increasing patient involvement in choosing treatment for early breast cancer

2275

Increasing Patient Involvement in Choosing Treatment for Early Breast Cancer Richard L. Street, Jr., Ph.D.,* Becky Voigt, B.S.N., R.N.,t Charles Geyer, Jr., M.D.,# Timothy Manning, M.S.,§ and Grego y P. Swanson, M.D., 1 1

Background. This investigation examined factors affecting patient involvement in consultations to decide local treatment for early breast cancer and the effectiveness of two methods of preconsultation education aimed at increasing patient particilpation in these discussions.

Methods. Sixty patients with Stage I or I1 breast cancer (1) were pretested on their knowledge about breast cancer treatment and optimism for the future, (2) were randomly assigned to one of two methods for preconsultation education: interactive multimedia program or brochure, (3) completed knowledge and optimism measures, (4) consulted with a medical oncologist, radiation oncologist, and general surgeon, and (5) completed self-report measures assessing their involvement in the consultations and control over deciision-making. The consultations were audiorecorded anid analyzed to identify behavioral indicators of patient involvement (question-asking, opinion-giving, and expressing concern) and physician utterances encouraging patient participation.

Results. College-educated patients younger than 65 years of age were more active participants in these consultations than were older, less educated patients. In addition, patients showed more involvement when they in- teracted with physicians who encouraged and facilitated patient participation. The method of education did not affect patient involvement although patients tended to learn more about breast cancer treatment after using the multimedia program than after reading the brochure.

From the *Institute for Health Care Evaluation, Texas A & M University Health Science Center, College Station, Texas; tCenter for Cancer Prevention and Care, Department of SHematology/Oncol- om, and Department of IIRadiology, Scott and White Clinic and Hos- pital, Temple, Texas; and Department of §Information Technology, Texas A & M University Health, Science Center, College Station, Texas.

Supported in part by a grant from the Texas Advanced Technol- ogy Program (Project #010366-105).

Address for reprints: Richard Street, Department of Speech Communication, Texas A&M University, College Station, TX 77843- 4234.

Received May 22, 1995; revision received July 25, 1995; ac- cepted July 25,1995.

Conclusions. Although patients vary in their expres- siveness, physicians may be able to increase patient participation in deciding treatment by using patient-centered behavior. Also, preconsultation education appears to be an effective clinical strategy for helping patients gain an accurate understanding of their treatment options before meeting with physicians. Cancer 1995;76:2275-85.

Key words: physician-patient communication, breast cancer, patient education, interactive computing.

The Problem

Patients with early breast cancer typically have a choice for local treatment with either mastectomy or breast- conserving therapy. In most cases, the method selected simply should be a matter of the patient’s preferences. However, even with a choice for treatment, many patients believe they have little control over the disease and its managernent.’r2 These patients in turn tend to take a passive role in consultations to choose a surgical procedure, which results in exchanges where doctors dominate the talk3 and offer their own preferences for treatment.4

The purpose of this investigation was two-fold. First, we assessed the relative effectiveness of two preconsultation educational interventions, printed material versus an interactive multimedia program, aimed at increasing patient involvement in consultations to choose treatment for breast cancer. Second, we examined the relative influence of two variables potentially affecting how a patient communicates with a doctor: the patient’s communicative predispositions related to age and education and the physician’s communication toward the patient. These issues warrant investigation because of the potential benefits associated with increased patient participation in deciding on breast cancer treatment.

Patients who ask questions, express concerns, and

2276 CANCER December 1,1995, Volume 76, No. 11

offer opinions generally receive more information and emotional support from providers, resources highly val- ued by patients generally4f5 and patients with breast cancer ~pecifically.‘,~ Also, compared with their more passive counterparts, patients who more actively participate in decision-making often believe they have greater control over their health, which in turn contri- butes to better health and quality of life For example, patients with breast cancer have reported fewer physical and psychologic problems after surgery when simply given a choice for treatment (e.g., mastectomy or breast con~ervation)”-’~ and when physicians showed interest in the patient’s perspe~tive.’~ Finally, patients with breast cancer vary considerably in their informational and emotional needs and in their expectations for the physician-patient relationship (e.g., pa- ternalistic, egalitarian, etc.).‘~’~ Patients who freely ask questions and express their views should help doctors better understand patient concerns, preferences, and expectations for care.

increasing Patient Involvement with Preconsultation Education

A patient’s reluctance to become involved in choosing treatment for breast cancer may be due to a variety of reasons, including being unaware of a choice for treatment, limited information about treatment alternatives, uncertainty about the patient’s role in decision-making, and being overwhelmed by the number of issues to con- ~ ider .~ , ’~- ’~ Thus, educational interventions for increasing patient involvement should have at least two aims. First, the education should legitimize patient participation by encouraging the patient to take an active role in the consultation and by stressing the importance of the patient’s perspective in disease management.’8,’9 Sec- ond, educational messages should provide a foundation of accurate information that can help the patient discuss treatment options in a competent and informed man-

Several studies have demonstrated that patient education before consultations can increase patient involvement in medical encounter^.^,^,^^ Of interest in this research is not whether preconsultation education can facilitate patient participation, but whether the effectiveness of the education is influenced by its format of delivery. We propose that interactive, multimedia programs may offer a more productive means of deliv- ering patient education than are materials presenting information only in written form. Compared with reading materials (e.g., brochures or pamphlets), multimedia programs may more effectively facilitate learning and retention of information because an array of media

ner. 14.15.17

(narration, text, motion picture, computer animation) are used to stimulate viewer interest and to organize and highlight important content.21*22 In addition, multimedia programs would allow for the incorporation of video segments of women sharing their stories” ( e g , initial reactions to the diagnosis, fears). Patients with breast cancer often find reassurance and support from listening to others discuss their Finally, an interactive” program allows the patient to choose which topics to view and in what order (e.g., with a touchscreen monitor or mouse). In this way, the program facilitates patient involvement and learning because the patient actively” explores an information en- vironment in accordance with her preferences, informational needs, and unique learning ~ t y l e . ’ ~ - ~ ~

Mediating Factors

The effectiveness of educational materials will depend in part on factors external to the intervention, but which can have a powerful influence on how the communication between doctor and patient unfolds. For example, a patient’s inclination to assume an active role in medical visits is in part related to personal, social, and cultural variables. In this study, we expect patient participation in discussions of treatment will vary depending on the patient’s age and level of education. Previous research has found that younger and more educated patients generally prefer more egalitarian relationships with providers, ask more questions, offer more opinions, and believe more strongly in participating in decision-making than do older and less educated patient^.'^-^^

Patient involvement also will be affected by how the physician communicates with the patient. Physi- cians can have a powerful influence on the patient’s communication because both doctors and patients generally assume the physician is the interactant who pri- marily controls the events of the c o n s ~ l t a t i o n . ~ ~ ~ Thus, patients will likely be more responsive when their physicians encourage patient participation and show interest in the patient’s questions, feelings, and be- l i e f ~ . ~ ~ , ~ ~ , ~ ~ , ~ ~ Conversely, if the patient perceives that the physician wishes to be in charge of the consultation, do most of the talking, and unilaterally make decisions for tests and treatment, then many patients will simply assume their traditionally passive role in the en- ~ o u n t e r . ~ , ~ ~

Hypotheses

In this investigation, patients with early breast cancer were randomly placed into one of two preconsultation education conditions, brochure or computer program.

Patient Involvement in Choosing Treatment/Street et al. 2277

Table 1. Characteristics of the Sample Patient’s Brochure group Multimedia group characteristic (n = 30) (n = 30)

Age

Range (yr) Mean (yr)

Education (n) <High school High school Some college College degree Postgraduate Stage of cancer (n) I I1 Ethnidtv (YO white)

60.8 35-82

0 14: 9 4 3

19 11 90

57.4 35-76

1 11 10 4 4

16 14 93

Three hypotheses were ex,amined. First, patients using an interactive, multimedL3 program will learn more about breast cancer treatment and will express more optimism about the future than will patients reading a brochure. Second, patients using the computer program will be more involved in decision-making than will patients reading the brochure. Third, patients who are more active participants in their consultations (a) are more educated and younger and (b) interact with physicians who encourage and who are perceived as facilitating patient involvement.

Methods

Research Setting and Participants

This research was conducted at the Scott and White Clinic and Hospital, a large, multispecialty health care facility in Temple, Texas. A patient was eligible for the study if she (1) had breast cancer clinically staged at 1 or 11,35 (2) could speak and read English, and (3) did not have a debilitating condition ( e g , Alzheimer’s Disease, stroke-impaired). Between June, 1993, and September, 1994,60 patients were enrolled into and completed the study. Table 1 presents the demographic and disease characteristics of the sample by experimental group. Physicians who treat patients with breast cancer also were invited to take part in the study. Of the 11 physicians invited, 10 agreed t40 participate. They were all male and included four medical oncologists, two radiation oncologist, and four surgeons.

Research Design and Procedures

Enrolling research participants. After receiving the breast biopsy results, patients at Scott and White are

counseled by an oncology nurse regarding upcoming consultations to decide treatment. Within a week, the patient returns to the clinic and meets separately with a medical oncologist, radiation oncologist, and general surgeon. Patients eligible for the study were asked to amve an hour before their first consultation to visit with the oncology nurse, who served as the project coordi- nator. After orienting the patient to upcoming ap- pointments, the nurse overviewed this project, solicited the patient’s participation, and obtained informed consent. Only four patients chose not to participate in the study.

Randomizing patients and completion of preconsultation materials. Before reviewing educational materials, patients completed measures assessing knowledge of breast cancer treatment and optimism about the future. Patients then were randomly assigned to one of two preconsultation education conditions: brochure group or interactive, multimedia program group. As can be seen in Table 1, there were no significant differences between the multimedia or brochure group with respect to the patient’s age, education, disease stage, or ethnic- ity. After reviewing the educational materials but before visiting with their physicians, patients completed the knowledge and optimism measures for a second time.

Consultations with physicians. With very few ex- ceptions, patients saw the medical oncologist first, followed by the radiation oncologist, and finally by the surgeon. Decisions regarding local treatment usually were made during the visit with the surgeon or shortly thereafter. Each consultation was audiorecorded with a small microcassette recorder placed on the desk in the examination room.

Completion of postconsultation measures. After all three consultations were concluded, the patient completed the knowledge and optimism measures for a third time. The patient also completed measures assessing perceptions of her control over the decision for treatment and of the degree to which she was involved in each of the three consultations.

Patient Education Materials

Interactive, multimedia program. The multimedia program, Options for Treafing Breast Cancer, is an interactive program driven by an Apple computer with a touchscreen monitor. Options consists of text, graphic display, audio narration, music, and audio-video clips. The program is divided into four sections: Introduction, Understanding the Problem, Treatment Options, and Experiences of Other Women. The Introduction” includes information on how to use the program. Under- standing the Problem” briefly overviews the anatomy


of the breast, where breast cancer may form, and the various stages of breast cancer. Treatment Options” presents information on two options for local treatment, mastectomy and lumpectomy with irradiation. On several occasions, text and narration state that the two treatments are comparable in their effectiveness and likelihood for cure. The Experiences of Other Women” section includes audiovisual clips of 8 women (four who chose lumpectomy and four who chose mastectomy) sharing their reactions to the diagnosis, their biggest help in coping with the disease, and their experiences during recovery and adjuvant therapy.

Several times throughout the program, the text and narration encourage the patient to ask questions, express concerns, and offer opinions when they visit with physicians. Typically, patients completed the program within 30 to 45 minutes.

Brochure. We also developed an eight-page brochure, Care of Patients With Early Breasf Cancer, that was divided into three sections. The first contains comments by four women (taken from the Options program) on their initial reaction to the discovery of breast cancer. The second and third sections parallel the Understand- ing the Problem” and Treatment Options” features of the multimedia program. The medical information in the brochure was the same as that in the multimedia program, only in written form. The brochure also included several statements encouraging patients to ask questions, express concerns, and offer opinions. How- ever, the brochure did not have a section comparable to the Experiences of Other Women” section of Opfions.

Patients took between 15-20 minutes to read the brochure. The medical information presented in the educational materials came from several sources including the American Cancer Society and the National Cancer Institute.

Measures Assessing Patients’ Knowledge and Optimism

Knowledge about breast cancer treatment was assessed with an 1 l-item, multiple choice test (see Appendix A for the test and the correct answers). Two of the questions had two correct answers. Patients received a knowledge score (the percentage of correct responses) for each of three times they took the test (i.e., pre-education, posteducation, and postconsultation). Of course, there is considerably more information presented in the educational materials than is asked about on the test. However, because patients were completing several self-report measures on several occasions, we made the test as brief as possible and still cover the most important facts” about treating early breast cancer.

Patients’ optimism was assessed three times (pre- education, posteducation, and postconsultation) with an eight-item instrument developed by Scheier and Carver.36 On five-point Likert scales, patients reported their outlook regarding the future, goals, control over life circumstances, and anticipated enjoyment of life.

Measures Assessing Patient Involvement and Physician Communication

Behavioral and self-report measures of patient involvement and physician communication were used because perceptions of communicative events do not always co- incide with observer-coded measures of communicative behaviors.37 This is a common occurrence because quantitative measures of communication (e.g., number of information-giving utterances) may not correlate with qualitative judgments of communication (e.g., in- formativene~s) .~~,~~ For example, a patient may give her opinion on only a few occasions yet perceive that she was quite assertive in doing so. Conversely, a patient may offer numerous opinions, yet believe she was not assertive enough because the doctor disregarded or did not understand the patient‘s concerns. Thus, several researchers have advised using multiple measures when analyzing communication in medical consultation^.^^"^

Behavioral measures. Four types of patients’ responses were coded. Question-asking included any health or medical question the patient directed to the physician. Opinion-giving represented utterances in which the patient made recommendations, stated a preference for treatment, disagreed with the physician, or offered an opinion about disease management. Ex- pression of concern included statements of negative emotions (e.g., frustration, anger), worries, or concerns. A composite measure, active communication, was the sum of the three types of responses.

Because of its potential influence on patient involvement, the physicians’ use of patient-centered responses were of primary interest in this study. Patient- centered utterances included statements of reassurance, support, and empathy. Also included in this category were partnership-building” utterances, communicative acts encouraging the patient to offer opinions, express feelings, and participate in de~ision-making.~~,~~

Two coders (graduate students in health communication) participated in four l-hour training sessions. All coding was conducted by having the coder first listen to the audiotape. If perceiving that a relevant event oc- curred (e.g., the patient asked a question or expressed an opinion), the coder then transcribed that portion of the dialogue from the audiotape. The coder listened to the tape again, followed the transcript, and made cod-

Patient Involvement in Choosing Treatment/Street ef al. 2279

ing decisions. The unit of analysis for coding discourse was the utterance,” which can be in the form of a com- plete sentence, independent clause, nonrestrictive dependent clause, multiple predicate, or e v a l ~ a t i o n . ~ ~ ’ ~ ~ , ~ ~ Reliability for coding was established by having each coder recode 15 consultations previously coded by the other.

Perceptual measures. Patients’ perception of involvement was assessed with seven 5-point Likert-scale items asking the patient to report the extent to which she asked questions, offered opinions, and expressed concerns when meeting with each physician. This scale was derived from items in Lerman et a l . ’ ~ ~ ~ Perceived Involvement in Care Scale (PICS). We modified the original PICS scale to make it applicable to patients with breast cancer. For example, the item I asked the doctor for recommendations about treatment” was used in- stead of the original item, I asked the doctor for recommendations about my medical symptoms.” The patient’s perceived control over the decision was mea- sured with five items derived from England and Evan’s4’ Perceived Decision Control (PDC) instrument. This measure also was worded to apply to breast cancer treatment.

Physician facilitation of patient involvement was garnered with the 5-item doctor facilitation” subscale of Lerman et a l . ’ ~ ~ ~ PICS measure. The scale measures the extent to which physicians were perceived as encouraging the patient to express concerns, opinions, preferences, and as interested in the patient’s understanding of information.

Results

Alpha reliabilities for th’e self-report measures were 0.82, 0.83, 0.68, and 0.78; for the optimism, perceived involvement, control over decision-making, and physician facilitation measure!;, respectively. Cohen’s kap- pas for the behavioral measures of patient involvement were 0.91 for question-asl8ng, 0.81 for opinion-giving, 0.72 for expressions of concern, and 0.82 for total active communication. Reliability for the physician’s patient- centered utterances was 0.68.

Knowledge about Breast Cancer Treatment and Optimism

Table 2 presents the means for the knowledge and optimism measures by experimental condition (brochure vs. computer program) and time (i.e., baseline, posteducation, and postconsultaition). To test the first hypothesis, 2 X 3 repeated measures ANOVAs were conducted. Regarding the knowledge test, there was a

Table 2. Knowledge and Optimism Scores by Experimental Condition and Time of Assessment Variable Baseline Posteducation Postvisit

Knowledge* Brochure group 58.5 76.4 79.4 Multimedia group 60.7 82.6 82.0

Brochure group 33.0 33.8 33.4 Optimismt

Multimedia erouu 33.8 34.1 34.4 * These scores are percent correct on the knowledge test t Scale range for the outimism measure was 8-40.

strong effect for time (F = 36.35, P < 0.001) as patients knew more about treating breast cancer after receiving the education (mean percent of correct responses, 79.5%; standard deviation [SD], 12.68%) than they did before education (mean, 60.1%; SD, 19.23%). Knowl- edge scores after the consultations were essentially the same (mean, 80.7%; SD, 11.29%) as they were after the preconsultation education. The effect for method of education approached significance (F = 3.30, P = 0.07) as patients in the computer group tended to learn more (mean, 75.5%; SD, 13.64%) than did patients in the brochure group (mean, 71.4%; SD, 15.17%). This effect is largely explained by the differences immediately after patients viewed educational materials. Although the two groups did not differ before the education, patients using the computer program generally scored higher (mean, 82.6%, SD, 11.58%) after the intervention than did patients reading the brochure (mean, 76.4%; SD, 13.77%) (Table 2).

Optimism scores were not affected by the timing of the assessment (F = 0.25, P = 0.78), the educational intervention (F = 0.95, P = 0.34), or the interaction between the two (F = 0.07, P = 0.93) (see Table 2). In fact, the only variable predicting a patient’s optimism was knowledge as the more patients knew about their options for treatment, the more positive their outlook for the future (r = 0.31, P < 0.01).

Patient Involvement in the Consultations

Data analysis. Before discussing results related to the second and third hypotheses, two observations about data analysis are in order. First, these data were coded at two different levels of analysis. For example, each patient had three observations for question-asking, opinion-giving, expressions of concern, perceived involvement, perceptions of physician facilitation, and physicians’ patient-centered utterances because these measures were scored for each consultation. However,


Table 3. Correlations Among the Communication Variables Variable

Varible 2 3 4 5 6 7 8

Patients’ 1. Question-asking 0.61* 0.43* 0.87* 0.14 0.05 0.50* 0.09 2.Opinion-giving 0.41* 0.83’ 0.39t 0.03 0.43* 0.39t 3. Express concerns 0.73’ 0.16 -0.02 0.253 0.14 4. Active communication 0.27$ 0.02 0.50* 0.253 5. Perceived involvement 0.20 0.03 0.58* 6. Perceived control of decision-making 0.09 0.36t Physicians‘ 7. Patient-centered utterances 0.18 8. Perceived facilitation of patient involvement * P < 0.001. t P < 0.01. $ P < 0.05.

each patient had one score for age, level of education, and perceived control over decision-making. As a result, we averaged the patients’ scores on the multiple measures to create one score per patient.

This approach is reasonable if patients did not communicate differently in some consultations relative to others. This was generally the case as patients’ question-asking (F = 0.13, P = 0.88), opinion-giving (F = 1.72, P = 0.18), expressions of concern (F = 0.01, P = 0.99), perceptions of physician facilitation (F = 1.84, P = 0.17), and the physicians’ use of patient-centered utterances (F = 1.27, P = 0.28) did not differ across the consultations. However, patients tended to report greater communicative involvement (F = 3.13, P = 0.05) in their interactions with surgeons (mean, 29.7; SD, 2.13; scale range, 7-35) than with the medical (mean, 26.9; SD, 2.36) and radiation oncologist (mean, 26.8; SD, 2.32). This finding is not surprising given that the decision for local treatment typically is made during the consultation with the surgeon.

In addition, the patients’ age and education were significantly and inversely correlated (r = -0.35, P < 0.01), a common phenomenon in patient samples.30f41 Thus, the effect of one variable might suppress or con- found the effect of the other. As a result, a variable was created in which patients younger than 65 years who attended college (n = 28) were contrasted with patients who either were older than 65 years or had a high school education or less (n = 32).

Findings. Table 3 presents correlations among the communication measures. Consistent with other research,37 patients’ perceptions of their own and the physicians’ communication were weakly to moderately related to the behavioral measures of communication.

Table 4 shows the means for the communication measures for the entire sample as well as for the younger, more educated patients, and for the older and less educated patients.

To test the hypotheses, analyses of covariance (AN- COVA) were conducted on each of the patient involvement measures. The patient’s perceptions of physician facilitation and the frequency with which physicians used patient-centered utterances served as the continu- ous variables. The patient’s age-education (younger, more educated vs. older or less educated) and experimental condition (computer program vs. brochure) were the categorical variables. As can be seen in Table 5, the experimental manipulation had little effect on the dependent measures. In effect, the second hypothesis, which predicted greater involvement by patients using the multimedia program, was not supported.

However, considerable support was offered the third hypothesis which predicted that patient involvement would be related to the patient’s age and education and to the physician’s communication toward the patient. Patients younger than 65 years who had attended college asked more questions, offered more opinions, produced more expressions of concern, and had more active communication than did less educated or older patients (see Table 4). However, the older and less educated patients did not perceive themselves to be less involved or to have less control over decision- making (see Table 4).

In addition, patients offered more opinions, were more active communicators, and perceived greater involvement and control over decision-making the more they perceived their physicians as facilitating patient involvement. The physicians’ use of patient centered ut-

Patient Involvement in Choosing Treatment/Streef et al . 2281

Table 4. Means for Behavioral and Perceptual Measures of Patients' and Physicians' Communication

Overall Younger, more Older, less Measure mean educated patients educated patients

Patients' Question-asking* 6.24 8.89 3.77 Opinion-giving* 4.79 6.34 3.34 Express concerns* 2.68 4.37 1.30 Active communication* 13.71 19.58 8.40 Involvemen tt 27.9 28.24 28.02 Control of decision$ 17.36 17.38 17.35 Physicians' Patient-centered utterances* 3.33 3.92 2.69 Perceived facilitation of patient involvement5 23.13 22.86 23.38 ' These scores represent average frequencies per consultation. Active communication is a composite index of question- asking, opinioin-giving, and expressions of concern. t Scale range i s 7-35. $ Scale range its 5-20. 5 Scale range is 5-25.

terances was predictive ol behavioral indicators of patient participation but was not related to the perceptual measures (see Table 3). Finally, the physician's communication appeared to make an independent contribution to patient involvement given that physicians were not perceived to communicate differently (F = 0.97, P = 0.38) nor did they use noticeably more patient-centered utterances (F = 2.43, P = 0.15) when interacting with younger, more educated patients compared with older or less educated patients (Table 4).

Decisions on Type of Surgery

The majority of patients in both experimental conditions opted for breast conslervation over breast removal.

Although more patients educated with the computer chose breast conservation (76%) than did those reading the brochure (58%), this difference failed to reach statistical significance.

Discussion

Variability in Patient Involvement

Patients varied considerably in the degree to which they were active participants in these consultations. Much of the variability was related to age and education as college-educated patients younger than 65 years more frequently asked questions, offered opinions, and ex-

Table 5. Analysis of Covariance Results (F scores) for Patient Involvement Measures Independent variable

Dependent variable

Behavioral Ques tion-asking Opinion-giving Express concerns Active communication Self-report Involvement Control of decision

Physician

Facilitation Patient-centered

0.55 10.26t

1.80 5.09$

26.29" 5.64t

13.48* 8.01t 1.60

12.17*

0.40 0.31

Patient

Age/education Educational condition

10.47-f

5.76$ 12.34'

4.77$

0.06 0.59

0.41 0.01 0.55 0.46

0.06 0.07

Values are F scores from the ANCOVA analyses. None of the interactions between patient age/education and educational condition reached statistical significance. * P < 0.001, tP<O.Ol. t P < 0.05.


pressed concerns than did older or less educated patients. These findings are consistent with other research indicating that younger, more educated patients generally prefer a more active and participatory role in medical consultations and decision-making than do older or less educated patient^.^^,^'-^^ Ho wever, patients’ perceptions of involvement and control over decision- making did not differ for patients differing in age and education.

Two somewhat divergent inferences could be drawn from these findings. The data may indicate that physicians will have greater difficulty stimulating active participation among patients who, due to social and cultural factors, assume that the patient’s role in the decision-making process is to listen and defer to the physician’s expert judgment. Conversely, these findings may simply reflect the fact that, even though some patients were more talkative than others, patients generally be- lieved they were involved in these discussions and had some control over decisions for treatment (Table 4).

The perplexity of this issue is attenuated by another major finding. Both behavioral (frequency of opinion- giving, total active communication) and self-report (involvement in consultations, control over decision-making) indicators of patient participation were directly related to the degree to which patients perceived physicians as facilitating patient involvement. Also, there were positive relationships between the physicians’ use of patient-centered utterances and behavioral indicators of patient involvement. Similar to research in primary care settings,27,28,33*34 this finding suggests that patient participation in discussions of breast cancer treatment is in part affected by the physician’s communication style.

As mentioned earlier, both physicians and patients generally think it appropriate for the physician to have considerable influence on the course and content of medical consultation^.^,^ Thus, patients may more readily participate in discussions of treatment if their physicians allow, encourage, and thus legitimize patient involvement. However, if the physician displays little interest in or need for the patient’s views, then most patients will not challenge this authority and sub- sequently will assume a passive role in the encounter. It is important to note that physicians can facilitate patient involvement not only with patient-centered talk (e.g., asking for the patient’s opinions, offering encouragement and support), but also with nonverbal behaviors (e.g., active listening, not i n t e r r ~ p t i n g ) . ~ ~ , ~ ~

The Value of Preconsultation Patient Education Patients with breast cancer vary not only in what they know about treatment issues but also in the accuracy of

this information. Our findings indicated that patients gained a clearer understanding of breast cancer treatment after reviewing the educational materials, regardless of method, than they had before the intervention. By providing educational interventions before consultations, patients will acquire valuable and accurate information that may facilitate physician-patient communication about treatment options and enhance the patient’s ability to provide informed ~onsent . ’~,’~ In addition, knowledge about breast cancer treatment was significantly correlated with optimism, a finding offering further support to the notion that information ac- quired from patient education interventions before treatment may contribute to the patient’s emotional well-being during treatment and r e ~ o v e r y . ~ ~ - ~ ~

Although patient involvement was not affected by the method of education, there was a trend for patients to learn more from the multimedia program than from reading the brochure (Table 2). These findings suggest that clinicians may accomplish some of their educational objectives by providing reading materials that are considerably cheaper to produce than are multimedia programs. However, a large number of educational materials in print, including those of the American Cancer Society, are written at the 12th grade level and higher.46,47 This is one reason patients in general, and especially those attending public health clinics, have difficulty understanding medical information presented in brochures and pamphlets.47 Thus, clinicians and health educators must be diligent in selecting and pro- ducing reading materials that are culturally sensitive and at a reading level comparable with the patient’s comprehension ability.

However, our findings are also consistent with re- views indicating that computer-assisted patient education is as effective if not superior to education using brochures and videotape^.^^ Given the costs of developing multimedia programs vis-a-vis their possible benefits, an important question for future research is to identify the conditions under which interactive technology pro- duces better outcomes than traditional methods of patient education. For example, coping style may be a particularly important variable affecting how a patient re- sponds to educational interventions. Some people (termed ”blunters”) generally avoid information related to their condition while others (referred to as “moni- tors”) actively seek out this i n f ~ r m a t i o n . ~ ~ , ~ ~ Future research could examine the possibility that information- seekers are particularly responsive to educational resources that encourage active and self-selecting explo- ration of disease and treatment information whereas information-avoiders have less interest in this information regardless of the presentational medium.


Yet another potentially mediating variable is the patient’s motivation to learn about a particular health issue. For example, appropriate educational materials, regardless of format, are likely valuable to patients con- fronting an important medical decision such as treatment for breast cancer. Thus, as in this study, patients will carefully review relevant information, be it in a brochure or multimedia program. However, if an individ- ual is not particularly interested in a certain health issue, as is often the case with messages promoting cancer screening and prevention, then interactive multimedia programs may more eff ect.ively engage viewers to carefully examine educational material^.^^,^^,^^

Limitations

Future research also should improve upon several limitations of this investigation. First, studies need to be conducted with more patients. Because transcript analysis of recorded consultations is a time-consuming en- terprise, researchers might benefit from using well de- signed self-report measures of communication that can be gathered efficiently in larger-scale studies. However, given our finding that physicians’ partnership-building utterances were not predictive of patients’ perceptions of physician facilitation, efforts must be made to develop perceptual measures that more closely correspond to behavioral indicators of cornm~nication.~~ For example, in addition to the global measure of physician facilitation used in this study, researchers could use items addressing specific facilitative responses (e.g., The physician did not interrupt me when I was speaking,” When I talked, the doctor looked at me and showed interest in what I was saying”’). Future studies also should assess patients’ preferences for their own and their physicians’ involvement to see if these beliefs explain why some patients are more active communicators than are others.

Finally, this investigation did not include a no education” condition. At Scott imd White, breast cancer patients are routinely given treatment information after their diagnosis but before tlhey meet with physicians to decide treatment. For ethical reasons, we chose not to withhold this information, and our brochure” condition was an effort to standardize the current practice. Nev- ertheless, although we observed significant gains in knowledge after the education, an important question for future research is to ascertain whether patients become more involved in decision-making when they receive some form of preconsultation education than when they do not.

Conclusions

First, although some patients (specifically those younger than 65 years and college educated) were more ex- pressive in discussing treatment, patients generally were more involved in these consultations when their physicians encouraged and facilitated patient participation. Second, providing preconsultation education about treatment options appeared to be an effective strategy for increasing patient understanding of treatment issues prior to their visits with physicians. Third, although patient involvement was not affected by method of education, patients tended to learn more about breast cancer treatment after using a multimedia program than after reading a brochure. Finally, patients more knowledgeable about treatment options also were more optimistic about the future.

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Appendix A. Knowledge About Treating Breast Cancer*

1. Which of the following best describes your changes of survival when breast cancer is found early? a. poor b. about 50-50 c. verygood d. don't know

a. only in the lump b. in other areas of the beast c. in other parts of the body d. all of the above e. don'tknow

a. mastectomy b. lumpectomy c. both lumpectomy and m,istectomy d. don't know

a. mastectomy b. lumpectomy c. both lumpectomy and mastectomy d. don't know

a. mastectomy b. lumpectomy c. both lumpectomy and mastectomy d. don't know

6. Generally, radiation therapy lasts for: a. 1-2weeks b. 3-5 weeks c. 5-7weeks d. 10-12 weeks e. don'tknow

a. your hair falls out b. your stomach and lungs are sore c. some of the skin may be irritated like a sunburn d. don'tknow

a. mastectomy b. lumpectomy c. both lumpectomy and mastectomy d. don'tknow

a. mastectomy b. lumpectomy with radiation c. both lumpectomy with r,adiation and mastectomy offer the same chance for survival d. don'tknow

radiation? a. the breast is preserved b. there is less chance that cancer will develop again in the cancerous breast c. mastectomy is the quicker form of treatment d. there is less soreness after surgery

mastectomy? a. the breast is preserved b. there is less chance that cancer will develop again in the affected breast c. lumpectomy with radiation is the quicker form of treatment d. there is less soreness after surgery

2. In early stages of breast cancer, cancer cells may be present:

3. This procedure involves the surgical removal of the breast.

4. This procedure involves the surgical removal of the cancerous lump and does not remove the entire breast.

5. Radiation therapy typically follows which form of treatment?

7. Which of the following usually happens after radiation therapy?

8. Generally, drug therapy (such as hormone therapy or chemotherapy) is needed to kill remaining cancer cells after which form of treatment?

9. In general, a patient's best chance for survival is with which procedure?

10. Which of the following (circle 1 or more answers) are advantage(s) of having a mastectomy rather than having a lumpectomy with

11. Which of the following (circle 1 or more answers) are advantage(s) of having a lumpectomy with radiation rather than having a

* Correct answers are in boldface tvue

increasing patient involvement in choosing treatment for early breast cancer

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