Colleagues could positively or negatively influence screening decisions. A participant said, “Some guidelines come out, and somebody will say, ‘Oh that’s trash. I’m not going to do that.’ And then it’s a little hard for the rest of us to easily incorporate that.” (BC rural)
Family physicians also felt that they had a unique screening style compared with specialists, stemming from their continuing long-term relationships with their patients. One physician said, “The specialists will tend to jump on the blood test wagon a lot faster than I think we will, because again they don’t know the patients.” (AB urban)
Time and financial costs were also identified as important practice factors in the decision-making process. A participant said, “Economics also plays a part…because it can take…half an hour to explain to a patient why you don’t want to do something. It can take 2 minutes to do it.” (ON rural)
The Physician-Patient Relationship
Decisions about cancer screening took place within an interactive relationship between the patient and physician. Physicians characterized the relationship as one of varying intensity and depth, and there appeared to be 3 key points about the relationship in terms of cancer screening. First, the stronger and more positive the relationship, the more likely that the physician would feel free to engage the patient in a discussion about not performing a test that is based on an unclear or negative guideline. One physician said, “If you’ve known somebody for a long time and they come to you with something that you don’t think is right, it’s a little bit easier to talk to them.” (PEI rural)
Conversely, if the relationship was new or tenuous, physicians felt “The lack of a good relationship has an impact…they tend not to go along with your recommendations.” (AB rural)
The second point regarding the physician-patient relationship was that when a guideline was unclear, it often called for a different interaction than when the guideline was clear. It involved more information giving, presented in a manner that assisted the patient. One physician said, “I try to give the patient as much information as I have, in words that they will understand, so that they can come to an informed decision. That’s what I do when the guidelines are unclear.” (ON urban)
The process of information-giving promoted finding common ground, particularly when patients were requesting a screening maneuver not backed by clear evidence. One participant said:[For] patients who want tests that we don’t necessarily think are indicated, I follow the evidence, and that’s a negotiation. …an explanation of the evidence and then almost throw it back at the patient...it’s not medical-legal. It’s not economic. It’s between me and my patient. (QC urban)
Finally, many physician participants observed that even when the guidelines are clear, many cancer screening decisions are not. As a result, they noted that this often necessitated a process of finding common ground by engaging patients in mutual decision making.
Discussion
Many of the factors we identified have been described previously.18-36 However, to the best of our knowledge they have not been combined into a comprehensive typology for cancer screening decision making that includes the physician-patient relationship and that deals with unclear and conflicting guidelines. One conceptual framework for the determinants of screening behavior22 is based on pediatric vaccinations and does not include unclear or controversial guidelines. Another more recent model is based on cancer care, not screening, but it does include some elements of communication between provider and patient.23 Our proposed model of decision making regarding cancer screening Figure 1 is a modification of these frameworks based on our findings and is specific to decisions about cancer screening.
One unique feature of our model is that it is embedded in the physician-patient relationship. In particular, the quality of this relationship and the clarity of the recommendation appears to be most important. It involves an interactive process and mutual discussion with the patient. This ultimately includes finding agreement and culminates in a mutual agreement between the patient and the physician about the cancer screening maneuver.37,38 Our findings are also in concordance with other literature on physician test-ordering. The concern about missing a diagnosis of cancer is similar to “chagrin bias” —when physicians are more likely to order inappropriate chest radiographs if they anticipated feeling regret if they missed a diagnosis of pneumonia.39
Limitations
Although attempts were made to have regional representation from the entire country (Canada), the findings may not be transferable to other family medicine settings. Two of the 10 focus groups were conducted by teleconference, which may bias results, because it is a different data collection method. However, previous experience with telephone focus groups had been successful. (C.H., personal communication) The 2 teleconference groups did not provide markedly different data from those conducted in-person. Also, because of budget restraints, 5 different moderators were used. The investigators organized training sessions to standardize focus group moderation across sites; however, it is difficult to estimate the potential bias, given that moderators have their own styles. Finally, the data were based on the perspective of physicians and not patients.