Managing the Clues in Cancer Care

March 2016 | Berry, Leonard L.

After building a strong relationship with her medical oncologist and giving informed consent for intensive chemotherapy, a middle-aged woman with newly diagnosed large cell lymphoma was ushered through an unmarked door into a large, poorly lighted, windowless room. She saw 12 closely spaced infusion chairs, separated only by thin, dingy curtains. Nurses with their backs to the patients sat in front of computer monitors scattered throughout the room. She found little room to navigate through patients, family members, and staff on her way to the only available chair. Although she had managed her fears with poise during the preceding weeks, she now experienced severe anxiety and a sudden loss of confidence in her oncologist.

Cancer care is a high-emotion service. The need for the service alone elicits intense emotions1. Patients’ experiences, good and bad, accumulate as a result of clues embedded in these experiences. Clues are the signals patients perceive in using a service. When interacting with a system of care, patients filter clues, organizing them into a set of impressions. Patients may perceive clues rationally or emotionally, and clues may be defined by their presence or absence2. Optimizing cancer patients’ service experiences requires sensitive management of the clues that comprise the overall service. Well-managed clues can evoke positive feelings, such as trust and hope. Poorly managed clues can exacerbate negative emotions, such as anxiety, stress, helplessness, anger, and fear.

The more important, variable, complex, and personal the service, the more clue-sensitive customers are likely to be2. Few services are more important, variable, complex, and personal than cancer care. Cancer patients are likely to be acutely aware of experiential clues during health care. What may seem to clinicians and staff to be a minor detail can constitute a powerful stimulus to patients. As one cancer patient said in an interview: “Patients are ultra-sensitive to the doctor’s words as clues to whether they will live or die.”

Three Clue Categories

Three categories of clues need to be managed well to create a coherent, reassuring experience that evokes positive feelings. Functional clues signal the technical quality or competence of the service. For example, the visible demonstration of physician expertise, teamwork, care coordination, and efficiency portrayed by care team members in a 1-day multidisciplinary cancer clinic offers a strong set of functional clues. Conversely, patients’ confidence and trust can be undermined when teams are dysfunctional and clinical care is uncoordinated. Poor communication among oncologists and between them and other care providers can be a powerfully negative functional clue.

Mechanic clues originate from tangibles in the service experience, often manifested in sights, sounds, smells, and textures. Care facilities, furnishings, and equipment produce the most influential mechanic clues. Patients entering the front door of a cancer center or hospital usually arrive under considerable stress; therefore, they are inordinately sensitive to how the facility and the tangibles inside affect them. Do these factors compound or moderate patient stress? Seton Medical Center in Austin, Texas, raised private funds to build a new breast cancer facility, using evidence-based design principles to help calm and comfort patients. Patients arriving for screening versus diagnostic mammograms are ushered to separate waiting areas. Comfortable chairs, soft colors, and natural light from floor-to- ceiling windows are intended to soothe. Instead of television sets, large monitors offer nature scenes and calming sounds, such as ocean waves and chirping birds. In the dressing room, patients receive warm robes. Butterfly symbols with the words “Where hope takes flight” appear throughout the facility. In contrast, the patient who entered the infusion room described at the beginning of this Editorial experienced off-putting mechanic clues.

Humanic clues emanate primarily from service providers via verbal and body language, tone of voice, and appearance. Many clinicians intuitively provide meaningfully positive humanic clues for their patients by sitting with them at eye level during conversation, rather than standing over them; by sharing their home telephone number; or by allowing a patient visit to go quiet for a few moments, without interruption, to convey “I am here for you; we are in this together.”

The words that clinicians use in communicating with patients play a critical role in clue management. From our clinical experiences (J.O.J. and B.S.), interviews with patients and clinicians (L.L.B.), and the medical literature, we have compiled phrases to avoid in the care of cancer and other seriously ill patients. At the top of the list of phrases never to say are the following: “There is nothing more that we can do for you”3 (implies abandonment); “You are lucky it is only stage 2” (trivializes a serious condition); “Why did you wait so long to come in?” (creates a feeling of guilt); and “Let’s not worry about that now”4 (nonanswers heighten anxiety).

We present these examples to encourage constructive discussion within cancer practices of negative words and phrases, that is, negative humanic clues that may promote dysphoric reactions in sensitive patients and family members.

The three clue types cited earlier play different roles, and they need to be managed in synchrony. Functional clues should offer reassurance about the providers’ medical competence. Mechanic clues influence initial impressions of the service, because patients experience the facility before they undergo any treatment. They make an impression, especially when patients use a facility frequently (a cancer center) or for an extended period (a hospital). Humanic clues offer the best chance to exceed patients’ service expectations, which requires pleasant surprise; human inter- action offers the opportunity to pleasantly surprise with uncommon kindness, respect, and extra effort. Table 1 presents a selection of interview quotes that illustrate these clue category roles.

Although every category is important, research in both business and health care settings reveal the disproportionately strong influence of humanic clues, especially for high-emotion services, such as cancer care.1, 5-7 Aloof, impersonal, blunt, hurried, and/or unprofessionally attired clinicians will affect how patients feel about the service. Even a modern, beautifully designed facility will not override negative humanic clues.

A single action may produce multiple clues. For example, Kaiser Permanente embeds its infusion pharmacy into the chemotherapy treatment space. Pharmacists visit patients for educational, feedback, and relationship-building purposes as chemotherapy is delivered. After they go home, patients can phone pharmacists directly, as needed. All three clue categories are activated by Kaiser’s conscious placement of its infusion pharmacy right where patients are treated.

Some actions can contribute both positive and negative clues. Use of an electronic health record during a patient visit can be a strong functional clue that the physician is leveraging modern technology to provide care and communicate with colleagues. However, it can be an even stronger negative humanic clue if the provider is more focused on the computer screen than on the patient.8

Becoming Clue Conscious

The Centers for Medicare and Medicaid Services collect and report patient satisfaction data for almost all US hospitals.9 More than 300 ambulatory oncology centers participate in Press-Ganey patient satisfaction surveys (data on file, Press- Ganey Performance Solutions, Virginia Beach, VA). Surveys are useful for benchmarking purposes and for high-level assessment of patient needs, but the method is inherently quantitative. To be truly patient-centered, though, a practice must manage its service clues effectively. Clue management requires ongoing investment in qualitatively understanding the service experience from the patient’s perspective—by discovering what that subjective impression currently is and determining what it should be, then closing this gap.

Staff at all levels need to become clue conscious. Practices can hold periodic clue scanning weeks, in which staff document positive and negative clues they experience as consumers using various services. Staff can then convene to share their findings and apply them to the practice. Specific staff, such as patient navigators, can query patients as they move through different phases of the cancer service. Open- ended questions about likes and dislikes can be especially revealing, for example, “What is the single best service experience you’ve had with us thus far?” or “If you were in charge of our cancer center for one day and could make only one change to improve our service, what change would you make?” Asking such questions can be a positive clue, as can the wording of a question. “How can we improve our service to you?” is a better question (and provides a better clue) than “Was everything okay?”

Patients always have a service experience when interacting with a health care organization and its staff. The experience is inherent, but a positive experience is not. The more patients have at stake, the more sensitive they are to the quality of the service performance. Patients’ service experience with a cancer practice is composed of a constellation of clues they sense, both subtle and overt, that impacts their emotions and feelings about the service and influences subsequent behavior, such as continuing the relationship, adhering to the treatment plan, and providing positive word-of-mouth communications about the organization.10, 11 By managing verbal and non-verbal clues, cancer centers can design more positive patient experiences.

Table 1. The Power of Service Experience Clues

Functional Clues

Patient: “My first time in the chemo chair I was armed with what the nurse taught me. I remember feeling positive and strong. . . . Being prepared made it much better.”

Oncologist: “When you have cancer, you don’t want to hear that ‘we can get you in in two weeks.’”

Health system president: “It is a powerful thing to say to patients that their treatment plan will be reviewed by multiple clinicians and their care will be coordinated.”

Cancer center pharmacist: “We stress to patients that oral chemo is not safer just because it’s a pill. We call patients every week and sometimes twice a week to monitor side effects, using a standardized questionnaire.”

Mechanic Clues

Patient: “The doctor draws everything on a piece of paper and gives it to me to take home.”

Cancer center president: “You can go through the building and you don’t think there are 10 patients in it. But right now there are

probably 100 patients in the facility. It was designed to create a sense of privacy.”

Cancer center senior administrator: “We put a satellite blood draw lab in the exam room area in case the doctor wants another blood test. Patients do not have to go back in line in the main lab area.”

Palliative care nurse: “We’ve co-located palliative care with hem/onc in our building. We stress to patients that palliative care is a normal part of cancer care and co-locating our two groups helps us make the case.”

Humanic Clues

Patient: “I could barely stand up when I finished my 34th radiation treatment. My goal was to walk out of the room under my own power. The technician said to me ‘I know these treatments are going to help you.’ That is exactly what I needed. You can’t script kindness. And I walked out under my own power.”

Patient: “Nurses look at the computer too much. It seems that the solution to everything is in the computer when sometimes holding your hand is what you need the most.

Patient: “Nurse Nancy is very kind and sympathetic. She hugs me. She told me: ‘Don’t worry, the tumor is not so big.’ . . . She didn’t use medical words; she uses easy words to understand.”

Cancer center administrator: “If a patient is uninsured or has unpaid co-pays we don’t make them feel bad but do try to help . . . . We’ve developed a ‘shame-free’ environment for the patient.”


Research support was provided by Mays Business School, Texas A&M University.

Authors’ Disclosures of Potential Conflicts of Interest

Disclosures provided by the authors are available with this article at

Author Contributions

Conception and design: All authors

Collection and assembly of data: Leonard L. Berry

Data analysis and interpretation: Leonard L. Berry

Manuscript writing: All authors

Final approval of manuscript: All authors

Corresponding author: Leonard L. Berry, Department of Marketing, Mays Business School, 4112 TAMU, College Station, TX 77843-4112; e-mail:


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