In a cross-sectional analysis of data from the 2000 National Health Interview Survey of 2,676 men, one-third reported their physician did not discuss the advantages and disadvantages of PSA screening before offering testing.10
Given the challenge to physicians to conduct informed decision making in the context of PCS, this study aimed to identify factors that facilitate or prevent PCS discussion. To our knowledge, this is the first qualitative study to report the barriers and facilitators for discussing PCS from the physician’s perspective.
When screening is indicated, we were able to classify the barrier and facilitators of PCS discussion into patient, physician, and system categories. A patient request facilitates a PCS discussion whereas comorbidities and a physician’s perception that the patient had limited ability to understand the issues surrounding testing may prevent the discussion. Comorbidities are not a surprising barrier because 75% of the encounters reviewed using chart-stimulated recall were for reasons other than health maintenance visits. Physicians’ attitudes may also influence the outcome though perhaps not as much as forgetfulness. A clear system driver of whether discussion occurs is time, especially when the extra time is provided in the context of an annual physical. Visits for other reasons prevent the discussion.
It is interesting to note that physicians were more likely to identify their own forgetfulness when reviewing their actual encounters with patients than when being interviewed. This may indicate either recall bias or that physicians may not be fully aware of the extent to which forgetfulness prevents them from offering PCS to their patients. For physicians, forgetting to order a test can be considered a malpractice error of omission in the US legal courts.22
Errors of omission are common. A recent study found that 96% of all the medical errors and 96% of the highly serious errors in inpatient and outpatient VA settings were errors of omission.23
The Institute of Medicine report, To Err is Human, discourages finding people to blame because most errors are latent errors and thus not active errors freely caused by people acting with justified beliefs.24
Instead, the report encourages the medical community to focus on the reduction of latent errors, as this is “likely to have a greater effect on building safer systems than efforts to minimize active errors.” Accordingly, systems that build physician reminders25,26
related to preventive care and counseling are needed to avoid denying patients from participating in screening decision making.
Our findings are consistent with prior literature. For example, a physician survey of 8 different barriers predetermined by the investigators showed that 50% of physicians indicated that lack of time and complexity of topic were barriers to discussing PCS, and nearly one-third agreed that language barriers affected initiation or quality of PCS discussion.29
The open-ended interview and the chart-stimulated recall technique in the present study allowed for the identification of many other important barriers to PCS discussion including patient comorbidity and physician forgetfulness. Furthermore, our finding that physicians perceive annual physicals as an important facilitator to discussing PCS is supported by 2 previous studies which demonstrate that health maintenance visits are a significant predictor of screening for cancer in community-based primary care practices.30,31
Notably, many of the reported barriers and facilitators are modifiable at the individual and/or system level, and therefore, should be considered when designing interventions to increase informed decision making in PCS. In particular physician reminder systems have been shown to increase physician preventive practices,25,26
and paramedical personnel can be trained to discuss the risk and benefits of and conduct cancer-screening tests.32
Another important finding of this study is that one-third of the physicians report that they sometimes conduct PCS without discussion. Physicians offer a variety of reasons for this practice, most commonly lack of time and competing demands, forgetfulness, limited patient health literacy, and fear of liability. This finding is concerning because many leading healthcare institutions such as the Institute of Medicine and most clinical practice guidelines have advised physicians, pending the results of 2 ongoing large randomized screening trials,31–33
to discuss the risks and benefits of PCS before performing any testing.
Finally, this study demonstrates that chart-stimulated recall is a feasible, acceptable method to study physician behavior. It is an innovative method by which to achieve triangulation in qualitative research when conducting physician interviews and increases the validity of data obtained by physician interview. Moreover, it helps address the well-described discrepancy between physicians’ perceived and actual behavior related to recommending cancer screening tests33–35
as well as recording bias inherent in methods based on chart abstraction.36–38
This study is limited because the small number of physicians and patient encounters may have prevented us from reaching thematic saturation, the point at which no new themes emerged from the data. Furthermore, the study was conducted in 1 large health system with a predominantly urban and suburban sample of physicians. The results, therefore, are not generalizable to rural physicians or to those who are not affiliated with large health systems. Despite these limitations, this is the first study to directly assess the circumstances that prevent or facilitate physician–patient discussion about PCS. Involving the patient in the PCS discussion is the first step towards the ideal goal of informed decision making. Greater involvement of patients in clinical decision making is consistent with recent Institute of Medicine recommendations to improve health care quality, in particular, the recommendations to make health care more patient-centered—that is, health care which is respectful of and responsive to patient preferences, needs, and values.39
The findings that there are multiple modifiable barriers and facilitators of PCS discussion should guide investigators in designing patient- and physician-targeted educational and decision support interventions that involve more patients in PCS decisions. Further exploration is warranted, for example, to evaluate how the physician-reported facilitators presented here affect the quality of PCS discussions.