Editorial poses tough questions about shared decision-making in prostate cancer screening decisions

The horse has left the barn. That's the conclusion of an editorial in response to the Archives of Internal Medicine study (see post below this one) on the relatively poor quality discussions men are having with their doctors on prostate cancer screening decisions.

Editiorial writers Steven Woolf and Alex Krist pose some tough questions:

"Some might even contend that the question addressed by (the study) (how often and how well is shared decision-making or SDM practiced) is beside the point--the horse having left the barn. The opportunity to embrace SDM occurs early in the diffusion of technologies, when they have not yet been adopted by the medical community as standards of care and when patients can freely choose among uncertain options. Prostate-specific antigen is at a different stage of diffusion. Today's practice environment presents few incentives or support tools for those clinicians and patients who prefer a discussion rather than simply marking a checkbox for PSA on a laboratory requisition form.

Promoting SDM under these conditions sets challenges for researchers and health care delivery systems. ...

Making SDM feasible also requires changes in the practice environment, beginning with tort reforms that protect clinicians who give patients an informed choice about cancer screening, as well as reimbursement reform to facilitate the time investment for such counseling. Procedures that allow for longer visits and access to counselors--either the primary care clinician, colleagues at practices, or "decision counselors" to whom patients can be referred--must be tested for feasibility and acceptability. Best practices for SDM should be detailed in practice guidelines for PSA screening, replacing the now vague language about informing patients before testing. In concert, messages from the public health community must do their part to shift public attitudes about screening to encourage getting facts over getting tests.

Without these efforts by researchers, health systems, public health leaders, payers, and the courts, SDM is unlikely to gain its footing in routine patient care. In the United States, where medical technologies are often adopted long before their effectiveness and safety are confirmed, the difficulties of implementing SDM for prostate cancer screening will likely recur with other modalities of care. What is ultimately required is a deeper change in culture among providers and consumers of health care to delay dissemination, resist the assumption that newer is better, wait for evidence, tolerate observation over intervention, and accept uncertainty."