Things left unsaid: important topics that are not discussed between patients with systemic sclerosis, their carers and their healthcare professionals-a discourse analysis.

INTRODUCTION: Systemic sclerosis (SSc) is a rare condition that can be complicated by interstitial lung fibrosis (SSc-ILD)-a major cause of mortality. This study explored information and communication needs of patients with SSc-ILD and their carers to understand what they are and whether they are met. METHODS: Qualitative research was performed, including in-depth individual interviews and observed conversations between pairs of patients, physicians and nurses, and between patients and physicians discussing experiences of SSc-ILD. The study was performed in Germany, Italy, Spain, the UK and the USA. Participants included 42 SSc-treating physicians, 21 patients with diagnosed SSc-ILD, 16 specialist nurses and five carers. RESULTS: Prognosis and mortality were the main unspoken topics acknowledged by patients, carers and healthcare professionals. Patients and carers felt afraid to ask physicians about mortality, and most physicians reported avoiding the question because their duty was to give patients hope and avoid causing additional distress. Patients often felt unable to ask physicians about relationships, family and work because of time constraints or because they felt these were not topics physicians would be concerned about. Often, specialist nurses felt that they had insufficient knowledge to provide adequate support. CONCLUSION: Key topics, including mortality and prognosis, are rarely openly discussed, leaving patients uncertain and anxious about the future. By communicating about difficult but important topics, physicians and nurses could help patients and carers manage and plan their lives. This study shows that a multi-professional team-based communication approach is likely to better address patient needs and priorities. KEY POINTS: • Key topics in SSc or SSc-ILD, such as mortality and prognosis, are rarely openly discussed in clinical consultations. • By communicating difficult but important topics, physicians and nurses could help patients manage their disease and plan their lives. • A multi-professional team-based communication approach is likely to better address patient needs and priorities and could be easily implemented without the need for significant additional resources.

Challenges in physician-patient communication for optimal management of systemic sclerosis-associated interstitial lung disease: a discourse analysis.

INTRODUCTION: Systemic sclerosis (SSc) is a rare, potentially life-threatening condition. The prognosis is difficult to predict, and treatment is complex. This can be difficult to understand or explain, posing challenges for effective physician-patient communication. Our study assessed communication between physicians and patients with systemic sclerosis-associated interstitial lung disease (SSc-ILD) to identify information gaps and needs. METHODS: Twenty-three 20-min consultations between physicians (rheumatologists, pulmonologists) and patients (19 real, 4 actors) with diagnosed SSc-ILD across 6 countries were observed and recorded. Interactional sociolinguistic discourse analysis was used to understand the pattern and meaning of communication, whether the needs of both participants were met, and the level of understanding between participants. RESULTS: In most consultations, patients were given little opportunity to explain their concerns or ask questions. Physicians used plain language but would revert to medical terminology for complex issues. Patients would also use medical terminology, despite not fully understanding the terms, which led to some physicians mistakenly believing that patients had a better understanding than they did. Differences in cognitive models between physicians and patients were often responsible for misunderstandings. However, during effective consultations, patients were invited to tell their story, and physicians used techniques to check and demonstrate understanding, express empathy and build rapport. CONCLUSIONS: Communication challenges between physicians and patients limit joint understanding of SSc-ILD and may result in both parties misunderstanding important information and patients being less aware of self-help management approaches. Strategies should be developed with physicians to facilitate effective communication and increase patient understanding and support. Key Points • Physicians and patients have different explanatory models for SSc-ILD. • The differences between the physician-constructed model of SSc-ILD and the personal model patients construct often result in misunderstandings. • Many patients with SSc have learned the medical terminology for their condition, but their often limited understanding may lead to missed opportunities for physicians to provide clear explanations and correct misperceptions. • The style of consultation determines the information patients share and the degree to which they feel supported by, and confident in, their physicians' care.