The patient-physician relationship did not appear to be an important determinant in the prostate and colorectal screening examples. For PSA screening it may be due to the unique character of the relationship male patients have with their physician. A recent study found that male patients experience many barriers to seeking help, and they find it difficult to discuss their health concerns and preventive care issues with their physicians.17 For colorectal screening by colonoscopy the relationship may not have been an important determinant because 2 other determinants appeared to be so important and may overshadow any others: the great majority of respondents believed that it was not recommended (83.5%); and family history played a very important role in influencing screening.
In the final statistical modeling, several additional physician factors appeared to influence screening decisions. In particular, both the perception of whether the screening test was recommended and the belief that the screening test could cause more harm than good contributed independently to the screening decision. The same factors were noted in our qualitative study, a finding supported by many examples in the literature.1,18,19 In addition, the importance that physicians attribute to the practice of colleagues appeared to influence screening decisions in the 2 conflicting examples (from a Canadian perspective)-PSA screening and mammography. This suggests an important role of colleagues in conflicting examples. Previous research has suggested that social influences play an important role-in particular, when uncertainty is high, or when the evidence is still evolving and recommendations based on the evidence are not in common practice.20
Our emerging model Figure 2 shows that there are more than just cognitive processes at work in this sort of decision-making. The findings suggest that aspects of the patient-physician relationship and the influence of colleagues affect decision-making as well. Further, our findings indicate that these determinants are important when the guidelines are unclear or conflicting.
Many of the factors identified in this study have been described previously.1,13,21, 34 There are also recent theories to help explain how and why physicians decide to screen their patients for cancer, including whether they agree with and adhere to recommended guidelines.24,35However, these theories were developed within the context of clinical decision making when the guidelines are clear. The unique contribution of our study and emerging model is that it concerns screening decisions with unclear or conflicting guidelines. The impact of uncertainty on this aspect of physician decision-making is important. Physicians need to make decisions in the face of uncertainty. They appear to do this by believing one side of the argument or another, by balancing the perceived good or harm from screening, and by looking for support from colleagues to bolster their decision. In addition, their patients play a key role in influencing these decisions, with the doctor and patient finding common ground, often resulting in a shared decision.
Limitations
We represented the clinical factors with dichotomous situations, when, in real encounters, there would be a much greater range in the level of intensity of factors such as patient anxiety, expression of expectation, and quality of the relationship. Also, even though the case vignettes provided some background, for the physician respondent it was a “one of” situation which does not reflect a typical primary care situation that includes continuing care of patients who have a variety of coexisting clinical issues. The magnitude of the influence of these factors may be considerably underestimated or overestimated with the use of clinical case vignettes.
The generalizability of the respondents may be a limitation, as they were younger (1.7 years, not significant) and more likely to be certificants than the non-respondents. The latter difference may have contributed to a trend that stressed the influence of patient anxiety and wishes, which reflects residency training issues in family medicine. Last, although the study was done in Canada, we believe the findings likely apply to US family physicians, as graduate training is quite similar in the two countries.
Conclusions
This study underlies the importance of the cognitive component in decision making-in particular, of perceptions of guidelines, and of the influence of patients and their needs and the patient-physician relationship.
Our results verify our model in general terms, but also build on and advance the conceptual model that evolved from our qualitative findings. It provides a useful framework for understanding clinical decision-making in the face of uncertainty or controversy, and may be applicable to other clinical domains.
In future research we plan to test the effect of race and cultural aspects of the patient and of the physician on physicians’ screening decisions. Ultimately, the model could be used to design interventions to assist with the implementation of preventive services guidelines, and to be included in future CME programs for practicing physicians.