Talking to patients about screening colonoscopy—where conversations fall short
This mixed-methods study reveals 6 key points often neglected in physician-patient discussions.
To determine whether there were predictors of a physician addressing more of the informational points than his or her peers, we examined bivariate associations of the following demographic and professional data: gender, race (white vs non-white), academic advancement (attending vs trainee), and specialty (general internist vs geriatrician).
We analyzed data using the Wilcoxon rank-sum test because the data were not normally distributed. We used SAS Statistical Software (SAS Institute, Cary, NC). The University of Pennsylvania Institutional Review Board approved the study. The project was supported by a grant from the Bach Fund of the Presbyterian Medical Center, University of Pennsylvania.
Results
How did the physicians talk to their patient?
The 30 study physicians were primarily women, one fifth were from under-represented minorities, and one third were either residents or fellows (TABLE 2). Of 13 key informational points endorsed by our physician panel (TABLE 1), the physician-subjects addressed a mean of 6.7 points (range, 3–10). Nearly all physician-subjects discussed the value of colorectal cancer screening, colonoscopy as a standard colorectal screening procedure, and sedation during the procedure. However, fewer than 20% addressed the following topics: insurance/scheduling, dietary changes, medication modification, and risks of colonoscopy. In this small sample, the number of topics mentioned did not differ significantly by physician characteristic (TABLE 2).
Two thirds of the physicians asked the simulated patient about her prior knowledge or experience with colonoscopy. Although this question was not among the original 13 informational points, it helped to guide the discussion by identifying specific preconceptions or prior knowledge of this test. Therefore, this post hoc 14th informational point was added to our list but not considered in our analyses.
Gain-framed messages used more than loss-framed messages
Nearly all physicians used gain-framed messages, and more than half also used loss-framed messages (TABLE 3). Only 1 physician offered only a loss-framed message. Overall, study physicians mentioned less than 2 gain- or loss-framed messages.
- The most common types of gain-framed messages were detecting cancer early, preventing cancer by taking out polyps, and screening at only a 10-year interval if the test result is negative.
- The most common loss-framed messages noted that colorectal cancer was the second most common cause of cancer death and that risk is increased with a family history of this cancer.
TABLE 3
Gain- and loss-framed messages and types of numeracy information used by study physicians
| TYPE OF MESSAGE OR NUMERACY | PHYSICIANS N (%) | OCCURRENCES IN INTERVIEWS, Total N (MEAN AMONG USERS, RANGE) |
|---|---|---|
| Message framing | ||
| Gain-framed | 29 (96) | 56 (1.9, 1–5) |
| Loss-framed | 20 (67) | 31 (1.6, 1–3) |
| Numeracy | ||
| Descriptive terms | 19 (63) | 36 (1.9, 1–3) |
| Statistical terms | 15 (50) | 30 (2.0, 1–5) |
| Temporal terms | 9 (30) | 11 (1.2, 1–2) |
| Proportions | 4 (13) | 5 (1.3, 1–2) |
| Fractions | 3 (10) | 3 (1.0, 1–1) |
Physicians avoided using numbers
Of the 15 types of numeracy information described by Ahlers-Schmit et al, our physicians used only 5. Nineteen physicians (63%) used descriptive terms such as “likely” or “increased,” and 15 (50%) used statistical concepts such as risk and second-most-common cause. Physicians avoided using numbers; 9 (30%) used temporal terms such as “early”; 4 (13%) cited a proportion; and only 3 (10%) used a fraction.
Colloquial language, or was it crude?
While reading the transcripts, we noted that some physicians used colloquial terms that could be regarded as crude. Other terms were probably too technical without an explanation. Some information was simply incorrect. We offer selected quotes to illustrate various types of language used.
About the prep:
- “Getting a colonoscopy is not the most fun experience…you have really bad diarrhea and you just empty out your guts.”
- “It’s basically Liquid Plumber for your bowels.”
- “Bowel prep…is kind of voluminous and associated with kind of massive bowel movements.”
- “Everybody hates the prep and you may be one of those and that’s just that.”
- “Generally you have to be up all night, sometimes, cleaning your bowels out.”
About the procedure:
- “It’s not the most comfortable screening exam in the world.”
- “It’s a test where they stick a lighted tube up your back-side.”
- “The stomach doctors put a camera up your bottom and look at the walls of your colon.”
- “They can go in with a microscope and look around and look at the colon itself.”
- “It’s a painless test.”
Word polyp is used, but not defined
Physicians often employed technical language when describing the pathology detected by colonoscopy. “Polyp” was mentioned by 20 physicians (67%) but rarely defined; “biopsy” by 5 (17%), and “lesion” by 6 (20%). Other technical terms were precancerous, symptomatic, and incapacitated.
