I don't find that most patients are particularly interested in the scientific details but are more interested in your expert opinion and how the recommendations apply to their well-being. Some minority are. Us docs ought to know the patients well enough to know the difference and respond accordingly.
maybe enough of these 3 letters with regard to the ESPCS but how about some grift for those of us whose PSA is driven by another 3 letters, BPH. if and when there are any useful studies of practice to review anyway–although the big "C" almost seems to crowd out attention to the benign crowd.
in the scheme of things that is sensible if comparing mortality to incontinence, but actually the trade offs in overdiagnosis and overtreatment are often similar quality of life concerns; and the extensive PSA testing in the 'uninvited' control group in the ESPCS noted by @Dries Develtere may relate in no small part to BPH associated quality of life challenges that drives Primary Care Docs to recommend PSA anyway outside prophylactic screening, maybe because folks are so freaked out about DRE. (no limit to 3 letter acronyms, well, I guess the limit is 26*26*26 . . .)
Interesting piece describing how challenging arriving at a decision with a patient is. Somehow I never thought in terms of “justice” when caring and advocating for my patients during the AIDS Pandemic of the early 1980’s. Whoever they were, or wherever they came from, I treated them with respect and kindness which as fellow Humans I knew they deserved, not only from the Hippocratic Oath, but because there usually was a transaction involved.
As far as Epistemic Justice, from what I can gather, this wan’t even a concept until the early 2000’s when it began popping up in reference to social and ideological issues.
I sincerely respect the knowledge, insight,and the intellect, talents I might not have in abundance, it took to write this article, . However, it didn’t get me, at high-risk for prostate cancer, any closer to any insight surrounding PSA screening.
As a Primary Care Physician I viewed "shared decision making" involves getting to know the patient and their preferences, priorities, and perceptions. Instead of spending the time explaining the detailed evidence for one decision over another, I invest in getting to know the patient. I then make my recommendations/options for the patient to be choices that might be best aligned with their own preferences. It is a refined form of parentilism. None of us are very good at understanding real risk (as this blog certainly makes clear). Expecting the patient to understand the risk and benefit of each choice is a fool's errand. I have been to physicians lately who essentially give me every choice possible, thinking that shared decision making means that I will decide which choice best. But to me, that is denying the essence of our role as knowlegable care providers. I want the physician's recommendation of the choices that knowing me, they feel are best for me. I am reminded of the long ago slogan of the American Academy of Family Physicians: "Ever wish you had a doctor who specialized in you."
Since I began working in a situation where I have far more time to spend with each patient, I find the level of epistemic injustice is declining in my patient-physician interactions. I do take the time to explain the rationale behind each test I'm ordering, whether it be an echocardiogram or a apolipoprotein B. How much detail I provide is dependent on my perception of how much detail the patient wants or needs or understands.
Excellent framework for medical decision making; try as I might to fully understand the nuances of plumbing/ financial planning/ accounting etc: many times it comes down to : “what would you do “. I think there’s a role for “parentalism “ in many of life’s decisions including medical.
What a smart essay! Well done. However, in the name of epistemic justice, I would argue shared decision-making is a must in the few scenarios—like PSA—for which there is robust and compelling trial data, and life-altering consequences. When best guesses and fuzzy data predominate (I.e. most decisions), patients rely on physician judgment. But when science knows the answer, patients should too.
I also appreciate this link; but my experience as a urological patient has actually been as if it were still 1993. My urologist has not taken to the idea of updating that approach.
I particularly note the paper you link on PSA density. and the general attitude that the PSA standard of care should not be "over three gets biopsy".
I don't find that most patients are particularly interested in the scientific details but are more interested in your expert opinion and how the recommendations apply to their well-being. Some minority are. Us docs ought to know the patients well enough to know the difference and respond accordingly.
maybe enough of these 3 letters with regard to the ESPCS but how about some grift for those of us whose PSA is driven by another 3 letters, BPH. if and when there are any useful studies of practice to review anyway–although the big "C" almost seems to crowd out attention to the benign crowd.
in the scheme of things that is sensible if comparing mortality to incontinence, but actually the trade offs in overdiagnosis and overtreatment are often similar quality of life concerns; and the extensive PSA testing in the 'uninvited' control group in the ESPCS noted by @Dries Develtere may relate in no small part to BPH associated quality of life challenges that drives Primary Care Docs to recommend PSA anyway outside prophylactic screening, maybe because folks are so freaked out about DRE. (no limit to 3 letter acronyms, well, I guess the limit is 26*26*26 . . .)
Interesting piece describing how challenging arriving at a decision with a patient is. Somehow I never thought in terms of “justice” when caring and advocating for my patients during the AIDS Pandemic of the early 1980’s. Whoever they were, or wherever they came from, I treated them with respect and kindness which as fellow Humans I knew they deserved, not only from the Hippocratic Oath, but because there usually was a transaction involved.
As far as Epistemic Justice, from what I can gather, this wan’t even a concept until the early 2000’s when it began popping up in reference to social and ideological issues.
I sincerely respect the knowledge, insight,and the intellect, talents I might not have in abundance, it took to write this article, . However, it didn’t get me, at high-risk for prostate cancer, any closer to any insight surrounding PSA screening.
As a Primary Care Physician I viewed "shared decision making" involves getting to know the patient and their preferences, priorities, and perceptions. Instead of spending the time explaining the detailed evidence for one decision over another, I invest in getting to know the patient. I then make my recommendations/options for the patient to be choices that might be best aligned with their own preferences. It is a refined form of parentilism. None of us are very good at understanding real risk (as this blog certainly makes clear). Expecting the patient to understand the risk and benefit of each choice is a fool's errand. I have been to physicians lately who essentially give me every choice possible, thinking that shared decision making means that I will decide which choice best. But to me, that is denying the essence of our role as knowlegable care providers. I want the physician's recommendation of the choices that knowing me, they feel are best for me. I am reminded of the long ago slogan of the American Academy of Family Physicians: "Ever wish you had a doctor who specialized in you."
Since I began working in a situation where I have far more time to spend with each patient, I find the level of epistemic injustice is declining in my patient-physician interactions. I do take the time to explain the rationale behind each test I'm ordering, whether it be an echocardiogram or a apolipoprotein B. How much detail I provide is dependent on my perception of how much detail the patient wants or needs or understands.
Excellent framework for medical decision making; try as I might to fully understand the nuances of plumbing/ financial planning/ accounting etc: many times it comes down to : “what would you do “. I think there’s a role for “parentalism “ in many of life’s decisions including medical.
What a smart essay! Well done. However, in the name of epistemic justice, I would argue shared decision-making is a must in the few scenarios—like PSA—for which there is robust and compelling trial data, and life-altering consequences. When best guesses and fuzzy data predominate (I.e. most decisions), patients rely on physician judgment. But when science knows the answer, patients should too.
A cogent explication of a common sense truism - you can’t do it all…
For those who want to learn more about prostate cancer and PSA screening: this is my view as an unbiased urologist https://beyondtheabstracturology.substack.com/p/psa-for-prostate-cancer-screening?r=4uml45&utm_medium=ios
I also appreciate this link; but my experience as a urological patient has actually been as if it were still 1993. My urologist has not taken to the idea of updating that approach.
I particularly note the paper you link on PSA density. and the general attitude that the PSA standard of care should not be "over three gets biopsy".
This is a very important point. Every doctor should try to stay up to date with the knowledge in the field!
I enjoyed this read - thank you for sharing! My personal approach with PSA testing generally aligns with your take in this.