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Am Fam Physician. 2008;78(4):510-512

Background: Approximately 55,200 of 148,600 patients diagnosed with colorectal cancer in the United States in 2006 are expected to die from the disease. Routine screening is recommended for persons 50 years or older; however, only one half of persons considered at risk because of age or family history are actually screened. There is some evidence that physicians may be compounding patient-related barriers by failing to recommend colorectal cancer screening. Little is known regarding the type of communication about screening that actually goes on between physicians and patients. Wolf and colleagues conducted two studies on the role of physicians in communicating about colorectal cancer screening. The first study surveyed physicians about their beliefs surrounding the importance of colorectal cancer screening and the extent to which they communicated relevant screening information to patients. The second study used videotaped medical encounters to determine how colorectal cancer screening recommendations were made in real-life clinical settings.

The Study: For the first part of the study, a survey was sent to primary care physicians asking about perceived importance of colorectal cancer screening and the physicians' own success in communicating practical points to patients. They were also asked how much time they thought was necessary to adequately explain colorectal cancer and relevant screening options. The survey had a response rate of 57.9 percent, with 270 of the 466 primary care physicians contacted returning the survey.

For the second part of the study, the authors used 18 colorectal cancer screening discussions culled from an existing data set of videotaped primary care encounters to analyze communication behaviors. These were coded according to whether specific informational tasks were performed such as explanation of benefits and risks, explanation of the nature of the procedure, and eliciting evidence of the patient's understanding about and preference for screening.

Results: Physicians estimated that it would take about four minutes to thoroughly discuss colorectal cancer screening. Overall, the importance of screening was rated high, with a particular emphasis on colonoscopy. Similarly, physicians had a high estimate of achieving detailed communication about screening. Volunteer faculty rated cost issues as a more important part of the discussion than did academic faculty, and suburban physicians were slightly more likely to emphasize screening with colonoscopy and computed tomography than were urban physicians.

The videotapes recorded visits ranging from about five minutes to one and a half hours. Patients were 49.1 to 74.5 years of age. The videos documented low rates of task accomplishment compared with what physicians taking the surveys said was important and said they accomplished. For example, in the survey, physicians rated the importance of describing the screening procedures as high (mean = 8.4 on a scale of 1 to 10; standard deviation = 1.9) and stated they discussed this point with 71.1 percent of their patients. In the video-tape, however, this point was communicated in only 28 percent of encounters. Similarly, high ratings of explaining risks and benefits were not corroborated in the video, with benefits only being mentioned in 28 percent of encounters and no mention of risks. Strong correlations between survey and video were few, but included offering more than one option for colorectal cancer screening and developing a plan for screening. Encounters that resulted in a screening plan included more of the informational/communication tasks reviewed in the survey and took more time. The discussions leading to a plan had a mean duration of 1.6 minutes.

Conclusion: Surveyed physicians varied with regard to the perceived importance of offering patients more than one option for colorectal cancer screening, but all rated the importance of colonoscopy as high. They also indicated that they accomplished specific tasks related to communicating with patients about screening, whereas videotaped interviews showed that physicians may not be communicating enough details about risks and benefits, the procedure, and all available options. Encounters that spent more time on these topics resulted more often in a plan for screening. The authors conclude that physicians tend to overestimate communication behaviors and that improvement is needed.

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Copyright © 2008 by the American Academy of Family Physicians.

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