Because effective doctor-patient communication has many benefits in cancer care, we primarily focus on the social interaction between the oncologist and the patient, that we expect to include the process through which communication can change the emotional state of the patient before and after the visit, and pave the way for patient satisfaction and trust in the physician. The study uses a multimodal approach. Doctor-patient interactions will be video-recorded to extract five behavioral indicators. Communicative behaviors of the physician, communicative behaviors the patient, misalignment in co-orientation and affiliation, expressions of patient confidence in the doctor, and linguistic markers of clinical uncertainty, will be used to explain positive and negative affective reactions after the visit controlling for the baseline emotional state at pretest, assessed using self-report and physiological data. The five categories will also be used to predict the perceived communication skills of the doctor and the patient's trust. Last, age, gender, ethnicity, and other trait-like dispositions will be used in data analysis to test a third research question, that is how individual and cultural differences that might bias doctor-patient communication. The research comprises two phases. Phase 1 will develop and pretest a reliable coding system for doctor-patient interactions during the visit and will involve about one-third of the total sample (approximately 20 patients). Phase 2 will verify the substantive hypotheses outlined above and will require about two-thirds of the sample (about 40 patients). Preliminary analyses will establish the reliability of the coding system and preprocess ECG data to obtain indices of emotional arousal. Substantive hypotheses will be tested using Partial Least Squares Structural Equation Modeling, a non-parametric approach suited for nonnormal or highly skewed data as well as with small samples.
The project is highly innovative for several reasons.
Firstly, it relies upon a multi-method research design, which combine quantitative measures, i.e. responses to scales assessing the emotional state and the perceptions of the patient, qualitative, i.e. close analysis of video recorded conversations transcribed accordingly to Conversation Analytic technique, and physiological measures, i.e. heart rate variability, obtained with a heart rate monitor device before, during, and after the visit. Using a multimethod approach provides a strong test of research hypotheses, leading to more firm conclusions about the three research questions.
Secondly, the project relies on a new coding system of the medical interaction developed within an emic approach.
Often coding systems are elaborated accordingly to principles that are derived from theories of standardly good communication such as those that shape protocols of Patient-Centered communication (Epstein, Street 2007), or, from the analysis of simulated visits with so-called standardized patients, frequently used for the examination and assessment of the communicative competences in the oncological context (cf. Feng et al 2013). On the contrary, the coding system of the participants' communicative actions developed in this project is built accordingly to bottom-up procedures, that is, accordingly to rules that ordinary participants manifest to follow when they engage in natural interaction (Sacks, Schegloff, Jefferson 1974), including that with the oncologist. There are several advantages in adopting an emic perspective, especially when considering patients of different language and cultures, for whom communicative behaviors and procedures to build, maintain or, repair to mutual affiliation may be subject, more than for participants in ethnically concordant interactions, to participants' negotiations acted upon moment by moment in the conversation. This opportunity is innovative also within the available literature in Conversation Analysis, within which the coding of interaction has been primarily applied in the context of primary care (cf. Stivers et al 2018), and only for what regards the physician's communicative actions related to the treatment recommendation.
Thirdly, a distinctive aspect of the study (as compared to most of the researches targeting communication in oncology, cf. Street and Voigt 1989, Street et al 2005, Isenberg et al 2018), is the opportunity to build a collection of visits that are video recorded (cf. Riddle et al 2003). This will allow a multimodal analysis, which will be helpful in assessing both verbal and nonverbal resources that participants to the visit rely on to build their mutual comprehension.
Finally, there are still very few studies, particularly in the Italian context, which examine in detail how the oncologist presents information to the foreign patient, how s/he involves him/her in the treatment decision-making processes in the visit, and how his/her participation is influenced by the presence of others (companions or linguistic-cultural mediators).
Built as such, the research results will prompt a substantial increase in the research of communication in oncology, both on national and international levels in so far as: 1) it will allow relating observational findings about communicative processes with self-reported and direct measures of interactants¿ inner states in a complex encounter such as the first oncological visit; 2) it will increase knowledge about the characteristics of oncological communication in context different non- Anglosaxon/anglophone contexts, predominant in the literature on communication and on oncological communication in particular; 3) it will enable the identification of potential differences in the communication aspects of the oncological visits, as well as in the participants¿ emotional responses reported indirectly and directly, in contexts involving Italian and foreign patients; 4) it will enable the opportunity to identify communicative "best practices" between the doctor and the patient , basing on the research findings, with particular regard to those communicative actions that may support the patient , mitigate distress and anxiety , and increase the patient¿s confidence in the doctor , and to design medical education interventions for doctors and medical students, based on those analyses.