Introduction
Methods
Study design, data measures, & data collection
Data analysis
Results
Participants
Themes
Behaviour & description | Supporting quotes for contextual factor of perceived guideline clarity | Supporting quotations for contextual factor of deferral to patient preference |
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General statements about perceived guideline clarity Physicians describe general confusion about what the guidelines recommend (first quote), confusion about which women the guideline applies to (second quote), and confusion between criteria for genetic testing versus screening mammography (third quote) | “Mm-hmm, yeah very, very vague, you know, you just read that, over and over and … It’s not clear… my feeling after reading the guideline a few times was like just do whatever you have to do. – P13 “My understanding of guidelines is that unless they’re in a high-risk group, it’s not recommended between ages 40 and 49… you need about three relatively first or second-degree relatives to be able to do that.” – P18 “When I send patients {to genetics} who I think are high risk and could potentially warrant earlier screening, and they’re not, I’m often surprised… I think I’m doing the right thing with my counselling. Because even for the patients who I think should have it, when genetics says no, they are not high risk than the average population despite you know, your mother at a young age having breast cancer they’re reassured I guess after speaking to the expert” -P14 | |
Behaviour 1: risk assessment Physicians describe that they do not perceive that the guidelines suggest to do a breast cancer risk assessment (first quote) and that if they do a risk assessment, the calculated risk is not tied to a specific management strategy (second quote) | “I think intuitively, you should be assessing risk with any decision that you make, obviously. But not – no, the guidelines, to me, did not point me towards something like the IBIS or anything like that… in terms of the actual numbers and what not, again, I had to kind of learn them myself.” -P20 “Yes, otherwise I think [the risk assessment] is useless… it spews something out to me but I don’t know how to interpret it or what the next step are… But if there was something… similar to the Framingham or Osteoporosis guidelines… if there’s kind of an interpretation of what to do once it spews out the [risk] value… [where] I know what to do when it’s low, moderate, or high risk.” -P14 | |
Behaviour 2: shared-care discussion Physicians may engage in shared-care discussion (or not), but either way do not feel the guideline does not inform whether shared-care should be done Physicians describe two situations where they defer to patient preference without complete informed discussion of potential screening harms | “It [the guideline] doesn’t tell you anything… it doesn’t tell you what the risks are, the benefits or how to counsel them… It puts a lot of emphasis on the patient value which I don’t think it’s fair. I think most patients if they’re in to see the doctor are valuing their health in some sort of way. And not helpful to the doctor or to the system” – P14 “I think it’s probably good just to start these conversations early, but that statement doesn’t help me very specifically. It doesn’t tell me that I should have those conversations early. I think that’s just my personal feeling that I should do it that way.” – P08 | “So if I thought her risk was high, then I would really push. And if I thought her risk was very low then I would spend a couple of minutes saying, ‘Listen, I really think you’re okay. There is a tiny bit of radiation and radiation is cumulative.’ But at the end of the day, I listen to peo’le and if somebody really wants a mammogram, you never know why they really want it, so I let them have it.” – P05 “If somebody brings it up and they are a bit adamant about getting it done. They’ve had a friend that has it. They’re anxious about it. They hear that the Americans do it. I don’t hold back, and I will be happy to do it.” -P01 |
Behaviour 3: decision/referral for screening mammography Physicians state that guidelines do not explain which benefits and harms should be discussed. They describe following radiology guidelines rather than the Task Force guidelines Physicians describe situations where they recommend screening due to past experiences (TDF domain: emotion) | “Like, what does that mean? …many patients will say, “What should I do?”.. and most practitioners don’t understand what the relative risks and benefits and can’t even have that conversation.” -P04 “The medical post had a blurb from Dr. XX, the Head of Mammography… she said that the Canadian Task Force was flawed, that the people on the panel weren’t mammographers… And I believed her, she had good data, she does this every day. She said the best screening was every year for 40–50. And yes, there will be false positives but you're going to save lives… So I think that the hard evidence probably supports doing it. The economic evidence doesn't. And I'm sticking with the head of the [City] Hospital versus the Canadian Task Force” -P05 “So, it’s frustrating, I don’t actually know what the right thing is to do, but I’m starting to add in ultrasound anyhow” – P17 | “So, I think you screen. I know it’s certainly not guideline-based, but I find it really hard to extrapolate guidelines to a person sitting in front of me. And you know, we all know women in their forties that have been diagnosed with breast cancer, they all have stories, and those stories are pretty impactful.” -P03 “It’s very hard to tell someone they can't have something and then take on the burden of, oh, I hope they don’t develop breast cancer at forty five and I'm the one that told them not to do it… it’s such an infrequent request in my population, that I usually will do the education, discuss the problems. Most of the time they're not interested in it, then if they are still are, I will order a mammogram.” – P02 |
The interaction of demographic characteristics and behavioural drivers
Demographic characteristic | TDF domain and description | Supporting quotations |
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Age | Older physicians were influenced to screen based on TDF domains of Emotion (past negative experience) and Social influence of the patient Younger Physicians described the TDF domain facilitator of Beliefs in Capabilities to explain when screening not recommended | “You know, over years, I’ve been in practice for 16 years… based on the positive cases that I saw in real life, I don’t believe that we have to wait until age 50 to start the screening. I saw lots of women that, you know, we missed or we diagnosed Grade 3 definitely below age 50. So, my belief in, based on my clinical experience is that age 50 for start screening is too late.” -013 “I would say 98% of the women I’ve spoken to, as long as I sit down and give them a proper explanation [of why screening not recommended routinely], and sometimes I would even refer them to Task Force. Most of them were very satisfied and don’t bring it up again.” – P16 |
Gender | Physicians who identified as female described TDF domain barriers of Emotion & Beliefs about Consequences | “It’s been proven to be so with my clinical experience all this year. And just like when they’re younger, we miss them. I just find it quite devastating. They just literally have more [tortuous] difficult journey than people older. So I’m just totally sold on that.” -P09 |
Location of medical training | Physicians with Canadian Training described Beliefs about Capabilities to discuss why screening not routinely recommended Non-Canadian Trained physicians held the Beliefs about Consequences that not screening would lead to inappropriate outcomes | “And that’s kind of been drilled into our heads…choosing wisely… our generation is probably a little bit more mindful… it’s minimal testing for things that are not guideline” -P14 “I’m conscious that everything should be evidence-based on guidelines but I just feel like it’s a little too late. I always do let people know that at least previously the guidelines in the States sort of were to start at age 40… there’s some degree of financial conservatism driving those guidelines in Canada, potentially.”- P02 |
Geographic area | Physicians working in higher resourced areas descrived Beliefs about consequences that patients still want screening even if harms were discussed; physicians working in lower resourced areas described the beliefs in capabilities to explain why screening not recommended | “I work in a pretty well-educated and affluent area, and I find people are pretty pro early screening..”. – P06 “I think with my training… not wasting resources doing things; I had some really good attendings that would question ‘are you doing something because that’s what you were taught or are you doing it because there’s actually research behind it’ and that was one of the things that really carried through with my practice” -P16 |