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Agency for Toxic Substances and Disease Registry
Evaluation Primer on Health Risk Communication Programs
Evaluation Case Example:
Communicating the NCI Mammography Screening Guidelines:
The Practicing Physician's Perspective
Background
Before announcing its decision to drop the mammography guideline for women under age 50, the Office of Cancer Communications (OCC) at the National Cancer Institute (NCI)  conducted a series of seven focus groups with obstetrician/gynecologists (ob/gyns) and primary care physicians. The purpose of the study was to (1) assess the likely impact of a change in the NCI mammography screening guidelines on physician decision making with regard to mammogram referrals, and (2) explore ways that NCI can best support physicians in their use of the new guidelines and in their communications with patients. Obtaining a better understanding of the environment in which physicians practice, including their attitudes and concerns about the new guidelines, was considered a prerequisite for developing effective communication materials.
Evaluation Approach
To achieve diversity in the seven focus groups, physicians were recruited based on a number of different variables: their practice setting (i.e., managed care and fee-for-service), length of time in practice (minimum of 5 years), patient base (minorities, low income, etc.) and sex. Physicians who had mammography equipment in their offices were excluded from participation in the study. Three of the groups were composed of full-time practicing ob/gyns or gyns; four groups were composed of primary care physicians who were either family physicians or internists. Fifty-five physicians participated; approximately one-fourth were members of a minority group.
The focus groups were convened in four locations: Baltimore, Maryland; Chicago, Illinois; Omaha, Nebraska; and Newark (Wyckoff), New Jersey. Overall, these sites were selected for their geographic, ethnic, racial, and socioeconomic diversity. During the focus groups, participants were asked to react to a number of sample print materials designed to support the introduction of the revised guidelines.
Findings and Lessons Learned
- Physicians have a strong sense of responsibility with regard to screening patients for breast cancer. This reflects the high level of concern they see in their patients; in part, it reflects their concerns about liability. However, their own commitment to fighting a deadly disease has touched them professionally and in some cases personally.
- Physicians firmly believe that mammography is the only effective means of detecting breast cancer at its earliest possible stage. Moreover, physicians are convinced that early detection is the single greatest factor influencing survival.
- Physicians prefer to take a conservative approach with respect to mammography. They follow the most stringent guidelines in screening low-risk patients. For high-risk patients, they order mammograms earlier and more frequently than the guidelines specify, as is evident from their desire for more explicit recommendations for high-risk women. Physicians do not like operating "in the gray zone" where they must rely primarily on self-judgement.
- NCI's guidelines are largely unknown to physicians, compared with those of the American Cancer Society (ACS) and the American College of Obstetricians and Gynecologists (ACOG). Lack of knowledge and familiarity with NCI may be responsible in part for physicians' questioning whether the guideline change is politically or scientifically motivated.
- Most physicians are highly resistant to decreasing their use of mammography, particularly in women under 50 years old. They indicate they would need strong, compelling evidence that mammography is either useless or harmful before they would change the way they currently practice. The scientific evidence, as presented to them, is seen as inconclusive; it does not convince them that a change in the guidelines is warranted at this time.
- It is important to physicians that their professional organizations endorse any change that takes place in the recommendations for mammography screening. Ob/gyns in particular are unlikely to support a change unless ACOG endorses it.
- Overall, the findings from the study suggest that a majority of physicians will simply ignore the new NCI guidelines and continue to practice as usual. As some physicians have realized, they can follow their current practices and still be in compliance with the new guidelines.
- Given that the communications environment is characterized by skepticism and resistance, it is likely that any communications program designed to introduce and support the guidelines will face stiff challenges. The sample materials presented in this study were largely unsuccessful because they could not overcome physicians' objections to the revised recommendation. New strategies based on what was learned about physicians as consumers in this study are now being developed.
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