Cancer Screening Practices Among Primary Care Physicians Serving Chinese Americans in San Francisco. Discussion
A majority of primary care physicians (84%) serving Chinese Americans in San Francisco reported performing regular clinical breast examinations and teaching breast self-examinations. The rate of performing Pap smears, however, was only 61%, and the rate of ordering annual mammograms for patients aged 50 and older was only 63%. The rates of ordering annual fecal occult blood testing and sigmoidoscopy at regular intervals of three to five years among patients aged 50 and older were 69% and 20%, respectively. This utilization rate is lower than published cancer screening guidelines and recommendations.
One explanation for this low utilization rate could be that the physicians have no preference for any specific cancer screening guideline. Although a majority of physicians (75%) reported following specific guidelines for breast screening, only about half reported following specific guidelines for cervical (55%) and colorectal (47%) cancer screening. The cancer screening guidelines issued by the American Cancer Society were most frequently cited. Confusion regarding the protocol and lack of agreement with the cancer screening recommendations issued by various organizations have been reported as reasons for not prescribing cancer screening tests by other physicians. Seventy percent of physicians in our study stated that a general consensus exists regarding breast-cancer screening guidelines. At the time this survey was conducted, however, the mammography-screening guidelines among women aged 40 to 49 were controversial—for example, at that time the National Cancer Institute did not support regular mammographic screening for women aged 40 to 49 years old. The extent to which physicians in our survey were knowledgeable about the content of guidelines that they claimed to follow was questionable. Our intention, however, was not to assess their knowledge or their adherence to specific cancer screening guidelines in this study.
Our study physicians reported lower levels of performance of six cancer screening tests [clinical breast exam (CBE), mammogram, Pap test, digital rectal exam, FOBT, and sigmoidoscopy] compared to those found in other national and community physician surveys. Prior studies have shown that physician self-reports often yield higher performance estimates for preventive services than patient reports or chart audits. Since this study relies on self-reported data, it is possible that our physicians overreported their screening practices. Over-reporting may be due to double-counting patients when the primary care physicians referred patients for screening tests to gynecology specialist who were also surveyed. Additionally, it is conceivable that those physicians who did not participate in our study were less likely to perform cancer screening examinations, thus further widening the gap between the performance rates in this population of physicians compared to rates reported in other physician surveys.
In our 1994 consumer telephone survey, only 31% of Chinese American women in the 50 to 74 age-group reported having a mammogram at regular intervals (>3 mammograms in the past 3 years). Among Chinese American women aged 20 to 74 years old, 47% reported having a clinical breast examination (>2 CBEs within 3 years) and 37% reported having a Pap smear (>3 Pap smears in the past 5 years) at regular intervals. However, in this 1995 physician survey of the same community, 63% of the study physicians reported ordering annual mammograms for patients age 50 and older, 84% reported performing regular CBEs and 61% reported performing Pap smears in the office. The discrepancy between screening rates reported by consumers and their physicians requires further investigation of the validity of such self-reported data. Buy Antibiotics
Younger physicians (35-49 years old) in our study were more likely (although not statistically significant due to small sample size) to report prescribing cancer screening tests (mammogram, CBE, Pap smear, digital rectal exam, FOBT, and sigmoidoscopy) than older physicians (>50 years old). Older physicians may be more likely to subscribe to the traditional idea that because the patient feels healthy and has no physical symptoms, prescribing the screening tests is not necessary. Similarly, we found that older Chinese women who had not had Pap smears felt the test to be unnecessary at their age, particularly since no physical signs of any abnormalities were present. The disinclination on the part of the patient as well as the physician make it even less likely that the test will be performed. These results point to a particular need to target older physicians’ continuing education efforts regarding cancer screening tests.
Previous studies have shown that the prevalence of cancer screening activities varies by physician specialty. Differences in prescribing screening tests in our physician survey were not demonstrated among different specialties except in performing Pap smears in asymptomatic women. Internists (48%) were significantly less likely than other specialty physicians [family or general practitioners (75%) and gynecologists (100%)] to perform Pap smears. These differences may be due to age, type II errors, or too small a sample to find significant differences. Physician gender has also been shown to affect screening services. A recent study has shown that patients of female, family, or general practitioners were more likely to receive Pap smears and mammograms than patients of male practitioners. Since most of our respondents (84%) were men, we did not investigate for a physician gender effect. tetracycline
The respondents to this study represented primary care physicians who served the Chinese population in San Francisco. Half of the physicians surveyed were drawn from a listing of Chinese surnames in the telephone directory Yellow Pages. Clearly, we might have excluded some non-Chinese physicians who served Chinese patients. In order to assess the representativeness of our participating physicians, we investigated the specialty of the 21 physicians who refused to participate in this study. We found the distribution to be similar to the participating physicians (57% internal medicine, 19% family practice, 14% OB/GYN, and 10% general practice).
The underuse of cancer screening tests by our study physicians might also be due to the physicians’ difficulties in overcoming the barriers to cancer screening. Barriers to screening implementation were investigated in this study. They were divided into three categories: a) patient-specific barriers, b) provider-specific barriers, and c) practice logistical barriers. The most frequently cited patient-specific barriers to cancer screening were: a) cost (mammography, FOBT), b) pain or discomfort (mammography, sigmoidoscopy), c) patient reluctance, patient is healthy, patient feels test is unnecessary (mammography, Pap smear, FOBT, and sigmoidoscopy), d) embarrassment (Pap smear), and e) inconvenience or bother (Pap smear, FOBT, and sigmoidoscopy). The physician-specific barriers were: a) inadequate training for screening procedures, such as CBE, Pap smear, and sigmoidoscopy and b) physician discomfort with performing screening tests when the patient came for an unrelated problem (eg, performing CBE). The practice logistical barriers were: a) unavailability of reminder system for cancer screening and b) unavailability of educational materials in Chinese language. canadian pharmacy
Based on the above-reported barriers to cancer screening, we suggest the following strategies to increase the performance of regular cancer screening among primary care physicians. First, cost is always a concern for most patients. In our consumer survey, insurance status was associated with screening practices. Chinese women with HMO and private health plans report higher screening tests than those not covered by insurance plans. In this study, 61% of patients were covered by either Medicaid or Medicare health insurance. As of January 1, 1998, Medicare beneficiaries now receive expanded coverage for breast, cervical, and colorectal cancer screening tests. No deductible is required for annual mammograms for women aged 40 and older. Pap smears are covered every three years for average-risk women and annually for high-risk women. For the first time, coverage for regular colorectal cancer screening for asymptomatic Medicare patients is provided. Despite available insurance coverage, however, this population’s lack of knowledge about the availability of such services as well as the extent of cost coverage acts as an additional economic barrier to screening. This lack of knowledge could be due largely to a language barrier. Physicians and their staffs can help their patients reduce their health costs by maximizing third-party payments and informing them about the expanded Medicare coverage. In addition, lack of knowledge about cost, availability of services, and extent of health insurance coverage may deter patients from seeking services. Thus, educational materials written in Chinese, which detail the resources of cancer screening, are necessary.
Second, although only a very small portion of patients experience significant discomfort in having screening examinations such as mammography, physicians or technicians can explain to their patients the screening procedures and the expected discomfort experienced by some individuals. In counseling their patients, physicians need to address individual patient concerns and show their strong convictions regarding cancer screening tests. Performing regular cancer screening may be difficult for some physicians servicing Chinese patients, however, because many of these patients do not schedule regular appointments, but a large number of patients are seen each day for acute care on a drop-in basis. Referrals or recommendations for mammography could still be incorporated in this kind of practice setting. buy brand cialis
Third, patient inconvenience contributes an obstacle to implementing fecal occult blood tests. Although explaining how to correctly do this test is time consuming for physicians, nurses or staff can be trained to emphasize the importance of performing the test correctly, and to educate patients in performing the test correctly. Physicians in this study perceived patient reluctance in taking the tests because the patients were healthy and felt the testing unnecessary. Chinese American women cited this same reason in the consumer telephone survey to explain why they did not have a mammogram and a Pap smear. This finding suggests that patients need to be educated about the screening guidelines and the importance and benefits of regular cancer screening among healthy people.
Educational interventions targeted at physicians should emphasize the importance of educating patients through individual counseling and educational materials. Communicating with patients in their native language is most effective, especially since most of these patients are foreign-born. In our consumer survey, the ability to speak English was significantly associated with breast and cervical screening knowledge and practices. A majority of study physicians and their staff could speak Chinese to their patients, and more than half had cancer screening educational materials (leaflets and brochures) in Chinese language available in their offices. Development of culturally appropriate educational materials (eg, posters, pamphlets, brochures, and videotapes) in Chinese language is needed for Chinese-speaking patients. generic albendazole
Fourth, to alleviate patient-barrier factors such as embarrassment, educational interventions for physicians designed to improve communication skills are also necessary. Physicians need to be sensitive about the cultural issues that pervade this population. Male physicians may be less aware of the issues of personal modesty among Chinese women. An additional gender issue is that many women may be reluctant to undergo a breast or pelvic exam performed by a male physician. Modesty, respect for authority, degree of acculturation, and preconceptions about health and illness are factors that need to be addressed to encourage better screening use among Chinese men and women.
A lack of expertise or inadequate skills to perform particular screening procedures is sometimes a major physician-specific obstacle to performing screening tests. Technical skills training programs for physicians can improve the performance of clinical breast examinations and other screening procedures. Physicians learn proper techniques for performing clinical breast examinations in a training session. Some of our physicians reported that they would be uncomfortable in performing a clinical breast examination during a patient visit for an unrelated health problem. These physicians could handle the patient’s immediate health problem and address patient concerns during that visit, but also set up an additional visit devoted to cancer screening. Since screening usually takes place during general check-up visits, the performance of cancer screening could be increased if such visits were systematically scheduled and if systems to remind physicians when and what screening tests were due (nurse-initiated flow chart, personal computer reminders, or chart-based reminders) were implemented. The effectiveness of reminder systems for physicians and their patients has been demonstrated in university and community practice settings. Less than half of our study physicians, however, reported having a reminder system for cancer screening. Physicians and their staffs can set up an office reminder system (such as medical record checklist and flow sheets, stickers and alerts, or computer-generated reminders) directed at themselves, and a patient-directed reminder system (such as reminder postcards, letters, or telephone calls) to promote regular cancer screening.
To improve regular cancer screening among Chinese Americans, we need to explore further the pathway of the medical care system and to examine the interaction process between the providers (primary care physicians) and the consumers (Chinese Americans). Multiple logistic regression will be performed in the future to investigate the factors predicting screening practices among the consumers and their providers so that specific interventions to increase the use of regular screening can be developed. triamcinolone acetonide
Conclusions
This is the first study of breast, cervical, and colorectal cancer screening practices among primary care physicians serving Chinese Americans in San Francisco. Cancer screening rates can be improved by targeting barriers related to prescribing cancer screening tests by physicians. Strategies to help physicians overcome patient-specific barriers (patient refusal, cost to patient, inconvenience to patient, lack of knowledge), physician-specific barriers (lack of expertise or training in performing screening tests), and office system-specific barriers (lack of reminder system and educational materials in Chinese language) were suggested. The data presented in this study provided a basis for developing interventions to increase performance of regular, cancer screening among primary care physicians serving this important population.