This study demonstrates that communication skills may be an important predictor of SM use. Patients of physicians who are better communicators, as measured by a standardized national medical skills examination, are more likely to undergo screening mammograms.
Discussions in the medical setting significantly affect patient decisions and related health outcomes [16
]. For over 50 % of women surveyed by Metsch, physicians represent the most important information source regarding breast health, surpassing telephone hotlines, family, friends and workplace [15
]. We also know from other areas of prevention and health promotion (e.g. smoking cessation, weight loss) that a communication style based on clear information, emotional support, shared decision-making and agreement on the nature of the issue facilitates patient compliance [36
]. The impact of physician communication is particularly important in breast cancer, where reduction of mortality is an attainable goal. Interestingly, many health care providers underestimate their patients’ information needs and desires [38
]. Lack of clear physician recommendations, confusion about who is in charge of preventive care and lack of dialogue have been identified by women as important reasons not to undergo SM [11
This study also confirmed that female doctors are more frequently successful at getting their patients to obtain SMs This has been noted by others as well and may reflect increased awareness of preventive measures and greater comfort discussing women’s health issues [31
]. Interestingly, this difference between male and female physicians persisted even at equal communication skills scores. Cooper-Patrick hypothesizes that female physicians’ practice style may be more conducive to partnership-building and participatory decision-making [42
]. Few communication assessment tools in medical education currently focus on the impact of gender. According to a recent systematic review by Dielissen et al, only 2 out of 21 communication skills assessment instruments explicitly presented gender as a criterion in their checklists [43
Our results also showed that patients of surgical specialists have 60 % higher odds of obtaining an SM. Surgeons are also often the first ones consulted for breast masses and are heavily involved in all aspects of managing breast cancer, from work-up of mammographic abnormalities to anti-estrogen therapy.
The patient’s area of residence was another important predictor of SM use. Women living in rural areas had a higher chance of undergoing mammograms than their urban counterparts. This effect persisted despite a clustering of physicians from the bottom quartile of communication skills score into rural areas. A study of 3100 Ontario physicians noted that physicians working in urban practices were less likely to adhere to breast cancer screening recommendations [5
]. Nutting hypothesizes that city physicians, in addition to having higher patient volume, are pressured by fee-for-service reimbursement, leaving little time for preventative measures [44
]. Patient mobility is another factor that may influence use of SM in urban women. Physicians in rural areas are often fewer in number, integrated into the communities where they practice, and known to most, facilitating doctor-patient relationships and patient retention. In contrast, urban patients are mobile and have access to a multitude of physicians. This lack of continuity in primary care does not facilitate prevention strategies. Thus the stronger association between physician communication skills and mammography uptake for urban patients that we noted may reflect the importance of better communication in motivating women to overcome potential barriers to mammography that are more prevalent in urban areas (poverty, transportation barriers, unfavorable attitudes toward preventative care, mistrust of the medical system).
Consistent with previous studies, other patient-related factors impacting the use of SM included higher age, lower socioeconomic status and education [5
]. In addition, women with a Charlson co-morbidity index ≥3 had 28 % less chance of undergoing SM compared to their healthy counterparts. Sicker patients may have more pressing health challenges. Furthermore, multiple medical co-morbidities may negate the long-term survival benefit of breast cancer screening.
Our study had several limitations. We measured communication skills using a validated physician skills evaluation exam applied at the end of training shown to predict a wide array of outcomes [28
]. Nevertheless, these scores do not provide the accuracy that more logistically involved approaches offer (e.g. direct observation of clinical encounters). The poor-to-moderate reliability of the MCCQE2 communication score component probably led to underestimating the strength of relationship between SM use and physician communication skills [47
]. If we adjust for attenuations produced by unreliability, the true estimate of the association would increase from an OR of 1.24 to an OR between 1.34 (α = 0.5) and 1.51 (α = 0.5). We were unable to include information on patient/physician preferred language. Linguistic proficiency is shown to affect patient decisions regarding treatment and providing informed consent [48
]. It can also be argued that women with a greater overall interest in health and preventative care may preferentially seek health care providers with a specific practice style, including superior communication skills [50
]. Finally, we were not able take into account patients’ place of birth and, if applicable, immigration details, even though country of origin and length of time since immigration may influence SM use [51