Power Couple: Doctor and Patient Communication

CURE, Summer 2014, Volume 13, Issue 2

A strong therapeutic alliance between cancer patients and oncologists has numerous benefits.

It has been 10 years since Julie Brown-Price learned she had breast cancer. Her diagnosis and treatment included a needle biopsy and lumpectomy, followed by a mastectomy, chemotherapy and radiation—a 15-month ordeal. Brown-Price, who was 47 at the time of her diagnosis, credits her positive relationship with her Minneapolis oncologist, Gail Bender, with helping her navigate the challenges of treatment. Their “therapeutic alliance” strengthened their bond, one that can positively affect the cancer experience in a number of ways.

For example, a recent study of young adults with cancer found that those who had a strong alliance with their oncologist had a greater sense of social support and less illness-related grief. The study also found that patients with a strong bond to their oncologist were more willing to adhere to treatment and more often took their oral medication.

Brown-Price’s alliance with Bender enabled her to feel safe discussing integrative therapies, such as nutritional supplements and acupuncture. “I had complete trust in her,” Brown-Price says. Her oncologist’s attitude helped, she says, because it gave her the sense that “we will deal with this together.”

Without question, cancer can upend a life. “Cancer isn’t like a bone fracture,” says Christian Boukaram, a radiation oncologist and professor of medicine University of Montreal. “It’s multisystemic and so much more complex.”

Boukaram, a member of the Society for Integrative Oncology and author of Healer of Cancer: The Power of the Mind, explains that any illness is likely to cause stress, but cancer can affect a person’s social, emotional and financial well-being—in addition to physical health. A strong therapeutic alliance can help patients accept the severity of the illness, improve quality of life and increase treatment satisfaction.

The perceived bond with the oncologist is extremely powerful. Patients seem to have a strong wish for the doctor to see them as more than a disease.”

A particular challenge for oncologists is dealing with patients who have difficulty with treatment adherence, including taking oral medication as prescribed, making needed dietary and lifestyle changes, and keeping medical appointments. The challenge is compounded by inefficiency in the system and an increasing demand for oncology services. This can lead to more physicians who see patients at a frenetic pace, limiting the amount of time they spend with them and making it difficult to communicate effectively. A 2009 meta-analysis revealed “a 19 percent higher risk of non-adherence among patients whose physician communicates poorly than among patients whose physician communicates well.”

Conclusions from a 2013 survey conducted by the Blue Shield of California Foundation also confirmed the power of a strong therapeutic alliance. The survey, which identified components of patient satisfaction among low-income state residents, found that successful communication between patients and providers produced a “wide range of positive outcomes, including bolstering patients’ satisfaction, trust in medical professionals, confidence and engagement in care decisions.” Ultimately, the study organizers found there were few key outcomes that were not affected by patients’ “perceived bonds with their providers.”

Boukaram says an important aspect of the therapeutic alliance is nonverbal communication. In an effort to “read between the lines,” he says, he observes whether a patient is fidgeting, interrupting or relying on someone else to answer—all are cues for him to dig a little deeper.

Effective questioning can also reveal gaps in information or even a misunderstanding about disease progression or treatment protocol. Bender says that at each visit, before patients leave the office, she makes sure to ask the same question in three different ways: “Do you have any questions? Is there anything else we should talk about? Are we set?”

Brown-Price found that Bender’s office staff also made it easy for her to adhere to her treatment. “Before you left the appointment, they made all the next appointments for you,” she recalls. “I was nervous about the ‘brain fog’ from chemo and whether I would need to take care of appointment changes, but the office took care of all that.”

Moreover, Bender knew that Brown-Price’s cancer would affect the entire family. “She told us she needed to have a meeting with all of us to let us know what was coming,” Brown-Price says.

Holly Prigerson, a professor of sociology in medicine at the Weill Cornell Medical College in New York, has researched the therapeutic alliance at the end of life but says her findings are relevant to all stages of treatment.

“The perceived bond with the oncologist is extremely powerful,” Prigerson says. “Patients should be given permission to talk. They should be asked, ‘How are you and your family coping?’ Patients seem to have a strong wish for the doctor to see them as more than a disease. This one shift, to discussing informally how the patient and family are doing, might change the whole dynamic.”

Many cancer patients want to know their prognosis, Prigerson says. If the doctor has information and the patient doesn’t—called “information asymmetry”—how can the patient be an equal partner and make informed choices? One way to address this issue is through “shared decision-making.”

[Read "Shared Decisions"]

Brown-Price’s experience holds lessons for how patients can feel empowered even when overwhelmed with their diagnoses. Don’t hesitate to seek a second opinion, she says. After an initial meeting with a local Minneapolis oncologist, Brown-Price chose to travel to MD Anderson Cancer Center in Houston. When she returned to Minneapolis and the first oncologist was dismissive to the point of laughing at her, she knew it was time to find a different doctor.

That’s when she found Bender, who, by contrast, welcomed her input and agreed to modify her chemotherapy schedule according to MD Anderson’s research.

Today, Brown-Price says she has just one wish for anyone facing a cancer diagnosis: “I hope everyone can find a Gail.”