Responding to the active and passive patient: flexibility is the key

BACKGROUND: Patients vary widely in their preferences and capacity for participation in medical decision-making. This study aimed to document oncologist responses to more extreme presentations and identify helpful and unhelpful strategies for clinicians. PATIENTS AND METHODS: A trained actor played the role of a patient with early stage breast cancer who was attending her first consultation with a medical oncologist. She adopted in random order two different consultation participation styles: that of a very anxious, active patient, and that of a depressed, passive patient. Medical consultations between the actor and 16 medical oncologists were videotaped and then analysed qualitatively by two trained raters. RESULTS: Strategies that facilitated shared decision-making with both patient types and were positively endorsed by the actor/patient included explicit agenda-setting, active listening, checking understanding, endorsing question-asking, offering decisional delay, and non-verbal behaviours conveying empathy and warmth. Oncologists successfully negotiated with the active patient to share control of the consultation, and responded to emotional cues from the passive patient. Unhelpful strategies were also identified. CONCLUSIONS: Few clinicians receive training in responding to differing communication styles in their patients that could potentially cause conflict and hinder optimal treatment decision-making. This study suggests some useful strategies for oncologists to consider, to widen their behavioural repertoire in the cancer consultation.