What Would you say to this Patient Cancer Care Providers Attitudes and Experiences GALLAGHER
“What would you say to this patient?” Cancer Care Providers’ Attitudes and Experiences Kathleen Mazor, EdD Thomas Gallagher, MD for the Adverse Event Project Team
TeamSarah Greene, MPH Douglas Roblin, PhDCarolyn Prouty, DVM Beth Lapham, BABrandi Robinson, MPH Cassandra Firneno, BACeleste Lemay, MPH Ben Dunlap, BA
BackgroundEffective patient-provider communicationcritical in cancer careCancer care poses special challenges- Communication about adverse events particularly difficultUnderstanding providers’ views importantto developing interventions
MethodsSurvey of cancer care providers– PCPs, Oncologists, Oncology RNsThree CRN sites– Kaiser Permanente, Georgia– Group Health Cooperative, WA– Reliant Medical Group, MATailored Design Method– Notification by email or letter– Incentive of gift card or chocolate– Follow-up with non responders
MethodsQuestionnaires– Two adverse event vignettes delayed diagnosis of breast cancer care breakdown resulting in delayed response to patient symptoms– Attitudes and values related to communicating with cancer patients
DemographicsGender41% MaleLength of time in practice13% < 5 years14% 5 to 10 years73% > 10 yearsPercent time spent in clinical practice79% > 80 percent
Delayed Diagnosis VignettePCP covering for colleague, seeing a 45 year-oldpatient over several visits for management of HTN.Patient mentions breast lump, which she had shownto her regular PCP 6 months ago, seems larger. What would you say?Colleague had noted breast lump issue 6 monthsago; had recommended re-exam, which did notoccur.Covering PCP had not thoroughly reviewed chart, sounaware of issue until the patient brings it up.Biopsy shows cancer with 3 positive nodes.
What providers would VOLUNTEER about what happened…19% would not give specific information about the event unless asked36% “Breast cancer can be difficult to diagnose in younger women like you, whose breast have lots of lumps”25% “…however, in you case an error happened that potentially delayed your diagnosis”20% “…the fact that your doctor did not reexamine your breasts potentially delayed your diagnosis”
Other Responses80% consider this a serious error75% view covering PCP as at least partially responsible96% view original PCP as at least partially responsible96% view patient as at least partially responsible75% would be “very” or “extremely” upset about the event
Delayed Response to SymptomsPCP/oncologist following 65 y/o male withhistory of hypothyroidism being treated forcolon cancer.After 3rd call Oncologist tells nurse torequest callswork; patient passes to reportPatient lab nurse several times out whiledriving to lab.fatigue and diarrhea (both common withhis chemotherapy regimen)In ER patient has hematocrit of 16 withguaiactells patient to schedule a visit forNurse positive stool.lab work if it gets worse and passesinformation to PCP and Oncologist, eachassumes the other is handling.
What providers would say about the cause of the event...27% would not volunteer a cause unless the patient asked.35% “This occurred because of a miscommunication about how serious your symptoms were.”38% “We should have followed up with you more promptly when you initially reported your symptoms to us”
Other Responses58% consider this a serious error90% view oncologist as at least partially responsible87% view PCP as at least partially responsible67% view RN as at least partially responsible68% view patient as at least partially responsible
Providers find it very/extremely difficult responding to a cancer patient who:Has unrealistic beliefs about prognosis 62%Expresses concern about a delayed dx 55%Expresses frustration about that provider’scommunication 39%Suspects a medical error 32%Is unhappy about care from another clinician 5%Is unhappy about communication w/ other another clinician4%
Attitudes69% believe their organization values good communication95% believe they communicate effectively71% believe they know when patients don’t understand62% believe they know when patients have unaddressed concerns or unanswered questions
Communication Breakdowns67% believed they are aware of most serious communication breakdowns61% believe most patients are reluctant to voice concerns about serious breakdowns in their care100% would want to know if a patient felt provider was not listening; not giving enough information
Alerting the System98% agree organizations should encourage patients to alert system about serious breakdown in care88% agree patient reports would provide actionable information100% would want to know if a patient believe s/he had experienced a serious breakdown in care
ConclusionsProviders …– are not always forthcoming following adverse events– find some communication situations to be especially challenging– aren’t always aware of patient-perceived breakdowns; concerns– want to know about patient-perceived breakdowns, concerns– support enhanced systems to solicit concerns
Next StepsThe “We Want to Know” campaign– System-level support for “We want to know” about breakdowns and concerns– Quick response– Integrate patient reports of concerns and breakdowns in existing training mechanisms
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