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Physicians' Perceptions of Guidelines Regarding Prostate Cancer Testing

Junseop Shim
Albany, NY

My recent research, in collaboration with Tom Stewart and Paul Sorum, involved physicians' judgment and decision making about prostate cancer. We approached the issue from two different perspectives. One was the question, "Why do so many primary care physicians order prostatic specific antigen (PSA) tests for their asymptomatic male patients in spite of the evidence-based recommendations against routine testing for prostate cancer?" which was presented at the 22nd Annual Meeting of the Society for Medical Decision Making. In this study, we compared U.S. physicians with French physicians. Paul Sorum describes this aspect of our study in his report.

The second perspective was the current debate over screening for the disease. We investigated the influence of the conflicting guidelines on physician judgment and decision making about screening and management of prostate cancer. More importantly, we explored the implications of these judgments and decisions for individual health care delivery and public health policy. The abstract of the paper is as follows:

The purpose of this study was to investigate primary care physicians' judgments and decision making about prostate cancer and to explore their implications for individual health care service and public health policy. Thirty-two primary care physicians from the Capital District of New York State participated in this study.

Judgment analysis was used to provide insight into the factors that physicians consider important in decision making about screening and management of prostate cancer. Two sets of 32 hypothetical patient scenarios were presented to the subjects. Cues in Set 1 were age, difficulty in urination, size of prostate, shape of prostate, and patient request for a prostate test. The physicians judged the probability of prostate cancer for each case and the likelihood that they would order a PSA test. In Set 2, PSA level replaced the patient request for a test as a cue. Physicians judged disease probability and likelihood that they would refer the patient to an urologist. A short questionnaire about knowledge of and attitude toward prostate cancer was also administered.

Physicians were classified as pro-screening, anti-screening, and conflicting according to their responses to the question, "What are the recommendations of official medical bodies about routine screening for cancer in asymptomatic males after age 50?" These recommendations have in fact been conflicting. Thirty-seven percent of the participants had inaccurate knowledge of guidelines, perceiving them as recommending either routine screening (28 percent) or no routine screening (9 percent).

While the pro-screening group was most likely to recommend a PSA test and to refer patients to an urologist, the anti-screening group was unlikely to recommend the test and referral.

The physicians in the conflicting group were highly polarized into two categories: They were either highly likely or highly unlikely to order a PSA test and to refer the patients to a urologist.

The results showed that physicians disagreed about the nature of current screening guidelines, and that their disagreement was reflected in the differences in PSA test ordering and patient referral decisions for a set of paper patients. In addition, physicians' disagreement was reflected in some patterns in their regular practice, and in their knowledge base regarding prostate cancer.

It was, of course, not possible to establish causality in this study, but there are important implications for individual health care delivery and public health policy that deserve further exploration.

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