Does Physician Clinical Competence or Communication Ability Play a Role in Low Value Cancer Screening?

Abstract

Background: Nearly one-third of health services represent low-value care, including non-recommended cancer screening. Diagnostic uncertainty and ineffective doctor-patient communication may be important contributors. We aimed to determine if better physician communication ability and clinical skills are associated with a lower likelihood of non-recommended cancer screening. Methods: A retrospective 3 cohort study was conducted comprised of international medical graduates who took the required Education Commission for Foreign Medical Graduates (ECFMG) certification examination between 1998–2004, entered practice in the United States in primary care, and saw Medicare patients in one or more of 3 cancer screening cohorts for an outpatient evaluation visit in 2014–2015. All Medicare patients seen by these physicians and their medical services and prescriptions were retrieved. ECFMG clinical assessment examination scores were used to measure communication ability and clinical skills. Main outcomes included non-recommended cancer screening for prostate cancer in men 70+ (cohort 1), cervical cancer in women 65+ (cohort 2), and colorectal cancer in individuals 75+ (cohort 3). Sensitivity analysis of recommended screening practices for prostate (<70 years) and colorectal cancer (<75 years). Multivariate GEE logistic regression estimated associations and adjusted for physician and patient characteristics, using patient as the unit of analysis. Results: Overall, 7136–7258 physicians and 673,654–1,561,737 patients were included in the 3 cohorts. Non-recommended screening occurred in 0.9%, 1.3%, and 10.0% of patients in the cervical, colorectal, and prostate cancer cohorts, respectively. Every 10% increase in the communication score was associated with a 12% increase in the odds of non-recommended screening for prostate (OR 1.12, 95% CI 1.06–1.19) and cervical cancer (OR 1.12, 95% CI 1.03–1.21) and by 10% for colorectal cancer, although the latter was not significant (OR 1.10, 95% CI 0.97–1.23). Better clinical skills were associated with 13% (OR 1.13, 95% CI 1.04–1.23) to 33% (OR 1.33, 95% CI 1.13–1.57) increased odds of prostate and colorectal cancer screening respectively. Better communication ability and clinical skills were also positively associated with recommended prostate cancer (OR 1.09, 95% CI 1.04–1.15, OR 1.11, 95% CI 1.03–1.19, respectively), and colorectal cancer screening (OR 1.11, 95% CI 1.02–1.20, OR 1.14, 95% CI 1.01–1.28, respectively). Conclusion: Physicians’ communication ability and clinical skills appear to be associated with a greater likelihood of non-recommended and recommended screening for prostate, cervical and colorectal cancer.