To Screen or Not to Screen, That Is the Question…

Physicians like to have all the answers and be able to remain in control of every situation. We are trained to think about broad differential diagnoses, but, in the end, we expect to have an answer and to be able to say with little doubt that we know what’s going on and what we should do. Even when we don’t know the cause of something, we can resort to using the term “idiopathic”; in other words, a nice way of saying “we do not know” without sounding too ignorant to our patients.

For many years, I have followed the controversy surrounding whether physicians should advise their older male patients to be screened for prostate cancer. I’ve seen the pendulum swing in opposite directions and have had to reverse my own thoughts on this issue several times. I have read the literature and analyzed each paper on its own merit, and have had to advise many men about what to do. My own philosophy has always been to advise patients based on what I would do under the same circumstances, recognizing that no two persons are completely alike and that each deserves to know the data behind the controversy.

At the current time, until there is more evidence and, perhaps, a scientific consensus of the screening benefits, the National Cancer Institute (NCI), the American College of Physicians (ACP), the American Cancer Society (ACS), and the Centers for Disease Control and Prevention (CDC) agree that men should learn all they can about what is known and what is not known regarding the benefits and limitations of early detection and treatment for prostate cancer, so that they can make their own informed decisions about whether to be screened or not.

While this is the party line, it leaves many physicians uncertain about what to do for those patients who are just not able to decide for themselves what approach to take to this and many other health-related problems that are similarly uncertain, and how best to find the time necessary to do this correctly for those who would benefit from full disclosure. Whether the patient is fully interactive, has a cognitive or emotional problem, or just an unwillingness to participate in one’s own healthcare, physicians must individualize how they provide care to their patients and be prepared to try different options if one does not work, given the confines of a busy practice.

It’s important to remember, however, that not everything in medicine is black and white. There are a surprising number of health-related issues where it’s not clear what the “right” thing to do is at a given time. It would be so simple if medicine always had an answer. It would also be so easy if we could always count on our patients for guidance after merely providing them with some literature and discussion points. I do not believe, however, that this is exactly what our patients expect or want in all circumstances either. “What would you do under the same circumstance?” is an all-too-frequent mantra heard by physicians everywhere. We need to be prepared to give our own opinions as to what we believe is the “best” option under the specific circumstances. We need to be prepared to state why we came to the conclusions we did based on evidence and appropriate literature.

It was not long ago that physicians would make all decisions on behalf of their patients, thinking that they knew best and had the patients’ best interests at heart. Patients accepted this as a way of life. That is no longer the situation. We live in the age of the Internet, and patients now often come to the doctor’s office prepared to discuss topics with a great deal of factual information at hand. Whether they fully understand the research they have read or are confusing unsubstantiated claims from popular articles with data based on sound scientific studies, most patients expect to be involved in their care now more than ever before, so physicians must be able to take the time to help guide them as necessary. We can schedule a visit for “counseling”; however, discussing the pros and cons of a lab test was not what Medicare intended for this billing code. It is the physician’s role to help our patients understand issues from data that are available without biasing them or causing confusion. This is simpler said than done, as it takes precious time to discuss all options and consequences of a given action, and even the choice of one’s words, body language, and facial expression convey our personal thoughts and opinions and may influence a patient’s decision without our knowing.

Knowing how best to proceed, how to prioritize our time, and just how much information to provide to a given patient is part of the ART of practicing medicine, a skill that each physician must acquire and implement. Unfortunately, the time it takes to thoroughly discuss options for prostate screening and many other tests with individual patients is not a luxury most physicians can afford given their busy schedules and small profit margin in the office. I wonder how detailed and thorough most discussions actually are given these limitations.

We can only do our best! The NCI, ACP, CDC, and ACS have made their recommendations for prostate cancer screening. Patients should make their own “informed decisions” after being presented with the pros and cons. We as physicians must find a way to carry out this mandate given our own limitations. Hopefully, we will do “right” for our patients.

Dr. Gambert is Professor of Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.