The results are startling, disturbing and very useful, says Hugh Stallworth, MD, MPH, national vice president of cancer control at the American Cancer Society (ACS). "This study certainly gives us an idea of what appears to be happening where the rubber meets the road at the doctor-patient interface," he says.
Researchers at Mount Sinai Medical Center in New York City believe the study illustrates a broad problem: flawed communication between many doctors and patients.
In the study, 169 primary care physicians in urban New York hospitals were asked whether they would order a mammogram for a healthy 45-year-old woman and a healthy 55-year-old woman, and if they would order a prostate specific antigen (PSA) test for a healthy 55-year-old man. They were also asked if they would discuss the pros and cons of the tests with the women and the man.
Nearly all the physicians would order the mammogram for the 55-year-old woman, and about three-fourths would not order the test for the 45-year-old woman, according to the study. One-fifth of the physicians said they would not discuss the test with the women. Yet, the American Cancer Society (ACS) and the National Cancer Institute recommend that women start having annual mammograms at age 40.
Only about one-fourth of the doctors said they would order the PSA test for the 55-year-old man, and one-third said they would not discuss the test with the patient. The ACS recommends that beginning at age 50, the PSA and digital rectal exams should be offered annually to men who have a life expectancy of at least 10 years.
Men at high risk (such as blacks and men with a first degree relative diagnosed with prostate cancer at a young age) should begin testing at age 45. Patients should be given information about the benefits and limitations of testing so they can make an informed decision, according to ACS guidelines.
Complex Topic, Language Barrier Short-Circuit Discussions
Physicians said the lack of time, the complexity of the topics, and a language barrier with patients influenced their tendency to decide without patient participation.
Lead author Andrew Dunn, MD, an assistant professor of medicine at Mt. Sinai School of Medicine, emphasizes that the majority of doctors reported discussing the PSA test with their patients. "But a third don''t. We think that''s a substantial number of doctors."
Dunn hopes the study will help the medical community understand the importance of faithfully holding such conversations. Doctors who are short on time can introduce the topic with videotapes, pamphlets and Internet sites, he says, then follow up with the discussion, which is vital.
"Ethically, it is the patient''s body, and they have wishes and preferences very different from the doctor''s, and it is the doctors'' responsibility to understand why those differences exist," says Dunn. "Care is generally better when patients are involved."
Repairing a Broken Process
Dunn suggests additional studies, in different parts of the country, to see if the findings would generalize elsewhere and point to a need for educating physicians about communicating with patients.
Stallworth says he imagines other study results would be similar. "This is a pretty clear signal that we''ve got a broken process here," he says. He favors figuring out solutions, such as coaching medical students, offering continuing education seminars, lengthening office visits and encouraging patients to press doctors for ample information.
For the doctor-patient relationship is no different from life''s other relationships, Stallworth says: they all require give and take. Doctor and patient need to connect on what it means to be healthy, the patient''s attitudes and beliefs about illness, and what the doctor is proposing and why.
Dunn says in his practice, discussions about these screenings are part of the clinical exam. "Most patients can understand the advantages to finding cancer early, and the disadvantage to tests that may have uncertain results," he says. "They''re always appreciative."
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