Abstract B17: Physician techniques in shaping prognostic conversations: Implications for black women.
Authors: James Jennifer 
Published: August 2014

Abstract
Background: Physician attitudes and adeptness at initiating end-of-life (EoL) conversations has been shown to be one of the greatest predictors of when patients with advanced metastatic cancer will make the transition from active treatment to EoL care. In the Medical Outcomes Study, minority patients rated their physicians decision-making styles lower than their white counterparts. Weeks (1998) writes that many cancer patients have an inadequate understanding of prognosis, and their overestimation of survival may greatly influence their treatment decisions. It is this discrepancy between what the patient assumes will happen and what the physician knows to expect based on medical expertise that is dependent on the patient-physician relationship. How prepared both patient and physician are for the various outcomes is based in their working relationship. Given these disparities, it is important to understand providers' experiences in conducting EoL conversations, and the particular barriers they perceive in communicating information to help patients make EoL decisions.
Methods: Semi-structured, in-depth interviews were conducted with 15 oncologists at a major academic research hospital. Physicians were asked about the patient-physician relationship and EoL decision making in patients with advanced cancer. Data was transcribed and analyzed using Atlas.ti in the grounded theory tradition.
Findings: Physicians reported that they view their role as being an adviser or an educator to the patient. They therefore see this process of preparing a patient for what to expect during the disease and treatment trajectory, and alerting them to possible outcomes as essential parts of their role as oncologists. These conversations and the patient-physician relationship make up a social process known as Prognostication.
This study identified three main types of prognostication: Quantitative, Categorical and Qualifying. All of these prognostic strategies can be further delineated into Death-Focused, Cure-Focused or Chronic-Disease-Focused Prognostication. Each of these sub-strategies can help frame and guide the process of prognosis. Physicians use their experience and intuition to determine the type of prognostication to use with their patients and what information to share in order to maintain a functioning therapeutic relationship and guide the patient through the disease and treatment trajectory.
Discussion: Physicians' use of experience and intuition to shape prognostic conversations with patients has important potential implications for women of color. A growing body of literature has documented the use of stereotypes by physicians in clinical encounters with Black patients. Research by van Ryn and Burke (2000) demonstrates that physicians tend to view Black patients as less intelligent, educated, pleasant and rational, as well as less likely to be compliant and more likely to lack social support. These are all traits pointed to by physicians in the current study as essential to the patient-physician relationship and indicators for how much prognostic information a patient would want to receive. The brief time allotted for most clinical encounters means that physicians may rely heavily on race-based stereotypes in order to gain an understanding of how much prognostic information patients want and how they want it presented.
Citation Format: Jennifer James. Physician techniques in shaping prognostic conversations: Implications for black women. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr B17.