How can we explain physician accuracy in assessing patient distress? A multilevel analysis in patients with advanced cancer

Abstract

Objective

To examine the determinants of the accuracy with which physicians assess metastatic cancer patient distress, also referred to as their empathic accuracy (EA). Hypothesized determinants were physician empathic attitude, self-efficacy in empathic skills, physician-perceived rapport with the patient, patient distress and patient expressive suppression.

Methods

Twenty-eight physicians assessed their patients’ distress level on the distress thermometer, while patients (N = 201) independently rated their distress level on the same tool. EA was the difference between both scores in absolute value. Hypothesized determinants were assessed using self-reported questionnaires. Multilevel analyses were carried out.

Results

Little of the variance in EA was explained by physician variables. EA was higher with higher levels of patient distress. Physician-perceived quality of rapport was positively associated with EA. However, for highly distressed patients, good rapport was associated with lower EA. Patient expressive suppression was also related to lower EA.

Conclusion

This study adds to the understanding of EA in oncological settings, particularly in challenging the common assumption that EA depends largely on physician characteristics or that better rapport would always favor higher EA.

Practice implications

Physicians should ask patients for feedback regarding their emotions. In parallel, patients should be prompted to express their concerns.

Introduction

Due to its high prevalence in cancer patients, from 22 to 58% [1], and particularly in metastatic cases [2], [3], [4], emotional distress has been endorsed as the 6th Vital Sign by the International Psycho-Oncology Society (IPOS) [5]. Routine distress screening has been strongly recommended to identify cancer patients who may need psychological or social interventions. However, systematic distress screening with validated tools is still rare [6]. Oncologists in particular may not consider distress screening an essential part of their job [7] and prefer to rely on their own clinical skills rather than using validated questionnaires [8]. Therefore, along with a continuous effort to implement routine screening, it is essential that oncologists infer patient distress accurately by themselves in order to make the necessary referrals. Besides, this ability to detect the emotions and cognitions of others accurately, also called empathic accuracy (EA) [9], has positive effects for patients, such as treatment adherence and appointment-keeping [10], [11]. Unfortunately, it seems that physicians do not perceive cancer patient distress accurately [12], [13]. To understand this phenomenon, we set out to investigate the correlates of physician EA on metastatic cancer patient distress. In fact, factors of EA have rarely been studied in a clinical setting, especially in oncology [10].

The theoretical framework of Norfolk et al. [14] guided our analyses. It was originally proposed in general practice and has been used successfully for the design and validation of physician training to develop rapport with patients [15].

In this model, the physician's empathic attitude, i.e. their willingness to understand and give room to a patient's emotions and feelings [16], is the starting point for the physician to detect patient cues concerning their thoughts and feelings. This empathic skill should lead to an accurate representation of the patient's state [17].

The model also specifies the importance of patient or physician-patient relationship variables. An important variable when applying this general model to our purpose is the patient's distress level. Indeed, a study of advanced cancer patients suggested that higher patient distress is more frequently detected and addressed by oncologists [18], probably because it is more visible than moderate distress. Therefore, we expected EA to increase with patient distress. However, this link could be moderated by two variables in Norfolk's model.

The first one is patient expressive suppression, i.e. the inhibition of ongoing emotion-expressive behavior [19]. Previous experimental research supports the importance of a person's verbal and non-verbal disclosure in allowing a ‘perceiver’ to detect his/her emotions [20], [21], [22], [23]. This should be true in a naturalistic clinical setting. Therefore, patient expressive suppression should be a barrier to physician EA, particularly in the case of high distress where the gap between a patient's actual and visible state can be large.

The second potential moderator is rapport. Defined as the connection between patient and physician and their mutual commitment to the relationship, rapport is essential for effective clinical communication [24]. Without it, patients would not feel at ease in expressing their emotions and/or physicians would pay less attention to patient cues. Consequently, poor rapport is expected to relate to lower EA, particularly again in the case of high patient distress where the EA gap can become huge.

To summarize, following the model of Norfolk et al. [14], the hypothesized correlates of EA were physician empathic positive attitude, higher self-efficacy in empathic skills, as well as lower patient expressive suppression and physician perception of low rapport as moderators of the link between patient distress and EA.