We identified three major themes from the data that may contribute to low CRCS rates and that may be targets for future intervention: physicians’ focus on colonoscopy, barriers to CRCS, and patients’ confusion about or rejection of CRCS.
First, primary-care physicians in this sample regularly recommended CRCS, but focused on colonoscopy, which is consistent with a national survey of physicians 7
and the recent increase in colonoscopy and decrease in FOBT use.2
Physicians’ communication processes generally precluded discussion of patient preferences and choice of test type. Rejecting FOBT alone as a sufficient screening method may have created missed opportunities for some patients to get screened. Additionally, some physicians conducted office-based FOBTs despite evidence suggesting that these tests should not be used 38,39
, which may have confused patients about the need for additional CRCS tests.
Our findings prompt the question “Why did physicians focus on colonoscopy to the exclusion of other tests?” Some physicians may be confused by the guidelines,6
which have been modified over time, include different tests,4,5,40,41
and provide little or no guidance on strategies to increase patient compliance.42
Physicians may perceive colonoscopy to be the standard of care.7,43
Some physicians may reduce the menu of test options to save time or reduce patients’ “information-overload.” 44,45
Competing demands for time may be a barrier to discussing CRCS options,43
and focusing on one test may seem like a better use of time, particularly when gastroenterology services are readily available, as was the case at this clinic.46
Physicians also may believe that they will persuade patients to get a colonoscopy over successive visits; however, continuity of care has been associated with more FOBT and less endoscopy use 47
and lower CRCS among patients overdue for health screenings.48
Second, some patients may not have made any progress toward CRCS due to unresolved questions about or barriers to CRCS. Although patients’ questions appeared to increase the content and interactive nature of CRCS discussions, there was little discussion of test options. Patients’ barriers decrease CRCS adherence,49
and physicians’ general encouragement to overcome or ignore barriers may not be sufficient. Physicians are still the most trusted source for health information,50
and those willing to engage in shared decision making may increase patients’ CRCS adherence.
Third, not all patients were motivated to get CRCS. Some patients distinguished between physician recommendations and “requirements,” and when given an opportunity to refuse CRCS, they did. Self-exemption beliefs 51,52
such as ‘never had any reason to [get a colonoscopy]…I’ve been healthy’ were the most common defensive processes expressed by patients. These beliefs and misconceptions protect individuals from accepting personal risk susceptibility and obviate their perceived need for screening.
Implications for Intervention
If physicians’ focus on colonoscopy is widespread, interventions should prepare patients for physicians’ preferences, teach negotiation skills if patients prefer different tests, or train physicians to present all test options.9,53
Which strategy to use should be informed by future studies that determine whether patient adherence increases when test acceptability, preferences, and barriers are addressed using a shared-decision making approach.12,54
To reduce patient barriers and ambivalence, physicians should recommend FOBT as an acceptable CRCS option,55,56
and clinics should assist with scheduling endoscopy appointments.57,58
This study involved one clinic site and a small number of Family Medicine and Internal Medicine physicians. Patients were participants in a concurrent trial designed to increase CRCS, agreed to schedule a wellness visit, and had medical insurance. Our use of audio-recordings precluded our ability to examine non-verbal communication,59
but was unlikely to significantly affect physician or patient behavior.60
However, similar to other studies of this type, our participants may be biased toward those who feel more confident in their relationships and communications with others.60
Our study may underestimate the amount and type of CRCS information given to patients over successive visits. Some patients had existing medical conditions, and physicians would rightly focus more time on those. Similar to other qualitative research, the purpose of this study was not to generalize results to a target population of patients and physicians, but rather to describe the phenomena of interest in detail using the original language of the participants.61
Our heuristic findings, along with other published studies, inform future CRCS research and interventions. Our findings also may be useful to clinicians who evaluate their communication practices with patients and consider modifying their approach when discussing CRCS.