1Medical Psychology Unit, 2Department of Cancer Medicine, University of Sydney, Australia
Received 5 April 2001; revised 3 September 2001; accepted 20 September 2001.
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Patients value audiotapes of their oncology consultations and letters summarising the discussion, and report improved recall and satisfaction when they receive them. However, studies to date have provided these interventions only after the initial or bad news consultation. This study aimed to evaluate the utility of audiotaping routine follow-up oncology consultations.
Patients and methods
This was a prospective study following a cohort of consecutive patients attending routine follow-up at oncology outpatient appointments with one oncologist. Patients were approached when they attended their appointment and offered the opportunity to be audiotaped. Acceptance rates and reasons for refusal were documented. Two weeks after the consultation, patients were telephoned regarding their response to the tape and were sent a letter summarising the consultation. Two weeks later they received a further telephone call regarding the letter and their perceptions of the comparative value of the two interventions.
Results
Seventy-five per cent of patients were female and for 40% English was not their first language. The patients had attended a median of 14 previous oncology appointments; 52 patients were offered audiotaping, 43 accepted and 30 decided to take home a copy of the audiotape. One patient felt recording had limited the discussion. Patients refused the tape most commonly because they felt no need for this aid, and accepted it most commonly to aid recall or share with family. Twenty-six patients listened to the tape, 14 did so more than once. Twenty had shared it with another person and over 75% thought it was useful. The majority (57%) preferred to receive both the tape and letter, with three preferring the tape alone and seven the letter. Married patients and those receiving bad news were more likely to want the tape.
Conclusions
Audiotaping follow-up consultations is an inexpensive procedure that is appreciated by the majority of patients. Randomised controlled trials of their impact are warranted.
Key words: doctorpatient communication, patient communication aids, routine clinics
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The busy setting of a hospitals outpatient department does not lend itself to effective clinicianpatient communication [4]. Furthermore, patients may feel overwhelmed by the complexity and emotional impact of the information they receive. Many patients report switching off if this occurs, thus inhibiting their ability to understand the information presented [5].
Several methods have been suggested to enhance the transfer of medical information, including a greater focus on doctorpatient communication in medical school curricula, the use of information leaflets and interactive computer programs [68]. Ideally such interventions should cater for patients varying information needs, allow for flexible information review and be economical in terms of time and money. Providing the patient with an audiotape of their oncology consultation satisfies these criteria and this strategy has now been widely evaluated [2, 911].
Audiotapes of oncology consultations have proved acceptable to both patients and doctors. Patients receiving such audiotapes report them to be useful, both to themselves and their families, report higher satisfaction with their medical communication, and in some studies demonstrate improved recall of facts presented during the consultation [915]. A recent overview of the relevant literature reported consistently positive outcomes from this practice, with no evidence of detrimental psychological effects [15].
All of the studies published to date have evaluated the use of audiotapes following initial referral to an oncology department or during a specific bad news consultation. However, the treatment of cancer is an ongoing process with many decisions required over the disease trajectory. Even during a routine follow-up appointment, new information and options may be presented. The current study was therefore conducted as a first step in exploring the utility of extending the scope of this intervention. We evaluated the feasibility and acceptability of providing audiotapes to cancer patients attending routine follow-up consultations within an oncology outpatient department. We felt it was premature to mount a randomised controlled trial of the intervention in this setting before we had assessed these parameters.
![]() |
Patients and methods |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Measures
Demographic information about patient age, gender, marital status, education, occupation, whether English was the patients first language and amount of information desired were obtained from the patient when recruited. Disease and history details, including diagnosis, date of diagnosis, date of initial referral to the oncology department and number of previous appointments in the oncology department, were obtained from medical records. The oncologist predicted whether or not the patient would elect to take a copy of the tape home. He recorded the aim of current treatment (adjuvant, symptom control or no treatment) and in the latter group whether recurrent disease was present. He also noted whether news delivered in that consultation was good, bad, or neither good nor bad. Patients similarly categorised the news they had received at the first follow-up telephone call. The length of the consultation was calculated from the tape recording.
Open responses were elicited from patients regarding their reasons for refusing or accepting both audiotaping and a copy of their tape. At the first follow-up telephone interview, patients were asked if they had noticed the audiotape recording during the consultation and whether they felt positive or negative about the recording process. They were then asked how many times they had listened to the tape, and if not why not. They were also asked if anyone else had listened to the tape, specifically their spouse, a child, another family member, a friend, their family practitioner or another person. Patients then responded to eight questions presented in a Likert format with five response options, determining the extent to which the tape had been useful, helped them to understand their situation, annoyed them, embarrassed them, helped them to remember what the doctor had said, caused anxiety, helped them to tell family and friends about their situation, and helped friends and family understand the situation. They were asked if the tape contained any information they had forgotten and whether they felt audiotapes of oncology consultations should be offered to patients on a routine basis. These items were derived from a previous study of audiotapes [2].
Similar questions targeting the summary letter were asked at the second follow-up telephone interview, and final questions were whether they found the letter or tape more useful, and whether they would have preferred to receive the letter alone, the tape alone or both.
Statistics
Data were entered on the statistical package for social sciences, SPSS. Frequencies were calculated for descriptive analyses. Univariate tests (2 and Students t tests) were used to explore predictors of audiotape use.
![]() |
Results |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
|
Demand
Of 52 patients offered audiotaping, 43 accepted (83%). Five of those refusing gave no reason, two did not want a reminder of the news received and two felt they did not need the audiotape. Of 43 patients audiotaped, 30 elected to keep the tape (70%). In contrast, the medical oncologist predicted that only 14% would do so.
Of those who did not accept the tape, six gave no reason, seven felt they did not need the tape and in addition one felt the cost was not justified. The most common reason for accepting the tape was to aid recall. Other reasons are listed in Table 2. Despite being framed as an open question with more than one response invited, most patients gave only one response to this question, suggesting they had a particular need in mind when accepting the tape.
|
The process
Of the 30 patients who elected to keep the audiotape, seven later reported they had been aware of the tape running, but only one person, who felt the audiotaping had limited what could be discussed in the consultation, felt negative about the process.
Two patients were not satisfied with the quality of the tape. One patient commented that it was hard to hear all that was said during her examination, which had occurred behind a curtain about 1 m away from the microphone. The second patient was able to hear the main points of the consultation but found it difficult to hear her own contribution.
Review
Four patients did not listen to the tape, 10 listened to it once and 10 twice. The remaining patients listened to it three or four times. Similarly, only one patient did not read the summary letter, seven read it once and 15 read it twice, with the remainder reading it more than twice.
Patients were more likely to give the audiotape (69%) than the letter (50%) to a family member or friend. The most common recipient was the spouse, and interestingly, no patient gave the tape or letter to their family practitioner. One patient announced that she was planning to send the tape to a family member who was a junior doctor. She thought that listening to the tape would assist his communication skills.
Satisfaction
All patients interviewed felt it was a good idea to give patients an audiotape of routine follow-up oncology consultations, with only one patient hedging her response by suggesting this would depend on the content discussed. Similarly, the majority of patients rated both the audiotape and letter highly in terms of overall usefulness, and as an aid to recall and family communication. Half of the patients reported the tape contained material they had forgotten, while two patients felt the letter contained forgotten material. Very few patients found the tape or letter embarrassing or annoying; more found the tape caused anxiety (five patients reported a lot or a little anxiety in response to both the tape and the letter) (Table 3).
|
![]() |
Discussion |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
This study extended previous work by exploring whether the utility of these interventions would extend to the domain of routine follow-up consultations. Such consultations may merely confirm the absence of recurrent disease. Others may contain bad news or an ongoing review of treatment. It might be expected that patients would be less interested in an audiotape of these possibly routine discussions.
In our earlier studies investigating audiotaping of initial consultations, 100% of patients elected to have their consultation audiotaped and all patients chose to take a copy home. Other studies have reported inclusion rates of between 94 and 100% [6, 10, 11]. In the current study, 52 patients were recruited, and 43 (83%) agreed to have their consultation audiotaped. Following their consultation, 30 elected to take their audiotape home (58% of the original sample and 70% of those audiotaped). In contrast, the oncologist involved predicted that only 14% would elect to take home a copy of the tape, on the basis of his knowledge of the content to be covered in that consultation. Thus, while the numbers of patients interested in an audiotape of a follow-up consultation are, as expected, less than those reported in studies of initial or bad news consultations, they are nevertheless far higher than their oncologist predicted.
Not surprisingly, patients most commonly refused the tape because they felt it would serve no purpose. They gave a range of reasons for wanting the tape, most commonly to aid recall, but also to act as a record for future reference if necessary. Other patients hoped it would aid family communication and understanding of their situation. One patient for whom English was not a first language noted that the tape would allow them to slowly review words and sentences they may not have understood when first spoken. Another patient who had been in an earlier taping study reported she had found a tape useful after her initial consultation and believed it would be useful again. Thus, assumptions cannot be made about the significance of various discussions and items of information to patients. While such discussions may be seen as mundane and routine by the oncologist, they may nonetheless hold value to the patient, who may therefore wish to review them. This is supported by the disparity between doctor and patient ratings of the news delivered in the consultation. Patients were much more likely to place a significant valence on the news delivered than the oncologist, who more commonly rated it as neither good nor bad.
Several groups were significantly more likely to want the tape than others. Three quarters of married patients wanted the tape, compared with 40% of unmarried patients. This is not surprising, given that spouses were the most common recipients of the tape and the desire to assist family members to understand their situation better was one of the most common reasons cited by patients for wanting the tape.
Patients rated by their oncologist as receiving bad news were most likely to want the tape, followed by those receiving neutral news. Those receiving good news were least likely to want the tape. Patients who wanted the tape were also more likely to have had a lengthy consultation, perhaps containing complex and new information. As patients situations can change rapidly, the exchange of important information is on-going and it appears that patients want continued access to that information, even if it contains bad news.
While several patients were aware of the tape running during the consultation, only one patient felt it had a negative impact by inhibiting discussion. The same patient was the only participant to qualify her support for providing other patients with audiotapes, depending on the content covered. Perhaps the patients right to stop the tape if it is felt to be intrusive should be communicated more forcefully. (This offer was contained in the consent form signed by patients before audiotaping began).
Almost all the patients who elected to take home a tape actually listened to it, often more than once. Similarly, after receiving a letter summarising the same consultation, patients reported reading it, usually more than once. Both interventions were rated highly in terms of overall usefulness, an aid to recall and an aid to family communication. Most patients wanted to receive both the tape and the letter. In an earlier study comparing patient responses to audiotapes and summary letters, we found the reported benefits were somewhat different [11]. Audiotapes provided a more complete record of the discussion and included non-verbal elements. Letters were more conveniently reviewed, stored and shared. Thus, while tapes are less costly in terms of the doctors time, they may not answer all the patients information needs.
While the audiotape and letter neither embarrassed nor annoyed patients, some reported that both interventions in-creased their anxiety. We followed up patients for only 2 weeks after receiving each intervention, so we were not able to determine if this perceived increase in anxiety persisted. Patients reporting anxiety nonetheless rated the usefulness of the audiotape highly, and would recommend it to other patients; thus the anxiety did not appear to be viewed as a serious down-side.
Unfortunately, the sample size in this study was not large enough to allow a multivariate analysis of predictors of valuing an audiotape of the follow-up oncology consultation. Furthermore, only patients who accepted the tape were interviewed at length, and so a more detailed understanding of why patients would reject this option or might be harmed by it was not obtained. Nevertheless, this pilot study has clearly demonstrated that such an intervention is feasible, welcomed by a significant proportion (more than half) of patients and perceived by those receiving it to have positive benefits. A larger randomised controlled trial is now clearly required to definitively evaluate this intervention.
![]() |
Footnotes |
---|
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
2. Dunn SM, Butow PN, Tattersall MH et al. General information tapes inhibit recall of the cancer consultation. J Clin Oncol 1993; 11: 22792285.[Abstract]
3. Audit Commission. What seems to be the matter: communication between hospitals and patients. NHS Report, 12. London: HMSO 1993.
4. Chaitchik S, Kreitler S, Shaked S et al. Doctorpatient communication in a cancer ward. J Cancer Educ 1992; 7: 4154.[Medline]
5. North N, Cornbleet MA, Knowles G, Leonard RC. Information giving in oncology: a preliminary study of tape-recorder use. Br J Clin Psychol 1992; 31: 357359.[ISI][Medline]
6. Butow PN, Dunn SM, Tattersall MH. Communication with cancer patients: does it matter? J Palliat Care 1995, 11: 3438.
7. Frederikson LG, Bull PE. Evaluation of a patient education leaflet designed to improve communication in medical consultations. Patient Educ Couns 1995; 25: 5157.[ISI][Medline]
8. Maslin AM, Baum M, Walker JS et al. Using an interactive video disk in breast cancer patient support. Nurs Times 1998; 94: 5255.[Medline]
9. Hogbin B, Fallowfield L. Getting it taped: the bad news consultation with cancer patients. Br J Hosp Med 1989; 41: 330333.[ISI][Medline]
10. McHugh P, Lewis S, Ford S et al. The efficacy of audiotapes in promoting psychological well-being in cancer patients: a randomised, controlled trial. Br J Cancer 1995; 71: 388392.[ISI][Medline]
11. Tattersall MH, Butow PN, Griffin AM, Dunn SM. The take-home message: patients prefer consultation audiotapes to summary letters. J Clin Oncol 1994; 12: 13051311.[Abstract]
12. Ong LM, de Haes JC, Kruyver IP et al. Providing patients with an audio recording of the outpatient oncological consultation; experiences of patients and physicians. Ned Tijdschr Geneeskd 1995; 139: 7780.[Medline]
13. Deutsch G. Improving communication with oncology patients: taping the consultation. Clin Oncol (R Coll Radiol) 1992; 4: 4647.[Medline]
14. Ford S, Fallowfield L, Hall A, Lewis S. The influence of audiotapes on patient participation in the cancer consultation. Eur J Cancer 1995; 31A: 22642269.
15. McClement SE, Hack TF. Audio-taping the oncology treatment consultation: a literature review. Patient Educ Couns 1999; 36: 229238.[ISI]
16. McConnell D, Butow PN, Tattersall MH. Audiotapes and letters to patients: the practice and views of oncologists, surgeons and general practitioners. Br J Cancer 1999; 79: 17821788.[ISI][Medline]