic communication, and stigma-mitigating skills) and overall breadth of skills. Hierarchical linear models that included a random intercept to account for individual clinician effects were conducted to assess the effects of ECS training on patient-reported outcomes (eg, stigma, satisfaction with communication, perceived OCP empathy) from pretraining to posttraining, because multiple patients were recruited per OCP at each time point. Cohen d was also calculated to assess effect sizes of pretraining to posttraining changes in both SPA and patient-reported study outcomes. Two-tailed significance tests were used, and P values < .05 were considered statistically significant.
Results
Descriptive Results
Across the 30 OCPs trained, 89 unique patients were surveyed pretraining and another 86 unique patients posttraining. All OCPs completed a posttraining SPA, with one OCP missing a pretraining SPA. OCPs were roughly equally distributed among medical doctors (n = 8 [27%]), advanced practice providers (n = 11 [37%]), and nurses (n = 11 [37%]). Demographic characteristics of patients surveyed pretraining did not significantly differ from those surveyed posttraining, except that patients in the posttraining group were significantly more likely to be male (n = 41, 46% male participants in pretraining; n = 53, 62% male participants in posttraining; P = .039). Table 1 presents the demographic characteristics of OCPs and patients, overall and according to group (ie, pretraining, posttraining).
Primary Outcome (ECS Training Skill Uptake)
The difference in change of skill use from pre- to post-SPAs was evident for five (of 23 communication skills): declare agenda [χ2(1) = 6.37; P = .012], acknowledge [χ2(1) = 5.44; P = .020]; praise patient efforts [χ2(1) = 6.25; P = .012], provide a rationale for asking about smoking status [χ2(1) = 7.36; P = .007], and prepare patients for recurring smoking questions [χ2(1) = 6.40; P = .011]. For skill categories, results from paired samples Student t tests showed an overall increase in empathic skills (t = –2.37; P = .025), stigma-mitigating skills (t = –3.88; P <.001), and breadth of skill use (t = –2.91; P =.007) from pretraining to posttraining (Table 2).
Table 2.
Pretraining and Posttraining Communication Skills
| Skill | Pretraining (n = 29) |
Posttraining (n = 30) |
Student t Test/McNemar χ2 | ||
|---|---|---|---|---|---|
| Absent | Present | Absent | Present | ||
| Agenda setting | Mean = 0.46, SD = 0.64 | Mean = 0.82, SD = 0.67 | t(28) = –1.78 | ||
| Declare agenda | 20 (71.4%) | 8 (28.6%) | 9 (30%) | 21 (70%) | 6.37a |
| Invite agenda | 25 (86.2%) | 4 (13.8%) | 26 (86.7%) | 4 (13.3%) | 0.14 |
| Negotiate agenda | 29 (100%) | 0 (0%) | 29 (100%) | 1 (3.3%) | NA |
| Take stock | 28 (96.6%) | 1 (3.4%) | 28 (93.3%) | 2 (6.7%) | 0.33 |
| Checking | Mean = 0.45, SD = 0.63 | Mean = 0.62, SD = 0.73 | t(28) = –1.22 | ||
| Check understanding | 20 (69%) | 9 (31%) | 17 (56.7%) | 13 (43.3%) | 1.33 |
| Check preference | 25 (86.2%) | 4 (13.8%) | 25 (83.3%) | 5 (16.7%) | 0.33 |
| Questioning | Mean = 2.38, SD = 0.98 | Mean = 2.52, SD = 1.15 | t(28) = –0.52 | ||
| Ask open questions | 2 (6.9%) | 27 (93.1%) | 4 (13.3%) | 26 (86.7%) | 0.33 |
| Clarify | 15 (51.7%) | 14 (48.3%) | 16 (53.3%) | 14 (46.7%) | 0.07 |
| Restate | 23 (79.3%) | 6 (20.7%) | 21 (70%) | 9 (30%) | 0.69 |
| Endorse question asking | 24 (82.8%) | 5 (17.2%) | 23 (76.7%) | 7 (23.3%) | 0.14 |
| Invite questions | 12 (41.4%) | 17 (58.6%) | 11 (36.7%) | 19 (63.3%) | 0.29 |
| Information organization | Mean = 1.10, SD = 0.72 | Mean = 1.17, SD = 0.80 | t(28) = –0.35 | ||
| Preview | 27 (93.1%) | 2 (6.9%) | 25 (83.3%) | 5 (16.7%) | 1.80 |
| Summarize | 24 (82.8%) | 5 (17.2%) | 27 (90%) | 3 (10%) | 0.67 |
| Transition | 18 (62.1%) | 11 (37.9%) | 17 (56.7%) | 13 (43.3%) | 0.22 |
| Review next steps | 15 (51.7%) | 14 (48.3%) | 17 (56.7%) | 13 (43.3%) | 0.08 |
| Empathic communication | Mean = 1.79, SD = 1.37 | Mean = 2.55, SD = 1.38 | t(28) = –2.37a | ||
| Encourage expression of feelings | 18 (62.1%) | 11 (37.9%) | 20 (66.7%) | 10 (33.3%) | 0.11 |
| Acknowledge | 17 (56.7%) | 12 (41.4%) | 11 (36.7%) | 19 (63.3%) | 5.44a |
| Validate | 15 (51.7%) | 14 (48.3%) | 14 (46.7%) | 16 (53.3%) | 0.33 |
| Normalize | 22 (75.9%) | 7 (24.1%) | 19 (63.3%) | 11 (36.7%) | 1.33 |
| Praise patient efforts | 21 (72.4%) | 8 (27.6%) | 12 (40%) | 18 (60%) | 6.25a |
| Stigma-mitigating skills | Mean = 0.55, SD = 0.57 | Mean = 1.17, SD = 0.76 | t(28) = –3.88b | ||
| Provide rationale | 14 (48.3%) | 15 (51.7%) | 5 (16.7%) | 25 (83.3%) | 7.36c |
| Prepare patient for recurring smoking questions | 28 (96.6%) | 1 (3.4%) | 21 (70%) | 9 (30%) | 6.40a |
| Suggest counterarguments | 29 (100%) | 0 (0%) | 29 (96.7%) | 1 (3.3%) | NA |
| Breadth of skills (total) | Mean = 6.75, SD = 2.61 | Mean = 8.93, SD = 3.34 | t(28) = –2.91c | ||
The Student t test was used for skill categories, and the McNemar test was used for individual skills. Agenda setting, checking, questioning, information organization, empathic communication, stigma-mitigating skills, and breadth of skills (total) were skill categories with sum of skills in respective categories. Boldface highlights scores for skill categories and not individual skills. NA = not applicable.
P < .05.
P < .001.
P < .01.
Secondary Results: Patient-Reported Outcomes
Perceived OCP Empathy and Satisfaction With Communication
OCP empathy scores were high pretraining (mean = 49.3 of maximum 50; SD = 2.0), and thus there was no significant difference in perceived OCP empathy from pretraining to posttraining (P > .05). Overall satisfaction with communication was higher at posttraining, compared with pretraining (t = 2.15, P = .034, d = 0.35), particularly with OCPs explaining things in a way that was easy to understand (t = 2.42, P = .017, d = 0.37) and the OCP knowing important information about the patient’s medical history (t = 2.17, P = .032, d = 0.34) (Table 3).
Table 3.
Pre-Post Differences in Patient-Reported Outcomes
| Measure | Possible Range | Observed Range |
Pretraining: Mean ± SD |
Posttraining: Mean ± SD |
Effect Size (Cohen da) | t [df] | P Value |
|---|---|---|---|---|---|---|---|
| CARE total | 10-50 | 40-50 | 49.3 ± 2.0 | 49.6 ± 1.6 | 0.17 | 0.88 [85] | .384 |
| At ease | 1-5 | 3-5 | 5.0 ± 0.3 | 5.0 ± 0.2 | 0.10 | 0.68 [144] | .500 |
| Tell story | 1-5 | 3-5 | 5.0 ± 0.2 | 4.9 ± 0.3 | –0.10 | –0.60 [136] | .547 |
| Listening | 1-5 | 3-5 | 4.9 ± 0.3 | 4.9 ± 0.3 | –0.01 | –0.05 [144] | .963 |
| Interested | 1-5 | 3-5 | 4.9 ± 0.5 | 4.9 ± 0.3 | 0.09 | 0.56 [141] | .576 |
| Understanding | 1-5 | 3-5 | 4.9 ± 0.5 | 4.9 ± 0.3 | 0.21 | 1.38 [138] | .170 |
| Compassion | 1-5 | 3-5 | 4.9 ± 0.4 | 5.0 ± 0.2 | 0.18 | 1.21 [143] | .230 |
| Positive | 1-5 | 3-5 | 5.0 ± 0.3 | 5.0 ± 0.2 | –0.01 | –0.03 [143] | .979 |
| Explaining | 1-5 | 3-5 | 4.9 ± 0.4 | 5.0 ± 0.3 | 0.20 | 1.31 [141] | .194 |
| Take control | 1-5 | 3-5 | 4.9 ± 0.4 | 4.9 ± 0.3 | 0.14 | 0.80 [101] | .425 |
| Plan of action | 1-5 | 2-5 | 4.9 ± 0.5 | 4.9 ± 0.3 | 0.12 | 0.20 [97] | .843 |
| CAHPS total | 6-24 | 16-24 | 23.5 ± 1.4 | 23.9 ± 0.4 | 0.35 | 2.15 [121] | .034 |
| Explain | 1-4 | 2-4 | 3.9 ± 0.4 | 4.0 ± 0.2 | 0.37 | 2.42 [142] | .017 |
| Listen | 1-4 | 3-4 | 3.9 ± 0.3 | 4.0 ± 0.2 | 0.25 | 1.69 [142] | .093 |
| Understand | 1-4 | 2-4 | 3.9 ± 0.3 | 4.0 ± 0.2 | 0.24 | 1.49 [128] | .138 |
| Know information | 1-4 | 2-4 | 3.9 ± 0.4 | 4.0 ± 0.2 | 0.34 | 2.17 [130] | .032 |
| Show respect | 1-4 | 3-4 | 4.0 ± 0.2 | 4.0 ± 0.2 | 0.12 | 0.80 [143] | .426 |
| Spend time | 1-4 | 2-4 | 3.9 ± 0.3 | 4.0 ± 0.2 | 0.23 | 1.53 [142] | .129 |
| LCSI total | 25-112 | 51.6 ± 17.1 | 49.6 ± 16.7 | –0.12 | –0.78 [144] | .434 | |
| LCSI internalized stigma | 9-45 | 24.3 ± 10.5 | 24.2 ± 11.3 | –0.01 | –0.04 [133] | .971 | |
| LCSI perceived stigma | 10-51 | 16.8 ± 6.6 | 15.8 ± 5.1 | –0.18 | –0.98 [107] | .329 | |
| LCSI constrained disclosure | 6-28 | 11.6 ± 5.2 | 10.5 ± 5.4 | –0.21 | –1.34 [128] | .183 |
CARE, CAHPS, and LCSI measures were tested for significant pre-post differences by using HLM models to allow for clinician effects. CARE and LCSI items have potential range of 1 to 5; range for CAHPS is 1 to 4. CAHPS = Consumer Assessment of Health Care Providers and Systems Program; CARE = Consultation and Relational Empathy; HLM = hierarchical linear models; LCSI = Lung Cancer Stigma Inventory.
Cohen d: small (0.2), medium (0.5), large (0.8).
Lung Cancer Stigma
There were no statistically significant differences in stigma scores from pretraining to posttraining assessments (all, P > .05), although effect sizes indicate that lung cancer stigma assessed posttraining was lower than stigma assessed pretraining (Cohen d for differences in stigma scores ranged from –0.01 to –0.21) (Table 3).
Post Hoc Analysis
Of the 15 patients who reported current smoking, one (of six) at pretraining and three (of nine) at posttraining accepted a referral to the smoking cessation program at MSK.
Discussion
Research has shown that stigma is a prevalent, clinically important psychosocial problem for patients with lung cancer and that OCPs may inadvertently trigger stigma during routine assessment of smoking history. The current article presents findings from the first OCP-focused intervention designed to enhance empathic communication and reduce stigma among patients with lung cancer in the context of OCPs taking a routine assessment of smoking history. The ECS training was successful in demonstrating communication skill uptake by OCPs, particularly for empathic communication and stigma-mitigating skills. These findings advance our previous research showing that communication skills can be learned28 and also suggest that OCPs can adopt empathic and stigma-mitigating skills in their routine clinical assessment of smoking behavior and advisement of cessation in cancer care.8 Short- and long-term effects of empathic and stigma-mitigating skills may have benefits for patients with lung cancer and need to be examined further. Although the numbers are small, the amount of participants who reported current smoking and subsequently accepted referral to the smoking cessation program at posttraining (three of nine) compared with pretraining (one of six) indicates potential for ECS training to improve patient engagement in tobacco treatment services. A planned randomized clinical trial with larger sample size and greater representation of patients who currently smoke will enable examination of this important outcome.
ECS training can target stigma mitigation through empathic communication, as shown by the effectiveness measurements in both OCPs and patients. Improvement in several salient communication skills, particularly empathic communication, and stigma-mitigating skills was evident for OCPs conducting smoking-related assessments. Although the results revealed significant pretraining to posttraining differences in lung cancer patients’ satisfaction with OCP communication, perceived empathy and lung cancer stigma as measured at the patient level did not differ significantly. Several possibilities exist for these null findings.
Patients reported high empathy scores for their respective OCPs, indicating a possible ceiling effect. All the OCPs were recruited from a single, large comprehensive cancer center with a longstanding institutional commitment to promoting excellence in communication skills.29 Conducting qualitative interviews with patients following their clinical interaction may provide more in-depth information about patient experience and communication with their respective OCPs.27
Similarly, there were no statistically significant posttraining differences in lung cancer stigma, although effect sizes were consistent with a reduction in two components of stigma (perceived stigma and constrained disclosure). It is plausible that over time, multiple encounters with OCPs who are routinely practicing ECS would mitigate high levels of lung cancer stigma. It is also possible that complementary, multilevel stigma-reducing interventions targeting patients, their social network, and society would be most effective in reducing patients’ experience of lung cancer stigma. Psychosocial support interventions that target internalized stigma in combination with OCP-focused ECS training may be most appropriate for patients who experience high levels of lung cancer stigma.
Effects of ECS training on patient-reported outcomes were limited and only evident for posttraining differences in satisfaction with communication. In a larger clinical trial, it would be helpful to examine improvements in other domains of OCP-patient interaction, including trust in OCP and higher patient activation. Subsequent larger trials with adequate number of patients who currently smoke should examine whether ECS training improves acceptance of referral for evidence-based tobacco treatment and cessation outcomes among patients with lung cancer who currently smoke.
This study was conducted at a single comprehensive cancer center in the northeast United States that has a well-established communication skills training and research laboratory dedicated to improving the quality of clinical communication. As such, the results may not be generalizable to other cancer centers or community oncology settings. In addition, the patient population was primarily White and reported a high level of socioeconomic status, and caution is warranted regarding generalizing the findings more broadly. This study involved a one-time assessment of patient outcomes. However, it may be beneficial to assess patient experience repeatedly given that lung cancer stigma may fluctuate over time. We limited our assessment of ECS training on patient outcomes to quantitative measures only. Studies relying on quantitative measurement of patient outcomes of communication skills trainings often show ceiling effects,28 and qualitative assessments are needed to better understand the full impact of ECS training on the lung cancer patient health-care experiences. Finally, to reduce burden, no demographic characteristics were assessed for OCPs. Future studies should collect data on OCP characteristics to better understand clinician variation in empathic communication skills.
Conclusions
Research indicates that perceived stigma within medical encounters, particularly triggered by routine assessment of smoking, is frequently reported and problematic for lung cancer patients’ well-being and quality of cancer care.2 Given that OCPs exhibited significant improvements in the uptake of several communication skills from pretraining to posttraining, and that patient-reported satisfaction with communication was significantly higher at posttraining compared with pretraining, promoting empathic OCP communication is a promising intervention target to help improve lung cancer patients’ satisfaction with communication and clinical care. These findings provide a foundation for further development and testing of a national model for training thoracic OCPs (and all key members of the OCP team) in best communication practices for both assessment of smoking history and engagement of patients who currently smoke in tobacco treatment delivery.
Given that persistent smoking is associated with poor clinical outcomes,30 it is essential that OCPs exhibit competent and empathic communication regarding the nature of nicotine dependence and the importance of smoking cessation for tobacco-dependent cancer patients, particularly for those diagnosed with lung and other smoking-related cancers. Our promising findings support the feasibility of conducting ECS with OCPs and suggest that empathic communication is a modifiable intervention target that requires further testing for mitigating the impact of stigma experienced during clinical encounters.8,9
Acknowledgments
Author contributions: S. C. B. served as the guarantor and takes responsibility for the content of the manuscript, including the data and analysis. S. C. B. and J. S. O. were responsible for conceptualization; S. C. B., N. H., E. A. S., A. M., and J. S. O. performed data curation; S. C. B., E. A. S., T. J. W., C. M. M., and J. S. O. were responsible for formal analysis; S. C. B. and J. S. O. were responsible for funding acquisition; S. C. B., N. H., C. L. B., M. J. S., M. R., A. M., and J. S. O. performed investigations; S. C. B., E. A. S., C. L. B., M. J. S., and J. S. O. were responsible for methodology; S. C. B., N. H., A. M., and J. S. O. were responsible for project administration; S. C. B. and J. S. O. supervised the study; and S. C. B., E. A. S., and J. S. O. wrote the original draft. All authors contributed to writing, reviewing, and editing of the manuscript.
Financial/nonfinancial disclosures: None declared.
Footnotes
FUNDING/SUPPORT: Research reported in this paper was supported in part by the National Cancer Institute [Grants R21CA202793, T32CA009461, P30CA008748, and K07CA207580].
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