Improving physician–patient communication about cancer pain with a tailored education-coaching intervention

Abstract

Objective

This study examined the effect of a theoretically grounded, tailored education-coaching intervention to help patients more effectively discuss their pain-related questions, concerns, and preferences with physicians.

Methods

Grounded in social-cognitive and communication theory, a tailored education-coaching (TEC) intervention was developed to help patients learn pain management and communication skills. In a RCT, 148 cancer patients agreed to have their consultations audio-recorded and were assigned to the intervention or a control group. The recordings were used to code for patients’ questions, acts of assertiveness, and expressed concerns and to rate the quality of physicians’ communication.

Results

Patients in the TEC group discussed their pain concerns more than did patients in the control group. More active patients also had more baseline pain and interacted with physicians using participatory decision-making. Ratings of physicians’ information about pain were higher when patients talked more about their pain concerns.

Conclusions

The study demonstrates the efficacy of a theoretically grounded, coaching intervention to help cancer patients talk about pain control.

Practice implications

Coaching interventions can be effective resources for helping cancer patients communicate about their pain concerns if they are theoretically grounded, can be integrated within clinical routines, and lead to improve health outcomes.

Introduction

An estimated 90% of patients with cancer experience at least moderate pain at some point in their illness, and almost half do not achieve adequate pain control [1]. Uncontrolled pain not only lowers quality of life, but it also can contribute to depression, patient refusal to undertake potentially beneficial therapy, and emotional burden on caregivers [1], [2], [3], [4]. Effective pain medications are available, yet they are often underutilized because patients are worried about dependency and side effects [5], [6] and because physicians do not understand the extent of the patient's pain [7]. While efforts to address system and provider-level barriers to effective pain control continue, patients and their families represent an opportunity for interventions because they stand to gain the most from effective pain management.

Pain management in cancer care could be improved through better physician–patient communication, particularly with respect to encouraging and facilitating patient involvement in discussing their pain experiences, options for pain relief, and concerns about medication. If patients talk more openly about these issues, physicians might gain a better understanding of how to provide more personalized care focused on the patient's unique pain control needs. Research across other clinical contexts has shown that clinicians give more information, achieve a better understanding of the patient's perspective, are more supportive, and are more accommodating when patients ask questions, express concerns, state their preferences, and make requests [8], [9], [10], [11], [12], [13], [14], [15].

This paper reports the results of an RCT testing the effectiveness of a theoretically grounded, tailored education and coaching intervention designed to help cancer patients communicate more effectively about pain and become more involved in deciding pain management treatment. While previous studies have tested coaching interventions to improve cancer pain self-management [15], [16], [17], [18], [19], none have examined whether these programs improved patients’ ability to communicate with doctors about pain control.

In other clinical contexts, ‘patient activation’ interventions have produced mixed results in part because few have been designed to explicitly target processes underlying communication skill development and performance [20] The intervention reported in this study was grounded in key tenets of social-cognitive theory [21] and models of communication competence [22], [23]. Social-cognitive theory posits that behavioral performance is largely a function of an individual's confidence (self-efficacy) to perform a specific behavior and expectations that the behavior will produce desired results [24]. In the context of making decisions about pain control, two aspects of self-efficacy are important, confidence in effectively talking to clinicians about pain and confidence in one's ability to achieve control over pain. While one takes place within the consultation and the other in everyday living, the two are connected in that effective communication about pain management can be a pathway for better decisions about pain control and greater confidence in self-managing pain [25].

From a communication competence perspective, one's success as a communicator requires both capacity (repertoire of communication-related knowledge and skills) and adaptability (ability to coordinate one's turn-taking and topic development with that of the other interactant) [26]. In particular, interventions should address three requirements for effective ‘performance’ as a communicator—motivation, knowledge, and action [22], [23]. While patients in pain presumably want effective pain control, they may need additional encouragement to be more proactive (and less reluctant) to talk to doctors about their needs [19]. With respect to knowledge, patients need some understanding of pain management options as well as techniques for how to talk to doctors about pain. In other words, it is difficult to actively communicate on a topic if one lacks pertinent content knowledge or communication skills. With respect to action, the link between cognition (knowing what to do) and behavior (doing) is facilitated primarily through practice and vicarious learning. Not surprisingly, patient activation interventions that employ modeling and rehearsal as pedagogical strategies also tend to be the most effective [27].

While a variety of formats have been used to deliver patient activation interventions (e.g., workbooks and printed material [28], [29], [30], interactive computer programs [31], [32], video [33], [34], and face-to-face or telephone coaching [35], [36]), we selected a coaching intervention using lay health educators for two reasons. First, to provide patients an opportunity to practice specific communication skills in a ‘live’ interaction, the use of a coach seemed most appropriate, especially if this was someone who could also provide encouragement and immediate feedback. Second, some research indicates that coaching interventions are more effective with older patients [37], [38], [39], a demographic group that makes up a sizeable proportion of patients with advanced cancer.

Finally, we examined whether the intervention was effective taking into account other factors that influence how patients communicate with physicians. In several studies, patients who were older, less educated, sicker, and minority status asked fewer questions, were more passive, and were less involved in decision-making than were younger, more educated, healthier, and Caucasian patients [13], [32], [40], [41], [42]. Patient participation is also affected by the clinician's communication style. Patients generally become more involved in the consultation, including decision-making, when physicians use more facilitative, supportive, and partnering communication [32], [41], [43], [44], [45]. Thus, for a patient communication intervention to have value, it must achieve the desired effect over and above other factors that influence patient participation in consultations.