Doctors who order PSA blood test without discussing it with patients

A new analysis published in the Annals of Family Medicine,”Primary Care Physicians’ Use of an Informed Decision-Making Process for Prostate Cancer Screening,” found that 24% of primary care physicians who responded to a survey said they ordered screening without discussing it with patients.

How’s that for shared decision-making?

Fewer than 48% of those surveyed said they discussed harms and benefits with patients before letting the men decide.  These doctors “were more likely to endorse beliefs that scientific evidence does not support screening, that patients should be told about the lack of evidence, and that patients have a right to know the limitations of screening; they were also less likely to endorse the belief that there was no need to educate patients because they wanted to be screened.”

(You can see the Reuters Health story on this study here. Was this the only mainstream news organization to report on this study?  If so, why? )

Let me remind you of a classic case of a doctor ordering a PSA test without telling a patient. About 15 months ago, I posted a video of lawyer Tim Glynn whose doctor ordered a PSA test without telling him.  His anger is still palpable 14 years after this incident.  “It drove tremendous consequences for my life on a piece of information that isn’t information – it doesn’t mean anything,” he says in the video.

And let me remind you of the DECISIONS study that found that “most prostate cancer screening decisions did not meet criteria for shared decision making because subjects did not receive balanced discussions of decision consequences, had limited knowledge, and were not routinely asked for their preferences.”

The body of evidence is growing:  many American men are not being provided the evidence they need to make an informed decision about prostate cancer screening.  And harms may occur as a result.

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Comments (6)

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Richard Hoffman

January 15, 2013 at 6:22 pm

That 24% of respondents, who were surveyed in 2007, failed to even discuss screening is disconcerting, especially because most contemporaneous guidelines were encouraging informed decision-making. Respondents who screened without discussion were more likely to cite time barriers and malpractice concerns. A potential strategy for overcoming these barriers would be to provide patients with decision aids. These decision support tools, which can be written, video, or web-based, have been shown to increase knowledge, reduce decisional conflict, and could also facilitate shorter, more focused clinic discussions. Furthermore, Washington State has passed legislation recognizing that using a decision aid constitutes evidence of an informed consent. The lawyer Ben Moulton (J Law Med Ethics Spring 2010) has argued that using decision aids “establishes a higher burden of proof for patients attempting to claim that they were not adequately informed of risks or alternatives.” Screening for prostate cancer is a complex, controversial, and important health decision that should be based on the preferences of an informed patient. Health care providers should engage patients in the decision-making process.

Kathy Nieder MD

January 17, 2013 at 8:11 am

This was a study of only Family Practice docs. It would be interesting to see if the Internists fair any better, though my guess is they would not.

David S. Most

January 21, 2013 at 7:40 pm

It takes a lot of time to discuss the pros and cons of screening. But absent physical symptoms in early stage CaP we only have PSA to warn a patient. Single PSA values are of limited values but PSA history built up over a few years can be of greater value. Yes, overtreatment can create morbidity. But prostate cancer untreated can cause death. Knowledge is power. Making a decision absent information is playing Russian Roulette.