a variety of reasons, an inadequate means to change practice behavior (Bero et al., 1998; Davis et al., 1992). For one, physicians may not see the guideline or retain its recommendations. Studies confirm that physicians tend to have limited familiarity with published practice guidelines, especially recent ones. A 1995 survey found that baseline mammograms, a practice no longer recommended, were still being ordered for women ages 30 to 39 (Reifel et al., 1998).

Physicians’ knowledge of practice guidelines tends to be uneven across organizations. The American Cancer Society guidelines on cancer screening, which were first issued in 1980 (ACS, 1980a), tend to be the most well known by physicians and the general public (Hamblin and Connor, 1998). When primary care physicians in Colorado were surveyed about the influence of guidelines on their screening practices for prostate cancer, 89 percent rated the American Cancer Society guidelines as moderately or highly influential, whereas fewer than one-third rated the guidelines of the U.S. Preventive Services Task Force as moderately or highly influential (Moran et al., 2000). A clear understanding of what is recommended is made more difficult by inconsistencies between the recommendations of different organizations and controversies over whether scientific evidence supports the practice.

Attitudes

Even if physicians are knowledgeable about recommendations, they may not agree that the proposed policy represents good care, is supported by valid evidence, meets accepted norms for their specialty or among local opinion leaders, or is applicable to their practice. Studies of family physicians in Ohio demonstrated disagreement with a substantial proportion of recommendations against cancer screening issued by the U.S. Preventive Services Task Force (Stange et al., 1992; Zyzanski et al., 1994). Finally, physicians may agree that it is appropriate for patients to obtain certain screening tests but disagree that it is their role to provide the service.

Ability

Clinicians who agree that screening is appropriate may be unable to offer testing and follow-up for a variety of operational reasons. These include lack of time, skills, personnel, equipment, adequate reimbursement, information systems, freedom from bureaucratic obstacles and medicolegal liability, and patient cooperation (see below). As noted earlier, the practice systems in which clinicians care for patients must be configured in an efficient design to facilitate the recognition of when patients are in need of screening (e.g., through the use of prompts or flow sheets); ease in administering tests or expediting referrals for testing elsewhere; and tracking sys-



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