Sample illustrative quotes for barriers and facilitators to Canadian Task Force on Preventive Health Care Guideline implementation
| Perceived barrier or facilitator | Illustrative quote |
|---|---|
| Perceived barrier | |
| Misalignment of guideline with patient expectations or preferences | “So, when I have a discussion — even though it’s not a brand-new guideline for cervical cancer, they may have had a physician who’s just told them that they need an annual Pap test. So, when I try to re-educate the patient, I often find that … ‘Oh, there’s new evidence now, newer guidelines suggest that you only need to do it every 3 years as long as your Pap test results are normal,’ but patients are often [not] open to being re-educated. They often have their own perception about what is needed and can be adamant about getting that done — even if they don’t have a lot of deeper understanding about the implications of doing that testing.” — P004 (2020) |
| Misalignment of task force guideline with other provincial or specialty guidelines | “What would make it easier … if it corresponds with provincial recommendations, it will be easier to implement.” — P010 (2020) |
| Perceptions of evidence strength or lack of consensus among health care professionals about recommendation | “I know that there is a recommendation … it is weak. So I kind of defer to — in fairness, see what other physicians have been practising and their thoughts on it and see if that has played a role.” — P020 (2020) |
| Time constraints to implement guideline or recommendation | “When you only have such an amount of time with each of your patients, you don’t have the luxury of time to go into explaining everything as far as preventive medicine goes because in that same 15- to 20-minute appointment, they also need refills, a blood pressure check, their oxygen checked or their big toe looked at. You’re constantly trying to multitask while you’re talking to them and examining them about ‘are you up to date to on your colon screening, are you up to date on your breast cancer screening, your cervical cancer screening.’ Then, usually they’re never up to date on everything, so then you have to educate them on … ‘okay, will you book an appointment with Nurse XXX [name at 22:55], she’ll do your Pap for you.’ And you’ll have to explain to them how to book that and stuff like that.” — P007 (2020) “I figure, they’re here, they’re undressed. It’ll take me 30 seconds. Why not just examine their breast? I’m using breast as an example because that’s the one thing that really threw us [recommendation was different from previous common practice]. So, yeah. It’s difficult and, frankly, the path of least resistance is to just do it. I can’t explain to them in 30 seconds why I shouldn’t do it” — P023 (2019) “So [shared decision-making conversations] could be tricky because I think, you know, in a primary care setting, unfortunately we’re constantly seeing patients for acute issues, and … so the vast majority of these visits are focused on addressing their concerns acutely, and we try to squeeze in health prevention where there is time. So, it doesn’t usually leave a lot of time to focus on health prevention, to be honest.” — P011 (2019) |
| Complexity of guideline or tool or lack of clarity on how to implement recommendation | “Another aspect of it is the complexity of the guidelines, so if … I’d probably spend more time talking to my patients and have longer appointment times than the average family doctor. I really value the opportunity to explain things to my patients, so that we essentially agreed on plans for investigating or treatment. So, trying to explain the pros and cons of doing cancer screening in a 15-minute appointment when you’re also trying to cover all of their routine screening and maybe addressing a couple other complaints that the patient brought in to talk about that day, makes it difficult. So, the simpler guideline is, the easier it is to implement as well.” — P004 |
| Lack of awareness of guideline or KT tools | “I think the biggest barrier is just ... are people aware of it, right?” — P001 (2020) “I think just awareness, right? Sometimes you forget. You get busy in your practice.” — P001 (2019) |
| Guideline out of date or not recently updated | “I just hope that the task force continues to use good-quality, up-to-date evidence for their guidelines.” — P005 (2017) |
| Concern about overlooking a diagnosis | “I think if you had a patient who had a very bad outcome when you followed a recommendation, that would make it hard. If, for example, I had a patient who I didn’t screen for prostate cancer who then had it, that would probably make me a little more anxious and I would remember that patient when I saw similar patients and I’d have an instinct to screen them more … if I felt that by changing my screening habits or by screening the way I was, I was missing people or I’d done someone harm by acting that way, I might change my practice.” — P020 (2018) |
| Patient understanding of the value of screening (perceptions often shaped by the media, social media) | “I think patients are just inundated with information to have their thyroid checked. So, sometimes I just give in.” — P005 (2020) “Well, some patients are pretty persistent. They want their thyroid checked when they are having trouble losing weight, or even though we just had it done 6 months ago, it was normal. So, sometimes doing the education with them … sometimes, regrettably, we might order a test just to appease a patient.” — P001 (2019) “Particularly with the PSA test, I have to say for the Canadian task force, [news provider; 8:08] and all the news media outlets are the worst there, because … I’ve been at the gym and I watch these urologists come on and say ‘every man should have a PSA’ and I sit there and I think ‘are you kidding? I’ve just finished explaining to all these men why they shouldn’t have a PSA and then the head of urology in the [association name; 8:28] says every man should get a PSA every single year. Don’t listen to anybody else.’ So, what are they doing? They’re listening to the news and then they’re coming in and insisting that they get a PSA every year.” — P021 (2018) |
| Lack of resources to facilitate screening (e.g., limited in Northern or remote communities) | “We have to take ... you know, we limited resources. So travel’s important. We have isolated communities. We have 11 official languages. We have, you know, technology sometimes can be a challenge and ... ultimately, does it benefit our patients?” — P019 (2018) |
| Perceived facilitators | |
| Electronic prompts, EMR reminders or mobile apps for patients | “When we actually do a complete physical with the patient and we have our template, at the end they have a screening part, you know just as a reminder to us, you know, screening for colon cancer, to make sure that this is up to date or mammogram, but I’ve never actually seen the lung cancer screening or the AAA screening on those templates … So, I find that even having those on those templates are kind of a reminder to be like, ‘Oh, does the patient fit this screening?’ and if so, we should probably do it. So, that’s probably one way that probably I could use them more and maybe I could even talk to my colleagues about including that on the templates, just so we remember to do that.” — P009 (2019) |
| Public or patient awareness of guideline recommendations | “Patients being aware of the guidelines. It’s really hard to have that conversation and convince them to not do those things, and I try to have those conversations, but sometimes it doesn’t go well, or let’s say the annual physical. They’re like ‘My doctor has always been doing this. Why aren’t you [doing] this,’ and then they think I’m a worse doctor for not doing it, and I try to talk to them and say, ‘hey, listen.’ It takes me longer to have this conversation than for me to just do those manoeuvres, or order the tests and be done with it, and then, they’re like ‘Maybe, but my doctor always did it.’ I think having that public perception and shifting that.” — P022 (2019) |
| Consensus on recommendation among health care practitioners or colleagues | “The more consensus there is, the more trust we have. So if 2 societies agree on a guideline, then I’m going to be implicitly more inclined to do that … like if you had ‘we recommend this and this and this’ and then you have ‘this also agrees with X and X society,’ that automatically ties in my trust in these societies, and the more consensus I see, the more trust I have with the guidelines.” — P016 (2018) |
| Financial incentive for screening | “I would say, to an extent, preventive care bonuses. Like … the ones that are for cervical cancer and for breast cancer and the FOBT; it’s a little bit easier to implement in the sense that you’re kind of keeping that in your mind and so there is some of that incentive to actually be focusing particularly on those at a re-visit.” — P004 (2019) |
| Ease of guideline use | “Also — and what’s fascinating is I found I trust guidelines more if the evidence is presented in and clear and understandable way.” — P007 (2018) |
| Strength of guideline evidence | “I personally think that the fact that it always comes with the level of evidence … what level of evidence it comes with. I find that makes it easier to implement because if it’s weak evidence, then I use more discretion, and if it’s strong evidence — if it’s a strong recommendation, I kind of use it more as something that I should really commit to doing. So, I think that the weakness or strength of the evidence helps me to implement it because it helps me with my decision-making process, whether or not I accept that guideline.” — P002 (2020) |
Note: EMR = electronic medical record, FOBT = fecal oculate blood test, KT = knowledge translation, Pap = Papanicolaou, PSA = prostate-specific antigen, task force = Canadian Task Force on Preventive Health Care.