Journal of General Internal Medicine

, Volume 22, Issue 12, pp 1681–1688 | Cite as

Barriers of and Facilitators to Physician Recommendation of Colorectal Cancer Screening

  • Carmen E. Guerra
  • J. Sanford Schwartz
  • Katrina Armstrong
  • Jamin S. Brown
  • Chanita Hughes Halbert
  • Judy A. Shea
Original Article



Colorectal cancer screening (CRCS) has been demonstrated to be effective and is consistently recommended by clinical practice guidelines. However, only slightly over half of all Americans have ever been screened. Patients cite physician recommendation as the most important motivator of screening. This study explored the barriers of and facilitators to physician recommendation of CRCS.


A 3-component qualitative study to explore the barriers of and facilitators to physician recommendation of CRCS: in-depth, semistructured interviews with 29 purposively sampled, community- and academic-based primary care physicians; chart-stimulated recall, a technique that utilizes patient charts to probe physician recall and provide context about the barriers of and facilitators to physician recommendation of CRCS during actual clinic encounters; and focus groups with 18 academic primary care physicians. Grounded theory techniques of analysis were used.


All the participating physicians were aware of and recommended CRCS. The overwhelmingly preferred test was colonoscopy. Barriers of physician recommendation of CRCS included patient comorbidities, prior patient refusal of screening, physician forgetfulness, acute care visits, lack of time, and lack of reminder systems and test tracking systems. Facilitators to physician recommendation of CRCS included patient request, patient age 50–59, physician positive attitudes about CRCS, physician prioritization of screening, visits devoted to preventive health, reminders, and incentives.


There are multiple physician, patient, and system barriers to recommending CRCS. Thus, interventions may need to target barriers at multiple levels to successfully increase physician recommendation of CRCS.


physician practice patterns colorectal cancer screening mass screening physician–patient relation communication barriers 


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Copyright information

© Society of General Internal Medicine 2007

Authors and Affiliations

  • Carmen E. Guerra
    • 1
    • 2
    • 3
  • J. Sanford Schwartz
    • 1
    • 2
    • 3
    • 4
  • Katrina Armstrong
    • 1
    • 2
    • 3
  • Jamin S. Brown
    • 5
  • Chanita Hughes Halbert
    • 2
    • 3
    • 6
  • Judy A. Shea
    • 1
    • 2
    • 5
  1. 1.Division of General Internal MedicineUniversity of Pennsylvania School of MedicinePhiladelphiaUSA
  2. 2.Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaUSA
  3. 3.Abramson Cancer CenterUniversity of PennsylvaniaPhiladelphiaUSA
  4. 4.Department of Health Management and Economics, Wharton SchoolUniversity of PennsylvaniaPhiladelphiaUSA
  5. 5.University of Pennsylvania School of MedicinePhiladelphiaUSA
  6. 6.Department of PsychiatryUniversity of PennsylvaniaPhiladelphiaUSA

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