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Can Fam Physician. 2005 Dec 10; 51(12): 1659.
Published online 2005 Dec 10.
PMCID: PMC1479496

Language: English | French

Patients’ anxiety and expectations

How they influence family physicians’ decisions to order cancer screening tests
Jeannie Haggerty, PHD, Fred Tudiver, MD, Judith Belle Brown, MSW, PHD, Carol Herbert, MD, CFPC, FCFP, Antonio Ciampi, PHD, and Remi Guibert, MD

Abstract

OBJECTIVE

To compare the influence of physicians’ recommendations and patients’ anxiety or expectations on the decision to order four cancer screening tests in clinical situations where guidelines were equivocal: screening for prostate cancer with prostate-specific antigen for men older than 50; breast cancer screening with mammography for women 40 to 49; colorectal cancer screening with fecal occult blood testing; and colorectal cancer screening with colonoscopy for patients older than 40.

DESIGN

Cross-sectional mailed survey with clinical vignettes.

SETTING

British Columbia, Alberta, Ontario, Quebec, and Prince Edward Island.

PARTICIPANTS

Of 600 randomly selected family physicians in active practice approached, 351 responded, but 35 respondents were ineligible (response rate 62%).

MAIN OUTCOME MEASURES

Decisions to order cancer screening tests, physicians’ perceptions of recommendations, patients’ anxiety about cancer, and patients’ expectation to be tested.

RESULTS

For all screening situations, physicians most likely to order the tests believed that routine screening with the test was recommended; physicians least likely to order tests believed routine screening was not. Patients’ expectations or anxiety, however, markedly increased screening by physicians who did not believe that routine screening was recommended. In regression models, the interaction between physicians’ recommendations and patients’ anxiety or expectation was significant for all four screening tests. When patients had no anxiety or expectations, physicians’ beliefs about screening strongly predicted test ordering. Physicians who believed routine screening was recommended ordered the test in most cases regardless of patient characteristics. But patients’ anxiety or expectations markedly increased the probability that the test would be ordered. The probability of test ordering went from 0.28 to 0.54 for prostate-specific antigen (odds ratio [OR] = 1.9), from 0.15 to 0.44 for mammography (OR = 2.8), from 0.33 to 0.79 for fecal occult blood testing (OR = 2.4), and from 0.29 to 0.65 for colonoscopy (OR = 2.2).

CONCLUSION

Differences in clinical judgment about recommended practice lead to practice variation, but physicians are also influenced by nonmedical factors, such as patients’ anxiety and expectations of receiving tests. In terms of magnitude of influence, clinical judgment is more powerful than nonmedical patient factors, but patient factors are also powerful drivers of family physicians’ decisions about cancer screening when practice guidelines are equivocal.

Résumé

OBJECTIF

Vérifier de quelle façon les recommandations du médecin, et les attentes et les inquiétudes des patients influencent la décision de prescrire quatre examens de dépistage du cancer dans des situations cliniques où les directives sont controversées: dosage de l’antigène prostatique spécifique pour le cancer de la prostate, mammographie pour le cancer du sein chez les femmes de 40 à 49 ans, recherche du sang occulte pour le cancer colorectal et coloscopie pour le cancer colorectal chez les patients de plus de 40 ans.

TYPE D’ÉTUDE

Enquête postale transversale accompagnée de vignettes cliniques.

CONTEXTE

Colombie-Britannique, Alberta, Ontario, Québec et Île-du-Prince-Édouard.

PARTICIPANTS

Sur 600 médecins de famille en pratique active choisis au hasard comme participants éventuels, 351 ont accepté; 35 des répondants étaient toutefois inadmissibles (taux de réponse: 62 %).

PRINCIPAUX POINTS À L’ÉTUDE

Décisions de prescrire des tests de dépistage pour le cancer; attitudes des médecins vis-à-vis des recommandation, inquiétudes des patients à propos du cancer et attentes des patients sur l’éventualité de subir un test.

RÉSULTATS

Dans tous ces cas de dépistage, le médecins les plus susceptibles de prescrire les tests étaient ceux qui croyaient qu’il est recommandé de faire un dépistage systématique; ceux qui étaient d’avis contraire étaient les moins susceptibles de demander un tel examen. Toutefois, les attentes et les inquiétudes des patients entraînaient une forte augmentation des demandes de dépistage chez les médecins qui ne croyaient pas ces examens nécessaires. L’analyse de régression a révélé une interaction significative entre les recommandations du médecin et les attentes et les inquiétudes des patients pour les quatre tests de dépistage. En l’absence d’attentes ou d’inquiétude des patients, l’opinion du médecin était un élément majeur dans sa décision. Les médecins qui croyaient au dépistage systématique prescrivaient le test dans la plupart des cas, quelles que soient les caractéristiques des patients. Mais les attentes et les inquiétudes des patients augmentaient de beaucoup la probabilité qu’un test soit prescrit. Cette probabilité variait de 0,28 à 0,54 pour l’antigène prostatique spécifique (rapport de cotes [RC] = 1,9), de 0,15 à 0,44 pour la mammographie (RC = 2,8), de 0,33 à 0,79 pour la recherche du sang occulte (RC = 2,4) et de 0,29 à 0,65 pour la coloscopie (RC = 2,2).

CONCLUSION

La façon dont les directives sont appliquées est influencée non seulement par le jugement clinique du médecin, mais aussi par des facteurs non médicaux tels les attentes et les inquiétudes des patients à l’idée de subir un examen. Même si l’opinion du médecin est le facteur prépondérant, les facteurs reliés aux patients ont aussi une influence considérable sur la décision de prescrire un dépistage pour le cancer lorsque les lignes directrices sont ambiguës.

EDITOR’S KEY POINTS

  • Physicians’ decisions to order cancer screening tests vary widely and depend on both physicians’ judgment and patients’ expectations. This survey describes the influence of patients’ expectations.
  • When patients have no anxiety or expectation of being screened, physicians’ perceptions of practice recommendations are the main determinants of decisions to screen.
  • High anxiety or expectations among patients, however, powerfully influence decisions to screen, even overriding some physicians’ inclinations not to order certain screening tests.
  • This study illustrates the influence of patient-centred care on evidence-based medicine. Patients’ perceptions significantly modified the evidence-based views of physicians.

Numerous studies have reported large variations in medical practice not explained by differences in medical indications.1,2 Variation is highest for clinical procedures where evidence for optimal care is equivocal, resulting in “supplier-induced demand” that reflects differences in physicians’ preferences and clinical judgment on issues where there is professional uncertainty.3

Clinical practice guidelines reduce professional uncertainty by synthesizing complex scientific evidence and translating it into clinical decision algorithms. The hypothesis that clear and unambiguous guidelines would reduce variance in practice rests on the notion that clinical decision making is principally a cognitive exercise. Yet variation persists even when there is clear consensus in practice guidelines. For example, guidelines since 1979 have recommended annual or biennial breast cancer screening with mammography for women 50 to 69 years,4 but screening rates have only recently achieved the established targets.5-8

This paper reports on part of a group of studies exploring physicians’ decisions on cancer screening when guidelines are conflicting or equivocal.9,10 We used qualitative inquiry to identify the factors that influence physicians’ decisions and to develop a conceptual model for decision making.9 Subsequently, we conducted a national survey of Canadian family physicians to test the model and to estimate the magnitude of the influence of key factors.10 As expected, we found that both physician and patient factors influenced these discretionary screening decisions, but we did not find that the quality of physician-patient relationships modified the effect of patient factors, as the qualitative inquiry suggested it might.

In this paper, we present a new analysis of the survey showing that patient factors modify physicians’ a priori clinical judgment to influence physicians’ decisions to order screening tests in clinical situations, regardless of the quality of the physician-patient relationship. We focus on patients’ anxiety about cancer and expectations of receiving screening tests.

METHOD

In 1999, a self-administered survey was mailed to 600 family physicians: 120 randomly selected from the records of each licensing body in British Columbia, Alberta, Ontario, Quebec, and Prince Edward Island. Eligible physicians were in active general medical practice (>15 h/wk). Equal numbers of urban and rural physicians were sampled to permit subgroup analysis by geographic location. Ethical approval was obtained from the review boards of all participating institutions. To ensure an adequate response rate, we used reminder postcards, second mailings, and telephone calls.11

Questionnaire design

Part 1 contained 40 questions on physicians’ perceptions of recommendations for screening and on the extent to which non-clinical factors influenced decisions to order screening tests that physicians do not usually offer to patients.9 The questionnaire also asked about practice characteristics, demographics, and personal experience with cancer and use of cancer screening tests.

Part 2 contained six clinical vignettes depicting situations for which practice guidelines at the time of the study were either conflicting or equivocal. Two vignettes were for prostate cancer screening with prostate-specific antigen (PSA) in men older than 50 years, two for breast cancer screening with mammography in women aged 40 to 49 years, and two for colorectal cancer screening with fecal occult blood testing (FOBT) or colonoscopy in adults older than 40 years. In 2001, the Canadian Task Force on Preventive Health Care changed its recommendation to annual or biennial screening with FOBT,12 but at the time this study was conducted, this screening test would have been considered discretionary.

Clinical vignettes elicit physicians’ decision-making behaviour for a hypothetical case. Their usefulness rests on the ability to vary specific factors of interest (independent variables) from one vignette to another, while keeping constant the context of the case (the frame). Patient factors that varied from one vignette to another within the same case frame were anxiety about cancer, expectation of being tested, family history of cancer, and an easy or difficult patient-physician relationship. In this study, our dependent variable was a yes or no decision (to order any of the four screening tests). The vignettes were developed by the clinician investigators (R.G., F.T., C.H., J.B.B.) from their own clinical experience (Figure 1).10

Figure 1
Sample clinical vignette

Each physician received a unique series of the six vignettes. There were 16 different versions of each clinical vignette reflecting all possible combinations of factors. We used a fractional factorial design to create series such that each physician had one vignette with all factors present, another with all factors absent, and the remaining four with a diversity of possible levels of the independent variables. Each series of clinical vignettes had a random order of presentation to avoid sequence bias.

Analyses

The outcome of interest for each test was the decision to order or not order the screening test. This binary decision was modeled by logistic regression for each of the four screening tests. We examined first the main effects of patients’ anxiety, patients’ expectations, and physicians’ perceptions of whether or not the test was recommended, controlling for family history of cancer. Then we looked for second-order interactions between patients’ anxiety or expectations and physicians’ perceptions of recommended practice to determine whether patient factors modified the effect of physicians’ a priori judgments.

Because each physician responded to two vignettes for each screening test, the logistic regression models included an additional random effect to account for the non-independence of responses from the same physician. The model’s parameters were estimated using the Generalized Estimating Equation approach (GENMOD procedure of SAS), with the option of an exchangeable correlation matrix (compound symmetry) to account for the random effect.

RESULTS

Of the 600 physicians contacted, 351 responded but 35 were ineligible, for a final response rate of 62.1% (351/565). Respondents’ demographic characteristics reflected the Canadian family physician population, except that respondents were more likely to be Certificants of the College of Family Physicians of Canada than nonrespondents were (Table 1).

Table 1
Physicians’ characteristics

Physicians’ perceptions of recommended practices

Most physicians believed that PSA, mammography, FOBT, and colonoscopy were not recommended for routine screening in these clinical situations, in keeping with the most influential Canadian guidelines.13 Except for colonoscopy, however, many physicians also believed either that routine screening was recommended or that best practice was unclear (Figure 2).

Figure 2
Family physicians’ perceptions that routine use of four cancer screening tests is recommended, not recommended, or unclear

Nearly all physicians agreed that patients’ anxiety (87%) or expressed expectations of being tested (88%) influence their decision to order a test that they would not usually recommend (Table 2). We found no differences between urban and rural physicians in factors that influence cancer screening decisions.

Table 2
Family physicians’ agreement that nonmedical factors would influence test-ordering behaviour

How factors affect decisions to order screening tests

For each vignette, test ordering was highest among physicians who believed routine screening was recommended, followed by those who perceived that the recommendation was unclear, then by those who believed it was not recommended. Each test was also more likely to be ordered when patients were anxious about cancer or expected to have the test; a test was most likely to be ordered when both anxiety and expectation were present. Figure 3 shows the percentage of physicians who ordered each test as a function of whether or not physicians believed the test was recommended for routine screening and whether or not patients were anxious or expected testing. The data suggest that patients’ anxiety and expectation modify physicians’ perceptions of recommended practice.

Figure 3
Clinical vignettes where screening test was ordered according to whether patient anxiety or expectation was present and whether physicians perceived that routine screening was recommended ( ◆ ), ...

Regression models confirm that each of the variables of interest significantly increased the likelihood that physicians would order a screening test (Table 3). For each screening decision we obtained an improved model with a significant interaction between a patient factor and a physician’s perception of recommended practice (Table 4). For PSA ordering, physicians’ perceptions of whether the test is recommended is modified by patients’ anxiety about cancer. Physicians’ beliefs about PSA screening were the most influential factor in the screening decision when patients were not anxious about having prostate cancer, but when patients were anxious, the independent influence of physicians’ perceptions diminished.

Table 3
Influence of principal factors on the likelihood that family physicians will order cancer screening tests
Table 4
Interaction effects between patient factors and physicians’ perceptions of recommended practice on the decision to order cancer screening tests

For mammography, FOBT, and colonoscopy, physicians’ perceptions of recommended practice were modified by patients’ expectations of receiving the test; only for mammography did patient anxiety remain significant. For instance, if a physician perceived that mammography for women 40 to 49 years old was not recommended or was unclear, then a patient’s expressed expectation of having mammography tripled the probability that mammography would be ordered. By contrast, if a physician perceived that routine mammography was recommended, then a patient’s expectation did not alter significantly the already high likelihood that a physician would order mammography.

DISCUSSION

Our study partially supports the hypothesis of professional uncertainty in discretionary decision making; that is, differences in physicians’ clinical judgment about recommended practice are consistent with differences in their clinical decisions.3 Results of this study demonstrate, however, that nonmedical patient factors are also powerful drivers of decision making and, consequently, of practice variation. The unique contribution of our study is a description of the relative magnitude of these nonmedical patient factors in modifying physicians’ a priori clinical judgments. We have shown how much physicians’ clinical judgment influenced test ordering differed according to patients’ anxiety or expectations.

When patients have no anxiety about cancer or expectation of being tested, physicians’ perception of recommended practice is the main driver of screening decisions for which guidelines are equivocal. Patients’ anxiety or expectations not only increased the likelihood of getting the screening test, but acted most powerfully on the screening decisions of physicians whose clinical judgment would otherwise make them least inclined to order the test. Our vignette design did not permit us to show whether an expectation of not being screened would lower the likelihood of test ordering by physicians who believe that the test is recommended, but a modifying effect in that direction is possible.14

Our model of decision making in cancer screening underlines the fact that there are more than just cognitive processes at work.9 Although our study focused on cancer screening decisions, other studies have shown that patients’ expectations and anxiety are predictors of physicians’ prescribing and referral.14-16 Family physicians’ responsiveness to patients’ anxiety and expectations around cancer screening is unsurprising given the emphasis on patient-centred care in family medicine training. This study illustrates how patient-centred medicine and evidence-based medicine converge in clinical practice as patients and doctors find common ground. The patient-centred approach itself becomes an important source of practice variation as physicians respond to each patient’s unique experience of illness.17,18

Physicians find it demanding to cope with patient requests for care, however, especially for diagnostic tests.19 Patient-driven decisions do not always result in optimal care for patients or for society, and thus pose a dilemma for physicians.18 Qualitative research, including ours,9 points to the difficulties physicians face when patients’ expectations conflict with their clinical judgment. It takes time to explain the complexities of scientific evidence, and in the end, the evidence might not be convincing to patients—especially when risks and benefits are accrued at a population level rather than at an individual level.20

When patients’ expectations conflict with clinical judgment, physicians also run the risk of jeopardizing their relationships with patients. In a qualitative study concerning prescribing antibiotics for colds, Butler and colleagues21 found that physicians acquiesce to patients’ expectations against their better judgment on what they perceive as minor issues, as a means of preserving and building relationships for leverage on more important issues. The same study also found that patients who have good relationships with their physicians are more accepting of physicians’ personal views.

As patients increasingly form their perceptions of risk of disease and efficacy of tests from information in the media, on the Internet, and in direct-to-consumer advertising, physicians need to be trained to respond to their patients’ expectations. One strategy might be to elicit explicitly patients’ expectations rather than inferring them. Often what is perceived to be a treatment expectation is, in fact, an expectation of information, reassurance, or symptom management.21,22 Physicians might overestimate expectations. In a study of antibiotic prescribing for otitis media, physicians perceived an expectation for antibiotics in 73% of clinical encounters, whereas only 2% of patients reported requesting antibiotics.23 Audiotape analysis of visits found that patients made direct requests of physicians in 22% of visits and asked specifically for diagnostic tests in 8% of visits.19

We did not find differences between urban and rural physicians’ decisions to order screening tests. This is surprising because other studies have found that contextual factors independently influence physicians’ practice patterns.1,24,25 Our finding could reflect the limitations of our case vignettes. Vignettes are as valid and reliable as standardized patients and more accurate than chart review in evaluating quality of care,26 but they probably do not reflect fully the complexity of considerations that physicians face in real clinical situations. We believe that the magnitude of odds ratios are underestimated by using clinical vignettes because we represented the patient factors by dichotomous situations, when actual encounters would have a much greater range.

CONCLUSION

This study underlines the importance of nonmedical factors in physicians’ decisions about cancer screening when guidelines are equivocal or conflicting. In the face of professional uncertainty, physicians make decisions by believing one side of the evidence base or the other and by giving serious consideration to patients’ anxiety and expectations of clinical care.

Biographies

• 

Dr Haggerty is an epidemiologist and primary care researcher in the Department of Community Health at the University of Sherbrooke in Longueuil, Que, and is Canada Research Chair on the Impacts of Health Services on the Population.

• 

Dr Tudiver is Director of Primary Care Research at East Tennessee State University in Johnson City.

• 

Dr Brown is a Professor in the Centre for Studies in Family Medicine at The University of Western Ontario in London, Ont.

• 

Dr Herbert is Dean of the Faculty of Medicine at The University of Western Ontario.

• 

Dr Ciampi is an Associate Professor in the Department of Epidemiology and Biostatistics at McGill University in Montreal.

• 

Dr Guibert is a practising clinician in the Mornington Peninsular Division of General Practice in Frankston, Australia.

Footnotes

Competing interests: None declared

References

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