Frequency of IDK-Qs
Twenty-six of the 63 (41.3%) students asked 1-6 IDK-Qs during the interviews. In total, 53 IDK-Qs occurred, of which 49 had a rising pitch.
No significant gender or scenario effect was observed: female (N = 38) and male (N = 25) students used IDK-Qs in almost equal proportions (39.5% vs. 44%, p = 0.995) and the ratio of IDK-Qs in the interviews with the curative scenario (N = 33) was higher than within the palliative scenario (N = 30) (67.9% vs. 32.1%, p = 0.127).
Content of IDK-Qs
Based on their content, IDK-Qs were attributed to three broad categories (see Table ): medical/treatment questions (N = 24), e.g. I don't know if you have already heard about chemotherapies [S53]; lifestyle/psychosocial questions (N = 18), e.g. I don't know if you have any, some plans for, for the future [S6]; and "inviting questions" questions (N = 11), e.g. I don't know if you have other questions [S51] (each IDK-Q is presented with its interview number and author (S = Student, O = Oncologist, SP = Simulated Patient).
The medical/treatment category included IDK-Qs about medical anamnesis, medical condition, symptoms, diagnosis, prognosis, treatment, side effects, as well as IDK-Qs assessing patient's perception of the medical situation and knowledge of anticancer treatments and inviting questions about the treatment. IDK-Qs in the lifestyle/psychosocial category addressed family and home situation, patient's employment, support, state of mind, psychological concerns and needs, and involvement of patient's relatives. Finally, the category of IDK-Qs "inviting questions" included broad probes for questions or information about unspecified topics.
Context of occurrence of IDK-Qs
IDK-Qs about medical and treatment issues mainly occurred in the first stages of the interviews after introducing one selves, students' probes about the reason for the consultation (opening stage) and the disclosure of diagnosis or treatment options. IDK-Qs about lifestyle and psychosocial aspects tended to be asked after discussion of treatment options and medical issues, while IDK-Qs inviting questions occurred at all stages of the interviews.
Intent function of IDK-Qs
Precise information requests (N = 7)
Seven IDK-Qs were classified as specific (indirect) questions since their seeming function was to request precise information: e.g., I don't know if you work [S11], I don't know if you knew [about the prognosis] [S28], I don't know if you know what this means [immunodepressed] [S34] (all IDK-Qs with precise information requests are marked by an * in Table ).
In reply to these questions, the simulated patients provided minimal information (e.g., not really [SP28], non-verbal no [SP34]), probably interpreting these IDK-Qs as a request for clarification.
Exploratory requests (N = 46)
In addition to IDK-Qs inviting questions, which have a large scope and generally (7/11) led to extended responses or requests for more information (e.g., I don't know if you have already questions now [S11]), 35 IDK-Qs seemed to have an exploratory function.
In discussions about the treatment plan (medical/treatment IDK-Qs), IDK-Qs were intended, for example, to find out what the (simulated) patient already knows (I don't know if you know a bit of [chemotherapy], if one has already talked to you [S24]), if he/she has any queries about the treatment (I don't know if you have any questions about these two treatments [chemotherapy and radiotherapy] [S44]) or if he/she wants to be informed about the side effects (I don't know if maybe you don't want to speak about or to the contrary you want to speak about [the side effects of chemotherapy] [S45]).
Concerning the psychosocial aspects (lifestyle/psychosocial IDK-Qs), IDK-Qs aimed, for example, to explore social support (I don't know if you have special enough relationships with your family doctor or with someone who knows a bit of your situation [S39]), involvement of relatives in the treatment process (I don't know if you would like to, I mean, to make an appointment with your relatives as well such that we can talk about it all together [S53]) or to disclose patient's concerns related to the future or to distressing side effects of chemotherapy [I don't know if for you it's awkward [the hair loss] [S63]).
Twenty-nine of these "scanning" questions (29/35) elicited extensive responses and six short or yes/no responses (6/35).
Simulated patient replies to IDK-Qs
In reply to 36 of the 53 IDK-Qs, simulated patients provided detailed responses and/or asked for more information. The fact that some IDK-Qs (N = 4) were pronounced with a falling pitch apparently didn't affect the responses, since simulated patients continued with extended information.
The following three contextualized excerpts of interviews illustrated the type of extended responses or requests for more information formulated by the simulated patients and at the same time shed some light on the interaction dynamics surrounding the IDK-Qs.
In excerpt 1, the actress simulating a breast cancer patient (SP) responded to an IDK-Q of a student (S) inviting questions in the "summary stage" of the interview (at 13 out of 15 min):
S45: I don't know if you have other questions that come to mind.
SP45: (2 s) Regarding my son, because I have a seven-year-old son, it's true that (1 s) we haven't really said to him what happened. So, I don't know whether (2 s) what I'm supposed to do for him, whether I'm supposed to tell him or not.
S45: (6 s) That's, I think that's really a personal choice, that's (1 s) it's true that he will see his mum tired, that he will see his mum without [hair?], who often has to go to the doctor, maybe you could try to explain to him. I think that will be hard.
(The student then asked another IDK-Q: I don't know if you want him to come to the next meeting, to one of the next sessions or if rather not.)
In excerpt 2, the student's IDK-Q about chemotherapy occurred at the beginning of the interview (at 2 min) after the disclosure of the breast cancer diagnosis and treatment options:
S53: I don't know if you have already heard about chemotherapies.
SP53: I think that the side effects are still quite serious. At least as far as I know.
SP53: Regarding tiredness, (1 s) hair loss, all this stuff.
S53: Okay (the student started to explain the side effects mentioned by the simulated patient.)
Excerpt 3 occurred in the first third of the interview (at 8 min). After the student has informed about the diagnosis of stomach cancer, addressed patient's concerns and disclosed the (poor) prognosis, she asked by an IDK-Q how the simulated patient felt (psychologically):
S28: I don't know how you feel.
SP28: I don't feel me anymore. I don't feel anything.
SP28: It's emptiness, it's a black hole that pulls me in. It's, even no desire to scream, (1 s) I can't have a grudge against anybody.
SP28: The doctor, the surgeon has done what he has done.
SP28: I'm (6 s) I can't fall asleep to forget, that's all (4 s) I understand those who jump from a bridge.
S28: (8 s) You told me earlier your short-term projects, you already talked about death and dying, that you will ask your relatives to incinerate you in a place you like and that you want to settle your affairs somewhat. After this news, is that still (1 s) something that you are planning to do?
Comparison with the oncologists
Five IDK-Qs were identified in the interviews of the 31 oncologists: three oncologists formulating 1 IDK-Q and one oncologist formulating 2 IDK-Qs. With regard to their content, three IDK-Qs concerned medical/treatment issues - I don't know if one has already talked to you about side effects [O1165], I don't know how you, you see the stuff chemotherapy, what does it mean for you [O1209], I don't know if there were any breast cancers in your family [O1240] - and two lifestyle/psychosocial issues - I don't know if you are married, if you have children [O1240], I don't know what it means for you to, to think of, of losing the hair [O1266]. Except for the one about the medical history of the family, the IDK-Qs appeared to have an exploratory intent; simulated patients provided extensive responses in relation to the hair loss [SP1266] and to their representation of chemotherapy [SP1209].
The oncologist IDK-Qs corresponded to the same content categories - except for the "inviting questions" category - and mainly functioned as exploratory questions, but they were rare compared to the student sample (5 vs. 53 occurrences, 4/31 oncologists vs. 26/63 students).