Providers find communicating about medical errors and adverse events challenging. In response to vignettes about a delayed cancer diagnosis and treatment delay, most providers acknowledged responsibility but were not always forthcoming about what occurred. While providers believe they communicate effectively, many patients may be reluctant to report concerns. Providers support encouraging patients to report serious care breakdowns and incorporating these reports into training to improve communication and care.

1. “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

2. Team
Sarah Greene, MPH Douglas Roblin, PhD
Carolyn Prouty, DVM Beth Lapham, BA
Brandi Robinson, MPH Cassandra Firneno, BA
Celeste Lemay, MPH Ben Dunlap, BA

3. Background
Effective patient-provider communication
critical in cancer care
Cancer care poses special challenges
- Communication about adverse events
particularly difficult
Understanding providers’ views important
to developing interventions

4. Methods
Survey of cancer care providers
– PCPs, Oncologists, Oncology RNs
Three CRN sites
– Kaiser Permanente, Georgia
– Group Health Cooperative, WA
– Reliant Medical Group, MA
Tailored Design Method
– Notification by email or letter
– Incentive of gift card or chocolate
– Follow-up with non responders

5. Methods
Questionnaires
– 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

6. Response Rates
759 questionnaires distributed
Overall response rate: 53%
– PCP response rate: 53% (333/630)
– Oncologist response rate: 44% (24/55)
– Oncology RN response rate: 64% (47/74)

7. Demographics
Gender
41% Male
Length of time in practice
13% < 5 years
14% 5 to 10 years
73% > 10 years
Percent time spent in clinical practice
79% > 80 percent

8. Delayed Diagnosis Vignette
PCP covering for colleague, seeing a 45 year-old
patient over several visits for management of HTN.
Patient mentions breast lump, which she had shown
to her regular PCP 6 months ago, seems larger.
What would you say?
Colleague had noted breast lump issue 6 months
ago; had recommended re-exam, which did not
occur.
Covering PCP had not thoroughly reviewed chart, so
unaware of issue until the patient brings it up.
Biopsy shows cancer with 3 positive nodes.

9. What providers would VOLUNTEER
about what happened…
19% would not give specific information about the
event unless asked
36% “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”

10. Other Responses
80% consider this a serious error
75% view covering PCP as at least partially
responsible
96% view original PCP as at least partially
responsible
96% view patient as at least partially
responsible
75% would be “very” or “extremely” upset
about the event

11. Delayed Response to Symptoms
PCP/oncologist following 65 y/o male with
history of hypothyroidism being treated for
colon cancer.
After 3rd call Oncologist tells nurse to
request callswork; patient passes to report
Patient lab nurse several times out while
driving to lab.
fatigue and diarrhea (both common with
his chemotherapy regimen)
In ER patient has hematocrit of 16 with
guaiactells patient to schedule a visit for
Nurse positive stool.
lab work if it gets worse and passes
information to PCP and Oncologist, each
assumes the other is handling.

12. 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”

13. Other Responses
58% consider this a serious error
90% view oncologist as at least partially
responsible
87% view PCP as at least partially
responsible
67% view RN as at least partially
responsible
68% view patient as at least partially
responsible

14. 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’s
communication 39%
Suspects a medical error 32%
Is unhappy about care from another clinician 5%
Is unhappy about communication w/ other
another clinician
4%

15. Attitudes
69% believe their organization values good
communication
95% believe they communicate effectively
71% believe they know when patients
don’t understand
62% believe they know when patients have
unaddressed concerns or unanswered
questions

16. Communication Breakdowns
67% believed they are aware of most
serious communication breakdowns
61% believe most patients are reluctant to
voice concerns about serious
breakdowns in their care
100% would want to know if a patient felt
provider was not listening; not giving
enough information

17. Alerting the System
98% agree organizations should
encourage patients to alert system
about serious breakdown in care
88% agree patient reports would provide
actionable information
100% would want to know if a patient
believe s/he had experienced a serious
breakdown in care

18. Conclusions
Providers …
– 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

19. Next Steps
The “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