Educating Physicians about Respect and Medical Distrust: Focus Groups Outcome

Introduction

Colorectal cancer causes significant morbidity and mortality in the United States. African-Americans have among the highest incidence and death rates in the nation. Screening for colorectal cancer improves outcomes. Multiple barriers, including perceived cost, inconvenience, transportation and fear, have been recognized to decrease adherence to screening recommendations. This study used a bi-directional learning focus group involving African-American adults and early career physicians to assess colorectal cancer screening barriers with attention to potential sociocultural concerns.

Methods

A bi-directional learning focus group of African American adults from a community church and early career physicians was conducted with a trained facilitator. An audio recording was transcribed verbatim with subsequent thematic analysis by two investigators using an iterative process. A post-focus group survey was conducted to confirm identified focus group themes with specific attention devoted to identifying potential sociocultural concerns. Analysis of pre- and post-focus group surveys was performed using Fisher Exact test with significance set a p<0.05. A second bidirectional learning focus group was conducted to review the results and to assess understanding of themes identified during the initial focus group.

Results

The focus group consisted of 18 members (7 African-American adults, 11 non-African-American early career physicians). 100% of participants recognized that there are recommended guidelines for colorectal cancer screening. The focus group identified lack of awareness (81%), colonoscopy preparation (80%), physician trust (60%), lack of insurance coverage (56%), transportation (56%), extended colonoscopy wait time (50%), insufficient physician discussion (50%) and fear of the procedure or cancer (35%) as screening barriers. However, community members more often than early career physicians identified historical racial disparity in health care (p=0.0474), physician respect toward patients (p=0.0128) and insufficient physician discussion (p=0.0006) as screening barriers.

Post-focus group surveys highlighted the desire for physicians to recognize the impact of historical racial disparities in health care delivery. While specific discussion about disparities was not desired, emphasis on communication, listening and shared decision- making was recommended. Factors which community members identified as demonstrating respect included providing adequate time for the appointment, listening with reciprocal communication, sitting and eye-contact during discussions, using titles or honorifics during initial meeting and performing physical examination as appropriate. While community and early career physicians appreciated that discussions about medical recommendations are necessary, there was a significant disparity in the perceived adequacy of physician-patient discussion. The second focus group discussion reviewed the results of the initial focus group, resulting in a mutual understanding of colorectal cancer screening barriers, including potential sociocultural concerns.

Conclusion

Colorectal cancer has a significant impact upon African-Americans. Bidirectional learning focus groups are a unique tool that can result in enhanced recognition of potential barriers to medical care. This study demonstrated that early career physicians learned from community members concerns about adherence to colorectal cancer screening that were previously not identified. This learning process can allow for implementation of specific practice strategies that can optimize care.