Vol. 29 No. 5 May 2005 Journal of Pain and Symptom Management 489

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1 Vol. 29 No. 5 May 2005 Journal of Pain and Symptom Management 489 Original Article Impact of Physician Sitting Versus Standing During Inpatient Oncology Consultations: Patients Preference and Perception of Compassion and Duration. A Randomized Controlled Trial Florian Strasser, MD, J. Lynn Palmer, PhD, Jie Willey, MSN, Loren Shen, BSN, Ki Shin, MD, Debra Sivesind, MSN, Estela Beale, MD, and Eduardo Bruera, MD Department of Palliative Care and Rehabilitation Medicine (F.S., J.L.P., J.W., L.S., K.S., D.S, E.Br.) and Department of Neuro-Oncology (E.Be.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA Abstract The purpose of this study was to determine the impact of physician sitting versus standing on the patient s preference of physician communication style, and perception of compassion and consult duration. Sixty-nine patients were randomized to watch one of two videos in which the physician was standing and then sitting (video A) or sitting and then standing (video B) during an inpatient consultation. Both video sequences lasted 9.5 minutes. Thirty-five patients (51%) blindly preferred the sitting physician, 16 (23%) preferred the standing, and 18 (26%) had no preference. Patients perceived that their preferred physician was more compassionate and spent more time with the patient when compared with the other physician. There was a strong period effect favoring the second sequence within the video. The patients blinded choice of preference (P 0.003), perception of compassion (P ), and other attributes favored the second sequence seen in the video. The significant period effect suggests that patients prefer the second option presented, notwithstanding a stated preference for a sitting posture (55/68, 81%). Physicians should ask patients for their preference regarding physician sitting or standing as a way to enhance communication. J Pain Symptom Manage 2005;29: U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved. Key Words Communication style, patient s preference, perception of physician s compassion The study was presented at the annual meeting of the American Society of Clinical Oncology, Chicago, IL, May 31 June 3, 2003 (Poster Discussion Session # 2958). Address reprint requests to: Eduardo Bruera, MD, Department of Palliative Care and Rehabilitation Medicine, Unit 008, The University of Texas, M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA. Accepted for publication: August 7, U.S. Cancer Pain Relief Committee Published by Elsevier Inc. All rights reserved. Introduction Hospitalized cancer patients cope with not only their disease and illness, but also curtailed privacy, an altered sense of dignity, and oftenunpredictable confrontation with bad news. The physician s level of compassion in everyday encounters is increasingly perceived as important by patients. The patient s perception of his or /05/$ see front matter doi: /j.jpainsymman

2 490 Strasser et al. Vol. 29 No. 5 May 2005 her physician s compassion is associated with increased physical function and emotional health and decreased physical symptoms. 1 Compassionate physician communication styles were found in several studies to correlate with patient satisfaction 2 5 or better psychological adjustment to breast cancer surgery. 6 A recent meta-analysis reported that informativeness, interpersonal sensitivity, and partnership building, three dimensions of communication, are related to patient satisfaction, compliance, and medical information recall. 7 A videotaped study reported the positive effect of short and simple compassionate statements on patients anxiety and perception of physicians compassion. 8 These results support the premise that patient physician communication can affect the shortterm psychological distress and long-term psychological adjustment and quality of life of cancer patients. 9 Several elements of patient physician communication have been emphasized, such as fulfillment of the patients general and individual information needs; recognition of the patients main concerns related to multiple dimensions (physical, psychological, social, existential/spiritual); 13 a physician communication style that reflects compassion, empathy, care, and understanding of the patient s coping difficulties; 1,7 how to break bad news; 14,15 and recognition of the patient s preferences regarding decision-making. 6,16 Our group previously found that the use of audiocassettes 11 and prompt sheets 17 could help improve communication and the perception of helpfulness among patients. Non-verbal communication also is an important element of physician patient communication, especially contributing to the emotional aspects of communication. 21,22 Traditional education regarding communication emphasizes the importance of physicians sitting down during the visit. 15,23,24 However, in daily practice it may be difficult due to time, physical space reasons, or availability of chairs for physicians to sit down during a visit. This is particularly difficult in the inpatient setting because of space limitation for health care professionals. There have been no prospective studies addressing the effect of physician posture on patient s perception of physician communication style. However, uncontrolled studies found that a standing position was perceived to be more deceptive 25 or dominant. 26 Because patient satisfaction is associated with visit duration in family medicine practice, 27 it is possible that patients estimate that the visit duration is longer when the physician is seated. To examine the isolated effect of sitting versus standing by the physician during an oncology inpatient visit, this study used a randomized, crossover, videotape-based design to address the following questions: 1) Do patients prefer a physician who is sitting or standing during an inpatient visit? 2) Is the sitting physician perceived as more compassionate than the standing physician? 3) Do patients perceive the duration of the visit as being longer if the physician sits? The large variation in circumstances and content of daily physician and patient interviews would make the results extremely difficult to interpret. Therefore, we chose to conduct a standardized laboratorybased study. Methods The University of Texas M. D. Anderson Cancer Center Institutional Review Board approved the study, and all patients provided written informed consent. Videotape Development Two videotapes with the physician standing or sitting as the primary difference were produced. The script of 9.5 minutes reflects a standard inpatient oncology consultation, with the discussion of the next steps in the light of progressive disease despite antineoplastic treatment. The content of the video is based on consultations from the palliative care clinic and audiotapes. 11 The script used a balance of medical and everyday language and was designed according to state-of-the-art guidelines about physician communication styles, patient information needs, the addressing of active multidimensional concerns, how to break bad news, and patient preferences regarding decision making. 1,8 12,14 16,24 Two professional actors not employed by M. D. Anderson Cancer Center portrayed the physician and patient. The video started with the scene of the patient as it is recognized that the initial presentation of the patient s problem is important. 7 The physician entered the

3 Vol. 29 No. 5 May 2005 Impact of Physician Sitting VS. Standing 491 room and either pulled up a chair and sat in it or pushed the chair away and remained standing. The gender and age of both the patient and physician were chosen to reflect the averages at M. D. Anderson Cancer Center (male physician in his fifties; female patient in her sixties). The same actors portrayed the physician and patient in both video sequences. The actors were blinded to the hypothesis of the study. They were told that we were examining the patient s perception of the physician s communication style, and we requested that they play their roles in both sequences as neither very emphatic nor very cold. The content and length of the two sequences were made to be identical by using an invisible earphone playing the script while acting. The actors were instructed to minimize non-verbal communication, use neutral body positions, maintain appropriate eye contact, and keep an even tone of voice. They were also directed to maintain an average compassion level. Twenty-seven volunteers from our team including nine non-health care workers listened (only audiotapes were provided) to the text of both sequences. All of them were asked to blindly identify whether the physician in the tape was sitting or standing: 5/27 (19%) chose correctly, 12/27 (44%) chose incorrectly, and 10/27 (37%) were unable to hear a difference. A total of seven health care professionals, including three social scientists specializing in patient s communications, reviewed the two videotapes. They concluded that there was not a substantial difference in either the physician or patient in two sequences, with the exception of the physician s posture. Patients Sixty-nine patients with advanced cancer were recruited from the inpatient units and outpatient areas of the Department of Palliative Care and Rehabilitation Medicine at M. D. Anderson Cancer Center. They were at least 16 years old and had a normal cognitive status defined as a normal state of arousal and an absence of obvious clinical findings of confusion or memory or concentration deficit. Also, the patients were able to understand and read English. Video Watching by Patients Patients were randomized to view video A, in which the physician was standing in the first sequence and sitting in the second sequence, or video B, in which the physician was sitting in the first sequence and standing in the second sequence. After undergoing baseline assessments (demographic information, Hospital Anxiety and Depression Scale (HADS) questionnaire 1 ), the patients watched the two short videotaped sequences with a neutral interval between the two. The research nurse was blinded to the order of the two sequences and entered the patient room during the interval between the two sequences to assist the patients in filling out the assessment instruments. The patients were blinded to the purpose of the study, randomization of sitting versus standing, and similarity of the wording and length of the scripts; they were informed that the purpose of the study was to evaluate two methods of communicating to determine which they prefer. Assessments Four sets of assessments were performed: 1) before watching the videos (demographics, HADS); 2) after watching each video sequence (physician compassion and attributes, patient satisfaction [with communication] questionnaire [PSQ]); 3) at the end of both video sequences (patients preference for physician seen in the first sequence or second sequence, perception of physician compassion and consultation time); and 4) after telling the patients the true purpose of the study (description of importance of sitting). The HADS questionnaire has been validated in a number of clinical situations and widely used in medically ill patients. 28 After viewing each sequence, patients were asked about their perception of physician compassion (PCo) 8 and general physician attributes (GPA) 8 by using a semantic differential format of pairs of statements with the 10-point Likert scale (0 worst, 10 best). For the perception of physician compassion, five statements of warm cold, pleasant unpleasant, compassionate distant, sensitive insensitive, and caring uncaring were used. This scale has been reported to be internally consistent (Cronbach s alpha coefficient, 0.92) in cancer survivors and non-cancer patients. 8 For the general physician attributes, five statements were used: 1) wants best for patient, 2) patient involvement in decision making, 3) encourage patient questions, 4) acknowledging patient s emotions, and 5)

4 492 Strasser et al. Vol. 29 No. 5 May 2005 caring for patients. The patients were asked to rate each of the questions on a scale of 0 (worst) to 10 (best). The scores with this tool ranged from 0 (worst) to 50 (best). After each video sequence the patients also completed the PSQ to evaluate how satisfied they would be with the physician s position (in general, with the physician s communication style). The PSQ was based on the family practice setting and consisted of 10 items rated on the Likert scale. The scores ranged from 0 (worst) to 100 (best). 29 After viewing each video sequence, the patients were asked about their level of physician preference ( Which of the two physicians you saw in the two video sequences would you rather have as your doctor? ), subjective perception of the time spent by the preferred physician (0 no more time, 10 much more time), and estimated more minutes spent by preferred physician ( How many more minutes did your preferred physician spend on the video compared with the physician you like less? ). After the patients completed watching both video sequences and the assessments, they were informed about the true rationale behind the study. The patients estimation of the quality of the actors was assessed with a single question ( How realistic was the professional actor at playing the physician you saw in the video? ). Patients also were asked about the importance of sitting ( How important is it for YOU that YOUR physician sits down when talking with YOU? ). Statistical Analysis The primary objective of this study was to determine whether the proportion of patients who blindly preferred the physician sitting was significantly different from that of proportion of patients who preferred the physician standing. The patients were also given the option of no preference. This study used a blinded crossover design to determine preference regarding the style of presentation (sitting or standing), while holding other variables in the videotapes constant. Each patient acted as his or her own control. Using a one-sample binomial test, we estimated that there was a statistically significant difference between a null-hypothesis proportion of preference for sitting of 50% (expected to occur by chance) versus 35% or less (or 65% or more), with a two-sided significance level of 0.05 and power of 80%. Using the chi-square test (with 1 degree of freedom), we sought to determine whether the proportion of patients who preferred the physician sitting (vs. standing or no preference) differed according to the video sequence. In a crossover analysis of continuous variables, three two-sample t-tests evaluated the group effect (the perceived difference between sitting and standing), period effect (whether the order of viewing the physician standing and sitting affected the patients ratings of physician compassion), and an interaction effect (whether the groups differed according to the order of the video sequence). This is equivalent to an analysis of variance with the independent variables of patient, position (sitting or standing), and time (order of video sequence). Paired t-tests were used to compare differences in the ratings of the two videos within both patient groups according to the order of the video sequence. Results Patient characteristics are summarized in Table 1. Most of the participants were white Table 1 Patient Characteristics (n 69) n (% a ) Age, years Median (range) 57 (20 86) Sex Female 36 (51) Marital status Married 46 (67) Race/Ethnicity White 58 (84) Black 5 (7) Hispanic 5 (7) Asian 1 (1) Education College or higher 45 (65) High School 18 (26) 12 grade 6 (9) Primary cancer GU 11 (16) Lung 9 (13) GI 8 (12) Hematological 7 (10) Sarcoma 6 (9) Other 28 (40) Cancer stage Metastatic disease 49 (71) Locally recurrent disease 20 (29) a Percentage, unless otherwise specified.

5 Vol. 29 No. 5 May 2005 Impact of Physician Sitting VS. Standing 493 Table 2 Patient s Blinded Choice After Viewing the Video Video A Video B (stand/sit) (sit/stand) Total (n 35) (n 34) (n 69) Choice n (%) n (%) n (%) Sitting 24 (69) 11 (32) 35 (51) Standing 4 (11) 12 (35) 16 (23) No preference 7 (20) 11 (32) 18 (26) (84%) and had a college education or higher (65%). Forty-nine patients (71%) had metastatic disease, the remaining patients had locally recurrent disease. The patient preferences regarding sitting and standing are listed in Table 2. Most of the patients (69%) who saw video A (physician standing first, then sitting) preferred the sitting sequence. However among those who saw video B, the preference was equally distributed between sitting (32%), standing (35%), and no preference (32%). The overall blinded preference for sitting was only 51%, which was not significantly different from that expected to occur by chance (50%). As shown in Table 3, the patients assessments of physician compassion and other general physician attributes were found, for the most part, not to differ significantly between sitting and standing (most significant variable: compassion, P 0.07). However, for all but two of the seven variables, the order of the video sequence was statistically significant favoring the second video (P 0.05). We also looked at differences between sitting and standing in the two groups of patients who saw the videos in two different sequences (Table 4). We found that in the group of patients who saw video A (physician standing first then sitting), assessments of physician compassion and other general physician attributes in the two sequences differed significantly for six of the seven variables (P 0.05). In contrast, no significant differences were detected in the group who saw video B (physician sitting first then standing). The question How important is it for YOU that YOUR physician sits down when talking with YOU? was scored (on a scale of 0 to 10, 0 not important, 10 very important); overall, the mean score ( standard deviation) was Fifty-five of 68 patients (81%) gave a score greater than 7 (favoring sitting). The score was not significantly different (P 0.2) in 35 patients who preferred sitting ( ) and the 16 patients who preferred standing ( ). However, the score was significantly different (P 0.05) between the 17 patients who had no preference (6.4 4) and the 51 patients who had preference ( ). The patients subjective perception of the time spent by their preferred physician (0 no more time, 10 much more time) and time difference between the two physicians was and minutes, respectively, in the 34 patients who preferred sitting physician, and 4.8 3(P ns) and minutes (P ns), respectively, in the 16 patients who preferred standing physician. The question, How realistic was the professional actor at playing the physician you saw in video? was scored by 69 patients with a mean of 7.35 ( 2.6) (range: 0 not realistic, 10 most realistic). The score was not significantly different according to the order of the video Table 3 Overall Differences Between Sitting and Standing and Between First Sequence and Second Sequence a Sitting Standing Sequence 1 Sequence 2 Mean Mean Mean Mean Root (SD) (SD) P (SD) (SD) P MSE Compassion (PCo) (12.8) 27.6 (12.7) (13) 31.5 (12.2) General Physician Attributes (GPA) Wants best for patients, (2.9) 6.4 (2.6) (3.0) 6.8 (2.4) Patients involvement in decision making, (3.2) 6.0 (3.1) (3.4) 6.8 (2.8) Encourage patient s questions, (3.0) 5.9 (2.8) (3.1) 6.7 (2.7) Acknowledging patient s emotions, (3.1) 5.4 (3.1) (3.1) 6.0 (3.1) Caring for patients, (2.8) 6.1 (2.9) (3.0) 6.8 (2.7) PSQ Satisfaction 53.9 (29.3) 52.0 (28.9) (28.3) 57.3 (29.2) SD standard deviation; MSE mean square error. a Significance levels based on analysis of variance with dependent variables of patient, position, and time. Error term used for both tests is square root of mean square error.

6 494 Strasser et al. Vol. 29 No. 5 May 2005 Table 4 Comparisons of the Mean Compassion (PCo), General Physician Attributes (GPA), and Patient Satisfaction Questionnaire (PSQ) Between Two Video Sequences Video A Video B mean (SD) mean (SD) Stand Sit P-value a Sit Stand P-value a Compassion (PCo), (12.5) 32.6 (12) (13) 30.3 (12.5) 0.18 General Physician Attributes Wants best for patients, (2.8) 6.9 (2.7) (3.1) 6.7 (2.2) 0.26 Patient involvement in decision making, (3.4) 7.1 (2.8) (3.5) 6.4 (2.7) 0.41 Encourage patient s questions, (3.1) 6.9 (3.0) (3.1) 6.4 (2.4) 0.91 Acknowledging patient s emotions, (3.0) 6.3 (3.0) (3.3) 5.8 (3.3) 0.91 Caring for patients, (3.0) 7.1 (2.6) (2.9) 6.5 (2.8) 0.42 PSQ Satisfaction 48.0 (27.7) (56.4(30.6) (29.4) 55.8 (30.0) 0.12 PCo Patient s Assessment of Physician Compassion: 5 items, 0 10 scale each item, (total score: 0 worse, 50 best); PSQ Patient Satisfaction Questionnaire, 10 items, 0 10 scale each item, (total score: 0 worst, 100 best). a Significance of the differences of the 7 variables in the sequence sitting versus standing or standing versus sitting, respectively, using a paired t-test with two-sided significance level. sequence. The mean realism score of the actor was 7.7 ( 2.6) in standing sitting sequence and 7.0 ( 2.6) in sitting standing sequence. At the end of the questionnaire, the patients were allowed to make comments regarding feelings of being upset by watching the video or concerns about the study overall; they reported no adverse events. In some cases, patients expressed that the physician in the video was less pleasant or desirable than their own physicians. None of the viewing sessions had to be interrupted due to patient distress. Discussion In this randomized crossover study, we examined the effect of the physician s posture sitting versus standing during an inpatient oncology consultation on the patient s blinded choice and perception of compassion and consultation duration. We controlled for many possible confounding factors regarding verbal and nonverbal communication. About half of our patients (51%) blindly preferred the sitting physician. However, a substantial number of patients preferred the standing physician (23%) or expressed no preference (26%). There was a trend favoring the sitting physician with regard to increased compassion (P 0.07) and the perception that the physician encouraged patient questions (P 0.05) and cared for patients (P 0.09). Other attributes and patient satisfaction with the physician s communication (PSQ) did not differ according to the physician s posture. Upon completion of the study, more than 80% of the patients expressed that they thought it was important for the physician to sit during the consultation. Our findings suggest that this group of well-educated, predominately white American patients prefer that the physician sit during visits. However, it is likely that the relevance of the physician s posture is limited when considered within the context of all of the other verbal and non-verbal aspectsof amedical visit, 21 and different components (i.e., task orientation, affection, partnership building) 3,24 of physician behavior. Therefore, many patients who state that it is important for the physician to be seated may not blindly select a sitting physician. The relative importance of sitting posture as compared with other variables of physician patient communication, such as eye contact, empathetic listening, asking open-ended questions, and the general setting (privacy, freedom from noise) should be addressed in future research. Our findings show that patients perceived that their preferred physician spent more time in their consultation than the non-preferred physician did, whether the preferred physician was sitting (n 35) or standing (n 16). These results are consistent with those of a prospective survey of 1486 primary care visits, in which the patient s perception of the ambulatory visit duration was associated with higher patient satisfaction, and that elements of patients anticipated need of longer visits included worries about his or her health and self-ratings of lower overall health. 27 The overall patient perception regarding consultation time was that the preferred visit

7 Vol. 29 No. 5 May 2005 Impact of Physician Sitting VS. Standing 495 lasted approximately 7 to 9 minutes longer than the non-preferred one did. Further research should confirm that simply adopting the posture preferred by the patient results in the perception of a longer consultation visit. Perhaps the most remarkable and unexpected finding of this study was the strong period effect. Patients consistently preferred the physician they saw in the second sequence with regard to overall choice, perception of compassion, time spent, physician attributes, and the PSQ. We have not been able to identify any previous reports of such a finding. It is possible that the generally bad news conveyed by the physician to the patient in this video was more readily accepted by the patients when they saw the video for the second time, therefore, they may have perceived the second physician to be more effective. These findings are potentially of significant importance in addressing the complex issue of patient choice when a patient is exposed to different clinical or experimental treatment options. This study has a number of limitations. First, the physician and patient belonged to specific age and ethnic groups attempting to represent a cross-section of oncology patients and physicians. However, our results may not be applicable to physicians and/or patients of different sexes, races, or age groups. Also, a potential source of bias is the fact that the patients were exposed to only two versions of one simulated patient physician encounter. However, exposing a single patient to multiple patient physician encounters would require spending several hours reviewing video with identical content. Thus, compliance with this approach might be reduced due to fatigue and/or boredom. Alternatively, several hundred patients could be randomly chosen to view different patient physician encounters. This should be attempted in future research, but it may be logistically difficult. A recent meta-analysis showed that female primary care physicians prefer more patientcentered communication and engage in longer visits when compared to their male colleagues. 31 The general nature of the discussion was a typical brief oncology interview focusing on the failure of a previous chemotherapy regimen for advanced breast cancer. The perception of patients regarding consultation may be quite different for neutral and positive interviews. In addition, a videotape-based study with breast cancer patients reported that patients prefer a patient-centered approach to the consultation (in contrast to a doctor-centered approach) when the patient has a poor prognosis. 32 Furthermore, the actors in our study controlled for known predictors of communication, such as distance from each other, eye contact, and time allotted for questions, and they maintained an average compassion level. It is possible that other factors are much more relevant than the physician s posture in influencing patient choice and perception of compassion. The script we used was designed based on audiotaped interviews 11 and applied recognized essential elements of good patient physician communication. 1,6,7,10 16 However, some patients might prefer a distinct communication pattern from their physician, 33 and patient expectations 34 might influence patients perception of communication style. Our study tested the hypothesis that the physician s posture influences patients choice of communication style and perception of compassion, consultation time, and physician attitude. Posture might influence other variables too, such as patients cancer-related self-efficacy and perceived control over the disease, 35 perception of having a choice, 36 recall of information, 37 burden of symptoms, 38 and possibly even psychological long-term outcomes. 39 Even though we found no differences in the main outcomes in patients with or without baseline anxiety or depression, we did not assess patient distress or anxiety after each video sequence. 8,30 Future studies should assess whether the physician s posture influences the patient s perception of technical dimensions, such as knowledge, competence, and effectiveness, as compared with that of the more emotional dimensions addressed in this study. It is possible that a sitting physician is perceived as more compassionate, whereas a standing physician is perceived as more knowledgeable, competent, and effective. Future studies should also be conducted with large enough sample sizes to allow for multivariate analysis of the contribution of the sitting/standing video sequence, patient s anxiety, and subject demographics on the subjective preference for one or the other physician in the video. In summary, about half (51%) of the patients in our study blindly chose the video with the

8 496 Strasser et al. Vol. 29 No. 5 May 2005 physician in sitting position, and there was a trend toward perception of higher levels of compassion in these cases. However, these results are not conclusive and more research is needed to better characterize the relative importance of physician posture in medical communication. Until better knowledge shows otherwise our findings suggest that physicians should ask patients for their preference for sitting or standing during interviews. Our findings emphasize the importance of developing appropriate evidence to support or modify the education that has been provided to physicians and other health care professionals regarding communication. Acknowledgments This work was made possible by the members of the multidisciplinary palliative care and rehabilitation team, the staff at the symptom control and palliative care outpatient center, the palliative care research team, The University of Texas Television Productions, and by all of our patients and their loved ones. Florian Strasser was supported by a grant from Swiss Cancer Research (BIL grant KFS ). References 1. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ 1995; 152: Willson P, McNamara JR. How perceptions of a simulated physician-patient interaction influence intended satisfaction and compliance. Soc Sci Med 1982;16: Buller MK, Buller DB. Physicians communication style and patient satisfaction. J Health Soc Behav 1987;28: Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract 1991;32: Fellowes D, Wilkinson S, Moore P. Communication skills training for health care professionals working with cancer patients, their families and/or carers. Cochrane Database Syst Rev 2004;(2):CD Blanchard CG, Labrecque MS, Ruckdeschel JC, et al. Information and decision-making preferences of hospitalized adult cancer patients. Soc Sci Med 1988;27: Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Med Care 1988;26: Fogarty LA, Curbow BA, Wingard JR, et al. Can 40 seconds of compassion reduce patient anxiety? J Clin Oncol 1999;17: Maguire P. Improving communication with cancer patients. Eur J Cancer 1999;35: McPherson CJ, Higginson IJ, Hearn J. Effective methods of giving information in cancer: a systematic literature review of randomized controlled trials. J Public Health Med 2001;23: Bruera E, Pituskin E, Calder K, et al. The addition of an audiocassette recording of a consultation to written recommendations for patients with advanced cancer: a randomized, controlled trial. Cancer 1999; 86: Smith TJ. The art of oncology: when the tumor is not the target. Tell it like it is. J Clin Oncol 2000;18: Heaven CM, Maguire P. The relationship between patients concerns and psychological distress in a hospice setting. Psychooncology 1998;7: Ford S, Fallowfield L, Lewis S. Doctor-patient interactions in oncology. Soc Sci Med 1996;42: Baile WF, Buckman R, Lenzi R, et al. SPIKES A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5: Bruera E, Sweeney C, Calder K, et al. Patient preferences versus physician perceptions of treatment decisions in cancer care. J Clin Oncol 2001; 19: Bruera E, Sweeney C, Willey J, et al. Breast cancer patient perception of the helpfulness of a prompt sheet versus a general information sheet during outpatient consultation: a randomized, controlled trial. J Pain Symptom Manage 2003;25: Larsen KM, Smith CK. Assessment of nonverbal communication in the patient-physician interview. J Fam Pract 1981;12: Ruusuvuori J. Looking means listening: coordinating displays of engagement in doctor-patient interaction. Soc Sci Med 2001;52: Robinson JD. Getting down to business: talk, gaze, and body orientation during openings of doctor-patient consultations. Human Comm Res 1998;25: Strecher VJ. Improving physician-patient interactions: a review. Patient Couns Health Educ 1983;4: DiMatteo MR, Taranta A, Friedman HS, et al. Predicting patient satisfaction from physicians nonverbal communication skills. Med Care 1980;18: Baile WF, Glober GA, Lenzi R, et al. Discussing disease progression and end-of-life decisions. Oncology 1999;13:

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