“Shared Decision Making:” Good in Theory. Less Good in Practice.

In May, the American Urological Association (AUA) attempted to silence its critics–including the United States Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS)–by abandoning its longtime recommendation of universal PSA testing of all men older than 40 to screen for prostate cancer. But since its constituency is, after all, urologists, it avoided the radical “no PSA screening at all” stance of the USPSTF, instead narrowing its PSA screening guidelines to exclude most men younger than 55 and older than 70.

This has made Dr. Otis Brawley, CEO of ACS, very happy. He claims that the AUA’s shift is now “truly consistent with the state of the science.” One could interpret this comment to say: “Since PSA testing is not perfect, we’d really prefer you not to use it at all, but if you insist, then please don’t use it very often.”

DecisionMakingThe rationale that the ACS—and now the AUA—use to justify this stance is to recommend a collaborative process.  Rather than simply ordering the test, the doctor should sit down with the patient and engage in a calm, reasoned discussion of the benefits, risks, and uncertainties of the PSA blood test in a process called “shared decision making.” To quote the ACS guidelines about PSA testing, “men should make an informed decision. This means that you should learn about prostate cancer and testing. You should think about the risks and possible benefits. Then after talking with your doctor, you should decide if testing is the right choice for you.”[1]

This sounds good in theory. Intelligent, informed conversations are definitely preferable to a doctor simply announcing, “I’m ordering a PSA test for you.”

Except for one minor detail: the data have shown us that intelligent, informed doctor-patient conversations and “shared decision making” are the exceptions, not the rule. One recent study states, “most US men report little shared decision making in PSA screening.” [2]

When researchers defined “shared decision making” as a clear discussion of three topics about PSA tests (benefits, risks, and uncertainties) and used a survey sample of 3,427 men aged 50 to 74 years, they found that almost two-thirds (65.1%) of the men had NOT had a “physician-patient discussion of either advantages or disadvantages” of having a PSA screening.

Twenty-seven percent of men reported that there had been a discussion of only the advantages of PSA screenings, while just 17 percent (about 1 in 6) said there had been a discussion of both advantages and disadvantages. The researchers continue, “only 8 percent reported discussion of all 3 elements (full shared decision making).” In 92 percent of the cases “shared decision making” simply didn’t occur.

Perhaps it is not surprising that patients won’t talk. We men—especially the older men of the “greatest generation” —have traditionally ceded medical decisions to our doctors. Plus, we really don’t like engaging in awkward conversations about medical issues “down there,” including discussions about the pros and cons of PSA testing.

So, what about training doctors to have the “shared decision making” discussion proactively?  Again, this sounds good in theory. So, the researchers tested this idea by training one group of physicians to initiate PSA screening discussions and compared them to a control group of untrained doctors. Then, the researchers asked the patients to report what they heard (or didn’t hear).[3]

The results: “Patients’ ratings of shared decision making were moderate and did not differ between groups.”  In other words, men did not notice a difference in approach between the doctors who were trained to initiate “shared decision making” discussions and those who were not.

The question is why. One reason may be that even physicians trained to initiate these conversations often experience resistance or indifference from their patients, who mostly just want to get their pants back on and get out of the exam room as fast as possible.

So, the AUA’s and ACS’s “shared decision making” recommendations sound great on paper, but it appears they’re not really connected to how patients and doctors operate in the real world.

In the meantime, media such as Consumer Reports and Men’s Journal will keep telling men that the badly flawed PSA test is mostly unneeded. As a result, many men will  conclude, “If the PSA test is this bad and I don’t need it anyway, why should I bother talking about it?” And doctors, already under pressure by administrators to be as productive as possible, probably will not try very hard to force an unwanted conversation.

What do you think? What strategies might make “shared decision making” a practical reality? Is it just contrary to our nature as men? Or is it contrary to the reality of increasingly time- and cost-pressured medical care?



[2] Paul K. J. Han, et al. “National Evidence on the Use of Shared Decision Making in Prostate-Specific Antigen Screening,” Annals Of Family Medicine ✦ www.Annfammed.Org ✦ Vol. 11, No. 4 ✦ July/August 2013.

[3] Michael S. Wilkes, et al. “Pairing Physician Education With Patient Activation to Improve Shared Decisions in Prostate Cancer Screening: A Cluster Randomized Controlled Trial,” Annals Of Family Medicine ✦ www.Annfammed.Org ✦ Vol. 11, No. 4 ✦ July/August 2013.

 

Comments

  1. Greg Hoffman says

    Being one of eight boys, mom had read about PSA testing some years back and “hounded” all 8 of us toget our PSA tested. So, no “shared conversation” for me. It was more “do what your mother tells you” Ha ha…Seriously, I think your closing statement is the main point…we men are reluctant to engage with our docs about issues below the equater, and insurance and care management forces continue to push for minimum patient contact time. For me, early detection turned out to show high degree, agressive PCa. Medical intervention has helped me get through the last 2 1/2 years with the expectations of more good years. One wonders what my outcomes would have been had I followed the USPSTF and, now, AUA guidelines!

  2. says

    A provocative post. I’ll add only that there is a significant body of opinion in the PCa research and treatment community that the Task Force’s conclusion was pre-determined: to get general practitioners off the hook from seriously thinking about PSA tests and offering meaningful counsel to men. It was a punt. They started with a conclusion and worked backward to (selectively) find data to support a foregone conclusion. Why the AUA would volunteer to be a co-conspirator is unfathomable. All this said: I remain grateful to my PCP for the DRE and the PSA test that led to my diagnosis. I prefer to be diagnosed and treated than undiagnosed and untreated.

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