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© 2000 American Society for Clinical Oncology Effect of Providing Cancer Patients With the Audiotaped Initial Consultation on Satisfaction, Recall, and Quality of Life: A Randomized, Double-Blind StudyFrom the Department of Medical Psychology, Department of Obstetrics/Gynaecology, and Department of Medical Oncology, Academic Medical Center, Amsterdam, the Netherlands. Address reprint requests to Lucille M. L. Ong, PhD, Universitair Medisch Centrum, Onderwijsinstituut, P.O. Box 80030, 3508 TA Utrecht, the Netherlands; email L.M.L.ONG{at}MED.UU.NL
PURPOSE: By means of a randomized double-blind study, the effect of providing taped initial consultations on cancer patients’ satisfaction, recall, and quality of life was investigated. PATIENTS AND METHODS: Consecutive cancer patients referred to either the gynecology or medical oncology outpatient clinic were eligible. Initial consultations were audiotaped. Patients were either provided with the tape (experimental group) or not (control group). Baseline variables included sociodemographics, preferences for information, coping styles, and clinical characteristics. Follow-up (after 1 week and 3 months) variables included attitudes toward the intervention, satisfaction, recall, and quality of life. Assessments took place through mailed questionnaires and telephone interviews. RESULTS: Two hundred one patients were included (response, 71%), 105 in the experimental group and 96 in the control group. Most patients (75%) listened to the tape, the majority of which (73%) listened with others. Almost all patients, both in the experimental group (96%) and control group (98%) were positive about the intervention. Expectations were confirmed; patients provided with the tape were more satisfied (P < .05) and recalled more information (P < .01) than patients without the tape. The intervention did not have an effect on quality of life. An interaction effect was found between the intervention and patients’ age on satisfaction with the taped consultation (P < .01) and recall of diagnostic information (P < .01); access to tapes seems more helpful in enhancing satisfaction in younger patients and recall of diagnostic information in older patients. CONCLUSION: Cancer patients and their families value the taped initial consultation. This intervention enhances their satisfaction and improves their recall of information. Tapes seem more helpful in enhancing satisfaction in younger patients and recall of diagnostic information in older patients.
THE NOTION THAT cancer patients wish to be well-informed about both general and specific aspects of their diagnosis, prognosis, and treatment has been underlined by several studies.1-5 Information is of considerable importance in helping patients and their families cope with threatening situations.6,7 Also, information enables patients with cancer to make treatment-related decisions.2,8,9 However, patients are often dissatisfied with the information they receive.10-13 Hogbin and Fallowfield14 identified several reasons for this, namely time constraints, poor communication skills in doctors, physicians withholding information, and patients’ incapability to remember the information. Patient dissatisfaction predicts anxiety,15 reduces adherence to treatment,16,17 and even seems to influence long-term outcomes.18 Not surprisingly then, the application of methods to optimize doctor-patient communication in oncology care has become a significant issue. These methods include training oncologists in counseling skills19-21 or insuring that a relative sits in at the consultation.22 Information in the form of leaflets is another option, although general information is not tailored to the individual needs of cancer patients.23 Moreover, it may confuse patients and even increase anxiety.24 A relatively novel approach, first suggested by Butt,25 is to provide patients with an audiotape of the consultation. Several uncontrolled studies have indicated that this procedure is appreciated by cancer patients and their relatives, as well as by participating oncologists.13,26-30 Randomized studies have demonstrated the effect of this intervention on reducing cancer patients’ anxiety31 and enhancing their recall of information23,31,32 and satisfaction.33 Also, tapes seem to facilitate patient requests for clarification of previously given information.34 In addition, Tattersall et al4 reported that cancer patients preferred audiotapes of their initial consultation to individualized letters. In an earlier study by the same research group,33 however, general information tapes about cancer seemed to actively inhibit patients’ recall of information. They also reported that consultation tapes did not significantly improve patient recall over the no-tape control group.33 Provision of tapes does not seem to reduce patients’ psychologic distress and feelings of depression.4,32 Moreover, McHugh et al32 suggested that issuing audiotaped bad news consultations to poor-prognosis patients who use repressive coping strategies may even be detrimental to their psychologic health. In this article, we will report the results of a randomized trial that assesses the effectiveness of providing cancer patients with the audiotaped initial consultation. Previous tape studies have examined this intervention in settings limited to a single, motivated clinician,4,13,23,33 a single diagnostic patient group,10,23 or the provision of a standard set of information by using a checklist.31 Therefore, the generalizability of these data to everyday clinical practice is limited. Like McHugh et al,32 we chose to investigate an unmodified clinical setting, with various oncologists, and more than one diagnostic and prognostic patient group. McHugh et al32 selected the bad news consultation to be audiotaped. In the present investigation, the initial consultation will be recorded. This consultation is usually highly emotional and informative. Moreover, the information provided is complex because it covers not only patients’ diagnosis and prognosis but also one or several treatment options. In all likelihood, audiotapes of this particular consultation will be beneficial aids in enhancing patient outcomes. Such an investigation has not yet been performed. In the present study, patient attitudes toward the intervention are described. Second, the effect of this intervention on patient satisfaction and recall of information is examined, given the positive results of an earlier pilot study.28 Third, the effect of this intervention on patient quality of life is investigated. On the basis of previous studies, we expect that providing cancer patients with a tape of the initial consultation will have a positive effect on their satisfaction and recall of information. We also expect that this intervention will not have an effect on their quality of life. As mentioned earlier, a similar study32 reported a negative effect of the provision of tapes on psychologic distress in poor-prognosis patients. Therefore, we also explore the effect of the intervention for patients with a good versus a poor prognosis. Also, the interaction between the intervention and patient age and coping styles is examined.
Sample Cancer patients referred to the gynecology or medical oncology outpatient clinic at the Academic Medical Center (AMC) in Amsterdam, who gave their informed consent, were eligible. Exclusion criteria were inability to speak, read, or write the Dutch language and obvious psychopathology. Patients were aware of their cancer diagnosis and were referred for an initial discussion of possible treatment options. During the recorded consultations, the following topics were usually discussed: reason for referral to a specialist, the specific aspects of the diagnosis, medical history, findings of the physical examination, the proposed treatment policy, prognosis, (short-term) side effects, and other (long-term) consequences of the treatment (eg, sexuality, fertility, and work). The physical examination that took place during these consultations was not recorded for technical and privacy reasons. The sample consisted of 201 consecutive patients with cancer. Eleven oncologists (six gynecologists and five medical oncologists) audiotaped initial consultations with their patients. Patients were entered onto the study between August 1994 and April 1997.
Study Design and Procedure
Questionnaires were sent the following week (T1) and after 3 months (T2). All patients were given a structured telephone interview at T1 and T2 to obtain additional outcome measures. Also, this procedure was observed to prevent patient dropout. After obtaining the second follow-up assessment, patients allocated to the control group were offered the audiotape of the consultation.
Variables and Instruments Patients’ prognoses, in terms of 5-year survival, were classified into the following two categories: less than 60% and more than 60% chance of a 5-year survival. These data were obtained from the treating oncologists. Monitoring (cognitive confrontation) and blunting (cognitive avoidance) coping styles were assessed by means of the Threatening Medical Situations Inventory.38,39 In our study, we used the shortened version of the Threatening Medical Situations Inventory, consisting of two out of the four hypothetical, threatening medical situations. This version proved to be valid in an oncological sample.5 Follow-up assessments. To assess patient attitudes toward the intervention, an instrument was developed and tested during an earlier pilot study.28 For the experimental group, this semi-structured questionnaire consisted of 11 questions regarding tape usage (three items), forgotten information and affective connotation (three items), and appreciation (five items). Two of the questions pertaining to appreciation were also used for the control group. Next, both disease-specific and generic quality of life were assessed. The Patient Satisfaction Questionnaire was used to measure patient satisfaction with the audiotaped consultation. It assessed satisfaction with needs addressed, active involvement in the interaction, interaction in general, information received, and emotional support received.40 The items were answered on visual analogue scales. In addition, patient satisfaction with medical care was assessed by means of the Patient Satisfaction Questionnaire-III.41 One of the five subscales (availability) of this instrument was not used for further analysis because this scale referred to aspects of satisfaction not applicable to the Dutch situation. To assess patient recall of information, each audiotaped consultation was analyzed to itemize the actual information conveyed by the oncologist, against which patient recall of information was measured during a telephone interview. The information provided by the doctor could fall into nine categories, including diagnosis, prognosis, operation, trial, chemotherapy (with or without hyperthermia), radiotherapy, alternative treatment plan (including no treatment), direct (short-term) side effects, and other (long-term) consequences of treatment. Most of these categories consisted of subcategories, for example, part of the body being treated, admittance to hospital necessary, and purpose of the trial. Correct responses were added for each separate category.
Analyses Repeated measures analysis of variance was performed to establish the effect of the intervention on patient quality of life, satisfaction, and recall of information (main effect). Study group was used as the between-subjects factor, and time (T1 and T2) was used as the within-subjects factor. Quality-of-life assessments at baseline were entered as covariates. P values less than .05 were considered statistically significant. If multivariate significance was observed, post hoc univariate comparisons established which variables contributed to the overall difference. To examine the interaction effect between the intervention and patient background characteristics on patient outcomes, repeated measures analyses of variance were performed with study group and background characteristics as the between-subject factors. Time (T1 and T2) was used as the within-subjects factor. Regarding patient satisfaction, only satisfaction with the taped consultation was investigated. For age and monitoring and blunting coping style, the median-split method was used to dichotomize these variables. Regarding patient prognoses, analyses of variance were performed for T1 only because the number of patients for the second assessment was too small to perform statistical analyses. P values less than .05 were considered statistically significant. Data analysis was conducted using Statistical Package for the Social Sciences, version 8.0.
Sample A total of 284 patients were eligible for the study. Of these, 201 patients (71%) were included; 105 patients were randomized in the experimental group and 96 patients in the control group. Reasons for noninclusion (n = 83) included the following: patient was too emotional (n = 24) or too ill (n = 19) to participate, patient found questionnaire too difficult to fill in (n = 8), patient refused for unknown reason (n = 17), and consultation was not recorded or incomplete (n = 15). Out of 201 patients, 187 (93%) returned the first follow-up questionnaire; 164 patients (82%) returned the questionnaire after 3 months. At T1, reasons for nonresponse (n = 14) included the following: too ill (n = 5), deceased (n = 1), no longer motivated (n = 1), and reason unknown (n = 7). At T2, reasons for nonresponse (n = 23) included: too ill (n = 12), deceased (n = 8), no longer motivated (n = 1), and reason unknown (n = 2). Regarding patient recall of information and patients’ attitudes toward the intervention at T1, 198 (98.5%) out of 201 patients were interviewed. Reasons for nonresponse (n = 3) were too ill (n = 2) and deceased (n = 1). At T2, 174 patients (87%) were interviewed. Reasons for nonresponse (n = 24) were too ill (n = 14), deceased (n = 8), no longer motivated (n = 1), and reason unknown (n = 1). Gynecologic cancers included cancer of the vulva, cervix, corpus, and ovary. The medical oncology patients were diagnosed with a primary malignancy (with or without metastases) of the testis, skin, bladder, liver, pancreas, colon, breast, or oesophagus. Table 1 lists the descriptive statistics for patient sociodemographic variables, preferences for information, and clinical characteristics. The P values indicate that there were no differences between the experimental and control groups regarding these variables.
Patients’ Attitudes Toward the Intervention: The Experimental Group Tape usage. After 1 week, 77 (75%) out of the 103 patients who were interviewed listened to the tape, whereas 29 patients (32%) listened between the first and second follow-up assessment. On average, they listened 2.1 times (range, one to 15 times) at T1 and 2.2 times (range, one to eight times) at T2. The most frequently mentioned reason patients gave for not listening to the tape was "I do not need to listen to the tape for information" (n = 14 at T1; n = 51 at T2). After 1 week, the second most frequently mentioned reason was "Listening to the tape would be too threatening at the moment" (n = 5). After 1 week, 45 (58%) out of 77 patients listened to the tape together with their partner, and 17 patients listened with their children. Fifteen patients shared the tape with other relatives and/or close friends. One patient gave the tape to the referring gynecologist. Also after 3 months, most patients (n = 22) shared the tape with their partner and/or their children. Some shared the tape with other relatives and/or close friends (n = 7). One patient gave the tape to the general practitioner. Forgotten information and affective connotation. After 1 week, 47 (61%) out of the 77 patients who listened to the tape found that the tape contained information they had forgotten. Eleven patients found that the tape contained upsetting information, whereas 41 patients (53%) found the information on the tape reassuring. After 3 months, half of the patients (14 of 29) found the tape containing both forgotten information and reassuring information. One patient found the information on the tape upsetting. Appreciation of taping procedure and intervention. The majority of patients did not take notice of the recording of the consultation at both follow-up assessments (69% at T1 and 60% at T2). The remaining patients were even positive about the taping procedure itself. After 1 week, the tape facilitated communication with relatives for 39 (51%) out of the 77 patients who listened to the tape. For 33 patients (43%), the tape prompted additional questions regarding their illness and its treatment. After 3 months, the tape facilitated communication with relatives for the majority of patients (18 of 29). Overall, almost all patients (96% at T1 and 98% at T2) were positive about the intervention and would recommend the intervention to cancer patients (93% at T1 and 96% at T2).
Patients’ Attitudes Toward the Intervention: The Control Group
The Effect of the Intervention on Patient Satisfaction
A main effect of time was found (F = 122.13, P < .001), indicating that patient satisfaction at T1 and T2 changed over time; satisfaction with interpersonal aspects, technical quality, communication, and general satisfaction decreased over time (P < .001). No interaction effect between the intervention and time was found (F = 1.80, P = .12).
The Effect of the Intervention on Patient Recall of Information The second expectation was confirmed. A main effect of the intervention was found for all information categories (Table 3), indicating that patients provided with the tape were able to recall more information regarding all topics discussed during the consultation (P < .001; except for trial procedure and chemotherapy, P < .01). Also, the tape group recalled more information at both follow-up assessments.
A main effect of time was established for seven out of the nine information categories. Patient recall decreased over time regarding information about prognosis (P < .05), operation (P < .001), trial procedure (P < .05), radiotherapy (P < .01), alternative treatment (P < .01), short-term side effects (P < .01), and other long-term consequences (P < .01). No interaction effect between the intervention and time was found.
The Effect of the Intervention on Patient Quality of Life
The Effect of the Intervention and Patient Background Characteristics Patient prognoses. No interaction effects were found between the intervention and prognosis on satisfaction, recall of information, and quality of life. Regarding recall of information about prognosis, operation, trial procedure, radiotherapy, and long-term consequences, statistical analyses were not performed because of the low number of patients. Patient age. An interaction effect (Table 5) was found between the intervention and age on satisfaction with the taped consultation (F = 6.5, P < .01); younger patients provided with the tape were more satisfied than younger patients allocated to the control group (P < .001). Within the group of older patients, provision of the tape made no difference in how satisfied they were with the consultation (P = .87).
Also, an interaction effect (Table 5) was found between the intervention and patient age on recall of diagnostic information (F = 8.8, P < .01); older patients provided with the tape recalled more information about their diagnosis compared with older patients not provided with the tape (P < .001). Although younger patients provided with the tape recalled more diagnostic information compared with younger patients without the tape (P = .04), this effect was not as strong as the one found within the group of older patients. No interaction effect was found between the intervention and age on quality of life. Patient coping styles. No interaction effects were found between the intervention and monitoring and blunting coping styles on satisfaction, recall, and quality of life.
In this article, the effectiveness of providing cancer patients with the audiotaped initial consultation was described. By means of a randomized double-blind design, the effect of this intervention on patient satisfaction, recall of information, and quality of life was investigated. Such an investigation, where the initial interview is recorded, using a variety of clinicians and more than one diagnostic and prognostic patient group in an unmodified clinical setting, has not been previously performed. The results show that the majority of patients (75%) listened to the audiotape, mostly together with relatives. This finding is comparable with data from previous tape studies. Furthermore, almost all patients, including patients who did not listen to the tape as well as patients allocated to the control group, appreciated the intervention and would recommend it to other cancer patients. The fact that most patients (77%) allocated to the control group still wished to receive the tape after 3 months underlines patient appreciation of this intervention. Our three expectations were confirmed. First, patients provided with the tape were more satisfied with the taped consultation as well as medical care in general. This study, using diverse clinician and patient samples, provides the first firm confirmation that taping the initial interview enhances satisfaction in cancer patients. Similar studies4,33 report that patient satisfaction with the taped interview was consistently high. Our data replicate this finding. Mean satisfaction scores ranged from 38.7 to 42.5 (scale 0 to 50). Post hoc analyses also showed a main age effect; older patients were more satisfied than younger patients (P < .01). Second, audiotapes facilitated recall of information; patients provided with the tape recalled more factual information about all nine categories of information than patients without the tape. This result confirms data from earlier controlled as well as uncontrolled studies,23,26-32 although it challenges findings from two Australian studies.4,30,33 In these studies, it was concluded that tapes did not influence cancer patients’ recall. An interesting finding of our study was that the intervention showed an unexpected long-term effect; the tape group recalled more information not only after 1 week but also after 3 months of follow-up. Third, no effect of the intervention on quality of life could be established. An effect of time was observed, demonstrating a decline in patients’ physical, role, and social functioning. This finding is not surprising given the fact that most patients had undergone a surgical treatment shortly before the second follow-up assessment (at 3 months). We explored whether certain subgroups of patients would benefit more or less from the provision of audiotapes. Apart from the study by McHugh et al,32 this issue has not received much attention in previous studies. Our results do not replicate the finding by McHugh et al,32 who reported a harmful effect in poor-prognosis patients regarding their psychological distress. Moreover, we did not find any interaction effect between the intervention and prognosis regarding patient outcomes. It should be noted, however, that the number of patients were small in these groups. Regarding satisfaction with the taped consultation, our data indicate that younger patients provided with the tape benefit more compared with younger patients without the tape. For older patients, access to the tape did not influence their satisfaction. Concerning recall of diagnostic information, both older and younger patients provided with the tape had a better recall compared with older and younger patients without the tape. This effect, however, was much stronger for older than for younger patients (P < .001 v P = .04). It should be mentioned, though, that this finding pertained to only one out of nine informational categories. An interaction effect between the intervention and patient monitoring and blunting coping styles could not be established. Concerning the blunting style, we did not anticipate such an effect because an earlier study showed that a blunting style was unrelated to cancer patients’ preferences for information.5 Concerning the monitoring style, this finding was somewhat unexpected, considering the following definition of this coping style: actively seeking information about a threatening situation.5 Also, this earlier study reported a positive relation between a monitoring style and cancer patients’ preferences for detailed information.5 Therefore, it seems reasonable to assume that high monitors provided with the tape would at least be more satisfied than high monitors without the tape. New studies are needed to replicate this finding. Some limitations of the present study need to be mentioned. First, most cancer patients were recruited from the gynecology outpatient clinic; therefore, women with a high chance of survival were overrepresented. Also, in studying interaction effects between the intervention and prognosis on outcomes, the number of patients in the poor-prognosis group was small. Future studies using more evenly divided prognostic groups are recommended. Overall, the results of the present study indicate that the provision of audiotaped initial consultations is valued by cancer patients and their relatives. Moreover, this intervention enhances patient satisfaction. Tapes also improve patients’ factual recall of information provided by their clinician, even after 3 months of follow-up. Furthermore, access to audiotapes seems particularly helpful in enhancing satisfaction in younger patients and recall of diagnostic information in both younger and older patients, although foremost in the latter. Optimizing outcomes such as these, without compromising the quality of medical care or the doctor-patient relationship, remains an important research direction for the future. As mentioned earlier, consequences of poor patient satisfaction and recall of information include increased anxiety and distress.15,43 Also, coping difficulties,43 lack of confidence in the medical staff,44 noncompliance,16,17 and doctor shopping45 can be possible costs. As Tattersall et al4 suggested, it could be argued that oncologists consider installing audiotape-recording facilities to offer new patients a taped consultation. The fact that taping consultations is feasible in busy outpatient clinics28 and does not seem to burden the workload of physicians,4,28 adds to the appeal of this intervention.
Supported by the Dutch Cancer Society contract grant no. AMC-94-760. We thank all patients, physicians, and nurses who participated in this investigation. We also thank Angela de Boer and Sjaak Molenaar for their helpful comments and statistical advice during the preparation of this manuscript.
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Copyright © 2000 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
2 tests (two-sided) for categorical variables. P values less than .05 were considered statistically significant. For the descriptive statistics regarding patient characteristics and patient attitudes toward the intervention, frequencies were calculated. 
