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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs
Relying on patients to volunteer information or on providers to elicit it in the course of standard care both are unlikely to be adequate. A study of the ability of medical oncologists and nurses in the United States to recognize on their own the psychosocial problems of their oncology patients found that these providers frequently failed to detect depression at all and when they did, greatly underestimated its seriousness (Passik et al., 1998; McDonald et al., 1999). This finding parallels data on the low rate of detection of depression in primary care settings when depression screening tools are not used. And while there is evidence for the effectiveness of structured clinical interviews in detecting some psychosocial needs (e.g., for treatment of depression), this approach is criticized for the amount of time it takes and the requirement for specialized (costly) personnel to conduct the interviews (Trask, 2004). Patients’ reluctance to volunteer information about their need for psychosocial services (Arora, 2003) can also impede the detection of problems.
In contrast, several screening tools and in-depth needs assessment instruments have been found to be effective in reliably identifying individuals with psychosocial health needs. Screening involves the administration of a test or process to individuals who are not known to have or do not necessarily perceive that they have or are at risk of having a particular condition or need. It is used to identify those who are likely to have a condition of interest and should benefit from its detection and treatment. A screening instrument yields a yes or no answer as to whether an individual is at high risk. A positive screen should be followed by a more in-depth needs assessment. In some practices, needs assessment may be performed without a preceding screen.
Many screening instruments are brief and can be self-administered by the patient—sometimes in the waiting room before a visit with the clinician. Instruments range from the low-tech, requiring only paper and pencil, to the high-tech, using a computer-based touch screen; some of the latter instruments automatically compare responses with those given previously and generate an automatic report to the clinician. The success of many practices in using such screening tools counters generalizations that patients are unwilling to discuss psychosocial concerns. Still, as discussed below, too few clinicians employ these reliable methods routinely to identify patients with psychosocial health needs.
Current practice Screening for psychosocial health needs using validated instruments is not routinely practiced in oncology. In a national survey3 of