Prescriptions for Health Providers

Tovia G. Freedman, DSW, LCSW

Disclosures

Cancer Nurs. 2003;26(4) 

In This Article

Methods

Qualitative research methods[22,23] were used to collect empirical data to deepen understanding of the treatment decision-making process in oncology, using breast cancer as the case example. Over a 2-year period, 25 women throughout the breast cancer continuum and 12 of their physicians were observed in vivo during 130 medical encounters. In addition, each of the 25 women and 12 physicians participated in individual audiotaped interviews that were transcribed verbatim. Observations of the in vivo medical encounters, ordinarily completely private and uniquely intimate, afforded the opportunity to analyze the actual interactions that transpired between these patients and physicians using content analysis and comparative methods of research.

The observations of the medical encounters took place in departments of surgical and medical oncology, reconstructive plastic surgery, radiation oncology, and bone marrow transplantation. These practices exist within a hospital environment connected to and partially constructed by the social and political rules and norms of the society. Within this framework, patients and physicians make numerous complex medical decisions regarding diagnosis, treatment, and care. That is, individuals make decisions within a context influenced and guided by many overlapping social systems.

The research project was introduced to the potential patient-participants by a physician or nurse who sought permission for the researcher to enter the examination room during the patient's initial medical encounter with a physician who had previously consented to participate in the research. The researcher explained the project and obtained written, voluntary informed consent from each of the patients. In addition to observing the medical encounters, the researcher accompanied patient-participants as they went for tests involving the radiology clinic, nuclear medicine, and the phlebotomy laboratory. Interviews, an additional data source, in the form of conversations, took place during these times. Fieldnotes were logged after each meeting. In addition, semistructured, audiotaped interviews were conducted with each patient and physician participant. These ranged in length from 1 to 6 hours each.

There also were a varied number of telephone contacts with patient-participants between their medical appointments. These contacts yielded observations and impressions by patient-participants regarding their medical encounters and the treatment decision-making process. Fieldnotes of these conversations were included in the data analysis. Overall, contact was maintained with the patient and physician participants over the 2-year period of data collection.

The patient and physician participants included Asian, Asian American, black, and white American individuals. All the patient-participants were women. Their education background ranged from high school to the doctorate level. Most of the women had completed high school or college. Their ages ranged from 26 to 79 years (mean, 45.9 years). Their average income was $42,500 (range, $3,600-$100,000). Most of the patient-participants had private medical insurance. At the time of the initial interviews, 23 of the women received a diagnosis of localized or node-positive disease. In this group, one woman went on to autologous bone marrow transplantation, and one experienced metastatic disease during the course of the study. Two women who had metastatic disease when they entered the study participated as autologous bone marrow transplant patients. Both of these women died shortly after completion of data collection. Two women declined to participate. One voiced mistrust for research in general, and the other had advanced disease and was to be treated out of the state. Two additional women agreed to participate. However, their final pathology reports indicated that they did not have breast cancer. Patient-participant treatments included breast conservation with radiation therapy, breast conservation with radiation and chemotherapy, mastectomy and immediate reconstruction with or without chemotherapy, and mastectomy alone.

The physician-participants included five women and seven men ranging in age from 35 to 56 years (mean, 42.9 years). The oldest physician was trained in hematology, before oncology was a specialty, and one physician was in the first oncology residency program. Two of the physicians were MD and PhDs, and two had completed MS degrees. The patient-participant perspective is presented in the next section. The physicians' perpsective was published previously.[24]

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