The effect of shared decision making on the screening of PSA

― Literature ―
 Paul K.J, et al. National Evidence on the Use of Shared Decision Making in Prostate-Specific Antigen Screening. Ann Fam Med July/August 2013 vol. 11 no. 4 306-314.

― Context for selection ―
 In our fellowship and residency of family medicine, we teach shared decision making in the most important of component 3 in PCCM and evaluate it through video review. We know some evidence about the impact of shared decision making on many health indexes. But more evidences are needed in the world of family medicine to explain its importance to various disciplines of medicine. This article attracted me so much.

― Summary ―
 PURPOSE Recent clinical practice guidelines on prostate cancer screening using the prostate-specific antigen (PSA) test (PSA screening) have recommended that clinicians practice shared decision making–a process involving clinician-patient discussion of the pros, cons, and uncertainties of screening. We undertook a study to determine the prevalence of shared decision making in both PSA screening and nonscreening, as well as patient characteristics associated with shared decision making.

METHODS A nationally representative sample of 3,427 men aged 50 to 74 years participating in the 2010 National Health Interview Survey responded to questions on the extent of shared decision making (past physician-patient discussion of advantages, disadvantages, and scientific uncertainty associated with PSA screening), PSA screening intensity (tests in past 5 years), and sociodemographic and health-related characteristics.

RESULTS Nearly two-thirds (64.3%) of men reported no past physician-patient discussion of advantages, disadvantages, or scientific uncertainty (no shared decision making); 27.8% reported discussion of 1 to 2 elements only (partial shared decision making); 8.0% reported discussion of all 3 elements (full shared decision making). Nearly one-half (44.2%) reported no PSA screening, 27.8% reported low-intensity (less-than-annual) screening, and 25.1% reported high-intensity (nearly annual) screening. Absence of shared decision making was more prevalent in men who were not screened; 88% (95% CI, 86.2%-90.1%) of nonscreened men reported no shared decision making compared with 39% (95% CI, 35.0%-43.3%) of men undergoing high-intensity screening. Extent of shared decision making was associated with black race, Hispanic ethnicity, higher education, health insurance, and physician recommendation. Screening intensity was associated with older age, higher education, usual source of medical care, and physician recommendation, as well as with partial vs. no or full shared decision making.

CONCLUSIONS Most US men report little shared decision making in PSA screening, and the lack of shared decision making is more prevalent in non-screened than in screened men. Screening intensity is greatest with partial shared decision making, and different elements of shared decision making are associated with distinct patient characteristics. Shared decision making needs to be improved in decisions for and against PSA screening.

― Discussion ―
 This article told us some important insights about shared decision making. First of all, shared decision making promotes screening effectively. The second, full shared decision making is associated with both non-screening and screening probably based on patients’ preferences and expectation about preventive care. The third, the definition of shared decision making is not yet established, so, we can explore best definition of shared decision making in future study. 
 It is often stated that the importance of family medicine is comprehensiveness, continuity and community-oriented care. But we cannot dismiss the importance of PCCM, especially component 3 “Finding common ground”. Japanese people have been often said to obey doctors’ opinion without their preference. But this comment gradually mismatches the reality of our practice. They also have their opinion and their preference and acknowledge the role of shared decision making. Don’t you think so? At that time, we can explore the style and role of shared decision making in Japanese medical culture. I am really interested in this theme. Let’s create evidence!