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Supportive Care and Quality of Life
December 20, 2007

Oncologist Communication About Emotion During Visits With Patients With Advanced Cancer

Publication: Journal of Clinical Oncology

Abstract

Introduction

Cancer care involves addressing patient emotion. When patients express negative emotions, empathic opportunities emerge. When oncologists respond with a continuer statement, which is one that offers empathy and allows patients to continue expressing emotions, rather than with a terminator statement, which is one that discourages disclosure, patients have less anxiety and depression and report greater satisfaction and adherence to therapy. We studied whether oncologist traits were associated with empathic opportunities and empathic responses.

Patients and Methods

We audio-recorded 398 clinic conversations between 51 oncologists and 270 patients with advanced cancer; oncologists also completed surveys. Conversations were coded for the presence of empathic opportunities and oncologist responses. Analyses examined the relationship with oncologists' demographics, self-reported confidence, outcome expectancies, and comfort to address social versus technical aspects of care.

Results

In 398 conversations, 37% contained at least one empathic opportunity; the range was 0 to 10, and the total empathic opportunities was 292. When they occurred, oncologists responded with continuers 22% of the time. Oncologist sex was related to the number of empathic opportunities; female patients seen by female oncologists had the most empathic opportunities (P = .03). Younger oncologists (P = .02) and those who rated their orientation as more socioemotional than technical (P = .03) were more likely to respond with empathic statements.

Conclusion

Oncologists encountered few empathic opportunities and responded with empathic statements infrequently. Empathic responses were more prevalent among younger oncologists and among those who were self-rated as socioemotional. To reduce patient anxiety and increase patient satisfaction and adherence, oncologists may need training to encourage patients to express emotions and to respond empathically to patients' emotions.

Introduction

High-quality cancer care relies on effective patient-oncologist communication, particularly among patients with advanced cancer whose emotional suffering may be quite intense. Such suffering often manifests as anxiety and depression,1 and when patients are able to disclose their concerns fully, they may cope better.2,3 Yet, patients with cancer typically disclose only 50% of their emotional concerns to oncologists.4,5 Patients may not want to burden oncologists with their concerns and instead may provide indirect cues or clues about their concerns.6 For example, rather than ask about prognosis, patients may simply say, “I'm not sure what there is to look forward to. ” These indirect cues are often missed by oncologists.1,7-9
Such cues or clues often create empathic opportunities, or moments that beg empathic responses from clinicians.10 Empathic responses directly address patients' emotions, validate their feelings, and invite further disclosure. Such responses are considered empathic continuers. Unfortunately, clinicians often do not respond to cues with expressions of empathy. They may avoid the emotion or may change the topic with empathic terminators that can negatively affect the patient-physician relationship. In response, some patients do not express any further emotions. Others continue to express emotion until their providers respond; this re-expression of emotion can increase visit time. Empathic continuers strengthen the patient-physician relationship, increase patient satisfaction, decrease the need to restate the negative emotion, and may make patients more likely to disclose future concerns.11,12 In addition, when oncologists respond empathically, patients are more likely to adhere to treatment plans.13 No researchers have examined how oncologist factors influence their elicitation of and response to patient emotion.
To assess the prevalence and nature of empathic communication in cancer care, we analyzed audio-recorded patient-oncologist outpatient visits. We examined oncologist factors that influence whether empathic opportunities arise and how oncologists respond in visits with patients with advanced cancer.

Patients and Methods

Participants

This report presents data from the Studying Communication in Oncologist-Patient Encounters (SCOPE) project, a three-site study from Duke University, the Durham Veterans Affairs Medical Center, and the University of Pittsburgh. This report included 398 audio-recorded conversations between 51 oncologists and 270 patients with advanced cancer. Fifty-three percent of patients had one visit audio-recorded; the other 47% had two visits with the same oncologist audio-recorded. Details of the study are reported elsewhere.14

Oncologists

We approached 110 medical, gynecologic, and radiation oncologists to participate in the study. Of the 110 oncologists, 74 (67%) consented. Twenty-one (19%) were ineligible because they did not see enough patients, and 15 (14%) refused. Of the 74 who consented, 51 had enough audio recordings (at least six) to include in this sample. A faculty investigator met with each oncologist to introduce the study. If oncologists agreed to participate, they signed a consent form and completed a baseline survey. Participating oncologists were offered $25 gift certificates on completion of the audio recordings of their visits.

Patients

Our goal was to identify patients with sufficiently advanced disease to increase the probability that conversations would contain emotional concerns. We asked oncologists or their midlevel provider staff to identify patients of whom they would not be surprised by death within 1 year. We assured oncologists and providers that this information would not be conveyed to patients. Patients provided written informed consent to participate and were told they were asked to enroll because they had been diagnosed with cancer. Other eligibility criteria included that patients spoke English; received primary oncology care at one of our study sites; and had access to a telephone.
Identified patients were sent an introductory letter and brochure that included a toll-free number that they could call to refuse participation. Patients who did not call within 10 days were contacted by phone. At this time, interviewers described the study to patients and asked permission to approach them in the clinic before their next scheduled oncology visit. Patients received a free parking pass ($7 value [US $]) for each visit that was recorded. Patients were ineligible if they were unable to provide informed consent as assessed by the interviewer (eg, dementia, delirium, or mental illness); were seen primarily by nonphysician providers or medical residents; were hearing impaired; or had a speech disorder.

Audio Recordings

Every attempt was made to audio-record conversations in oncology clinics without disrupting clinic flow. We contacted oncologists with reminders 1 day before the designated visit. We placed digital recorders unobtrusively in the exam rooms before the oncologists entered and retrieved recorders at the end of the visit. We asked all health care providers and family members present to sign a consent form that allowed their voiced to be audio-recorded. This protocol was approved by each institution's institutional review board.
We used Suchman's definitions of empathic opportunities and physicians' responses to them.10 These definitions are based solely on patients' verbal expressions of negative emotions, not on positive emotions or praise opportunities. Two independent coders were trained extensively; 15% of audio recordings were coded by both raters. Interrater reliability was high for the presence of an empathic opportunity (κ = 0.71). We coded whether patients expressed the emotion directly or indirectly. Some indirect empathic opportunities relied on tone or pace of voice (eg, “Well… I guess it is what it is”). We coded physicians' responses as empathic continuers or terminators (κ = 0.71) Table 1 lists example codes and κ measures. Continuers consisted of five behaviors that have been organized by educators under the mnemonic NURSE: Name, Understand, Respect, Support, and Explore.15-17

Survey Measures

Physicians completed a baseline survey before the audio recording. We assessed factors that might be related to the presence of and response to empathic opportunities.18 Some factors are based on social cognitive theory19 and may affect whether physicians create environments in which patients feel comfortable expressing emotions and how oncologists respond when patients express emotions. Oncologists may lack the confidence to address emotion.20 Oncologists also may have low outcome expectancies that addressing emotion will lead to better outcomes.21 Finally, oncologists may see themselves as more technical rather than socioemotional in orientation and therefore may be more comfortable addressing medical rather than psychosocial issues.22

Physician demographics.

At baseline, oncologists were asked to report their age, race, ethnicity, sex, and years in practice.

Confidence.

Oncologists were asked seven items about their confidence in addressing patients' concerns. Sample items read, “Please rate how successful you think you would be in…′initiating a discussion about a patient's concerns, ' and ‘moving patient to discuss other concerns’” (1 = not at all confident to 5 = extremely confident; α = .92).23

Outcome expectancies.

Oncologists were asked an adapted nine-item communication outcomes questionnaire to assess possible outcomes of communication behaviors. A sample item read, “Your patient will become uncontrollably upset if you ask about his or her feelings” (1 = not unlikely to 5 = very likely). We reversed the metric to make positive outcome expectancies higher scores. In our sample, this scale had moderate reliability of α = .61, unlike the higher reliability reported in another study.21

Comfort with psychosocial talk.

Oncologists were asked the Physician Belief Scale, which includes 32 items to assess comfort with psychosocial talk. A sample item read, “Doctors should not focus on psychosocial problems until they have ruled out organic disease ” (1 = strongly agree to 5 = strongly disagree; α = .84; summed score ranged from 32 to 160).24

Socioemotional versus technical orientation.

Oncologists answered two questions to assess their socioemotional orientation. The questions read, “Do you think you are more inclined toward the social and emotional aspects of patient care or more inclined toward the technological and scientific aspects? ” (social and emotional v technological and scientific) and, “Are you a little more inclined to the aspects you chose in the last question or a lot more inclined? ” (a little more inclined v a lot more inclined).22

Analyses

Our primary dependent variables were the number of empathic opportunities and empathic continuer responses. The number of empathic opportunities was coded for each conversation and then was summed for each oncologist. Wilcoxon rank sum tests and Pearson correlation coefficients were used to examine the relationship between the number of empathic opportunities and oncologist factors. For each oncologist, we calculated the number of empathic opportunities in which he or she responded with a continuer. We then dichotomized this variable: oncologists who never used a continuer versus oncologists who used at least one continuer. χ2 tests, t tests, and Wilcoxon rank sum tests were used to examine the relationship between continuers and oncologist factors. Analyses were conducted using SAS Version 9.2 (SAS Institute Inc, Cary, NC).

Results

Sample Demographics

Fifty-one oncologists participated; most were white and male (Table 2); mean age was 44.7 years (standard deviation [SD], 8.4 years); most were medical oncologists (90%), whereas others were gynecological oncologists (8%) and radiation oncologists (2%). Of the 270 patients, 74% were white, 50% were male, and the mean age was 60.4 years (SD, 12.9). Malignancies represented were hematologic (28%), lung (16%), breast (15%), colon or gastrointestinal (12%), brain (10%), and other (19%), which included gynecologic, prostate, and head and neck. According to physician post-visit surveys, 70% of the patients were currently undergoing treatment, and 74% of these were receiving chemotherapy. Most patients were not new patients to the oncologists; 90% had known their oncologists for at least 6 months and had more than two visits. The mean length of conversations was 18 minutes (SD, 14; range, 0.5 to 88 minutes).
Oncologists reported high confidence in their abilities to address patients' concerns (mean, 4.0; SD, 0.6 on a 5-point scale) and moderate beliefs that addressing emotions would benefit patients (mean, 3.9; SD, 0.4 on a 5-point scale). Most reported being somewhat comfortable with psychosocial talk (mean, 84.5; SD, 9.9 on a 0 to 100 scale) and were more likely to rate their orientation as technical (67%) than socioemotional. Sixty-one percent of oncologists stated that they had received some past communication training.

Empathic Opportunities

A total of 292 empathic opportunities occurred in 398 conversations (mean, 0.73; SD, 1.34; range, 0 to 10 per conversation). Across all conversations (range, 6 to 8 conversations per oncologist), oncologists encountered a median of 5.0 empathic opportunities each (interquartile range = 6.0), with one oncologist encountering none and 17 (one third of total) having three or fewer. Of the 292 empathic opportunities, 68% were direct and 33% were indirect. An example of a direct empathic opportunity was, “I'm scared about what my lower white blood count means. ” An example of an indirect empathic opportunity was, “Oh no. What do we do now? ” Forty-seven percent of patients expressed an empathic opportunity at some point in all of their recorded conversations. Conversations shorter than 10 minutes were less likely to contain an empathic opportunity than conversations lasting 10 minutes or more (P < .0001).

Responses to Empathic Opportunities

When patients initiated an empathic opportunity, oncologists responded with continuers in 27% of patient cases and terminators 73% of the time. An example continuer was, “It's not easy for anybody in your family. ” An example terminator was, “Give us time. We are getting there,” which represents premature reassurance for a patient who was feeling upset at his progress. Forty-one percent of oncologists never used a continuer in response to an empathic opportunity. There was no difference in response based on whether patients expressed their emotions directly or indirectly.

Oncologist Characteristics, Empathic Opportunities, and Responses

Presence of empathic opportunities was related to sex concordance of the patient and the oncologist (P = .03). The percentage of visits containing at least one empathic opportunity were as follows: 52% of those in which female patients saw female oncologists; 44% in which female patients saw male oncologists; and 28% of male patients' visits with either sex of the oncologist. No other variables were associated with the presence of empathic opportunities.
Several oncologist characteristics were related to their responses to empathic opportunities (Table 3). Oncologists who used more empathic statements were younger than those who did not (mean age of those who used at least one continuer, 42.4 years; SD, 7.8; mean age of those who never used a continuer, 48.1 years; SD, 8.3; P = .02). Also, oncologists who responded with at least one continuer were more likely to describe themselves as socioemotional rather than technical (80% v 45% for socioemotional and technical, respectively; P = .03). No other variables were associated with responses to empathic opportunities, including having had communication training in the past. We do not present a multivariable model because age, sex, and socioemotional rating are related to each other in our study. Female physicians are on average 10 years younger than male physicians and are more likely to have socioemotional orientation (66.7% v 33.3%). Thus, all three variables are representing the same group: young, female oncologists who describe themselves as socioemotional.

Discussion

We observed nearly 400 conversations between oncologists and patients with advanced cancer and found several key results. First, empathic opportunities were relatively uncommon in these conversations; sex concordance was related to the presence of empathic opportunities. Second, oncologists generally expressed high levels of confidence, yet neither this nor previous training in communication was related to empathic opportunities or their responses. Third, and most important, empathic responses were rare. Oncologists who were younger or who rated themselves as socioemotional were most likely to respond empathically.
Empathic opportunities were not prevalent in these encounters, were less common than that found in a previous study,25 and were less frequent than those found in a study of primary care and surgery (52% and 53%, respectively).26 The low occurrence of empathic opportunities may be partially due to the types of visits that were audio-recorded. Some visits were relatively short; shorter visits were less likely to contain empathic opportunities. Although our inclusion criteria and coding did not allow us to characterize the goals of each visit, it is likely that these shorter visits were follow-up appointments for patients receiving active treatment. In such brief encounters, opportunities for patients to express emotions may have been somewhat limited. In addition, some of these patients had already been seen by fellows or midlevel providers (eg, nurse practitioners or physician assistants), which left the physician visit as a brief opportunity for the patient and oncologist to check in with each other. This is a relatively common practice in our oncology clinics and may differ from oncology care in other countries, such as Australia and the United Kingdom. It also could be that, because oncologists did not respond to patient emotion with empathic continuers, the patients were less likely to express other emotions.
Female patients were more likely to raise at least one negative emotion, and thus create an empathic opportunity, when their oncologist was a woman. Although many have examined sex differences in communication in general,27 no one has examined how sex concordance affects patients' expression of emotion. Women are more comfortable discussing emotions than men.28 Therefore, it may be that, when both members of the dyad are women, patients are more comfortable expressing their emotions. No other factors were associated with patient expression of negative emotion.
Further, we found that oncologists were confident that they could address patient emotion and also that they perceived that addressing emotion would help patients or themselves. With moderate to high levels of confidence and outcome expectancies, it is not surprising that neither was related to the presence of or response to empathic opportunities. For these important constructs, better measures with more variability are needed. For other physician skills, confidence and outcome expectancies are predictors.29 It may be that oncologists are confident they can address patient emotion, but they are not confident they can recognize patient emotion when it occurs. We did not differentiate between confidences for these different skills.
Finally, on average, oncologists responded to patient emotion with empathic language only 22% of the time. Although limited time may curtail one's ability to explore emotional content, it should not affect the oncologist's ability to respond with at least a brief empathic statement when negative emotions are expressed. When oncologists do not do so, they risk increasing patient distress.11,12
Some oncologists were more likely to respond to patient emotion with empathic language. The prevalence of this behavior among younger oncologists could reflect more recent shifts in training that has focused on patient-physician communication. Younger physicians in this study received their training in the early 1990s, when physician-patient communication skills were already commonly taught in medical schools and residencies. However, even though more than half of oncologists stated that they had received previous communication training, training was unrelated to responses to empathic opportunities. Alternatively, younger oncologists may be less likely to have experienced burnout from the challenging field of cancer care and may still attend to the subtle signals patients send. Oncologists who self-rated as more socioemotional were more likely to use continuers in response to empathic opportunities. It is unknown what contributes to an oncologist feeling more comfortable with socioemotional factors than technical factors. Indeed, most oncologists participating in our study rated themselves as more technical than socioemotional, which differs greatly from physicians who choose to enter primary care fields.30 It may be that oncologists who are more socioemotionally oriented entered oncology for different reasons than those who view themselves as more technical. Further, it is unknown whether this trait is modifiable through intervention.
This study has several limitations. First, oncologists were not asked to choose conversations expected to be emotionally-laden (eg, delivering bad news). Therefore, the low prevalence of empathic opportunities may result from the types of visits audio-recorded. We could not differentiate among the types of visits in our analyses. Second, most oncologists who participated in this study came from academic medical centers; this may limit generalizability. Also, because the measure of socioemotional orientation required oncologists to choose between being socioemotional or technical, we could not capture those oncologists who perceived themselves as high on both traits. Finally, because we only audio-recorded visits, we were unable to code nonverbal expressions of patient emotion and oncologist responses. Although nonverbal behaviors are important, oncologists' verbal expressions are least likely to be misunderstood or missed by patients.
Oncologists and patients need to work to create an alliance conducive to patients expressing their emotions. This happens, in part, when oncologists respond empathically when patients express negative emotions. Oncologists, despite their high levels of confidence in addressing emotions, may need more training to recognize emotions and to learn how to respond to patient concerns. Lastly, this relationship is bidirectional. Many empathic opportunities were indirect, and patients may be more satisfied if they can learn how to express their emotions more directly so that oncologists can respond appropriately.

Authors' Disclosures of Potential Conflicts of Interest

The author(s) indicated no potential conflicts of interest.

Author Contributions

Conception and design: Kathryn I. Pollak, Robert M. Arnold, James A. Tulsky
Financial support: Kathryn I. Pollak, James A. Tulsky
Data analysis and interpretation: Kathryn I. Pollak, Robert M. Arnold, Amy S. Jeffreys, Maren K. Olsen, James A. Tulsky
Manuscript writing: Kathryn I. Pollak, Robert M. Arnold, Amy S. Jeffreys, Stewart C. Alexander, Maren K. Olsen, Amy P. Abernethy, Celette Sugg Skinner, Keri L. Rodriguez, James A. Tulsky
Final approval of manuscript: Kathryn I. Pollak, Robert M. Arnold, Stewart C. Alexander, Maren K. Olsen, Amy P. Abernethy, Celette Sugg Skinner, Keri L. Rodriguez, James A. Tulsky
Table 1. Codes for Empathic Opportunities and for NURSE Continuers
 DefinitionExamplesκ
Empathic Opportunity   
    Direct empathic opportunityExplicit verbal expression of emotion“I have been really depressed lately.”0.71
    Indirect empathic opportunityImplicit verbal expression of emotion“Does this mean I am going to die?”0.71
Continuers   
    NameState patient emotion“I wonder if you're feeling sad about the test result.”0.70
  “I can see this is making you angry.” 
    UnderstandEmpathizing with and legitimizing patient emotion“I can imagine how scary this must be for you.”0.66
  “Many of my patients feel discouraged when they aren't seeing the response they want, so it makes sense that you feel this way.” 
    RespectPraise patient for strength“You've done a great job at keeping everything in perspective”1.0
  “I applaud you for your courage in all of this.” 
    SupportShow support“I will be with you until the end.”1.0
  “No matter what happens, I will always be your doctor.” 
    ExploreAsk patient to elaborate on emotion“Tell me more about what is upsetting you.”0.85
  “What do you mean when you say this is not going to happen to me?” 
Abbreviation: NURSE, Name, Understand, Respect, Support, and Explore.
Table 2. Demographics of Patients and Physicians
VariablePatients (N = 270)Physicians (N = 51)
Age, years*  
    Mean60.444.7
    SD12.98.4
% white7480
% male4980
% college graduate34100
Years since fellowship  
    Mean14.7
    SD8.5
Abbreviation: SD, standard deviation.
*
Missing data on age for one physician.
Missing data on race/ethnicity for 28 patients.
Missing data on education for 27 patients.
Table 3. Associations of Physician Attributes and Responses to Empathic Opportunities
VariableNo Continuer (n = 21)At Least One Continuer (n = 29)
Sex, %  
    Male4853
    Female2080
Orientation, %*  
    Technical5545
    Socioemotional2080
Age*  
    Mean48.142.4
    SD8.37.8
Confidence  
    Mean4.04.0
    SD0.70.6
Outcome expectancies  
    Mean3.83.9
    SD0.40.4
Comfort with psychosocial talk  
    Mean85.083.6
    SD8.510.5
NOTE. Analyses were conducted on 50 physicians; one physician had no empathic opportunities.
Abbreviation: SD, standard deviation.
*
P <.05.
Supported by National Cancer Institute Grant No. R01CA100387.
Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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Information & Authors

Information

Published In

Journal of Clinical Oncology
Pages: 5748 - 5752
PubMed: 18089870

History

Published in print: December 20, 2007
Published online: September 21, 2016

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Authors

Affiliations

Kathryn I. Pollak
From the Duke Comprehensive Cancer Center, Cancer Prevention, Detection, and Control Research Program; the Department of Community and Family Medicine; the Department of Biostatistics and Bioinformatics; the Department of Medicine; the Center for Palliative Care, Duke University Medical Center; the Center for Health Services Research, Durham Veterans Affairs Medical Center, Durham, NC; the Division of General Internal Medicine, Department of Medicine; the Institute for Doctor-Patient Communication; the Institute to Enhance Palliative Care, University of Pittsburgh School of Medicine; and the Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
Robert M. Arnold
From the Duke Comprehensive Cancer Center, Cancer Prevention, Detection, and Control Research Program; the Department of Community and Family Medicine; the Department of Biostatistics and Bioinformatics; the Department of Medicine; the Center for Palliative Care, Duke University Medical Center; the Center for Health Services Research, Durham Veterans Affairs Medical Center, Durham, NC; the Division of General Internal Medicine, Department of Medicine; the Institute for Doctor-Patient Communication; the Institute to Enhance Palliative Care, University of Pittsburgh School of Medicine; and the Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
Amy S. Jeffreys
From the Duke Comprehensive Cancer Center, Cancer Prevention, Detection, and Control Research Program; the Department of Community and Family Medicine; the Department of Biostatistics and Bioinformatics; the Department of Medicine; the Center for Palliative Care, Duke University Medical Center; the Center for Health Services Research, Durham Veterans Affairs Medical Center, Durham, NC; the Division of General Internal Medicine, Department of Medicine; the Institute for Doctor-Patient Communication; the Institute to Enhance Palliative Care, University of Pittsburgh School of Medicine; and the Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
Stewart C. Alexander
From the Duke Comprehensive Cancer Center, Cancer Prevention, Detection, and Control Research Program; the Department of Community and Family Medicine; the Department of Biostatistics and Bioinformatics; the Department of Medicine; the Center for Palliative Care, Duke University Medical Center; the Center for Health Services Research, Durham Veterans Affairs Medical Center, Durham, NC; the Division of General Internal Medicine, Department of Medicine; the Institute for Doctor-Patient Communication; the Institute to Enhance Palliative Care, University of Pittsburgh School of Medicine; and the Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
Maren K. Olsen
From the Duke Comprehensive Cancer Center, Cancer Prevention, Detection, and Control Research Program; the Department of Community and Family Medicine; the Department of Biostatistics and Bioinformatics; the Department of Medicine; the Center for Palliative Care, Duke University Medical Center; the Center for Health Services Research, Durham Veterans Affairs Medical Center, Durham, NC; the Division of General Internal Medicine, Department of Medicine; the Institute for Doctor-Patient Communication; the Institute to Enhance Palliative Care, University of Pittsburgh School of Medicine; and the Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
Amy P. Abernethy
From the Duke Comprehensive Cancer Center, Cancer Prevention, Detection, and Control Research Program; the Department of Community and Family Medicine; the Department of Biostatistics and Bioinformatics; the Department of Medicine; the Center for Palliative Care, Duke University Medical Center; the Center for Health Services Research, Durham Veterans Affairs Medical Center, Durham, NC; the Division of General Internal Medicine, Department of Medicine; the Institute for Doctor-Patient Communication; the Institute to Enhance Palliative Care, University of Pittsburgh School of Medicine; and the Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
Celette Sugg Skinner
From the Duke Comprehensive Cancer Center, Cancer Prevention, Detection, and Control Research Program; the Department of Community and Family Medicine; the Department of Biostatistics and Bioinformatics; the Department of Medicine; the Center for Palliative Care, Duke University Medical Center; the Center for Health Services Research, Durham Veterans Affairs Medical Center, Durham, NC; the Division of General Internal Medicine, Department of Medicine; the Institute for Doctor-Patient Communication; the Institute to Enhance Palliative Care, University of Pittsburgh School of Medicine; and the Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
Keri L. Rodriguez
From the Duke Comprehensive Cancer Center, Cancer Prevention, Detection, and Control Research Program; the Department of Community and Family Medicine; the Department of Biostatistics and Bioinformatics; the Department of Medicine; the Center for Palliative Care, Duke University Medical Center; the Center for Health Services Research, Durham Veterans Affairs Medical Center, Durham, NC; the Division of General Internal Medicine, Department of Medicine; the Institute for Doctor-Patient Communication; the Institute to Enhance Palliative Care, University of Pittsburgh School of Medicine; and the Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
James A. Tulsky
From the Duke Comprehensive Cancer Center, Cancer Prevention, Detection, and Control Research Program; the Department of Community and Family Medicine; the Department of Biostatistics and Bioinformatics; the Department of Medicine; the Center for Palliative Care, Duke University Medical Center; the Center for Health Services Research, Durham Veterans Affairs Medical Center, Durham, NC; the Division of General Internal Medicine, Department of Medicine; the Institute for Doctor-Patient Communication; the Institute to Enhance Palliative Care, University of Pittsburgh School of Medicine; and the Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA

Notes

Address reprint requests to Kathryn I. Pollak, PhD, Duke University Medical Center, Community and Family Medicine, 2424 Erwin Rd, Suite 602, Durham, NC 27705; e-mail: [email protected]

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Kathryn I. Pollak, Robert M. Arnold, Amy S. Jeffreys, Stewart C. Alexander, Maren K. Olsen, Amy P. Abernethy, Celette Sugg Skinner, Keri L. Rodriguez, James A. Tulsky
Journal of Clinical Oncology 2007 25:36, 5748-5752

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