is there a cost to poor communication in cancer care? a critical review of the literature

PSYCHO-ONCOLOGY

Psycho-Oncology 14: 885–886 (2005)Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.970

COMMENTARY ON

IS THERE A COST TO POOR COMMUNICATIONIN CANCER CARE? A CRITICAL REVIEW

OF THE LITERATURE

PETER SALMON*

Division of Clinical Psychology, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool L69 3GB, UK

THE CHALLENGES OF A FUNCTIONALDEFINITION OF POOR COMMUNICATION

It has become axiomatic that communication iscentral to the quality of health care, but Thorneet al. remind us to think carefully about whycommunication matters. Their defining position isan outcomes-oriented approach. That is, poorcommunication is poor because it leads to pooroutcomes. This functional definition contrasts witha widespread tendency to regard poor and goodcommunication as distinguished topographically;for example, to regard certain kinds of questioningor focus as generally bad and others as generallygood. By focusing on outcomes of communica-tion, and reviewing specifically the negative out-comes, their paper helps us avoid this trap.However, it then confronts us with some impor-tant challenges for communication training andresearch.

One concerns the ambiguity around recognisingcommunication that is poor or good. Commu-nication might lead to a negative outcome in onesituation}with a particular patient and clinicianat a specific stage in their relationship and at aspecific point in a specific consultation}but goodoutcomes in another. Correspondingly, the samegood outcome might be achieved, in differentsituations, by different kinds of communication. In

practice, communication training often embracesthese subtleties, but there is a need, that Thorneet al. highlight, for research and theoreticalframeworks to adopt more contextual approachesthat can accommodate them also.

Confidence about whether communication ispoor depends on confidence about whether theoutcomes are poor. However, ‘poor’ is a valuejudgement and depends on perspective. Forexample, that 25% of patients received chemother-apy within the last 6 months of life (Emmanuelet al., 2003) is a poor outcome in the context ofdebate on aggressive treatment, but not necessarilyto patients who, of course, do not know that theyare beginning their last 6 months of life and valueeven small chances of survival. Thorne et al.’sreview of cost implications will help in persuadingcontrollers of funding that communication mattersbut, while reduced health service cost is a goodoutcome to a health economist and a servicemanager, it is ambiguous to a clinician concernedabout unmet need. As Thorne et al. observe,claims for communication will be most powerfulwhere compassion and cost-effectiveness converge.Therefore, an important reference point in evalu-ating communication should be knowledge ofwhat patients prefer, but Thorne et al. point outthat we know insufficient about how patients’preferences relate to the guidelines and principlesthat have come to shape communication trainingand research.

Another challenge is that functional definitionsare necessarily circular: poor communication isrevealed by adverse outcomes}which are then

Copyright # 2005 John Wiley & Sons, Ltd.

*Correspondence to: Division of Clinical Psychology, Uni-versity of Liverpool, Whelan Building, Brownlow Hill, Liver-pool L69 3GB, UK. E-mail: psalmon@liv.ac.uk

attributed to poor communication. Thereforecommunication can be blamed for an ever-widen-ing range of poor outcomes. For example, Thorneet al. cite Ramirez et al.’s (1995) inference, fromfinding that clinicians who felt insufficientlytrained in communication were more distressedthan others, that communication training couldreduce burnout. However, clinicians might blamelack of training because they are unhappy. Morepowerful explanatory levers might lie in clinicians’personality or the employers’ management style.Thorne et al.’s review shows the need for more

research and fewer assumptions about outcomesof communication.

REFERENCES

Emmanuel EJ, Young-Xu Y, Levinsky NG, Gazelle G,Saynina O, Ash AS. 2003. Chemotherapy use amongMedicare beneficiaries at the end of life. Ann InternMed 138: 639–643.

Ramirez AJ, Graham J, Richards MA et al. 1995.Burnout and psychiatric disorder among cancerclinicians. Br J Cancer 71: 1263–1269.

P. SALMON886

Copyright # 2005 John Wiley & Sons, Ltd. Psycho-Oncology 14: 885–886 (2005)