Patients' Perceptions of Physicians Communication and Outcomes of the Accrual to Trial Process

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Patients' Perceptions ofPhysicians Communication andOutcomes of the Accrual toTrial ProcessCharles H. Grant , Kenneth N. Cissna & Lawrence B.RosenfeldPublished online: 10 Dec 2009.

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Patients’ Perceptions of PhysiciansCommunication and Outcomes of the

Accrual to Trial Process

Charles H. Grant, IIIDepartment of Speech Communication

University of Tennessee

Kenneth N. CissnaDepartment of Communication

University of South Florida

Lawrence B. RosenfeldDepartment of Communication Studies

University of North Carolina

The purpose of this study was to examine the relations among patients’ perceptions oftheir physicians’ communicative behavior during the informed consent interview, thepatient’s feeling of being confirmed by the physician and satisfied with care deliveredby the physician, and the patient’s decision to participate in a clinical trial or not. Re-spondents included 130 cancer patients who were eligible for a clinical trial and whohad recently discussed trial participation with their physicians. Results indicated thata linear combination of the variables physician affiliative style, physician dominant orcontrolling style, patient satisfaction, patient confirmation, patient preference for de-cision making, patient desire for information, and patient age discriminate betweenpatients who agree to participate in clinical trials and patients who refuse to partici-pate. Physicians’ affiliative communicative behaviors and patient satisfaction wereclearly important to patients who agreed to participate. Motivations for patients whodeclined to participate in trials were less clear. Implications for physicians who offerclinical trials to their patients are that specific communication skills may enhancetheir patients’ satisfaction and may help increase enrollment in clinical trials.

Reiser (1985) says in his foreword to Cassell’s (1985)Talking with Patients, Vol-ume 1: Theory of Doctor–Patient Communicationthat “Medical encounters beginwith dialogue” (p. iv). Cassell based his book on the premise that “all medical care

HEALTH COMMUNICATION, 12(1), 23–39Copyright © 2000, Lawrence Erlbaum Associates, Inc.

Requests for reprints should be sent to Charles H. Grant, III, Department of Speech Communication,105 McClung Tower, University of Tennessee, Knoxville, TN 37996. E-mail: [email protected]

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flows through the relationship between physician and patient” (p. 1). Unfortu-nately, the relationship between physician and patient has been neglected in an im-portant sub-area of medical research and practice: recruiting patients to participatein research trials of promising new treatments (Gotay, 1991). In no area is this ne-glect more crucial than in research trials concerning cancer.

Clinical trials are an important tool in the development of more effective treat-ments for certain types of cancers—treatments that significantly increase the sur-vival rates for large numbers of patients (Foster, 1994; Hunter et al., 1987).However, continued success in the development of new treatments is being slowedby a lack of patients willing to participate in ongoing cancer trials (Foster, 1994).Only about 3% of all newly diagnosed cancer patients in this country enter clinicaltrials annually (Gotay, 1991; Mansour, 1994).

If a patient is eligible for a cancer trial, prior to enrollment, a physician or othertrained health care professional must communicate to the patient the risks and ben-efits of the trial as well as alternative treatments available. In the United States, thepatient also must sign a consent form designed to protect his or her rights (Simon,1993). The document describes in detail the purpose and nature of the study, anyforeseeable risks and benefits, and a statement explaining confidentiality, com-pensation, and the voluntary nature of participation (Williams, 1991). Formalizedscrutiny of informed consent by institutional review boards concentrates on theverbal content of written forms and ignores how the doctor presents the informa-tion to the patient.

In this study, we focus specifically on the way the information is communi-cated to the patient in the informed consent interview. How physicians presentthis information has been shown to be critical to patients in forming their atti-tudes toward the treatments offered in the clinical trial (Lawrence et al., 1993),and may make a difference in the patient’s decision about participation in thetrial (Gotay, 1991). Many reasons are reported for patients not entering trials,but little of the extant research focuses on the physician–patient relationship. Inher extensive review and critique of the accrual to trials literature, Gotay foundonly one study of cancer patients in which investigators actually talked to pa-tients to determine why they did or did not participate in trials (Barofsky &Sugarbaker, 1979). One of Gotay’s suggestions for future research was that re-searchers interview cancer patients to ask them why they did or did not partici-pate in trials.

In this study we explore patients’ decisions to participate in cancer clinical tri-als, on the one hand, and patients’ perceptions of physicians’ communicator stylesas well as patients’ overall satisfaction with care delivered by the physicians, onthe other hand. Specifically, the purpose of this study is to examine the relationsamong the communicative behavior of the physician in the interview, the patient’sfeeling of being confirmed, the patient’s satisfaction with the care delivered by thephysician, and the patient’s decision to participate in a trial or not.

24 GRANT, CISSNA, ROSENFELD

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LITERATURE REVIEW

This brief literature review focuses on the literature on accrual to trials, physi-cian–patient communication, satisfaction, confirmation, decision making, and in-formation seeking.

Accrual to Cancer Clinical Trials

Much of the literature on accrual to cancer clinical trials emphasizes the importanceof accruing large numbers of patients to the trials (Cheson, 1991; Farrar, 1991;Gotay, 1991; Guy, 1991; Hunter et al., 1987; Peto, Collins, & Gray, 1993), and fo-cuses on the barriers or obstacles to accruing patients to trials (Gotay, 1991; Ho,1994; Langley et al., 1987; Taylor, 1992; Taylor & Kelner, 1987a). Barriers to can-cer clinical trials reported in the literature tend to fall into one of three categories(Gotay, 1991): (a) physician characteristics, (b) patient characteristics, or (c) trialcharacteristics. Other obstacles reported less frequently include pragmatic issues,such as reimbursement for costs associated with trials (Antman, 1993; Einstein,1994) and transportation to the facility where treatments are administered.

Physicians’ attitudes and motivations regarding clinical trials have been studiedextensively by Taylor, Margolese, and Soskolne (1984), Taylor and Kelner (1987a,1987b),andLangleyetal. (1987).Tayloretal.andTaylorandKelner(1987a,1987b)reported that many oncologists refused to discuss trials with patients because theyfelt the informed consent procedure would adversely affect their relationships withtheirpatients.Patientcharacteristics,suchasage(Hunteretal.,1987;Kaye,Lawton,&Kaye,1990),education (Llewellyn-Thomas,McGreal,Thiel,Fine,&Erlichman,1991), socioeconomic status (McCusker, Wax, & Bennett, 1982), and personal mo-tivations (Penman et al., 1984) are also reported in the literature. The trials them-selves can be barriers to the accrual of participants. They are often consideredunnecessarily complex and burdensome to both patients and physicians (Foley &Moertel, 1991; Peto et al., 1993; Taylor et al., 1984).

The consensus among oncology experts was that clinical trials are the optimalmethod for evaluating the quality of cancer treatments and cancer control interven-tions (Veney, Kory, Barnsley, & Kaluzny, 1991), and that slow accrual delays de-velopment and application of potentially life-saving treatments (Gotay, 1991;Johansen, Mayer, & Hoover, 1991). This study examines aspects of the physi-cian–patient relationship in an effort to understand this important process.

Physician–Patient Communication

The physician–patient communication literature is fragmented (Pendleton, 1983)and typically focuses on the content rather than the relational component of physi-cian–patient interaction (Pettegrew&Turkat, 1986).Pendleton’s reviewof thedoc-

PERCEPTIONS OF PHYSICIANS’ COMMUNICATION 25

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tor–patient communication literature reported studies of doctor–patient communi-cationprocessesandoutcomesthat identified thesignificanceof thedoctor’sstyleofcommunication. For example, Stimson and Webb (1975) found that the process ofcareandthepersonalqualitiesof thedoctorhadmoretodowiththepatient’sexpecta-tionsandsatisfactionthantheclinicalcontentof theinterview.Wolf,Putnam,James,and Stiles (1978) reported results with similar implications in a later study in whichthey developed a medical interview satisfaction scale. More recent studies, some ofwhich includedcancerpatients,have founda relationbetween theexpressiveabilityofdoctorsandpatientsatisfactionwithand liking for thedoctors (Chan&Woodruff,1997; DiMatteo, Taranta, Friedman, & Prince, 1980; Street & Wiemann, 1987).Conversely, Kaplan, Greenfield, and Ware (1989) found that patients’ negativehealth outcomes were associated with more controlling behaviors by the doctors.

Physicians’ styles of communication have been associated with patient satis-faction and compliance. The social interaction model (Ben-Sira, 1976, 1980) hasbeen offered to explain the relation between communication styles of physiciansand patients’ satisfaction with health care (Buller & Buller, 1987). Buller and Bull-er (1987) and Buller and Street (1991) found two underlying dimensions of com-municator style, affiliation and control. Physicians high on affiliation wereperceived by their patients as establishing and maintaining a positive relationshipwith them. Physicians high on control attempted to establish and maintain their au-thority and influence. This was seen by patients to affect negatively their relation-ships with their physicians.

In summary, patients who perceive their physicians’ style of communication tobe affiliative are more likely to be satisfied with their medical care, and patientswho are satisfied with care are more likely to comply with the recommendations oftheir physicians. Hence, if a physician is perceived by her or his patient to have anaffiliative communication style, and that physician recommends a clinical trial as atreatment option, the likelihood of the patient agreeing to participate in the trialshould be optimized.

Patient Satisfaction

Hall, Roter, and Katz’s (1988) meta-analysis of 41 independent studies of healthcare provider behaviors in medical encounters indicated that patients are more sat-isfied when their health care providers (a) offer more information to the patients,(b) exhibit greater technical and interpersonal competence, and (c) engage in part-nership-building strategies including social conversation and more positive thannegative talk, and, generally, more communication overall. Similarly, Bertakis,Roter, and Putnam (1991) found patient respondents most satisfied with medicalinterviews when the atmosphere was affiliative and lacked physician domination.In a study of 366 hospitalized adult cancer patients, Blanchard, LaBrecque,Ruckdeschel, and Blanchard (1990) identified four variables that predicted patient


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satisfaction and explained 62% of the variance: “perception of needs addressed thatday,” “perception of emotional support provided by the physician,” “older patient,”and the physician behavior, “discusses treatment.” Patients are likely to be moresatisfied with their physicians if they view the physicians’ communication behav-iors or styles positively, and more satisfied patients are more likely to agree to par-ticipate in a clinical trial.

Confirmation

A correlate of satisfaction that appears to relate to physician communication style isthe patient’s feeling of being confirmed (Cissna & Sieburg, 1981). Health commu-nication experts report that patients often feel as if they are objects rather than peo-ple due to disconfirming communication by health care professionals (Northouse& Northouse, 1985). Confirming communication, on the other hand, recognizespatients as unique human beings with personal problems. Gustafsson, Tibbling,and Theorell (1992) found that confirmation by a physician correlates well with sat-isfactory interaction between physician and patient, and concluded that confirma-tion is important in helping the patient feel aided and improved. In a study of 20dentists and 10 other health care professionals (e.g., physicians, nurses, and medi-cal technologists), Dangott, Thornton, and Page (1978) found disconfirming com-munication prevalent among the health care professionals: most communicationwas authoritarian in nature and did not allow for responses from the patients.

If patients perceive that their physician is attempting to control them, lacks con-cern, or is indifferent, they are not likely to be satisfied with the care they receive.Satisfaction may not be possible in many cases without the patient’s perception ofconfirming behavior from the physician, and patients who feel disconfirmed areunlikely to be interested in participating in a clinical research trial.

Decision Making and Information Seeking

In general, patients are more satisfied when they get more information, perhaps be-cause doctors who give more information appear nicer and more concerned abouttheir patients (Roter & Hall, 1992). Also, patients may feel that they have morepower and control in making decisions about treatment. Ende, Kazis, Ash, andMoskowitz (1989) found that, in general, patients had little interest in making treat-ment decisions, and that as illness severity increased, patient desire to make deci-sions decreased even further. Similarly, Beisecker and Beisecker (1990) found thatpatients expressed a strong desire to receive medical information and did not wantto accept the responsibility of making decisions. Cassileth, Zupkis, Sutton-Smith,and March (1980) found that cancer patients generally preferred to be involved intreatment decisions. They suggest, however, that older patients desire less informa-tion and depend more on their physicians for treatment decisions. In a study of hos-


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pitalized adult cancer patients, Blanchard, LaBrecque, Ruckdeschel, andBlanchard (1988) reported that older patients more often prefer the more traditionalauthoritarian model of the physician–patient relationship where they leave deci-sions up to their physicians. Other studies concurred that cancer patients typicallywant to be well-informed about their illness, and to rely on their physician’s advicefor treatment (Penman et al., 1984; Siminoff, Fetting, & Abeloff, 1989).

Patients’ desires to participate in decisions regarding treatment options mayhave an impact on their enrollment in clinical trials. Some patients may prefer thatthe physician make all decisions dealing with treatment, and others may prefer tobe actively involved in treatment decisions. In addition, some patients prefer to getas much information as possible about the disease and treatment options, and oth-ers prefer not to be confused or bothered with a lot of information. Patients who aremore dependent on their physicians to make treatment decisions may be morelikely to accept physician-offered clinical trials.

Summary and Hypothesis

Cancer patients’ relationships with their physicians often affect their treatment de-cisions (even if the decision is to relinquish decision making to the physician).These relationships appear to be dependent on communication between the physi-cian and the patient. Particular styles of communication have been associated withpatient satisfaction. Patient age also has been associated with satisfaction and per-ceived level of decision-making involvement. Therefore, the following hypothesis(H), addressing the relation between these variables and the decision to participateor not participate in a clinical trial, was tested in this investigation:

H1: A linear combination of the variables physician affiliative style, physi-cian dominant or controlling style, patient satisfaction, patient confir-mation, patient preference for decision making, patient desire for in-formation, and patient age discriminate between patients who agree toparticipate in clinical trials and patients who refuse to participate inclinical trials.

PROCEDURE

Site for the data collection in this investigation was a major regional cancer hospitalaffiliated with the medical school of a large public university in the southeasternUnited States. Physicians (i.e., oncologists, radiologists, and surgeons) at the Can-cer Center, and the primary care nurses and research nurses who work with them,were sent a letter to notify them of the study, explain the study to them, and encour-age them to participate in it.


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Data were gathered through an interview schedule consisting of four estab-lished measurement instruments. Potential respondents were telephoned by theprincipal investigator (with the exception of a few respondents who were inter-viewed in the hospital for their convenience).

Respondents

Respondentsfor thisstudywere130patientsdiagnosedwithvarioustypesofcancers(e.g.,breast, lung,prostate,brain,cervical,melanoma, lymphoma)andeligible foratleastoneongoingorupcomingclinical trialat theCancerCenter.Althoughpatients’cancerswerediagnosedatdifferentstages,allwereconsideredveryserious.Patientswith less serious diseases were not considered for this study. Of the 130 patients, 92agreed toparticipate inaclinical trial and38declinedparticipation.Themeanageofrespondents in this study was 59.46 years. Of the 92 patients who agreed to partici-pate in clinical trials, 42 were male and 50 were female, and, of the 38 patients whodeclined to participate in clinical trials, 27 were male and 11 were female. For thisgroup of respondents, men were slightly predominant and more likely to decline tri-als thanwomen,χ2(1,N=130)=7.44,p< .01.However, there isnoevidence to indi-cate that gender is related to agreement to participation in a clinical trial.

Instruments

The four instruments selected for this investigation were adapted for the telephoneinterview format. To simplify the instructions to respondents and the task of gather-ing and analyzing the data, a common response scale was used. The item responsescale chosen for all four instruments was a six-point Likert scale that asked respon-dents to select a point on a continuum ranging from 6 (strongly agree) to 1 (stronglydisagree).

Communicator style measure. Following Buller and Buller (1987) andBuller and Street (1991), physicians’ communication style was assessed using amodified version of the Communicator Style Measure (CSM) developed by Norton(1978). However, instead of the 36-item measure used in the two aforementionedstudies, this study used a 20-item version of the CSM developed by Pettegrew andTurkat (1986). This version of the measure includes the most representative twoitems from each of 10 subconstructs that make up the original 52-item CSM. Reli-ability was established by Garko (1992, 1994).

Buller and Buller (1987) and Buller and Street (1991) proposed that the conceptof communicator style fits within a two-dimensional framework: affiliation(friendly, relaxed, open, impression-leaving, and attentiveness) and dominance/ac-tivity (dominant,contentious,anddramatic).Becausemuchof the literaturerefers tophysician behavior as controlling, the two general styles are labeled affiliation and


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dominant/controlling. A correlation analysis was conducted to determine the asso-ciation among the subconstructs or variables within each dimension for this particu-lar population of respondents. Although Norton (1983) recommended usingMcQuitty’s elementary linkage analysis (ELA; 1957) rather than the morewell-known factor analysis to determine the structure of the CSM, initially we at-tempted to conduct a principal components factor analysis of the CSM. It did not ac-count formuchvarianceanddidnotproduceausefulorparsimoniousrepresentationof the data. We then followed Norton’s recommendation and used McQuitty’s ELAwith more success. The ELA is a method of clustering that has been described asanalogous to factor analysis. The difference between factor analysis and ELA is thatELA results in a typal structure instead of attempting to achieve a simple structure.McQuitty (1957) described atypeas a category of some variable that is of such a na-ture that other variables in the category are more like ones in the category than theyare like variables not in the category. The clusters or commonalities are revealedthrough the use of product-moment correlations among the set of variables. Thecloser the variables (in terms of their correlations), the more they have in common(Pettegrew & Turkat, 1986). Figure 1 presents the results of the ELA for the CSMvariables.Weakcorrelationsare fromr = .33 to .46,moderatecorrelationsare fromr= .47 to .55, and strong correlations are fromr = .56 to .75.

Based on the results of the ELA, the CSM was reduced to six variables (seeTable 1). The selection of these variables was based on their relation to eachother, not just on their reliabilities. This makes for a more robust and useful setof variables making up the structure of the CSM. Both items representing the


Friendly

Attentive

RelaxedCom ImageCom Image

Precise

Dominant

.58

.56

.75.35

.53

.62

.52

.44

.50

.35

.29

.43

FIGURE 1 McQuitty’s elementary linkage analysis.

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variable “contentious” were dropped because they did not produce a reliablescale. The amount of missing data for these items—75 of the respondents omit-ted at least one item of this variable—indicated that the variable probably wasnot relevant to the context of this study.

Perceived confirmation scale. The Perceived Confirmation Scale (PCS)was used to measure the extent to which a patient feels confirmed by his or her doc-tor. The PCS is a 6-item Likert-type scale developed by Sieburg (1973) to reflectthe extent to which a person feels confirmed by another. The respondent rates a des-ignated other in terms of the extent the other’s behavior reflects an awareness of, in-terest in, acceptance of, respect for, liking for, and trust for the respondent.Cronbach’s alpha reliability was .85 for respondents in this investigation (cf.Cissna, 1979, regarding reliability).

Patient satisfaction questionnaire (PSQ). Patient satisfaction with careprovided by the doctor was assessed using a 25-item questionnaire (DiMatteo &Hays, 1980) consisting of four subscales: (a) patients’ general satisfaction with andcommitment to their physician (5 items; e.g., “You don’t think you would recom-mend this doctor to a friend,” “You really liked this doctor a great deal”); (b) theirperception of the physician as having communicated sufficient information to them(8 items; e.g., “This doctor explained perfectly to you everything you could everwant to know about your medical condition,” “This doctor always explained thereason for examination procedures or medical tests”); (c) their perception of their


TABLE 1Communicator Style Variables Used in Analysis

Variable Examples

Friendly To be friendly, the doctor frequently acknowledged yourcontributions to the interview.The doctor was an extremely friendly communicator.

Communicator image Compared to other physicians you’ve had, this person was anextremely friendly communicator.You found it very easy to maintain your conversation with thisdoctor.

Relaxed The doctor was a very relaxed communicator during the interview.Under the pressure of the interview, the doctor came across asrelaxed.

Attentive The doctor deliberately reacted in such a way that you know he orshe was listening to you.The doctor really liked to listen to you very carefully.

Precise The doctor liked to be strictly accurate when he or shecommunicated with you.

Dominant In the interview the doctor generally spoke very frequently.

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physician’s affective behavior (9 items; e.g., “This doctor always treated you with agreat deal of respect and never ‘talked down’ to you,” “This doctor usually did nottry to make you feel better when you were upset or worried”); and, (d) their percep-tion of the physician’s technical competence (3 items; e.g., “You had some doubtsabout the ability of this doctor,” “This doctor always seemed to know what he [orshe] was doing”). Two items included in the questionnaire used by DiMatteo andHays (1980) regarding the physician’s inquiry into the patient’s family and job sta-tus did not apply to this study and were omitted.

Principle component factor analysis of the PSQ revealed a one-factor rather thana four-factor solution; therefore, the 25 items were combined into a single patientsatisfaction scale, which had an alpha reliability of .91 (cf. DiMatteo & Hays, 1980,regarding reliability).

The autonomy preference index. Decision-making and information-seeking preferences of patients participating in this study were measured using the6 general items of the 15-item decision-making subscale and all 8 items of the infor-mation-seeking subscale of the Autonomy Preference Index (API). The 9 items notused in the decision-making subscale relate to three clinical vignettes that representdifferent levels of illness severity (Ende et al., 1989). The vignettes are not applica-ble to this study, and most patients consider cancer an extremely severe illness(Morrow, Hickok, & Burish, 1994).

Principlecomponent factoranalysiswasusedtoexaminethestructureof theAPI.The factorstructure thatemergeddidnotmatch the twosubscalesof theAPI.The in-formation-seekingsubscalewasnotcoherentandhad lowreliability,andwas, there-fore dropped from further analyses. Four items were selected to represent thedecision-makingsubscaleof theAPI (e.g., “The importantmedicaldecisionsshouldbe made by your doctor, not by you,” “You should go along with your doctor’s ad-viceevenifyoudisagreewith it”).Alphareliability for the4-itemsubscalewas.77.

Statistical Analyses

Discriminant analysis (DA) was used to determine the best set of dependent vari-ables for distinguishing between patients who said “yes” and those who said “no” toparticipation in a clinical trial (H1).

RESULTS

Table 2 presents the means and standard deviations for 9 of the 10 variables (age isthe missing variable) entered into the DA. Group differences on each of the 9 vari-ables are noted.

DA, using 10 variables to distinguish patients who agreed to participate in clini-cal trials and patients who declined to participate in clinical trials, produced a sta-


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tistically significant discriminant function, Wilk’sΛ = .813,p < .01. Although theDA forces all variables entered into the discriminant function, 5 of the vairableshad standardized coefficients below .3 and, therefore, were dropped from furtherconsideration in this discussion. Table 3 presents the results of the DA.

To test the usefulness of these findings, a classification table ofhits (correctidentification of a respondent based on the application of the discriminant func-tion) andmisses(incorrect identification) was constructed. Twenty of the 37 pa-


TABLE 2Mean Scores of Variables for Respondents Who Declined Trials and Agreed to Trials

Declined Triala Agreed to Trialb

Variable M SD M SD

Precise 5.47 1.224 5.74 0.646Communicator image 4.96 1.650 5.70** 0.659Friendly 5.03 1.289 5.58** 0.488Relaxed 5.49 1.142 5.68 0.801Attentive 5.49 .997 5.58 0.753Dominant 5.08 1.320 5.45 0.999Patient satisfaction 20.62 3.588 21.90* 2.361Confirmation 5.72 .663 5.83 0.436Autonomous decision makers 4.11 1.399 3.54* 1.414

an = 37.bn = 89.*p < .05. **p < .001.

TABLE 3Discriminant Analysis Separating Group 1 (Declined Trial)

and Group 2 (Agreed to Trial)

Discriminant Function Variables Standardized Coefficients

Attentive –.45132Communicator image .44574Friendly .73430Relaxed –.27077Autonomous decision makers –.34592Confirmation –.24375Age –.22561Patient satisfaction .39191Dominant .22230Precise –.12175Group Centroids:

Declined trial –.73903Agreed to trial .30724

Note. Underlined variables were used in the analysis.

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tients who said “no” to clinical trials (54.1%) and 70 of the 89 patients who said“yes” to clinical trials (78.7%) were correctly classified (4 patients were not in-cluded in the analysis because of missing data), for an overall success rate of71.43%. The chi-square associated with these results is 24.704, indicating an ef-fect size (w) of .49, which is very close to what is considered a large (.50) effectsize (Cohen, 1977; Rosenthal, 1991).

To interpret the discriminant function, weights associated with each variablewere considered in light of the group centroids. With a negative group centroid forthe patients who said “no” to clinical trials, variables with a negative weight weremaximized and those with a positive weight were minimized in order to obtain theideal characterization of the patients in this group. Based on the discriminant func-tion, patients who said “no” to clinical trials, as distinguished from patients whosaid “yes,” perceived their physicians to be more attentive (e.g., the doctor was agood listener); less friendly (e.g., not acknowledging the patient’s contributions tothe interview, and not being an extremely friendly communicator); as having a lessfavorable communicator image (e.g., compared to other physicians the patient hashad, this doctor was not an extremely good communicator, and it was not easy tomaintain a conversation with this doctor). These patients characterized themselvesas less satisfied with their medical care, and as more autonomous decision makers.

With a positive group centroid for the patients who said “yes” to clinical trials,variables with a positive weight were maximized and those with a negative weightminimized in order to obtain the ideal characterization of these patients. The pa-tients who said “yes” to clinical trials perceived their physicians as being morefriendly, as having a better communicator image, and as being less attentive; also,they perceived themselves as being more satisfied with medical care and as lessautonomous decision makers.

DISCUSSION

Patients who agreed to clinical trials perceived their doctors as being significantlymore friendly and as having a better communicator image than patients who de-clined clinical trials. These communicative behaviors of physicians appear to beimportant to accruing patients to clinical trials. Also, patients who agreed to clinicaltrials were significantly more satisfied with their medical care than patients who de-clined participation in clinical trials. It stands to reason that a satisfied patient ismore likely to be open to a clinical trial as a treatment option than a patient who isnot satisfied with the care. The data in this study revealed that particular communi-cative behaviors are more likely to result in patient satisfaction. Therefore, one maysurmise that those same physician communicative behaviors would lead to pa-tients’ being open to the possibility of a clinical trial as a treatment option.

Patients who agreed to clinical trials were significantly less autonomous withregard to decision-making preferences than patients who declined to participate in


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clinical trials. Decision-making preferences appear to be moderately importantwhen it comes to predicting patients’ participation in clinical trials. In addition,younger patients desired more autonomy in decision making than did older pa-tients,t(128) = 3.44,p < .001. These findings, taken together, appear consistentwith the literature that suggests that younger patients are more autonomous deci-sion makers (Ende et al., 1989), but seem to contradict research that shows thatthese younger, more autonomous patients are more likely to participate in clinicaltrials (Hunter et al., 1987). In other words, in this study, more autonomous deci-sion makers (who also were younger patients) were more likely to decline partici-pation in the clinical trials. It has been reported in the literature that older patientsprefer to leave treatment decisions to their physicians (Blanchard et al., 1988).Therefore, older patients may be more likely to participate in clinical trials if theyare offered the option by their physicians.

No significant difference was found between patients who agreed to participatein clinical trials and patients who declined to participate with respect to their per-ception of being confirmed by their doctors. This is an unexpected result, as confir-mation has been strongly correlated with patient satisfaction and with affiliativecommunication behaviors. However, patients who agreed to clinical trials and pa-tients who declined in this particular study all felt highly confirmed by their doc-tors. Scores were very high on the PCS for almost all respondents in both groups(the mean was 34.8 on a scale that ranges from 6–36). Based on these results, con-firmation, as it was measured in this study, is not a good predictor of patients’ deci-sions to participate in clinical trials.

Discriminant analysis revealed that cancer patients who agree to clinical trialswant their doctors to be friendly and to tell them what to do or at least to helpthem make decisions. Communicator image is clearly an important variable inthe accrual to trial process. During the informed consent interview, cancer pa-tients want a physician with whom they can maintain a conversation and whothey consider to be a good communicator. If they perceive this, they are likely toagree to participate in the clinical trials being offered. Those cancer patients inthe informed consent process who want their doctors to tell them what to do arestill looking for doctors who are friendly and are willing to develop a relation-ship with them.

Oncologists should recognize that being perceived by patients as “friendly” andbeing perceived as having a good “communicator image” may influence consider-ably a patient’s decision to participate in a clinical trial. The importance of clinicaltrials to the development of new treatment regimens for cancer patients cannot beoverstated. The more patients who enroll in cancer clinical trials, the more validand reliable the results and the sooner new treatments can be made available to allcancer patients. Results from this study strongly suggest that communication vari-ables have a significant effect on cancer patients’ decisions regarding participationin clinical trials.


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It is not clear why patients who say “no” to trials characterize their physiciansas more attentive than do those who say “yes.” One would assume thatattentive(listening actively) would be associated with friendly behaviors, but that appearsnot to be the case here. The behaviors related to the attentive variable include:“The doctor deliberately reacted in such a way that you knew he/she was listeningto you,” and “The doctor really liked to listen to you very carefully.” Perhaps pa-tients who declined participation in trials felt that their doctors paid attention tothem when they said “no.” Also, patients who agreed to trials may not have ques-tioned their doctors or actively participated in the interview. If this were the case,patients may not have perceived their doctor as actively listening, but that did notmatter to them. Based on the results of the discriminant analysis, the variablesfriendly, communicator image, and attentive are most effective predicting patientswho say “yes” to clinical trials, but also are important in understanding the percep-tions of patients who say “no” to clinical trials.

Our focus on the relationship dimension of physician–patient communicationshould not be interpreted as minimizing the importance of the content of their talk.We encourage future research that further explores how physicians and patientsmake decisions about such issues as accrual to clinical trials, including analyses ofthe actual discourse that transpires between them. Our study was limited by its uti-lization of survey data collected from patients and by its emphasis on the relation-ship issues. Although they are not the only important issues involved inunderstanding either physician–patient relationships generally, or the accrual totrial process in particular, as this study has shown, the relationship issues are vitalones that cannot be ignored.

As Ruckdeschel, Albrecht, Blanchard, and Hemmick (1996) suggested, treat-ing patients with life-threatening illnesses requires rhetorical sensitivity andadaptability on the part of physicians. Results of this study indicate that particularcommunication skills and behaviors, such as those touched on here, may help phy-sicians become more sensitive in the eyes of their patients, and may enhance theirability to adapt to the needs of their patients. For the patients in this study, theseparticular communication behaviors clearly lead to patient satisfaction and thelikelihood that they will enroll in clinical trials. Norton (1983) reminded us thatpeople can adapt communication styles, sometimes even radically, and the resultsof this study suggest that physicians who are discussing clinical trials with patientsmay have good reason to do so.

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Documents

Patients' Perceptions of Physicians Communication and Outcomes of the Accrual to Trial Process