OBJECTIVE: Our purpose was to determine the factors involved in the cancer screening decisions of family physicians in situations where the clinical practice guidelines are unclear or conflicting as opposed to when they are clear and uncontroversial.
STUDY DESIGN: We analyzed discussions with focus groups using a constant comparative approach.
POPULATION: A total of 73 family physicians in active practice participated in 10 focus groups (1 urban group and 1 rural group in each of 5 Canadian provinces).
OUTCOME MEASURES: Our main outcome measures were participants’ perceptions regarding cancer screening when the guidelines were unclear or conflicting.
RESULTS: We propose a model of the determinants of cancer screening decision making with regard to unclear and conflicting guidelines. This model is rooted in the physician-patient relationship, and is an interactive process influenced by patient factors (anxiety, expectations, and family history) and physician factors (perception of guidelines, clinical practice experience, influence of colleagues, distinction between the screening styles of specialists and family physicians, and the amount of time and financial costs involved in performing the maneuver).
CONCLUSIONS: Our model is unique, because it is embedded in the physician-patient relationship. Ultimately, a modified model could be used to design interventions to assist with the implementation of preventive services guidelines.
Every year physicians and patients receive hundreds of messages about guidelines for cancer screening. Ideally, physicians will adopt and adhere to the evidence-based clinical practice guidelines. By doing so, there is maximum application of a proven technology to those who can most benefit, and valuable resources are not wasted in examinations that are not based on good or fair evidence. However, many physicians are not adhering to cancer screening guidelines backed by good evidence.1,2 Also, many are performing cancer screening procedures that are not recommended (either because of a lack of evidence or because they have been shown to be ineffective).3
Most of the literature on physician cancer screening has dealt with facilitators or barriers to the adoption of commonly recommended guidelines. These studies did not address the factors that affect physician practice when the guidelines are unclear or conflicting, or when they clearly recommend against the procedure. We defined an “unclear” guideline as a “C” recommendation (insufficient evidence to recommend the maneuver) from the Canadian Task Force on the Periodic Health Examination (CTFPHE).4 Guidelines were “conflicting” when at least 2 organizations gave different recommendations for the same cancer screening examination.
Despite the CTFPHE guidelines,4 inconsistencies in practice remain. Although the CTFPHE recommends that breast cancer screening begin at age 50 years, 59% of women aged 40 to 49 years reported having mammograms in 1994,5 a rate nearly equivalent to those aged 50 to 59 in Ontario.6 It is clear that family physicians—the major cancer screeners in many countries—are frequently not following guidelines. The use of ineffective procedures or those for which the evidence is unclear can waste scarce health resources and lead to harm for those whose test results are false positive. The objective of our study7 was to determine the factors involved in the cancer screening decisions of family physicians in situations where the clinical practice guidelines were unclear or conflicting (prostate-specific antigen testing, mammography for ages 40 to 49 years, colorectal tests) as opposed to when they were clear and uncontroversial.
Methods
Ten focus groups7 were conducted with 1 urban group and 1 rural group in each of 5 Canadian provinces: British Columbia (BC), Alberta (AB), Ontario (ON), Quebec (QC), and Prince Edward Island (PEI). Ethical approval was obtained from all participating institutions. We focused on family physicians because they are the main preventive health care providers in Canada, and physician recommendation is the most important predictor of whether an individual obtains a particular screening test.8 Eight focus groups were conducted face to face, and 2 were done by teleconference because of the geographic remoteness of 2 rural areas. Each focus group was co-facilitated by a local research assistant and 1 of the investigators. The focus group moderators participated in a 2-hour training session to ensure standardization across sites. The group sessions lasted approximately 60 to 90 minutes; all were audiotaped and transcribed verbatim.*Table w1
Recruitment and Sampling
We used maximum variation sampling to ensure heterogeneity within the groups and to recruit physicians who would serve as information-rich participants with a wide range for age, practice type, location, and education.9,10 Recruitment involved a 2-step process:11 First, urban and rural family physicians were randomly selected from lists provided by each local area’s licensing body; and second, physician recruiters (“leader figures”) from each local area identified physicians who they believed would provide an adequate variance of opinions.