Talking to patients about screening colonoscopy—where conversations fall short
This mixed-methods study reveals 6 key points often neglected in physician-patient discussions.
Methods
13 key points regarding screening colonoscopy
We reviewed published literature and Internet sources to develop a preliminary list of topics a primary care physician could address when discussing colorectal cancer screening, especially screening colonoscopy. We used NLM Gateway and Medline databases and the following search terms: colonoscopy, patient education, patient instructions, guidelines, physician, colon cancer, counseling, and knowledge. A medical librarian directed the search. Despite having expert assistance, we did not find any publications that offered a peer-reviewed, validated list of topics to guide physicians’ discussions about screening colonoscopy.
We then conducted an Internet search using the terms colon cancer, colon cancer screening, colonoscopy, and colon cancer patient education. We categorized data from identified sites such as the American Gastroenterological Association, Up-to-Date, the American Cancer Society, and the National Library of Medicine, among others, into 13 common topics (TABLE 1). Three points addressed general information about colorectal cancer, and the rest dealt with colonoscopy specifically. A panel of 2 gastroenterologists and 3 internists from the same institution independently judged each item on the list for importance, relevance, and feasibility for discussion. Except for one panelist, all endorsed the need to address the 13 items.
TABLE 1
Percentage of physicians who covered key colorectal cancer screening points
| TOPIC | INFORMATIONAL POINT | PHYSICIANS ADDRESSING TOPIC (N=30), % |
|---|---|---|
| General colorectal prevention | ||
| 1. Standard preventive health care procedure | Recommended* as a standard screening test for those age 50 and older | 83 |
| 2. Value of screening | Can prevent cancer as well as detect cancer at a treatable stage | 83 |
| 3. Risk of colorectal cancer | Prevalence or incidence either nationally or regionally (family history)† | 43 |
| Specifics about colonoscopy | ||
| 4. Anesthesia | Sedation to reduce discomfort; risk information discussed or to be reviewed by anesthetist | 87 |
| 5. Gastrointestinal prep | Use of laxative, usual types used, and what patient can expect | 77 |
| 6. Abnormalities detected by colonoscopy | Finds growths (polyps) or cancer | 76 |
| 7. Description of procedure | Camera at the end of a flexible tube views the entire colon and tiny tweezers at the end sample or remove growths | 70 |
| 8. Follow-up after a negative test | Experts recommend screening after a negative test every 10 years | 67 |
| 9. Patient experience or knowledge‡ | Any personal or family/friend experience with colonoscopy or knowledge about the test | 64 |
| 10. Transportation | Another person must accompany the patient after procedure | 53 |
| 11. Insurance/scheduling | Insurance coverage, who arranges for the procedure, where test is performed | 13 |
| 12. Diet | Diet the day before and day of procedure, importance of hydration | 10 |
| 13. Risk of colonoscopy | Risk of bowel perforation or other complication | 10 |
| 14. Medications | Changes in medications for the procedure | 3 |
| *Recommendation by expert panels need not be specified. Physicians often just say, “We recommend.” | ||
| †Family history not necessary in this study because the patient was said to be at average risk for colorectal cancer. | ||
| ‡Point was not identified originally by the review and excluded from analysis. | ||
Physician sample
Of 135 providers practicing in 2 primary care and 1 geriatrics practice affiliated with the same urban academic medical center, we invited 30 physicians to participate. This sample was chosen to adequately represent female and minority physicians as well as physicians at different levels of training (TABLE 2). The physicians were invited to participate either by e-mail (N=19) or in person (N=11), and all invitees consented. Interviews were conducted alone in the physician’s office or in a practice conference room, and they were audiotaped with the physician’s consent.
Interviews lasted fewer than 15 minutes and did not intrude on patient care time. Study physicians read a vignette of a fictitious 51-year-old African American woman who was an established patient in their practice, without a family history of colon cancer but with arthritis and hypertension. We asked each physician to inform the patient (simulated by the interviewer) about colorectal cancer screening and colonoscopy, as well as the logistics of getting this test. To standardize the interaction, interviewers predefined the patient’s responses to questions. For example, if the physician asked about prior knowledge of colonoscopy, the simulated patient replied that she had none. Study physicians were not prompted in any way and, though not given time restrictions, all were brief and to the point.
TABLE 2
Study physician characteristics
| CHARACTERISTIC | PHYSICIANS WITH CHARACTERISTIC (N=30), % | INFORMATIONAL POINTS ADDRESSED,* MEAN (SD) |
|---|---|---|
| Total | 100 | 6.73 (1.84) |
| Gender | ||
| Female | 66 | 6.70 (1.89) |
| Male | 34 | 6.80 (1.81) |
| Race | ||
| White | 80 | 6.84 (1.80) |
| Non-white | 20 | 6.20 (2.17) |
| Level of training | ||
| Attending | 63 | 6.84 (1.98) |
| Trainee | 37 | 6.54 (1.63) |
| Specialty | ||
| General Internal Medicine | 90 | 6.89 (1.83) |
| Geriatrics | 10 | 5.33 (1.53) |
| * All comparisons P >.05 | ||
Analysis
Interview transcripts were anonymous, identified only by a study number. The 2 study investigators coded transcribed interviews independently as to whether physicians addressed the 13 informational points. Inter-rater concordance in coding was 90%. We also independently evaluated the interviews according to the use of gain- or loss-framed messages (eg, detecting colon polyps early before cancer develops vs colorectal cancer being the second most common cause of cancer death). We independently classified types of numeracy information provided into 15 categories.22 We also independently examined audiotaped transcripts for examples of colloquial terms/slang or technical language. Because we are unaware of a validated approach to characterizing a physician’s language in this manner, we asked a layperson for assistance in identifying colloquial/slang terms.
