title: Why hasn't this patient been screened for colon cancer? An Iowa Research Network study.
abstract: BACKGROUND
  Less than half of eligible Americans have been screened for colorectal cancer (CRC). The objective of this study was to describe physicians' reasons for screening or not screening specific patients for CRC and their approach to CRC testing discussions.
  
  
  METHODS
  This study used mixed-methods. Physicians described their reasons for screening or not screening 6 randomly chosen patients who were eligible for CRC screening (3 screened and 3 not screened) whose CRC testing status was ascertained by medical record review. Verbatim transcripts from physicians responding to structured interview questions were used to identify themes. Specific elements of discussion were examined for their association with each physician's screening rate. Fifteen randomly chosen Iowa family physicians from the Iowa Research Network stratified by privileges to perform colonoscopy, flexible sigmoidoscopy, or neither procedure dictated the reasons why 43 patients were screened and 40 patients were not screened.
  
  
  RESULTS
  Reasons patients were not up to date fell into 2 major categories: (1) no discussion by physician (50%) and (2) patient refusal (43%). Reasons for no discussion included lack of opportunity, assessment that cost would be prohibitive, distraction by other life issues/health problems, physician forgetfulness, and expected patient refusal. Patients declined because of cost, lack of interest, autonomy, other life issues, fear of screening, and lack of symptoms. Patients who were up to date received (1) diagnostic testing (for previous colon pathology or symptoms; 56%) or (2) asymptomatic screening (44%). Physicians who were more adamant about screening had higher screening rates (P<.05; Wilcoxon rank sum). Physicians framed their recommendations differently ("I recommend" vs "They recommend"), with lower screening rates among physicians who used "they recommend" (P=.05; Wilcoxon rank sum).
  
  
  CONCLUSIONS
  Reasons many patients remain unscreened for CRC include (1) factors related to the health care system, patient, and physician that impede or prevent discussion; (2) patient refusal; and (3) the focus on diagnostic testing. Strategies to improve screening might include patient and physician education about the rationale for screening, universal coverage for health maintenance exams, and development of effective tracking and reminder systems. The words physicians choose to frame their recommendations are important and should be explored further.
authors.affiliation: Department of Family Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City 52242, USA. barcey-levy@uiowa.edu
authors.forename: Barcey T
authors.initials: BT
authors.lastname: Levy
authors.forename: Terri
authors.initials: T
authors.lastname: Nordin
authors.forename: Suzanne
authors.initials: S
authors.lastname: Sinift
authors.forename: Marcy
authors.initials: M
authors.lastname: Rosenbaum
authors.forename: Paul A
authors.initials: PA
authors.lastname: James
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D003113:Colonoscopy; D015179:Colorectal Neoplasms / Q000517:prevention & control*; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007484:Iowa; D008297:Male; D008403:Mass Screening; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D010565:Persuasive Communication; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians'; D019035:Rural Health Services; D012812:Sigmoidoscopy