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First they try to take away our mammograms, and now this? Last week, the U.S. Preventive Services Task Force (USPSTF) followed up their October 2011 draft guidelines to recommend, definitively, that doctors not offer routine Prostate-Specific Antigen (PSA) screening for prostate cancer. They concluded from recent clinical trials that the harms from over-diagnosis (biopsies and surgeries complicated by infection, bleeding, and incontinence) outweighed the benefits of early detection and treatment. Not surprisingly, the move was not universally welcomed, in part because the notion of not doing everything in our power to hunt down cancer seems almost sacrilegious.
But one key detail of the guidelines has been largely overlooked, the part that takes into account what individual patients want. "Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by the patients," the authors write. "Similarly, patients requesting PSA screening should be provided with the opportunity to make informed choices to be screened that reflect their values about specific benefits and harms."
Thereís no doubt doctors are still ordering the test. As of 2005, 24-48% of men aged 50 or older were being screened routinely, and those numbers may not shrink with the new guidelines: In a study published last week, Hopkins researchers polled 100+ PCPs within their network; they found that only 49% of them agreed with the guidelines and that even fewer (24%) said that they would now stop ordering the tests or be much less likely to order them. Their answers didnít vary based on the number of years since theyíd finished residency or their type of training. They also found that providers struggled to stop screening men older than 75 or who with low life expectances (a practice that has been recommended by the USPSTF and other societies for years).
So what gives? Why do we doctors waste precious health care resources on a test that, by at least some estimations, does more harm than good? Doctors responding to the surveys said they ordered the test because their patients expected it. Many also noted that it took too long to discuss its pros and cons, that they were worried about malpractice repercussions, and that they were uncomfortable with uncertainty.
In short, they werenít engaging patients in true shared decision making.
We know that doctors arenít great at having these conversations. In a rush to get through a patientís ten-item problem list in thirty minutes, Iíve definitely been guilty of brushing over the discussion myself. And while Iíve been raised in a medical environment in which PSA testing has almost always been in question, older doctors seem to default toward giving the test: In the 2012 Hopkins survey, doctors who didnít discuss PSA testing with patients were much more likely to say theyíd disregard the guidelines than doctors who reported engaging patients in the decision.
But there's hope: Shared decision making is a learnable skill. If we donít have enough time to discuss details, we can use decision aids to help us. Good documentation of the resulting discussions should quell our fears about potential lawsuits. And as for our discomfort with uncertainty: if we do our jobs right, itís our patients' level of comfort that matters, not ours.
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About the authorIshani Ganguli, MD, is a journalist and a second-year resident physician in internal medicine/primary care at Massachusetts General Hospital. She studied biochemistry and Spanish at Harvard College and received her More »
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