The results of this study demonstrate that among older Chinese American women with regular primary care providers, perceptions of having received a physician's recommendation for cancer screening were far from universal. As predicted, the language used during the visit was related to physicians' cancer screening recommendations. Specifically, Chinese women who reported that their regular physicians communicated with them in Chinese were less likely to have received regular mammography or to have had up-to-date colorectal cancer screening. In addition, physician specialty, length of relationship with the physician, as well as women's age and educational level, influenced women's receipt of cancer screening recommendations from their physicians.
Our finding of a positive association between physicians' communicating in English and patients' receipt of cancer screening recommendations may be explained by several factors. In our study, all physicians who communicated with patients in English only were non-Chinese. On the other hand, physicians speaking Chinese were mostly Chinese immigrants who had received medical degrees from their country of origin. It is possible that Chinese-speaking physicians are less aware of cancer screening guidelines. Alternatively, they may consider their Chinese patients to have a lower cancer risk than the general U.S. population.23
Another possible explanation is that Chinese physicians may not recommend screening because they assume their patients' cultural views (e.g., fatalism and belief in self-care) will lead them to refuse screening. Chinese physicians may also choose not to discuss screening, assuming that Chinese women are reluctant to discuss cancer or discuss body parts, such as breasts and the cervix.22
On the other hand, some women visiting English-speaking physicians may have been accompanied by an interpreter, a variable not included in the survey, which adds to the complexity of the communication process. Future research is needed to determine which of these possible factors explain our results.
The associations between physician specialty and screening recommendations found in our study are inconsistent with earlier studies that found physicians in family and general practice recommended mammography less often than internists did.24
In addition, our data also do not support other studies indicating that female physicians are more prevention oriented and more likely to recommend mammography than male physicians.25–27
Future research needs to explore reasons for these discrepancies, such as the context of practice28
and physicians' beliefs about cancer and cancer screening needs in Chinese Americans29
and prevention orientation.27
Consistent with prior literature,30
our study also indicates that a longer patient-physician relationship is associated with a higher cancer screening recommendation rate among Chinese American women. This may be because physicians had accumulated more knowledge about their patients and their patients had developed a higher degree of trust toward their physicians,30
which made discussion and recommendation of breast and cervical cancer screening easier and more acceptable to older Chinese American women.
The association between older age and fewer cancer screening recommendations is consistent with prior findings that physicians are less likely to recommend cancer screening to older patients,29,31,32
possibly because of competing causes of mortality. We did not find evidence that older patients primarily speak Chinese with their physicians, for our data show that significant proportions of both older and younger patients spoke Chinese with their physicians (about 65% and 67% among women aged 50–64 and ≥65, respectively.) In addition, the influence of language use on screening recommendation did not differ by age; it is also likely the result of differences in communication style between physicians and their younger and older age patients. For instance, it is possible that younger women were more assertive and initiated discussion and requested cancer screening more often than did older women, who were more likely to be passive and modest.33,34
Future qualitative research is needed to confirm this hypothesis and disentangle the dynamic physician-patient communication process.
Several limitations of this study should be taken into account when interpreting the results. First, the study participants were drawn from a convenience sample in a metropolitan area, resulting in a highly educated study sample. Women who did not attend social organizations where recruitment took place or who had a low socioeconomic status possibly were underrepresented. Second, all measures were obtained by participants' self-report, which is subject to reporting bias, social desirability bias, and recall bias. In addition, some important physician variables, such as physician perceived benefits of cancer screening, cultural perspectives, and acculturation level, were not available for analysis, which limited our ability to further explain the findings. Third, the study findings are limited to women who have a regular physician. Fourth, although participants were drawn from the same geographic area, it is likely they visited different physicians over time. It may also be possible that women concurrently visited specialists, such as an obstetrician-gynecologist, who may have been responsible for female cancer screening tests. In addition, the sample is likely to include patients of the same physician. Although physicians may communicate with each of their patients differently, the possible patient contamination and clustering effects may have overestimated study results.