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

How can we explain physician accuracy in assessing patient distress?

A multilevel analysis in patients with advanced cancer

Sophie Lelorain

^a,b,

*, Anne Bre´dart

^c,d

, Sylvie Dolbeault

^c,e,f

, Alejandra Cano

^c

, Ange´lique Bonnaud-Antignac

^g

, Florence Cousson-Ge´lie

^h,i

, Serge Sultan

^j

aUniversityofLilleNorddeFrance,DepartmentofPsychology,Lille,France

bUDL3,URECA,Villeneuved’Ascq,France

cInstitutCurie,Psycho-oncologyUnit,Paris,France

dParisDescartesUniversity,LPPSEA4057–IUPDP,Boulogne-Billancourt,France

eInserm,U669,Paris,France

fUniverstityofParis-SudandUniversityofParisDescartes,UMR-S0669,Paris,France

gUniversityofNantes,EA4275SPHERE‘bioStatistics,PharmacoepidemiologyandHumansciEncesResearch’,Nantes,France

hUniversityofMontpellier3,LaboratoryEpsylon‘DynamicsofHumanAbilities&HealthBehaviors’,Montpellier,France

iICM,InstitutRe´gionalduCancerdeMontpellier,EpidaurePreventionandEducationCancerCenter,Montpellier,France

jUniversityofMontreal,SainteJustineUniversityHospitalResearchCenter,Montreal,Canada

1. Introduction

Duetoitshighprevalenceincancerpatients,from22to58%[1], andparticularlyinmetastaticcases[2–4],emotionaldistresshas beenendorsedasthe6thVitalSignbytheInternationalPsycho- OncologySociety(IPOS)[5].Routinedistressscreeninghasbeen stronglyrecommendedtoidentifycancerpatientswhomayneed

psychologicalorsocialinterventions.However,systematicdistress screening with validated tools is still rare [6]. Oncologists in particularmaynotconsiderdistressscreeninganessentialpartof theirjob[7]andprefertorelyontheirownclinicalskillsrather thanusingvalidated questionnaires[8].Therefore,along witha continuousefforttoimplementroutinescreening,itis essential thatoncologistsinferpatientdistressaccuratelybythemselvesin ordertomakethenecessaryreferrals.Besides,thisabilitytodetect the emotions and cognitions of others accurately, also called empathicaccuracy(EA)[9],haspositiveeffectsforpatients,suchas treatmentadherenceandappointment-keeping[10,11].Unfortu- nately,it seems that physiciansdo not perceive cancer patient distressaccurately[12,13].Tounderstandthisphenomenon,we ARTICLE INFO

Articlehistory:

Received8July2013

Receivedinrevisedform15October2013 Accepted30October2013

Keywords:

Physicianempathicaccuracy Oncology

Patientdistress Rapport

Expressivesuppression

ABSTRACT

Objective:Toexaminethedeterminantsoftheaccuracywithwhichphysiciansassessmetastaticcancer patientdistress,alsoreferredtoastheirempathicaccuracy(EA).Hypothesizeddeterminantswere physician empathic attitude,self-efficacy in empathic skills,physician-perceived rapportwith the patient,patientdistressandpatientexpressivesuppression.

Methods:Twenty-eightphysiciansassessedtheirpatients’distresslevelonthedistressthermometer, whilepatients(N=201)independentlyratedtheirdistresslevelonthesametool.EAwasthedifference betweenbothscoresinabsolutevalue.Hypothesizeddeterminantswereassessedusingself-reported questionnaires.Multilevelanalyseswerecarriedout.

Results:LittleofthevarianceinEAwasexplainedbyphysicianvariables.EAwashigherwithhigher levelsofpatientdistress.Physician-perceivedqualityofrapportwaspositivelyassociated withEA.

However,forhighlydistressedpatients,goodrapportwasassociatedwithlowerEA.Patientexpressive suppressionwasalsorelatedtolowerEA.

Conclusion:This study adds to the understanding of EA in oncological settings, particularly in challengingthecommonassumptionthatEAdependslargelyonphysiciancharacteristicsorthatbetter rapportwouldalwaysfavorhigherEA.

Practiceimplications: Physiciansshouldaskpatientsforfeedbackregardingtheiremotions.Inparallel, patientsshouldbepromptedtoexpresstheirconcerns.

ß2013ElsevierIrelandLtd.Allrightsreserved.

* Corresponding author at: URECA, EA 1059, Universite´ Lille 3, UFR de Psychologie,RueduBarreau,BP60149,F-59653Villeneuved’AscqCedex,France.

Tel.:+330320416968;fax:+330320416036.

E-mailaddress:sophie.lelorain@univ-lille3.fr(S.Lelorain).

ContentslistsavailableatScienceDirect

Patient Education and Counseling

j ou rna l hom e pa ge :ww w. e l s e v i e r. c om/ l o ca t e / pa t e duc ou

0738-3991/$–seefrontmatterß2013ElsevierIrelandLtd.Allrightsreserved.

http://dx.doi.org/10.1016/j.pec.2013.10.029

setouttoinvestigatethecorrelatesofphysicianEAonmetastatic cancer patient distress. In fact, factors of EA have rarelybeen studiedinaclinicalsetting,especiallyinoncology[10].

The theoretical framework of Norfolket al. [14] guided our analyses.Itwasoriginallyproposed ingeneralpracticeand has beenusedsuccessfullyforthedesignandvalidationofphysician trainingtodeveloprapportwithpatients[15].

In this model, the physician’s empathic attitude, i.e. their willingnesstounderstandandgiveroomtoapatient’semotions andfeelings[16],isthestartingpointforthephysiciantodetect patientcuesconcerningtheirthoughtsandfeelings.Thisempathic skillshouldleadtoanaccuraterepresentationofthepatient’sstate [17].

Themodelalsospecifiestheimportanceofpatientorphysician- patient relationship variables. An important variable when applyingthisgeneralmodeltoourpurposeisthepatient’sdistress level.Indeed,astudyofadvancedcancerpatientssuggestedthat higherpatientdistressismorefrequentlydetectedandaddressed by oncologists [18], probably because it is more visible than moderatedistress. Therefore, we expected EA toincrease with patientdistress.However, thislinkcouldbemoderated bytwo variablesinNorfolk’smodel.

Thefirstoneispatientexpressivesuppression,i.e.theinhibition of ongoing emotion-expressive behavior [19]. Previous experi- mentalresearchsupportstheimportanceofaperson’sverbaland non-verbaldisclosureinallowinga ‘perceiver’todetecthis/her emotions [20–23]. Thisshouldbe truein a naturalistic clinical setting. Therefore, patient expressive suppression should be a barriertophysicianEA, particularlyin thecaseofhighdistress wherethegapbetweenapatient’sactualandvisiblestatecanbe large.

The second potential moderator is rapport. Defined as the connection between patient and physician and their mutual commitmenttotherelationship,rapportisessentialforeffective clinicalcommunication[24].Withoutit,patientswouldnotfeelat easeinexpressingtheiremotionsand/orphysicianswouldpayless attentiontopatientcues.Consequently,poorrapportisexpected torelatetolowerEA,particularlyagaininthecaseofhighpatient distresswheretheEAgapcanbecomehuge.

Tosummarize,followingthemodelofNorfolketal.[14],the hypothesizedcorrelates ofEAwerephysicianempathicpositive attitude,higherself-efficacyinempathicskills,aswellaslower patientexpressivesuppressionand physicianperceptionof low rapportasmoderatorsofthelinkbetweenpatientdistressandEA.

2. Methods

2.1. Inclusioncriteria

Inclusioncriteriaforphysicianswereworkinginacancerward or in a palliative care unit and treating patients meeting the followinginclusioncriteria:ageover18years,metastaticcancer fromandbeyondthe4thlineofchemotherapyforprimarybreast cancer,andfromandbeyondthe2ndlineofchemotherapyforany othertypeofprimarycancer.Secondand4thlinesofchemother- apywerechosentoreachpatientslikelytohavesymptomsoftheir disease,oftenassociatedwithdistress.Patientshadtohavealready consultedthephysicianatleast3timesbeforetheirinclusion,so thattheyhadaminimumknowledgeofeachother.Non-inclusion criteriawerepsychiatriccomorbiditiesandhematologicalcancers, deemedtoospecificcomparedtoothercancers.

2.2. Procedure

Physicians at the ‘Institut Curie’ (Paris), the ‘Institut de Cance´rologie de l’Ouest’ (Nantes), ‘Hoˆpital Nord Laennec’

(Nantes) and at the ‘Polyclinique Bordeaux Nord Aquitaine’

(Bordeaux)wereinvitedtoparticipateinthestudy.Theywere givenadetaileddescriptionofthestudyandawritteninformed consenttosign.

Upon acceptance, they completed a questionnaire assessing theirempathicattitudeandself-efficacyinempathicskills.They thenhadtoinclude10consecutivepatientsmeetingtheinclusion criteria.Attheendofaconsultationwiththephysician,patients werebrieflyintroducedtothestudybythephysicianandgivena detailed written study description, the questionnaires and a writteninformedconsent.Ifpatients agreedtoparticipate,they signedtheinformedconsentandhadoneweektocompletethe questionnairesandreturnthemtotheresearchteamintheprepaid envelopeprovided. When dataweremissing, participantswere contactedbyphonebytheresearchassistantandaskedtoprovide the missing information. On the same day of each inclusion, physicians had to fill in a short questionnaire assessing their perception of the patient (i.e. an empathic accuracy task, see Section2).

Thestudyprotocolwasapprovedbytheinstitutionalreview boardoftheCurieInstituteandbytheFrenchnationaladvisory committeefortheprocessingofinformationinhealthresearch.All patientandphysiciandatawereanonymous.

2.3. Samples

DatacollectionwascarriedoutfromMay2011toMarch2012.

Following the usual recommendations of sample size for multileveldesignssuchasthis one[25],ourgoalwastoobtain a sampleof50 physicians,eachwitha minimumof5patients, ideally10.

Sixty-fourphysicianswereinvitedtoparticipate.Amongthem, 11physicianshadnoeligiblepatients,14refusedtoparticipateand 11accepted,buteventually9ofthesedidnotincludeanypatients becauseoflackoftimeand2becausetheyfoundittoodifficultto suggest this study to metastatic cancer patients. So, the final physiciansamplewascomposedof28clinicians,mostlymedical oncologists(seeTable1).

Two-hundred-and-onepatientswereincluded.Thenumberof patient refusals and whether they differ from the others are unknown.Mostparticipantswerefemaleandlivedwithsomeone, theirmeanagewas62yearsandtheprimarycancersiteswere breast,colorectalandlungcancers(Table1).

2.4. Measures

PhysicianempathicattitudewasmeasuredusingtheJefferson Scale of Physician Empathy (JSPE), a 20-item 7-point Likert response scale. It provides physician self-evaluation (e.g. ‘An importantcomponentoftherelationshipwithmypatientsismy understanding oftheemotionalstatusofthepatients andtheir families’) and a global score ranging from 20 to 140 [26]. Its psychometricpropertieshavebeenverifiedinnumerousstudies [26,27].Inoursample,Cronbach’salphawas0.69fortheoverall scale.

Physicianself-efficacyinempathicskillswasassessedbyasingle self-reported 7-point Likert ad-hoc item: ‘In general, I feel competenttodetectmypatients’ emotionaldistressandneeds’

ratedfrom0‘stronglydisagree’to7‘stronglyagree’.

Rapport wasassessedbya single7-pointLikert ad-hocitem assessingphysician-perceived qualityofrapportwithapatient:

‘Whatisthequalityofyourrelationshipwiththispatient?’rated from1‘verydifficultrelationship’to7‘veryeasyrelationship’.

Patient emotional distress was evaluated with the distress thermometer[28],thewidelyusedscreeningvisualanalogscale (i.e. without anchors), which ranges from ‘no distress’ at the

bottomto‘veryhighdistress’atthetop,wherethepatientrates his/herdistresslevelwithinthelastweek.

Patientexpressivesuppressionwasassessedwiththe4-item7- point Likert expressive suppression scale from the Emotion Regulation Questionnaire (ERQ-Fr) [29]. Expressive suppression describestowhatextentpeoplegenerallyinhibitongoingemotion- expressivebehavior(e.g.‘WhenIamfeelingnegativeemotions,I makesureIdon’texpressthem’).Theexpressivesuppressionscore rangesfrom4to28.Inoursample,Cronbach’salphawas0.83.

EAondistress.Independently fromthepatient,thephysician had to rate the patient’s emotional distress on the distress thermometer. The physician was instructed as follows: ‘Your patient was asked to rate his/her emotional distress on this thermometer.Indicate thedistresslevel youthink your patient rated.’The EA scorewas generated bycalculatingthe absolute valueofthedifferencebetweenthepatient’sandthephysician’s rating, as recommended in the empathic accuracy literature [30,31].Itisameasureofabsoluteagreementbetweenclinicians andpatientsondistress.

2.5. Statisticalanalyses

To respect the two-level hierarchical structure of patients (level1) clustered withindoctors(level 2), multilevel analyses wereperformedwithMLwiNsoftware2.27[32,33].Theseanalyses

areanextensionofthegenerallinearmodeltakingintoaccountthe possibledependencebetweenindividualswithingroups[34,35].

Forlevel1variableswithpossibledependencewithinphysicians, differenttypes of effects, i.e. intra- or inter-physician,must be disentangled.

We started from theempty model which only contains the intercept(overallpopulationmean)andresidualsforbothpatients (

s

²e) and physicians (

s

²phy). Thismodel enabled theintraclass correlation(ICC) tobecalculated, which isthe variancedue to physicians,i.e.

s

²phy/(

s

²phy+

s

²e).

Next, we introduced physician variables (Model 1). The interaction between patient distress and patient expressive suppression was then specified (Model 2). Rapport was added with both intra- and inter-physician effects disentangled since dependence can be assumed between patients of the same physicianonthisvariable(Model3).Within-effectindicatesthe effectofrapportonEAwithinaphysician,whilebetween-effect expresses theeffectofthegroupmeanofrapporton thegroup mean ofEA[36,37].In thefinalstep(Model4),theinteraction betweenrapportandpatientdistresswasspecified.

Modelfitwasevaluatedwiththe 2LogLikelihood( 2LL).The smallerthe 2LL,thebetterthemodelis.Thedifferencein 2LL between twomodelswastestedusing achi squaretest. Lastly, althoughmultilevelanalysesdonotprovideanR²fortheexplained variance,apseudoR²canbecomputedasthereductioninvariance betweentwomodels,forexample:(

s

²Model1

s

²Model2)/

s

²Model1. 3. Results

3.1. Descriptiveresults

Themeanforthephysicians’confidenceintheirabilitytodetect distress was5.2(SD=0.9),theyreported on averagevery good relationships with their patients (5.7/7, SD=1.1), and they overestimated patient distress by 2.77 points on average (SD=2.06;Table2).

3.2. Physicianeffects,Models0and1

TheICCcomputedfromtheemptymodel(Table3)was4%.This meansthatalmostallthevarianceintheoutcomedependsonlevel 1 variables and noton physicianvariables. In Model 1,neither physician empathicattitudenor self-efficacyin empathic skills wassignificantlyassociatedwithEAand,overall,themodelwas notbetterthantheemptymodel(

D

2LL=2.44,non-significantat p<.05,Table3).Model1wasthusdiscarded.

3.3. Patientvariables,Model2

In Model 2, the introduction of patient distress, patient expressive suppression and their interaction significantly im- Table1

Descriptionofsamples.

Mean(standarddeviation) [samplerange],or% Physicians(N=28)

Female(%) 64.3

Age 46.8(7.8)[31–64]

Medicalspecialty(%)

Medicaloncologist 75

Physicianinpalliativecare 10.7

Miscellaneous(e.g.oncologicalradiologist) 14.3

Yearsofexperienceinoncology 19.0(8.4)[1.5–33]

Patients(N=201)

Age 62.0(11.5)[27–89]

Livingalone(%) 34.3

Female(%) 72.6

Education(%)

Noqualification 9.5

Lessthanhighschool 37.8

Bachelorsdegreeormore 32.3

Mastersdegreeormore 20.4

Primarycancersite(%)

Breast 45.3

Colorectal 20.9

Lung 14.9

Prostate 5

Miscellaneous 13.9

Table2

Descriptiveresults.

Meanandstandarddeviation Samplerange Possiblerange

Patient-levelvariables(level1,N=201)

Expressivesuppression^a(ERQ) 15.0(6.4) 4–28 4–28

Qualityofrapport^b 5.7(1.1) 2–7 1–7

Patientdistress^a(Distressthermometer) 2.85(2.54) 0–10 0–10

Patientdistress^b(Distressthermometer) 4.65(2.62) 0–10 0–10

Empathicaccuracy 2.77(2.06) 0.04–8.45 0–10

Physician-levelvariables(level2,N=28)

Empathicattitude^b(JSPE) 97.6(11) 78–123 20–140

Self-efficacyinempathicskills^b 5.2(0.9) 3–7 1–7

a Patient-reported.

b Physician-reported.

provedthefitofthemodel(

D

2LL=14.7,p<.01,Table3).Greater patientdistresswasassociatedwithhigherEA(i.e.lessdeviation between patient and physiciandistress assessment in absolute value).TherewasnoeffectofpatientexpressivesuppressiononEA, butitinteractedsignificantlywiththelevelofdistressasratedby patients.The interactionwasplottedfor patientsuppressionat percentile20and80(Fig.1). Forpatientdistressunder5,lower expressive suppression was associated withlower accurate EA (higherabsolutevalue),thatisanoverestimationbythephysician whenpatientdistressisverylow.¹Forpatientdistressabove5,the pattern was the opposite: higher expressive suppression was associatedwithloweraccurateEA(i.e.anunderestimationbythe physician when patient distress is very high), while lower expressive suppression wasrelated to betterEA (low absolute value).

3.4. Physician-perceivedqualityofrapport,Models3and4 Onlythebetween-physicianeffectwassignificantly different fromzero.Physicianswhoreportedon averagea higherrapport withtheir patients evidencedon averagea betterEAscore(i.e.

lower absolute value). On the contrary, within a physician, variationinrapportwasnotrelatedtoEA(Model3).

The specificationof theinteractionterm(Model 4)between patientdistressandrapportimprovedthemodelatp<.001.The interactionwasplotted(Fig.2)forrapportatpercentile20(solid line, lowrapport) and 80(dotted line, highrapport), theother parametersbeingheldconstantandcorrespondingtothesample medians. For physician-perceived high rapport with a patient (dottedline),EAdecreasedslightly(slightlyhigherabsolutevalue) bypatientdistress.EAwasbetterforlowpatientdistressthanfor highpatientdistress.Forphysician-perceivedlowrapport(solid line),EAincreasedstronglybypatientdistress.EAwaslow(i.e.

high absolute value) for low patient distress (i.e. physician overestimationof distress),but highforhigherpatientdistress.

Table3

Summaryofmultilevelmodelsforthepredictionofphysicianempathicaccuracyonpatientdistress.

Models Emptymodel Model1

Notretained

Model2 Model3 Model4

Parameters Fixedeffects

Intercept 2.77^***(0.16) 2.77^***(0.16) 2.74^***(0.16) 5.74^***(1.16) 5.84^***(1.11)

Physicianempathicattitude 0.03(0.02)

Physicianself-efficacyinempathicskills 0.31(0.22)

Patientdistress 0.16^**(0.06) 0.17^**(0.06) 0.19^**(0.05)

Patientexpressivesuppression 0.04(0.02) 0.04(0.02) 0.03(0.02)

Patientdistresspatientexpressivesuppression 0.02^*(0.01) 0.02^*(0.01) 0.01(0.01)

Physician-perceivedqualityofrapport

Within-physicianeffect 0.10(0.17) 0.26(0.18)

Between-physicianeffect 0.52^**(0.20) 0.53^**(0.19)

Patientdistressphysician-perceivedqualityofrapport 0.22^***(0.07)

Randomeffects

Physicianvariances²phy 0.14(0.19) 0.09(0.17) 0.15(0.18) 0.01(0.14) 0

Patientvariances²e 4.06(0.43) 4.05(0.43) 3.76(0.40) 3.76(0.40) 3.57(0.36)

Modelfit: 2LL 858.10 855.66 843.40 837.19 826.19

Differencein 2LLbetween2models(df) 2.44(2dfwithM0) 14.7^**(3dfwithM0) 6.21^*(2dfwithM2) 11.00^***(1dfwithM3) Effectsignificance=estimate/standarderror(inbrackets).Foreachmodel,therandomslopemodel,whichallowstheslopestovaryacrossphysicians,wastested.Norandom slopemodelsweresignificantlybetterthanthemodelwithoutrandomslopeeffects;thesemodelswerethereforediscarded(datanotshown,availableonrequest).

* p<.05.

** p<.01.

*** p<.001.

0,9 1,8 2,7 3,6

0 3 6 9

Empathic accuracy in absolute value

Patient distress on the distress thermometer

Fig.2.Interactionbetweenpatientdistressandphysician-perceivedqualityof rapportonEA.Solidline:lowphysician-perceivedqualityofrapport(percentile20).

Dottedline:highphysician-perceivedqualityofrapport(percentile80).

1,4 2,1 2,8 3,5

0 3 6 9

Empathic accuracy in absolute value

Patient distress on the distress thermometer

Fig.1.Interactionplotbetweenpatientdistressandpatientexpressivesuppression onEA.Solidline:lowpatientexpressivesuppression(percentile20).Dottedline:

highpatientexpressivesuppression(percentile80).

1For very low patient distress, the physiciancould be either accurate or overestimatepatientdistress.Forexample,ifthepatientrateddistressat1withan EAof3points,itmeantthatthephysicianoverestimatedthepatient’sdistressby2 points.

Fordistressabovethevalueof4,EAforlowrapportbecameeven betterthanforhighrapport.

3.5. Randomeffects

Atphysicianlevel, allvariance wasexplainedfrom Model0 (

s

²phy=0.14)toModel4(

s

²phy=0).ThispseudoR²of100%means that these models are very good at explaining EA differences betweenphysicians.Inparticular,theintroductionofrapportin Model3wasthemostbeneficialforexplainingphysicianvariance (

s

²phyfrom0.15inModel2to0.01inModel3,Table3).Atpatient level,12.1%ofvariance (pseudoR²)wasexplainedbetween the emptymodel(

s

²e=4.06)andModel4(

s

²e=3.57).Thismeansthat much remains to be explained regarding patient or patient–

physicianrelationshipvariablesaffectingEA.

4. Discussionandconclusion

4.1. Discussion

At the physician level, only physician-reported quality of rapportwiththepatientwasrelatedtoEA.Physicianswithahigh rapport on average demonstrated high EA on average. At the patient level, patient distress interacted with both patient expressivesuppressionandphysician-perceivedqualityofrapport withthepatienttoexplainlevelsofEA.However,contrarytoour hypothesis, for high patient distress, physician-perceived good rapportappearedtoimpedeEA.

The theoretical model chosen assumes that EA depends significantlyonphysicians.Thiswasindeedfoundinexperimental studieswherea‘perceiver’(e.g.physiciansinourstudy)had to

‘read’ a ‘target’ (e.g. patients) in a social interaction [38,39].

However,itwasonlytruewhen‘targets’andtheissuesdiscussed betweenthetwopeoplewererelativelyhomogeneous:alwaysthe sameissuesdiscussedby‘targets’withsimilarsociodemographic characteristics[38,39].Incontrast,instudieswithheterogeneous

‘targets’or‘target’thoughts,onlyverylittleEAvariancewasdueto perceivers[40,41].TheverylittleEAvarianceduetophysiciansin ourresearch(ICCof4%)corroboratestheselatterstudiesanddoes not support the contention that, in naturalistic settings, EA dependsonstableperceiverskills.

In this respect,we didnot findanycorrelationof physician empathicattitudenorofphysicianself-efficacyinempathicskills withEA.Inlinewithpreviousresearch[42,43],thissuggeststhat empathicattitudewouldnotaloneguaranteeactualEA.Itmightbe that self-reported empathic attitude depends in part on social desirability and does not adequately reflect actual physician motivationandengagementtoinferpatientmentalstates[44].An alternativewouldbethatthemotivationtobeempathicdoesnot influence effective EA in practice [45]. Also contrary to our hypothesis, physician self-efficacy in empathic skills was not related to EA. This is compatible with previous observations suggestingthatpeopletendtooverestimatetheirempathicskills comparedtotheiractualones[46–48].

In contrast, physician-reported good rapport was positively related toEA, as already evidenced in clinical and non-clinical settings[49,50].However,afurtherandstrikingfindingwasthe unexpecteddirectionoftheinteractionfoundbetweenrapportand patientdistress.Itsuggeststhatphysician-perceivedgoodrapport couldbeabarriertoEAforhighlydistressedpatients.Itmightbe that,inordertoavoidplacingphysiciansindifficultywiththeir emotions,patientswouldwithholdtheirdistresswheninteracting withthem[51].Itcouldalsobethatphysicianswouldperceive rapportwithpatients for whomtheyhavegenerated animage whichtendstobestableovertime.Then,asdemonstratedinnon- clinicalcontexts[39,52],physicianswouldrelymuchmoreonthis

pre-existing image rather than on external cues coming from interactionswithpatientstoinfertheirmentalstates.Blindedby this pre-existing representation, they would not focus their attentiononchangesinpatientdistressresultingfromthedisease trajectory.

Nevertheless, to be detected, patient distress and concerns must be clearly expressed. Our result that patient expressive suppressionappearstoimpedeEAconfirmsexperimentalresearch findingsabouttheimportanceofemotiondisclosureforEA[20–

22,53].Thispointisall themorevital incancer settingswhere manycancer patientsconcealtheirpsychologicalconcernsfrom clinicians[51,54],assuming,amongotherreasons,thatemotional issuesarenotwithinthedoctor’sscope[51].

Theseresultsmustbeinterpretedinthelightofthefollowing limitations.First,duetothelimitedphysiciansampleandthus lowstatisticalpower,typeIIerrorsarelikely.Furtherresearch shouldreplicatethesepromisingresults.Secondly,measurement flaws should be noted. The single ad-hoc item for assessing physician-perceived qualityof rapportdoes not provideinfor- mation about which elements physicians draw on to judge rapport.However,thisdrawbackdoesnotdiminishitsinforma- tive valuein relationtoEA, whateverelements itis basedon.

Self-efficacyinempathicskillswasalsomeasuredusingasingle ad-hocitem,andtheJSPE,withaCronbach’salphaof0.69anda probablesensitivitytosocialdesirability,mightnotbetheideal measure for empathic attitude. Hence, our conclusion that physiciancharacteristicsdonotrelatetoEAmustberegarded with these limitations in mind. In order to circumvent these drawbacks,twopromisingapproachesmaybetoconsider:(1) physician empathic attitude but with a control for social desirability [55] and, (2) the general interpersonal sensitivity ofphysiciansmeasuredbystandardizedtests[10]insteadofself- reported empathic attitude. Another limitation of the EA measure on thedistress thermometer is that the same rating givenbythepatientandthephysicianmightnotmeanthesame thingtobothofthem.Finally,duetothecross-sectionaldesign, noclearcausaldirectioncouldbeestablished.Inparticular,there was no way to determine whether rapport facilitates EA or whether‘easilyreadable’patientsfacilitatephysician-perceived rapportwiththepatient.

4.2. Conclusion

In spiteoftheselimitations, thisstudyis oneoftherareEA researchworksinaclinicalsetting.Itchallengestheassumptions thatEAfalls,aboveall,withinthephysician’sskillsorcharacter- istics and that physician-perceived rapport always favors an adequateperceptionofpatients.Italsostrengthenstheimportance ofthepatient’scleardisclosureoftheirconcerns.

4.3. Practiceimplications

If our results were further confirmed, physicians should be awarethattheirempathicattitudeandself-efficacyindetecting patientdistresscannotbereliedon.Theyshouldbepromptedtobe moreattentivetopatientcues,evenandparticularlywhengood rapport is established. As suggested in other settings, asking patientsforfeedbackaboutwhattheyarefeelingcouldcounteract wronginferencesandpreserveEA[38,48,56].Thisisallthemore importantsinceEAhasbeenrelatedtoclinicaloutcomesinchronic conditions[10,11].

Inparallel,patientsshouldbeencouragedtotakeanactiverole in consultations, expressing more clearly their concerns and emotions.Thispointisparticularlyrelevantsincepatient-targeted interventionshavebeensuccessfulinenhancingpatientpartici- pationinoncologyconsultations[57].

Conflictofinterest Nonedeclared.

Acknowledgments

ThisstudywassupportedbyINCASHS2008and2009awarded toSergeSultanandAnneBre´dart.Itwasconductedwhenthefirst authorwasapostdoctoralfellowatUniversite´ ParisDescartesand theInstitutCurie.ThefirstauthoralsothankstheInstitutCurieand the SIRIC ONCOLille, Grant INCa-DGOS-Inserm 6041, for their supportduringthewritingofthearticle.

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