In the early 1990 guidelines onwar...

In the early 1990 guidelines onward screening for prostate cancer were in sharp conflict. The American Urological Association, American Cancer Society, and other collections advocated screening, while conservative organizations so as the U.S. Preventive Services Task Force and the Canadian Task Force onward the Periodic Health Examination maintained that the evidence was insufficient to make a recommendation.

In the decade that followed, the once-embattled organizations converg around the notion of shared decision making. Proponent of screening came to recognize that patients were entitled to know about the scientific uncertainty surrounding the benefits of screening and the potential harms induced on false-positive results and treatment complications. Whether treatments are necessary or effective remains unclear as described in the review on Bhatnagar and Kaplan (1) in this issue of American Family Physician. Critics of screening came to recognize that the absence of evidence of effectiveness did not manifest ineffectiveness and that patients had a right to know about the possibility of benefits.

In 1997 the American body of Physicians (2) recommended that the physician "describe the potential benefits and known harms of [prostate] screening listen to the patient's troubles and then individualize the decision to screen"

In 1998 the American Academy of Family Physicians (3) advised physicians to "coun-sel [men] regarding the known risks and uncertain benefits of screening for prostate cancer."

In 2000 the American Urological Association (4) stated that "the decision to use prostate-specific antigen (PSA) testing for the early detection of prostate cancer should be individualized. Patients should be informed of the known risks and the potential benefits."

In 2001 the American Cancer Society (5) stated that "prior to testing, men should have an opportunity to learn about the benefits and limitations of testing for early prostate cancer detection and treatment."

In 2002 the U Preventive Services Task Force (6) conclud that "clinicians should not order the PSA experiment without first discussing with the patient the potential further uncertain benefits and the possible harms...."

Despite the consensus forward the appropriateness of shared decision making, there is limited evidence about the frequent occurrence with which it occurs in practice. Audio recordings of clinical attacks conducted a decade ago revealed that patients received without fault [i]or[/i] blemish [i]or[/i] flaw information on 9 percent of decisions. (7) In a view (8) published in 2001, just 17 percent of physicians reported that they would decide whether to order a PSA experiment based on patient preferences. solely two thirds of men who are guarded even know that they have been exhibitioned (9) These data suggest that little shared decision making is occurring.

Physicians contest a variety of disincentives to engaging in shared decision making. There is limited time and reimbursement for lengthy discussions. Many physicians have inadequate support to review the benefits, risks, and scientific uncertainties surrounding options, and about question whether it is the best way to make decisions. (10) Many patients have difficulty processing the information. Physicians and patients who believe intuitively in the benefits of screening find little motivation to engage in shared decision making. Many patients arrive at the engagement with the expectation that they will be exhibitioned or that the physician will commend which tests are appropriate.

Perhaps the starkest disincentive to shared decision making is medicolegal belong tos Physicians worry that not performing screening, regardless of a patient's precedence puts them at risk if the patient bring outs invasive prostate cancer in the time to come This dilemma was expressed poignantly in an essay by the agency of Merenstein, (11) a family physician whose residency program was su because it had taught him to engage in shared decision making. He described the trauma of the experience, which caused him to view patients as possible plaintiffs: "I no longer discussed the risks and benefits of prostate cancer screening. I ordered more laboratory and radiologic touchstones and simply referred more." (11)

From the physician's perspective, eschewing shared decision making brings potential benefits: it saves time, obviates the reimbursement and logistic challenges of shared decision making, and minimizes liability for failure to cover Abandoning shared decision making also has a downside. It conflicts with the professional etho to "do the right thing" and support informed choice. It introduces medicolegal vulnerabilities if the patient petitions for complications that result from screening. The effectiveness of shared decision making, a great deal of like prostate cancer screening, is uncertain. Scientific evidence is inadequate to determine whether benefits outweigh harms for patients or physicians.

Circumstances that call for shared decision making in patients' choices about screening--an uncertain balance between benefits and harms that is best determined from personal preferences--also apply to the physician deciding to refrain from shared decision making. Just as the patient must decide, based forward personal values, whether the benefits outweigh the risks, the physician must decide whether what is gained through circumventing the challenges of shared decision making is offshoot by its harms to the patient and physician. It is a personal choice that single conscience, not guidelines, can dictate.