Nobody thought it was possible. Could all indoor workplaces in Ireland—including pubs—be made smoke-free? Now, a law enacted in 2004 is seen as a triumph for public health policy worldwide.1

Smoking kills 438,000 people a year in the United States, and 8.6 million have a serious smoking-related illness.2 Research shows many outpatient physicians do not judge it worthwhile to talk with their patients about quitting smoking because they assume they will have no effect. The assumption is that even if patients quit, they will relapse.

Yet ample evidence suggests hospitalists can have a positive effect by intervening during a patient’s hospital visit.

Data also show that an individual will relapse an average of seven times before being able to take the step for the long term. Relapse is a part of the process, each time teaching an individual something about his or her motivation and behavior.

“Doctors who address smoking with patients can double or even triple the chances of their quitting,” says Shawn Ralston, MD, pediatric hospitalist at Presbyterian Hospital in Albuquerque, N.M. A few pointed questions and a show of compassion to the patient in the hospital could make a world of difference.

Golden Opportunity

Stephen Liu, MD, MPH, a hospitalist and an assistant program director at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, N.H., has been interested in smoking-cessation interventions since his residency in DHMC’s Leadership Preventive Medicine Residency Program in 2003, where he worked on improving care for pneumonia patients. His efforts took off as a result of the Centers for Medicare and Medicaid Services (CMS) pay-for-performance measures, which made smoking-cessation counseling a key component of admission and discharge documentation for a number of disease states.

The approach used with adult patients at DHMC is the brainchild of Colleen Warren, a registered nurse on the medicine unit on which Dr. Liu worked.

“The more times that smokers hear the message [about quitting], the more likely they are to try to quit,” says Dr. Liu. “We capitalized on that [point when] we developed a tobacco treatment team in our hospital. The team, which includes two to five motivated nurses, social workers, or care managers in most units of the hospital, pursued training including an online tobacco treatment course through U Mass Medical Center.”

In January 2006, DHMC was awarded a grant from the New Hampshire Department of Health and Human Services to standardize the treatment of hospitalized smokers. This includes conducting tobacco screening, assessing a patient’s readiness to quit, providing brief counseling, documenting the status and stage of change into the electronic medical record, and referring the patient to community resources upon discharge. The funding allowed the institution to support Warren and Dr. Liu as they coordinated the team and its work. These efforts, including counseling, nicotine replacement therapy, and cessation medications, are also available free to DHMC employees.

DHMC is participating in the CMS demonstration project, in which the hospital publicly reports performance measures for several conditions on the CMS Web site. In addition, many more performance measures are publicly reported on the DHMC quality-measures Web site. Although the team initially targeted the intervention to performance measures related to pneumonia and heart failure hospitalizations, they decided to offer interventions to all patients admitted to the hospital. Of these patients, about 20% are smokers, Dr. Liu says.

Because financial support wasn’t available at first and staff time was voluntary, the work was more difficult. Data from a six-month pilot intervention on two inpatient floors at DHMC showed patient assessments increased from 2% to 85%. In addition, the percentage of eligible heart failure and pneumonia patients receiving smoking cessation advice or counseling prior to discharge has risen from 30% before 2005 to 80% to 90%.

“We have found that hospitalization is a golden opportunity to address smoking cessation in patients in that they become acutely aware of how the smoking has affected their health,” says Dr. Liu. Because patients frequently go without smoking for several days while hospitalized, they learn they can live without smoking and feel much better.

“The key for our kind of intervention is not only assessing it and addressing it while they are hospitalized, but making sure that we link them to resources after they leave,” Dr. Liu says. Those resources include telephone quit lines or local support groups and/or local cessation clinics.

Counseling patients can be personally and professionally fulfilling, says Dr. Liu. He recalls a 50-year-old man—a lifelong smoker—admitted for pancreatitis. The day he was discharged, he showed Dr. Liu a hospital-produced packet of information. The patient said he had been reading it during his stay, decided he was motivated to quit, and had called the quit line.

Dr. Liu and his team use what they call the five A’s:

• Ask (does the patient smoke and has he/she tried to quit?);
• Advise the patient to quit;
• Assess (if the patient is ready to try to quit);
• Assist (the patient in planning treatment and referrals); and
• Arrange for a follow-up visit.

As part of their counseling, DHMC team members ask patients whether they have used assistive medication, such as nicotine-replacement therapy, bupropion (Wellbutrin) or varenicline (Chantix), in their attempts. They find out what patients have and have not tried. Then they ask, “How can we as a hospital help so that you will not restart smoking when you get home?”

A slightly longer counseling session with a motivated patient means a provider can explore whether they know their triggers for smoking, such as stress, alcohol use, or being around other smokers, and help the patient develop a proactive plan for when they are re-exposed to triggers upon discharge.

Counseling Parents of Hospitalized Children

In Dr. Ralston’s case, her research and the research of others inspired her to begin counseling the parents of hospitalized children.3-4 She was conducting research on respiratory illness, specifically bronchiolitis—the most common reason children are hospitalized.

She noticed the vast majority of children had had secondary smoke exposure. The work of C. Andrew Aligne, MD, formerly in the department of general pediatrics at the University of Rochester (N.Y.) Medical Center, inspired her.5-6 His analyses of attributable risk data revealed that the major and preventable cause of death in children is secondary smoke from parents.

But the issue really crystallized for Dr. Ralston when she encountered the work of Jonathan Winickoff, MD, MPH, an assistant professor of pediatrics at Harvard Medical School and a researcher with the Massachusetts General Hospital Center for Child and Adolescent Health Policy in Boston.

“The AHRQ guidelines show a huge amount of literature that say hospitalization is a great time to address smoking in adults,” says Dr. Ralston. “The [quit rate in office patients] will move from 5% to 12% or 15%, depending on the message. But in hospitalized adults, the quit rate can rise to 25% or 27%. Dr. Winickoff said, ‘Why can’t hospitalization for children be a teachable moment for parents?’ ”7

Another researcher who inspired Dr. Ralston was William R. Miller, PhD, who created the motivational interviewing model. Motivational interviewing is used with individuals to elicit and examine the ambivalence surrounding their unhealthy behaviors. Dr. Miller, retiring this year from the University of New Mexico (Albuquerque), began his work in the area of alcohol abuse. He and his colleagues have increasingly used motivational interviewing in other areas of addiction.

Dr. Ralston says what she has learned from motivational interviewing—and how she counsels parents of hospitalized children differently because of it—primarily pertains to her willingness to talk to people about a difficult subject. Instead of bombarding parents with facts about how smoking is bad for their children—which they already believe but don’t want to talk about—she learned to focus on the parents’ needs instead of the effects on the child.

“And there is the issue of bringing it up when this is not technically your patient,” she says. But after fine-tuning and developing her technique, she now assumes a value-neutral, nonjudgmental, open-ended approach using motivational interviewing. “Eventually it becomes easy to do.”

When approaching a parent to offer help, says Dr. Ralston, “I will lead by acknowledging that the experience the parent is having is extremely stressful. Then, after addressing the primary illness of the child and what the plan is for that, I say, ‘I see [from our records] that you are smoking. Have you tried to quit? Are you interested in quitting now? What might I be able to do to help you?’ If there is an opening, then I’ll go into more extensive counseling.

“You don’t need all the data behind you. I use my expertise more to motivate pediatricians, not the parents.” Another tack she takes to motivate pediatricians to empathically address smoking is to ask them to think of something they do that they know is bad for them but that they continue to do.

Conclusion

“There have been some studies that have shown [disappointing] outcomes when we intervene with hospitalized patients, but I’m more optimistic,” says Dr. Liu. “I feel that as long as we can make a difference in some people’s lives and get them to quit after they leave the hospital, then it’s worth the effort.”

Look at what you are willing to do, advises Dr. Ralston. “If that is a brief message and then a referral to a quit line, that’s fabulous,” she says. “You still might double the quit rate.” Given the temporal nature of the hospitalist-patient relationship, there may be a good number of ways hospitalists could effect change by offering a few encouraging words. TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Koh HK, Joossens LX, Connolly GN. Making smoking history worldwide. N Engl J Med. 2007 Apr 12;356(15):1496-1498.
2. Centers for Disease Control and Prevention. Targeting Tobacco Use: The Nation’s Leading Cause of Preventable Death, 2007. Available at www.cdc.gov/Tobacco/basic_information/00_pdfs/AAGTobacco2007.pdf. Last accessed June 18, 2007.
3. Ralston S, Kellett N, Williams RL, et al. Practice-based assessment of tobacco usage in southwestern primary care patients: a Research Involving Outpatient Settings Network (RIOS Net) study. J Am Board Fam Med. 2007;20(2):174-180.
4. Ralston S, Mahshid R. The pediatric hospitalist and the smoking parent. Pediatric Research Day 2006. Available at http://hsc.unm.edu/pedsresearch/ORAL%20PRESENTATIONS.htm Albuquerque: Office of Research and Creative Endeavors, Department of Pediatrics, University of New Mexico Health Sciences Center; 2006. Last accessed June 18, 2007.
5. Aligne CA, Stoddard JJ. Tobacco and children. An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997 Jul;151(7):648-653. Erratum in: Arch Pediatr Adolesc Med 1997 Oct;151(10):988. Comment in: Arch Pediatr Adolesc Med. 1997 Dec;151(12):1269. Arch Pediatr Adolesc Med. 2000 Aug;154(8):850.
6. Leonard K, Mosquera M, Aligne CA. Pediatrics in the community: Taking a collective breath to help children who have asthma. Pediatr Rev. 2007;28:152-153.
7. Winickoff JP, Hillis VJ, Palfrey JS, et al. A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the stop tobacco outreach program. Pediatrics. 2003 Jan;111(1):140-145.

Nobody thought it was possible. Could all indoor workplaces in Ireland—including pubs—be made smoke-free? Now, a law enacted in 2004 is seen as a triumph for public health policy worldwide.1

Smoking kills 438,000 people a year in the United States, and 8.6 million have a serious smoking-related illness.2 Research shows many outpatient physicians do not judge it worthwhile to talk with their patients about quitting smoking because they assume they will have no effect. The assumption is that even if patients quit, they will relapse.

Yet ample evidence suggests hospitalists can have a positive effect by intervening during a patient’s hospital visit.

Data also show that an individual will relapse an average of seven times before being able to take the step for the long term. Relapse is a part of the process, each time teaching an individual something about his or her motivation and behavior.

“Doctors who address smoking with patients can double or even triple the chances of their quitting,” says Shawn Ralston, MD, pediatric hospitalist at Presbyterian Hospital in Albuquerque, N.M. A few pointed questions and a show of compassion to the patient in the hospital could make a world of difference.

Golden Opportunity

Stephen Liu, MD, MPH, a hospitalist and an assistant program director at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, N.H., has been interested in smoking-cessation interventions since his residency in DHMC’s Leadership Preventive Medicine Residency Program in 2003, where he worked on improving care for pneumonia patients. His efforts took off as a result of the Centers for Medicare and Medicaid Services (CMS) pay-for-performance measures, which made smoking-cessation counseling a key component of admission and discharge documentation for a number of disease states.

The approach used with adult patients at DHMC is the brainchild of Colleen Warren, a registered nurse on the medicine unit on which Dr. Liu worked.

“The more times that smokers hear the message [about quitting], the more likely they are to try to quit,” says Dr. Liu. “We capitalized on that [point when] we developed a tobacco treatment team in our hospital. The team, which includes two to five motivated nurses, social workers, or care managers in most units of the hospital, pursued training including an online tobacco treatment course through U Mass Medical Center.”

In January 2006, DHMC was awarded a grant from the New Hampshire Department of Health and Human Services to standardize the treatment of hospitalized smokers. This includes conducting tobacco screening, assessing a patient’s readiness to quit, providing brief counseling, documenting the status and stage of change into the electronic medical record, and referring the patient to community resources upon discharge. The funding allowed the institution to support Warren and Dr. Liu as they coordinated the team and its work. These efforts, including counseling, nicotine replacement therapy, and cessation medications, are also available free to DHMC employees.

DHMC is participating in the CMS demonstration project, in which the hospital publicly reports performance measures for several conditions on the CMS Web site. In addition, many more performance measures are publicly reported on the DHMC quality-measures Web site. Although the team initially targeted the intervention to performance measures related to pneumonia and heart failure hospitalizations, they decided to offer interventions to all patients admitted to the hospital. Of these patients, about 20% are smokers, Dr. Liu says.

Because financial support wasn’t available at first and staff time was voluntary, the work was more difficult. Data from a six-month pilot intervention on two inpatient floors at DHMC showed patient assessments increased from 2% to 85%. In addition, the percentage of eligible heart failure and pneumonia patients receiving smoking cessation advice or counseling prior to discharge has risen from 30% before 2005 to 80% to 90%.

“We have found that hospitalization is a golden opportunity to address smoking cessation in patients in that they become acutely aware of how the smoking has affected their health,” says Dr. Liu. Because patients frequently go without smoking for several days while hospitalized, they learn they can live without smoking and feel much better.

“The key for our kind of intervention is not only assessing it and addressing it while they are hospitalized, but making sure that we link them to resources after they leave,” Dr. Liu says. Those resources include telephone quit lines or local support groups and/or local cessation clinics.

Counseling patients can be personally and professionally fulfilling, says Dr. Liu. He recalls a 50-year-old man—a lifelong smoker—admitted for pancreatitis. The day he was discharged, he showed Dr. Liu a hospital-produced packet of information. The patient said he had been reading it during his stay, decided he was motivated to quit, and had called the quit line.

Dr. Liu and his team use what they call the five A’s:

• Ask (does the patient smoke and has he/she tried to quit?);
• Advise the patient to quit;
• Assess (if the patient is ready to try to quit);
• Assist (the patient in planning treatment and referrals); and
• Arrange for a follow-up visit.

As part of their counseling, DHMC team members ask patients whether they have used assistive medication, such as nicotine-replacement therapy, bupropion (Wellbutrin) or varenicline (Chantix), in their attempts. They find out what patients have and have not tried. Then they ask, “How can we as a hospital help so that you will not restart smoking when you get home?”

A slightly longer counseling session with a motivated patient means a provider can explore whether they know their triggers for smoking, such as stress, alcohol use, or being around other smokers, and help the patient develop a proactive plan for when they are re-exposed to triggers upon discharge.

Counseling Parents of Hospitalized Children

In Dr. Ralston’s case, her research and the research of others inspired her to begin counseling the parents of hospitalized children.3-4 She was conducting research on respiratory illness, specifically bronchiolitis—the most common reason children are hospitalized.

She noticed the vast majority of children had had secondary smoke exposure. The work of C. Andrew Aligne, MD, formerly in the department of general pediatrics at the University of Rochester (N.Y.) Medical Center, inspired her.5-6 His analyses of attributable risk data revealed that the major and preventable cause of death in children is secondary smoke from parents.

But the issue really crystallized for Dr. Ralston when she encountered the work of Jonathan Winickoff, MD, MPH, an assistant professor of pediatrics at Harvard Medical School and a researcher with the Massachusetts General Hospital Center for Child and Adolescent Health Policy in Boston.

“The AHRQ guidelines show a huge amount of literature that say hospitalization is a great time to address smoking in adults,” says Dr. Ralston. “The [quit rate in office patients] will move from 5% to 12% or 15%, depending on the message. But in hospitalized adults, the quit rate can rise to 25% or 27%. Dr. Winickoff said, ‘Why can’t hospitalization for children be a teachable moment for parents?’ ”7

Another researcher who inspired Dr. Ralston was William R. Miller, PhD, who created the motivational interviewing model. Motivational interviewing is used with individuals to elicit and examine the ambivalence surrounding their unhealthy behaviors. Dr. Miller, retiring this year from the University of New Mexico (Albuquerque), began his work in the area of alcohol abuse. He and his colleagues have increasingly used motivational interviewing in other areas of addiction.

Dr. Ralston says what she has learned from motivational interviewing—and how she counsels parents of hospitalized children differently because of it—primarily pertains to her willingness to talk to people about a difficult subject. Instead of bombarding parents with facts about how smoking is bad for their children—which they already believe but don’t want to talk about—she learned to focus on the parents’ needs instead of the effects on the child.

“And there is the issue of bringing it up when this is not technically your patient,” she says. But after fine-tuning and developing her technique, she now assumes a value-neutral, nonjudgmental, open-ended approach using motivational interviewing. “Eventually it becomes easy to do.”

When approaching a parent to offer help, says Dr. Ralston, “I will lead by acknowledging that the experience the parent is having is extremely stressful. Then, after addressing the primary illness of the child and what the plan is for that, I say, ‘I see [from our records] that you are smoking. Have you tried to quit? Are you interested in quitting now? What might I be able to do to help you?’ If there is an opening, then I’ll go into more extensive counseling.

“You don’t need all the data behind you. I use my expertise more to motivate pediatricians, not the parents.” Another tack she takes to motivate pediatricians to empathically address smoking is to ask them to think of something they do that they know is bad for them but that they continue to do.

Conclusion

“There have been some studies that have shown [disappointing] outcomes when we intervene with hospitalized patients, but I’m more optimistic,” says Dr. Liu. “I feel that as long as we can make a difference in some people’s lives and get them to quit after they leave the hospital, then it’s worth the effort.”

Look at what you are willing to do, advises Dr. Ralston. “If that is a brief message and then a referral to a quit line, that’s fabulous,” she says. “You still might double the quit rate.” Given the temporal nature of the hospitalist-patient relationship, there may be a good number of ways hospitalists could effect change by offering a few encouraging words. TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Koh HK, Joossens LX, Connolly GN. Making smoking history worldwide. N Engl J Med. 2007 Apr 12;356(15):1496-1498.
2. Centers for Disease Control and Prevention. Targeting Tobacco Use: The Nation’s Leading Cause of Preventable Death, 2007. Available at www.cdc.gov/Tobacco/basic_information/00_pdfs/AAGTobacco2007.pdf. Last accessed June 18, 2007.
3. Ralston S, Kellett N, Williams RL, et al. Practice-based assessment of tobacco usage in southwestern primary care patients: a Research Involving Outpatient Settings Network (RIOS Net) study. J Am Board Fam Med. 2007;20(2):174-180.
4. Ralston S, Mahshid R. The pediatric hospitalist and the smoking parent. Pediatric Research Day 2006. Available at http://hsc.unm.edu/pedsresearch/ORAL%20PRESENTATIONS.htm Albuquerque: Office of Research and Creative Endeavors, Department of Pediatrics, University of New Mexico Health Sciences Center; 2006. Last accessed June 18, 2007.
5. Aligne CA, Stoddard JJ. Tobacco and children. An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997 Jul;151(7):648-653. Erratum in: Arch Pediatr Adolesc Med 1997 Oct;151(10):988. Comment in: Arch Pediatr Adolesc Med. 1997 Dec;151(12):1269. Arch Pediatr Adolesc Med. 2000 Aug;154(8):850.
6. Leonard K, Mosquera M, Aligne CA. Pediatrics in the community: Taking a collective breath to help children who have asthma. Pediatr Rev. 2007;28:152-153.
7. Winickoff JP, Hillis VJ, Palfrey JS, et al. A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the stop tobacco outreach program. Pediatrics. 2003 Jan;111(1):140-145.

Nobody thought it was possible. Could all indoor workplaces in Ireland—including pubs—be made smoke-free? Now, a law enacted in 2004 is seen as a triumph for public health policy worldwide.1

Smoking kills 438,000 people a year in the United States, and 8.6 million have a serious smoking-related illness.2 Research shows many outpatient physicians do not judge it worthwhile to talk with their patients about quitting smoking because they assume they will have no effect. The assumption is that even if patients quit, they will relapse.

Yet ample evidence suggests hospitalists can have a positive effect by intervening during a patient’s hospital visit.

Data also show that an individual will relapse an average of seven times before being able to take the step for the long term. Relapse is a part of the process, each time teaching an individual something about his or her motivation and behavior.

“Doctors who address smoking with patients can double or even triple the chances of their quitting,” says Shawn Ralston, MD, pediatric hospitalist at Presbyterian Hospital in Albuquerque, N.M. A few pointed questions and a show of compassion to the patient in the hospital could make a world of difference.

Golden Opportunity

Stephen Liu, MD, MPH, a hospitalist and an assistant program director at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, N.H., has been interested in smoking-cessation interventions since his residency in DHMC’s Leadership Preventive Medicine Residency Program in 2003, where he worked on improving care for pneumonia patients. His efforts took off as a result of the Centers for Medicare and Medicaid Services (CMS) pay-for-performance measures, which made smoking-cessation counseling a key component of admission and discharge documentation for a number of disease states.

The approach used with adult patients at DHMC is the brainchild of Colleen Warren, a registered nurse on the medicine unit on which Dr. Liu worked.

“The more times that smokers hear the message [about quitting], the more likely they are to try to quit,” says Dr. Liu. “We capitalized on that [point when] we developed a tobacco treatment team in our hospital. The team, which includes two to five motivated nurses, social workers, or care managers in most units of the hospital, pursued training including an online tobacco treatment course through U Mass Medical Center.”

In January 2006, DHMC was awarded a grant from the New Hampshire Department of Health and Human Services to standardize the treatment of hospitalized smokers. This includes conducting tobacco screening, assessing a patient’s readiness to quit, providing brief counseling, documenting the status and stage of change into the electronic medical record, and referring the patient to community resources upon discharge. The funding allowed the institution to support Warren and Dr. Liu as they coordinated the team and its work. These efforts, including counseling, nicotine replacement therapy, and cessation medications, are also available free to DHMC employees.

DHMC is participating in the CMS demonstration project, in which the hospital publicly reports performance measures for several conditions on the CMS Web site. In addition, many more performance measures are publicly reported on the DHMC quality-measures Web site. Although the team initially targeted the intervention to performance measures related to pneumonia and heart failure hospitalizations, they decided to offer interventions to all patients admitted to the hospital. Of these patients, about 20% are smokers, Dr. Liu says.

Because financial support wasn’t available at first and staff time was voluntary, the work was more difficult. Data from a six-month pilot intervention on two inpatient floors at DHMC showed patient assessments increased from 2% to 85%. In addition, the percentage of eligible heart failure and pneumonia patients receiving smoking cessation advice or counseling prior to discharge has risen from 30% before 2005 to 80% to 90%.

“We have found that hospitalization is a golden opportunity to address smoking cessation in patients in that they become acutely aware of how the smoking has affected their health,” says Dr. Liu. Because patients frequently go without smoking for several days while hospitalized, they learn they can live without smoking and feel much better.

“The key for our kind of intervention is not only assessing it and addressing it while they are hospitalized, but making sure that we link them to resources after they leave,” Dr. Liu says. Those resources include telephone quit lines or local support groups and/or local cessation clinics.

Counseling patients can be personally and professionally fulfilling, says Dr. Liu. He recalls a 50-year-old man—a lifelong smoker—admitted for pancreatitis. The day he was discharged, he showed Dr. Liu a hospital-produced packet of information. The patient said he had been reading it during his stay, decided he was motivated to quit, and had called the quit line.

Dr. Liu and his team use what they call the five A’s:

• Ask (does the patient smoke and has he/she tried to quit?);
• Advise the patient to quit;
• Assess (if the patient is ready to try to quit);
• Assist (the patient in planning treatment and referrals); and
• Arrange for a follow-up visit.

As part of their counseling, DHMC team members ask patients whether they have used assistive medication, such as nicotine-replacement therapy, bupropion (Wellbutrin) or varenicline (Chantix), in their attempts. They find out what patients have and have not tried. Then they ask, “How can we as a hospital help so that you will not restart smoking when you get home?”

A slightly longer counseling session with a motivated patient means a provider can explore whether they know their triggers for smoking, such as stress, alcohol use, or being around other smokers, and help the patient develop a proactive plan for when they are re-exposed to triggers upon discharge.

Counseling Parents of Hospitalized Children

In Dr. Ralston’s case, her research and the research of others inspired her to begin counseling the parents of hospitalized children.3-4 She was conducting research on respiratory illness, specifically bronchiolitis—the most common reason children are hospitalized.

She noticed the vast majority of children had had secondary smoke exposure. The work of C. Andrew Aligne, MD, formerly in the department of general pediatrics at the University of Rochester (N.Y.) Medical Center, inspired her.5-6 His analyses of attributable risk data revealed that the major and preventable cause of death in children is secondary smoke from parents.

But the issue really crystallized for Dr. Ralston when she encountered the work of Jonathan Winickoff, MD, MPH, an assistant professor of pediatrics at Harvard Medical School and a researcher with the Massachusetts General Hospital Center for Child and Adolescent Health Policy in Boston.

“The AHRQ guidelines show a huge amount of literature that say hospitalization is a great time to address smoking in adults,” says Dr. Ralston. “The [quit rate in office patients] will move from 5% to 12% or 15%, depending on the message. But in hospitalized adults, the quit rate can rise to 25% or 27%. Dr. Winickoff said, ‘Why can’t hospitalization for children be a teachable moment for parents?’ ”7

Another researcher who inspired Dr. Ralston was William R. Miller, PhD, who created the motivational interviewing model. Motivational interviewing is used with individuals to elicit and examine the ambivalence surrounding their unhealthy behaviors. Dr. Miller, retiring this year from the University of New Mexico (Albuquerque), began his work in the area of alcohol abuse. He and his colleagues have increasingly used motivational interviewing in other areas of addiction.

Dr. Ralston says what she has learned from motivational interviewing—and how she counsels parents of hospitalized children differently because of it—primarily pertains to her willingness to talk to people about a difficult subject. Instead of bombarding parents with facts about how smoking is bad for their children—which they already believe but don’t want to talk about—she learned to focus on the parents’ needs instead of the effects on the child.

“And there is the issue of bringing it up when this is not technically your patient,” she says. But after fine-tuning and developing her technique, she now assumes a value-neutral, nonjudgmental, open-ended approach using motivational interviewing. “Eventually it becomes easy to do.”

When approaching a parent to offer help, says Dr. Ralston, “I will lead by acknowledging that the experience the parent is having is extremely stressful. Then, after addressing the primary illness of the child and what the plan is for that, I say, ‘I see [from our records] that you are smoking. Have you tried to quit? Are you interested in quitting now? What might I be able to do to help you?’ If there is an opening, then I’ll go into more extensive counseling.

“You don’t need all the data behind you. I use my expertise more to motivate pediatricians, not the parents.” Another tack she takes to motivate pediatricians to empathically address smoking is to ask them to think of something they do that they know is bad for them but that they continue to do.

Conclusion

“There have been some studies that have shown [disappointing] outcomes when we intervene with hospitalized patients, but I’m more optimistic,” says Dr. Liu. “I feel that as long as we can make a difference in some people’s lives and get them to quit after they leave the hospital, then it’s worth the effort.”

Look at what you are willing to do, advises Dr. Ralston. “If that is a brief message and then a referral to a quit line, that’s fabulous,” she says. “You still might double the quit rate.” Given the temporal nature of the hospitalist-patient relationship, there may be a good number of ways hospitalists could effect change by offering a few encouraging words. TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Koh HK, Joossens LX, Connolly GN. Making smoking history worldwide. N Engl J Med. 2007 Apr 12;356(15):1496-1498.
2. Centers for Disease Control and Prevention. Targeting Tobacco Use: The Nation’s Leading Cause of Preventable Death, 2007. Available at www.cdc.gov/Tobacco/basic_information/00_pdfs/AAGTobacco2007.pdf. Last accessed June 18, 2007.
3. Ralston S, Kellett N, Williams RL, et al. Practice-based assessment of tobacco usage in southwestern primary care patients: a Research Involving Outpatient Settings Network (RIOS Net) study. J Am Board Fam Med. 2007;20(2):174-180.
4. Ralston S, Mahshid R. The pediatric hospitalist and the smoking parent. Pediatric Research Day 2006. Available at http://hsc.unm.edu/pedsresearch/ORAL%20PRESENTATIONS.htm Albuquerque: Office of Research and Creative Endeavors, Department of Pediatrics, University of New Mexico Health Sciences Center; 2006. Last accessed June 18, 2007.
5. Aligne CA, Stoddard JJ. Tobacco and children. An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997 Jul;151(7):648-653. Erratum in: Arch Pediatr Adolesc Med 1997 Oct;151(10):988. Comment in: Arch Pediatr Adolesc Med. 1997 Dec;151(12):1269. Arch Pediatr Adolesc Med. 2000 Aug;154(8):850.
6. Leonard K, Mosquera M, Aligne CA. Pediatrics in the community: Taking a collective breath to help children who have asthma. Pediatr Rev. 2007;28:152-153.
7. Winickoff JP, Hillis VJ, Palfrey JS, et al. A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the stop tobacco outreach program. Pediatrics. 2003 Jan;111(1):140-145.

Supplement Editors:
Susan J. Rehm, MD, and Alpesh N. Amin, MD, MBA

Contents

Infections in hospitalized patients: What is happening and who can help?
Alpesh N. Amin, MD, MBA, and Susan J. Rehm, MD

Impact of community-acquired methicillin-resistant Staphylococcus aureus in the hospital setting
Thomas M. File, Jr., MD

Emerging issues in the management of infections caused by multidrug-resistant gram-negative bacteria
Louis B. Rice, MD

Complicated skin and soft-tissue infections: Diagnostic approach and empiric treatment options
James I. Merlino, MD, and Mark A. Malangoni, MD

Empiric treatment options in the management of complicated intra-abdominal infections
John A. Weigelt, MD

Antibacterial treatment strategies in hospitalized patients: What role for pharmacoeconomics?
Morton P. Goldman, PharmD, BCPS, and Radhika Nair, PhD

Supplement Editors:
Susan J. Rehm, MD, and Alpesh N. Amin, MD, MBA

Contents

Infections in hospitalized patients: What is happening and who can help?
Alpesh N. Amin, MD, MBA, and Susan J. Rehm, MD

Impact of community-acquired methicillin-resistant Staphylococcus aureus in the hospital setting
Thomas M. File, Jr., MD

Emerging issues in the management of infections caused by multidrug-resistant gram-negative bacteria
Louis B. Rice, MD

Complicated skin and soft-tissue infections: Diagnostic approach and empiric treatment options
James I. Merlino, MD, and Mark A. Malangoni, MD

Empiric treatment options in the management of complicated intra-abdominal infections
John A. Weigelt, MD

Antibacterial treatment strategies in hospitalized patients: What role for pharmacoeconomics?
Morton P. Goldman, PharmD, BCPS, and Radhika Nair, PhD

Supplement Editors:
Susan J. Rehm, MD, and Alpesh N. Amin, MD, MBA

Contents

Infections in hospitalized patients: What is happening and who can help?
Alpesh N. Amin, MD, MBA, and Susan J. Rehm, MD

Impact of community-acquired methicillin-resistant Staphylococcus aureus in the hospital setting
Thomas M. File, Jr., MD

Emerging issues in the management of infections caused by multidrug-resistant gram-negative bacteria
Louis B. Rice, MD

Complicated skin and soft-tissue infections: Diagnostic approach and empiric treatment options
James I. Merlino, MD, and Mark A. Malangoni, MD

Empiric treatment options in the management of complicated intra-abdominal infections
John A. Weigelt, MD

Antibacterial treatment strategies in hospitalized patients: What role for pharmacoeconomics?
Morton P. Goldman, PharmD, BCPS, and Radhika Nair, PhD

Abstract

Background A physician’s recommendation is a powerful motivator for a patient to undergo colonoscopy for colorectal cancer screening, yet little is known about how physicians address this topic.

Methods We recruited 30 primary care physicians and physicians-in-training from 4 practices to counsel a “patient,” simulated by a researcher, regarding the need for screening colonoscopy. Audiotapes of the physician-patient encounters were transcribed. Preserving physician anonymity, we assessed each encounter for key informational points, positive or negative message framing, type of numeracy information, and use of colloquial or technical language.

Results Study physicians addressed a mean of 6.7 (standard deviation=1.8) of 13 key informational points. Most physicians (≥80%) discussed the benefits of colorectal cancer screening, the recognition of colonoscopy as a standard exploratory procedure, and the use of sedation. However, few (<20%) addressed the risks of colonoscopy, the nuances of scheduling, or the need for dietary and medication changes. Nearly all physicians (98%) used messages that focused on the positive aspects of screening (gain-framed messages), and many (67%) also used messages that focused on the risk of not screening (loss-framed messages). Numeracy information generally was expressed simply, but half of the physicians used statistical terms. Half used colloquial terms to describe the prep and procedure.

Conclusion Though most physicians used positive, simple terms to describe colonoscopy, they often omitted key information. Correcting for the areas of insufficient information found in our study—perhaps with supplementary educational sources—will help ensure that patients are adequately prepared for colonoscopy.

Colorectal cancer screening has the potential to reduce deaths from colorectal cancer by at least one third.¹ Yet only half of eligible patients in the US who are age 50 or older have undergone screening.² Patients often say they haven’t been screened because their physician didn’t recommend it.^3-5

A physician’s recommendation is strongly predictive of whether a patient actually undergoes colorectal cancer screening, even after adjusting for multiple confounders.^6-9 Yet several studies have found that, even after the physician has recommended or ordered an endoscopic study of the colon, many patients do not follow through.^10-12 Successful completion of screening colonoscopy requires, in part, that a patient understand the need for the procedure and receive sufficient instruction about it. Thus, failure to undergo this test may reflect patient concerns or misunderstandings due to inadequate communication.^13,14

In many settings, the primary care physician bears the responsibility for telling the patient about screening colonoscopy because the endoscopist meets the patient only at the time of the procedure. Supplementary educational programs can also play a role. Unfortunately, though, while these materials appear to reduce patient anxiety and increase adherence to screening recommendations,^15-17 they are infrequently used.

Looking at physician communication with an eye toward improvement

Our goal in conducting this study was to evaluate the way in which physicians discuss the need for screening colonoscopy with their patients. Using a simulated patient scenario, we wanted to examine 4 dimensions of each discussion: completeness; type of messaging; type of numeracy information (ie, numerical and mathematical data); and use of colloquial vs technical language.

• Completeness reflected the number of key informational points addressed.
• Type of messaging focused on the use of loss- or gain-framed messages, both of which have been linked to increased patient intention to adopt a cancer prevention behavior or test.^18-20 Gain-framed counseling emphasizes the positive aspects of screening; loss-framed, the risks of not screening.
• Type of numeracy information. Because poor numeracy skills are thought to impair the accuracy of patients’ perceptions of cancer risk,²¹ we categorized the type of numeracy information provided by physicians following an approach developed by Ahlers-Schmidt and colleagues.²²
• Colloquial vs technical language. Because colonoscopy involves sensitive topics such as the bowels and feces, and because language choices may affect acceptance of care,²³ we evaluated physicians’ use of terminology when describing the procedure.

We felt that by looking at these dimensions, we could help physicians to refine screening colonoscopy messages so that conversations with patients could be more clear, complete, and balanced.

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

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

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.

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

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.

Discussion

An informed patient is a willing patient

Our study physicians addressed only half of the 13 informational points, likely reflecting the time constraints of a typical office visit. Primary care physicians appear to expect that either the colonoscopist or other sources of information would fill in the gaps. As reported in several studies, unanswered questions can discourage patients from keeping their scheduled colonoscopy appointment.^10,11 In one report of African-American church members, those with adequate knowledge about colorectal cancer screening were more likely to complete screening.²⁴

Wolf and Becker suggested that discussions about cancer screening address 4 broad topics: the probability of developing the cancer, the operating characteristics of the screening test(s), the likelihood that screening will benefit the patient, and potential burdens of the test.²⁵ Instead of a balanced and lengthy discussion, our study physicians generally emphasized the positives such as the value of avoiding colon cancer, the standard nature of this test, and the benefit of being sedated for the procedure. Thus, gain-framed messages about colorectal cancer were the norm for our study physicians.

Half of the physicians also offered loss-framed messages emphasizing the need to avoid the consequences of colorectal cancer and the increased threat associated with a family history of this malignancy. Research in mammography screening suggests that loss-framed messaging may be a more powerful motivator than gain-framed messaging,²⁶ but it is not clear if this observation can be generalized to colorectal cancer screening.

Walking a fine line with the particulars of risk

Our study physicians rarely provided data on the probability of developing colorectal cancer. Physicians may avoid this topic because many patients have difficulty understanding information about the risk of colorectal cancer.¹¹ In support of this approach, Lipkus and colleagues reported that various ways of informing patients about colorectal cancer risk did not affect their intention to be screened.²⁷ Of concern, most of our physicians did not address the common misconception that colorectal cancer screening is unnecessary in the absence of symptoms.²⁸

Overall, the level of numeracy information provided by study physicians required minimal patient understanding of mathematical and statistical concepts. Most information was descriptive, such as colonoscopy being “more thorough” than other tests. Though statistical concepts such as “risk” were often mentioned, few physicians offered probabilities or incidence data. Experts recommend providing such data,²⁵ but Web sites have been criticized for offering excessive numerical cancer risk data.²² Therefore, physicians must walk a fine line between providing adequate information and offering data that require a high level of health numeracy for understanding.

6 key points physicians often overlook

Most physicians failed to mention dietary and medication changes, scheduling/insurance coverage issues, and risk of complications from colonoscopy. Nearly 60% failed to discuss the patient’s risk of colorectal cancer. Almost half did not mention the need for a companion to accompany the patient after the test. Scheduling challenges, in particular, are known to interfere with completing colonoscopy.¹¹

Many neglect to describe the procedure

Thirty percent of physicians failed to describe the procedure itself, so it is not surprising that patients complain they have a poor understanding of test logistics.^11,29,30 Denberg and colleagues have reported that mailing an informational brochure about colonoscopy can increase the number who keep their appointment.³¹

How language choices may affect understanding

Other researchers have identified additional patient barriers to colonoscopy, including fear of pain, concern for modesty, and desire to avoid the bowel prep.^11,32 These concerns may be mitigated or heightened by the physician’s language. In our review of transcripts, physicians often used slang or colloquial language to describe the procedure, probably in an attempt to convey information in a familiar way. This language may be viewed as crude and potentially discouraging, but further research is needed to evaluate patient receptiveness to different ways of speaking about sensitive topics.

Additionally, physicians commonly used technical terms such as “polyp” and “biopsy” without explaining them. Technical language may increase racial disparities in adhering to scheduled colonoscopy. In a family medicine clinic, patients from minority groups had particular difficulty understanding medical terms and procedure names.²⁸ Because little time is available for counseling about cancer screening tests, and because patients retain only a limited amount of information about procedures,³³ supplementary informational sources are warranted.^15-17,31 Options include brochures, telephone calls, letters, e-mails, Web site data, and videotapes, but it is unclear which sources optimally improve patient adherence to screening colonoscopy.³⁴

Study limitations include simulated interaction

There were a number of limitations to this study. First, the investigators “simulated” the patient. Though study physicians were told to act as if they were speaking to a regular patient, they may still have unconsciously modified their usual approach to addressing this topic.

Second, we did not assess the effectiveness of these discussions in motivating actual patients to receive colonoscopy.

Other limitations included the following:

• We did not set a time period for these discussions, so they may have been even more limited in actual practice.
• We studied physicians from a single health care setting wherein colonoscopy appears to be the preferred approach to screen an average risk patient for colorectal cancer. In addition, in this health care system, this test is performed by a gastroenterologist, rather than a primary care physician.
• We did not determine whether patients regard our selected quotes as too colloquial or technical.
• This study did not address the important barrier of a physician forgetting to recommend colorectal cancer screening.³⁵

Further research, next steps

Our study supports the hypothesis that physicians differ widely—but are generally deficient—when informing patients about screening colonoscopy. They generally emphasize the positives of colonoscopy and use terms that are colloquial, avoiding statistical concepts that may be hard for patients to understand. Future studies need to address the effectiveness of these approaches to discussing screening colonoscopy.

Given the central role of the primary care physician in motivating patients to undergo screening colonoscopy in a limited time period, it appears that additional supports are needed to supplement physician discussion about this important preventive care procedure.

Correspondence
Barbara J. Turner MD, MSEd, University of Pennsylvania, 1123 Blockley Hall/6021, 423 Guardian Drive, Philadelphia, PA 19104; [email protected]

Abstract

Background A physician’s recommendation is a powerful motivator for a patient to undergo colonoscopy for colorectal cancer screening, yet little is known about how physicians address this topic.

Methods We recruited 30 primary care physicians and physicians-in-training from 4 practices to counsel a “patient,” simulated by a researcher, regarding the need for screening colonoscopy. Audiotapes of the physician-patient encounters were transcribed. Preserving physician anonymity, we assessed each encounter for key informational points, positive or negative message framing, type of numeracy information, and use of colloquial or technical language.

Results Study physicians addressed a mean of 6.7 (standard deviation=1.8) of 13 key informational points. Most physicians (≥80%) discussed the benefits of colorectal cancer screening, the recognition of colonoscopy as a standard exploratory procedure, and the use of sedation. However, few (<20%) addressed the risks of colonoscopy, the nuances of scheduling, or the need for dietary and medication changes. Nearly all physicians (98%) used messages that focused on the positive aspects of screening (gain-framed messages), and many (67%) also used messages that focused on the risk of not screening (loss-framed messages). Numeracy information generally was expressed simply, but half of the physicians used statistical terms. Half used colloquial terms to describe the prep and procedure.

Conclusion Though most physicians used positive, simple terms to describe colonoscopy, they often omitted key information. Correcting for the areas of insufficient information found in our study—perhaps with supplementary educational sources—will help ensure that patients are adequately prepared for colonoscopy.

Colorectal cancer screening has the potential to reduce deaths from colorectal cancer by at least one third.¹ Yet only half of eligible patients in the US who are age 50 or older have undergone screening.² Patients often say they haven’t been screened because their physician didn’t recommend it.^3-5

A physician’s recommendation is strongly predictive of whether a patient actually undergoes colorectal cancer screening, even after adjusting for multiple confounders.^6-9 Yet several studies have found that, even after the physician has recommended or ordered an endoscopic study of the colon, many patients do not follow through.^10-12 Successful completion of screening colonoscopy requires, in part, that a patient understand the need for the procedure and receive sufficient instruction about it. Thus, failure to undergo this test may reflect patient concerns or misunderstandings due to inadequate communication.^13,14

In many settings, the primary care physician bears the responsibility for telling the patient about screening colonoscopy because the endoscopist meets the patient only at the time of the procedure. Supplementary educational programs can also play a role. Unfortunately, though, while these materials appear to reduce patient anxiety and increase adherence to screening recommendations,^15-17 they are infrequently used.

Looking at physician communication with an eye toward improvement

Our goal in conducting this study was to evaluate the way in which physicians discuss the need for screening colonoscopy with their patients. Using a simulated patient scenario, we wanted to examine 4 dimensions of each discussion: completeness; type of messaging; type of numeracy information (ie, numerical and mathematical data); and use of colloquial vs technical language.

• Completeness reflected the number of key informational points addressed.
• Type of messaging focused on the use of loss- or gain-framed messages, both of which have been linked to increased patient intention to adopt a cancer prevention behavior or test.^18-20 Gain-framed counseling emphasizes the positive aspects of screening; loss-framed, the risks of not screening.
• Type of numeracy information. Because poor numeracy skills are thought to impair the accuracy of patients’ perceptions of cancer risk,²¹ we categorized the type of numeracy information provided by physicians following an approach developed by Ahlers-Schmidt and colleagues.²²
• Colloquial vs technical language. Because colonoscopy involves sensitive topics such as the bowels and feces, and because language choices may affect acceptance of care,²³ we evaluated physicians’ use of terminology when describing the procedure.

We felt that by looking at these dimensions, we could help physicians to refine screening colonoscopy messages so that conversations with patients could be more clear, complete, and balanced.

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

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

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.

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

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.

Discussion

An informed patient is a willing patient

Our study physicians addressed only half of the 13 informational points, likely reflecting the time constraints of a typical office visit. Primary care physicians appear to expect that either the colonoscopist or other sources of information would fill in the gaps. As reported in several studies, unanswered questions can discourage patients from keeping their scheduled colonoscopy appointment.^10,11 In one report of African-American church members, those with adequate knowledge about colorectal cancer screening were more likely to complete screening.²⁴

Wolf and Becker suggested that discussions about cancer screening address 4 broad topics: the probability of developing the cancer, the operating characteristics of the screening test(s), the likelihood that screening will benefit the patient, and potential burdens of the test.²⁵ Instead of a balanced and lengthy discussion, our study physicians generally emphasized the positives such as the value of avoiding colon cancer, the standard nature of this test, and the benefit of being sedated for the procedure. Thus, gain-framed messages about colorectal cancer were the norm for our study physicians.

Half of the physicians also offered loss-framed messages emphasizing the need to avoid the consequences of colorectal cancer and the increased threat associated with a family history of this malignancy. Research in mammography screening suggests that loss-framed messaging may be a more powerful motivator than gain-framed messaging,²⁶ but it is not clear if this observation can be generalized to colorectal cancer screening.

Walking a fine line with the particulars of risk

Our study physicians rarely provided data on the probability of developing colorectal cancer. Physicians may avoid this topic because many patients have difficulty understanding information about the risk of colorectal cancer.¹¹ In support of this approach, Lipkus and colleagues reported that various ways of informing patients about colorectal cancer risk did not affect their intention to be screened.²⁷ Of concern, most of our physicians did not address the common misconception that colorectal cancer screening is unnecessary in the absence of symptoms.²⁸

Overall, the level of numeracy information provided by study physicians required minimal patient understanding of mathematical and statistical concepts. Most information was descriptive, such as colonoscopy being “more thorough” than other tests. Though statistical concepts such as “risk” were often mentioned, few physicians offered probabilities or incidence data. Experts recommend providing such data,²⁵ but Web sites have been criticized for offering excessive numerical cancer risk data.²² Therefore, physicians must walk a fine line between providing adequate information and offering data that require a high level of health numeracy for understanding.

6 key points physicians often overlook

Most physicians failed to mention dietary and medication changes, scheduling/insurance coverage issues, and risk of complications from colonoscopy. Nearly 60% failed to discuss the patient’s risk of colorectal cancer. Almost half did not mention the need for a companion to accompany the patient after the test. Scheduling challenges, in particular, are known to interfere with completing colonoscopy.¹¹

Many neglect to describe the procedure

Thirty percent of physicians failed to describe the procedure itself, so it is not surprising that patients complain they have a poor understanding of test logistics.^11,29,30 Denberg and colleagues have reported that mailing an informational brochure about colonoscopy can increase the number who keep their appointment.³¹

How language choices may affect understanding

Other researchers have identified additional patient barriers to colonoscopy, including fear of pain, concern for modesty, and desire to avoid the bowel prep.^11,32 These concerns may be mitigated or heightened by the physician’s language. In our review of transcripts, physicians often used slang or colloquial language to describe the procedure, probably in an attempt to convey information in a familiar way. This language may be viewed as crude and potentially discouraging, but further research is needed to evaluate patient receptiveness to different ways of speaking about sensitive topics.

Additionally, physicians commonly used technical terms such as “polyp” and “biopsy” without explaining them. Technical language may increase racial disparities in adhering to scheduled colonoscopy. In a family medicine clinic, patients from minority groups had particular difficulty understanding medical terms and procedure names.²⁸ Because little time is available for counseling about cancer screening tests, and because patients retain only a limited amount of information about procedures,³³ supplementary informational sources are warranted.^15-17,31 Options include brochures, telephone calls, letters, e-mails, Web site data, and videotapes, but it is unclear which sources optimally improve patient adherence to screening colonoscopy.³⁴

Study limitations include simulated interaction

There were a number of limitations to this study. First, the investigators “simulated” the patient. Though study physicians were told to act as if they were speaking to a regular patient, they may still have unconsciously modified their usual approach to addressing this topic.

Second, we did not assess the effectiveness of these discussions in motivating actual patients to receive colonoscopy.

Other limitations included the following:

• We did not set a time period for these discussions, so they may have been even more limited in actual practice.
• We studied physicians from a single health care setting wherein colonoscopy appears to be the preferred approach to screen an average risk patient for colorectal cancer. In addition, in this health care system, this test is performed by a gastroenterologist, rather than a primary care physician.
• We did not determine whether patients regard our selected quotes as too colloquial or technical.
• This study did not address the important barrier of a physician forgetting to recommend colorectal cancer screening.³⁵

Further research, next steps

Our study supports the hypothesis that physicians differ widely—but are generally deficient—when informing patients about screening colonoscopy. They generally emphasize the positives of colonoscopy and use terms that are colloquial, avoiding statistical concepts that may be hard for patients to understand. Future studies need to address the effectiveness of these approaches to discussing screening colonoscopy.

Given the central role of the primary care physician in motivating patients to undergo screening colonoscopy in a limited time period, it appears that additional supports are needed to supplement physician discussion about this important preventive care procedure.

Correspondence
Barbara J. Turner MD, MSEd, University of Pennsylvania, 1123 Blockley Hall/6021, 423 Guardian Drive, Philadelphia, PA 19104; [email protected]

Abstract

Background A physician’s recommendation is a powerful motivator for a patient to undergo colonoscopy for colorectal cancer screening, yet little is known about how physicians address this topic.

Methods We recruited 30 primary care physicians and physicians-in-training from 4 practices to counsel a “patient,” simulated by a researcher, regarding the need for screening colonoscopy. Audiotapes of the physician-patient encounters were transcribed. Preserving physician anonymity, we assessed each encounter for key informational points, positive or negative message framing, type of numeracy information, and use of colloquial or technical language.

Results Study physicians addressed a mean of 6.7 (standard deviation=1.8) of 13 key informational points. Most physicians (≥80%) discussed the benefits of colorectal cancer screening, the recognition of colonoscopy as a standard exploratory procedure, and the use of sedation. However, few (<20%) addressed the risks of colonoscopy, the nuances of scheduling, or the need for dietary and medication changes. Nearly all physicians (98%) used messages that focused on the positive aspects of screening (gain-framed messages), and many (67%) also used messages that focused on the risk of not screening (loss-framed messages). Numeracy information generally was expressed simply, but half of the physicians used statistical terms. Half used colloquial terms to describe the prep and procedure.

Conclusion Though most physicians used positive, simple terms to describe colonoscopy, they often omitted key information. Correcting for the areas of insufficient information found in our study—perhaps with supplementary educational sources—will help ensure that patients are adequately prepared for colonoscopy.

Colorectal cancer screening has the potential to reduce deaths from colorectal cancer by at least one third.¹ Yet only half of eligible patients in the US who are age 50 or older have undergone screening.² Patients often say they haven’t been screened because their physician didn’t recommend it.^3-5

A physician’s recommendation is strongly predictive of whether a patient actually undergoes colorectal cancer screening, even after adjusting for multiple confounders.^6-9 Yet several studies have found that, even after the physician has recommended or ordered an endoscopic study of the colon, many patients do not follow through.^10-12 Successful completion of screening colonoscopy requires, in part, that a patient understand the need for the procedure and receive sufficient instruction about it. Thus, failure to undergo this test may reflect patient concerns or misunderstandings due to inadequate communication.^13,14

In many settings, the primary care physician bears the responsibility for telling the patient about screening colonoscopy because the endoscopist meets the patient only at the time of the procedure. Supplementary educational programs can also play a role. Unfortunately, though, while these materials appear to reduce patient anxiety and increase adherence to screening recommendations,^15-17 they are infrequently used.

Looking at physician communication with an eye toward improvement

Our goal in conducting this study was to evaluate the way in which physicians discuss the need for screening colonoscopy with their patients. Using a simulated patient scenario, we wanted to examine 4 dimensions of each discussion: completeness; type of messaging; type of numeracy information (ie, numerical and mathematical data); and use of colloquial vs technical language.

• Completeness reflected the number of key informational points addressed.
• Type of messaging focused on the use of loss- or gain-framed messages, both of which have been linked to increased patient intention to adopt a cancer prevention behavior or test.^18-20 Gain-framed counseling emphasizes the positive aspects of screening; loss-framed, the risks of not screening.
• Type of numeracy information. Because poor numeracy skills are thought to impair the accuracy of patients’ perceptions of cancer risk,²¹ we categorized the type of numeracy information provided by physicians following an approach developed by Ahlers-Schmidt and colleagues.²²
• Colloquial vs technical language. Because colonoscopy involves sensitive topics such as the bowels and feces, and because language choices may affect acceptance of care,²³ we evaluated physicians’ use of terminology when describing the procedure.

We felt that by looking at these dimensions, we could help physicians to refine screening colonoscopy messages so that conversations with patients could be more clear, complete, and balanced.

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

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

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.

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

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.

Discussion

An informed patient is a willing patient

Our study physicians addressed only half of the 13 informational points, likely reflecting the time constraints of a typical office visit. Primary care physicians appear to expect that either the colonoscopist or other sources of information would fill in the gaps. As reported in several studies, unanswered questions can discourage patients from keeping their scheduled colonoscopy appointment.^10,11 In one report of African-American church members, those with adequate knowledge about colorectal cancer screening were more likely to complete screening.²⁴

Wolf and Becker suggested that discussions about cancer screening address 4 broad topics: the probability of developing the cancer, the operating characteristics of the screening test(s), the likelihood that screening will benefit the patient, and potential burdens of the test.²⁵ Instead of a balanced and lengthy discussion, our study physicians generally emphasized the positives such as the value of avoiding colon cancer, the standard nature of this test, and the benefit of being sedated for the procedure. Thus, gain-framed messages about colorectal cancer were the norm for our study physicians.

Half of the physicians also offered loss-framed messages emphasizing the need to avoid the consequences of colorectal cancer and the increased threat associated with a family history of this malignancy. Research in mammography screening suggests that loss-framed messaging may be a more powerful motivator than gain-framed messaging,²⁶ but it is not clear if this observation can be generalized to colorectal cancer screening.

Walking a fine line with the particulars of risk

Our study physicians rarely provided data on the probability of developing colorectal cancer. Physicians may avoid this topic because many patients have difficulty understanding information about the risk of colorectal cancer.¹¹ In support of this approach, Lipkus and colleagues reported that various ways of informing patients about colorectal cancer risk did not affect their intention to be screened.²⁷ Of concern, most of our physicians did not address the common misconception that colorectal cancer screening is unnecessary in the absence of symptoms.²⁸

Overall, the level of numeracy information provided by study physicians required minimal patient understanding of mathematical and statistical concepts. Most information was descriptive, such as colonoscopy being “more thorough” than other tests. Though statistical concepts such as “risk” were often mentioned, few physicians offered probabilities or incidence data. Experts recommend providing such data,²⁵ but Web sites have been criticized for offering excessive numerical cancer risk data.²² Therefore, physicians must walk a fine line between providing adequate information and offering data that require a high level of health numeracy for understanding.

6 key points physicians often overlook

Most physicians failed to mention dietary and medication changes, scheduling/insurance coverage issues, and risk of complications from colonoscopy. Nearly 60% failed to discuss the patient’s risk of colorectal cancer. Almost half did not mention the need for a companion to accompany the patient after the test. Scheduling challenges, in particular, are known to interfere with completing colonoscopy.¹¹

Many neglect to describe the procedure

Thirty percent of physicians failed to describe the procedure itself, so it is not surprising that patients complain they have a poor understanding of test logistics.^11,29,30 Denberg and colleagues have reported that mailing an informational brochure about colonoscopy can increase the number who keep their appointment.³¹

How language choices may affect understanding

Other researchers have identified additional patient barriers to colonoscopy, including fear of pain, concern for modesty, and desire to avoid the bowel prep.^11,32 These concerns may be mitigated or heightened by the physician’s language. In our review of transcripts, physicians often used slang or colloquial language to describe the procedure, probably in an attempt to convey information in a familiar way. This language may be viewed as crude and potentially discouraging, but further research is needed to evaluate patient receptiveness to different ways of speaking about sensitive topics.

Additionally, physicians commonly used technical terms such as “polyp” and “biopsy” without explaining them. Technical language may increase racial disparities in adhering to scheduled colonoscopy. In a family medicine clinic, patients from minority groups had particular difficulty understanding medical terms and procedure names.²⁸ Because little time is available for counseling about cancer screening tests, and because patients retain only a limited amount of information about procedures,³³ supplementary informational sources are warranted.^15-17,31 Options include brochures, telephone calls, letters, e-mails, Web site data, and videotapes, but it is unclear which sources optimally improve patient adherence to screening colonoscopy.³⁴

Study limitations include simulated interaction

There were a number of limitations to this study. First, the investigators “simulated” the patient. Though study physicians were told to act as if they were speaking to a regular patient, they may still have unconsciously modified their usual approach to addressing this topic.

Second, we did not assess the effectiveness of these discussions in motivating actual patients to receive colonoscopy.

Other limitations included the following:

• We did not set a time period for these discussions, so they may have been even more limited in actual practice.
• We studied physicians from a single health care setting wherein colonoscopy appears to be the preferred approach to screen an average risk patient for colorectal cancer. In addition, in this health care system, this test is performed by a gastroenterologist, rather than a primary care physician.
• We did not determine whether patients regard our selected quotes as too colloquial or technical.
• This study did not address the important barrier of a physician forgetting to recommend colorectal cancer screening.³⁵

Further research, next steps

Our study supports the hypothesis that physicians differ widely—but are generally deficient—when informing patients about screening colonoscopy. They generally emphasize the positives of colonoscopy and use terms that are colloquial, avoiding statistical concepts that may be hard for patients to understand. Future studies need to address the effectiveness of these approaches to discussing screening colonoscopy.

Given the central role of the primary care physician in motivating patients to undergo screening colonoscopy in a limited time period, it appears that additional supports are needed to supplement physician discussion about this important preventive care procedure.

Correspondence
Barbara J. Turner MD, MSEd, University of Pennsylvania, 1123 Blockley Hall/6021, 423 Guardian Drive, Philadelphia, PA 19104; [email protected]