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1.  What Patients Value When Oncologists Give News of Cancer Recurrence: Commentary on Specific Moments in Audio-Recorded Conversations 
The Oncologist  2011;16(3):342-350.
This study was designed to understand patient perspectives on what patients value when oncologists communicate news of cancer recurrence. This study adds to the empirical evidence base about how oncologists should discuss news of cancer recurrence and identifies recognition, guidance, and responsiveness as patient-centered qualities of communication in this situation.
Learning Objectives
After completing this course, the reader will be able to: Incorporate the three themes identified in this study to refine discussion with patients of their cancer recurrence.Manage discussion with patients of cancer recurrence with recognition of the impact of the news on the patient and guidance as to next steps.
This article is available for continuing medical education credit at CME.TheOncologist.com
Purpose.
Recommendations for communicating bad or serious news are based on limited evidence. This study was designed to understand patient perspectives on what patients value when oncologists communicate news of cancer recurrence.
Study Design and Methods.
Participants were 23 patients treated for a gastrointestinal cancer at a tertiary U.S. cancer center within the past 2 years, who had semistructured qualitative interviews in which they listened to audio recordings of an oncology fellow discussing news of cancer recurrence with a standardized patient. Participants paused the audio recording to comment on what they liked or disliked about the oncologist's communication.
Results.
Three themes were identified that refine existing approaches to discussing serious news. The first theme, recognition, described how the oncologist responded to the gravity of the news of cancer recurrence for the patient. Participants saw the need for recognition throughout the encounter and not just after the news was given. The second theme, guiding, describes what participants wanted after hearing the news, which was for the oncologist to draw on her biomedical expertise to frame the news and plan next steps. The third theme, responsiveness, referred to the oncologist's ability to sense the need for recognition or guidance and to move fluidly between them.
Conclusion.
This study suggests that oncologists giving news of cancer recurrence could think of the communication as going back and forth between recognition and guidance and could ask themselves: “Have I demonstrated that I recognize the patient's experience hearing the news?” and “Have I provided guidance to the next steps?”
doi:10.1634/theoncologist.2010-0274
PMCID: PMC3228111  PMID: 21349951
Communication; Medical ethics; Information-seeking behavior; Palliative care
2.  “Could I add something?”Teaching communication by intervening in real time during a clinical encounter 
Supervising learners communicate places faculty preceptors in a classic educational dilemma. What should a preceptor do when the learner is not communicating well and is not asking for help? What usually happens, in our experience, is that the preceptor decides at some point that they can't stand it anymore—then they interrupt the learner and takes over the conversation. Interrupting in this way, however, comes at the cost of deskilling the learner. Thus the authors have developed an alternative teaching strategy designed for communication tasks such as giving serious or bad news. In the strategy recommended here, the preceptor `sets up' the possibility that the preceptor may intervene in the encounter. If the preceptor does intervene, the preceptor explicitly hands the conversation back to the learner; and afterwards, debriefs the learner. This method is designed to decrease the risk to the patient while maximizing learning. It offers a way to teach communication skills more effectively in clinic using intentional goal setting with learners, careful observations, intervention when the conversation is not going well, and reflective feedback based on the learner's goals.
doi:10.1097/ACM.0b013e3181dbac6f
PMCID: PMC3097516  PMID: 20505408
4.  Psychological and Behavioral Dynamics in Chronic Atypical Facial Pain 
Anesthesia Progress  1986;33(5):252-257.
The authors discuss the relationship between atypical facial pain and psychiatric disturbance. They present contemporary viewpoints and describe four cases that illustrate underlying psychodynamic mechanisms associated with pain in patients who had undergone various dental procedures and other treatments without success. They identify factors which might lead to the early detection of underlying psychological problems and discuss the role of learning, the family system and other factors in producing a chronic pain syndrome.
PMCID: PMC2177480  PMID: 3465263

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