How the GIST Intercampus Seed Grant Grew a Crop of NIH Applications

Together with Dr. Paul Maciejewski, I co-direct the Cornell Center for Research on End-of-Life Care. At our weekly Center meetings, we were discussing a common critique of our NIH grant applications. A consistent criticism was that our studies were atheoretical and lacked a conceptual framework.  We realized that our program of research would benefit from a relevant theoretical framework that could be applied to the clinical problems that we studied.

We began our search for theories that might provide the conceptual underpinnings of our research. Paul noticed that our Cornell, Ithaca faculty member, Dr. Valerie Reyna, had formulated Fuzzy-Trace Theory.  Fuzzy-Trace Theory would suggest that communication of a significant “bottom line” – compared to one that conveys arbitrary, verbatim facts -- would promote patients’ ability to “get the gist” of what they need to know to make informed choices.  Although verbatim and gist representations are both used in decision-making, people generally prefer a “fuzzy” processing of gist information whereby the focus is on the basic meaning of the information, its implications, and “fit” with a patient’s values. Gist communication principles have yet to be applied to prognostic understanding of decision-making in the context of advanced illness despite their clear relevance and enormous potential. The need for more effective communication strategies may be especially great in the context of communication of life-threatening, potentially anxiety-provoking information, which we have shown reduces patients’ ability to hear scan results accurately.  

By capitalizing on the insights of Fuzzy-Trace Theory, our clinical applications provide an innovative approach for promoting patients’ prognostic understanding that focuses on the bottom-line gist of the medical message (e.g., rather than technical details of medical diagnostic tests or treatments). We expect this new approach to medical communication, which distills the essence of the message and presents it in a way that strives to make it comprehensible, will promote patients’ understanding, and thus more informed patient decision-making. More specifically. we expect this approach will increase the likelihood of the better end of life (EoL) outcomes with which informed EoL decision-making is associated (e.g., more value-consistent care, less intensive, more palliative care, better quality of life and therapeutic bonding with oncologists).  Below lie grants that we have submitted based on the “gist” approach to medical communication. 

•    The application of this “gist” approach resulted in pilot funding from a Cornell Intercampus seed grant to conduct a study to determine how oncologist communication of scan results could be used to improve patient’s prognostic understanding and decision-making. 
•    We also developed the Oncolo-GIST intervention that produced a Meyer Cancer Cancer application and an NIH R21 application to pilot test an intervention that trains oncologists in communicating in ways that we expect will promote patients’ ability to “get information simply and transparently” (GIST).  
•    A postdoctoral fellow, Dr. Heather Derry, in our NIA T32 training program is applying for an NCI R03 and American Cancer Society (ACS) pilot funding based on preliminary results demonstrating that anxiety and poor prognosis interfere with an advanced cancer patient’s ability to “get the gist” that death is near. She is also applying for a K99 for 5 years of support for this work.
•    A Weill Cornell Medicine medical student, James Gang, receive an MSTAR summer grant to work with me to develop Bone Marrow Transplant/BMT-GIST communication to explain: a) why patients need a transplant, b) what the procedure involves, and c) the main risks.  We video-recorded Dr. Shore, Associate Director of the NYPH BMT Clinic, discussing each of these points in a “gist-like” way to promote patient understanding of BMT. We will submit an NCI R21 to test how well this approach improves informed consent of patients considering BMT.
•    Dr. Login George is a postdoctoral fellow at MSKCC who is applying for a K99 award to examine psychological influences on prognostic understanding (gist) and he has prepared a manuscript from our NCI Coping with Cancer R01 showing that patients who get the gist that chemotherapy is not curative have a better understanding of their prognosis. 
•    Dr. Paul Maciejewski mentioned the gist studies to his colleagues in the WCM Radiology Department and they were enthusiastic about its applicability to communication of diagnostic images in the recent push for “patient-facing” interactions in Radiology. Preliminary discussions center around piloting a clinical intervention to improve patient comprehension of imaging results.
In all these ways, the gist seed from Ithaca, NY has grown into a crop of NYC, NY collaborations that we expect to result, ultimately, in several NIH-funded studies and, ultimately, lead to an NCI Program Project of these GIST projects based at WCM.

-Holly G. Prigerson, PhD, Irving Sherwood Wright Professor in Geriatrics and Sociology of Medicine