Joe Biden apparently was not even informed of whether he would like to continue with PSA testing beyond 70. He now has advanced prostate ca with mets. I am sure he would disagree with the original premise expounded in this article.
I agree with this analysis and the need for epistemic justice, but rather than looking to antiquity for guidance based on an abstract, vague and fanciful notion such as “harmony in a tri-partite soul” sensible practitioners of medical science in the modern era would be better served by contemporary empirically grounded philosophy, specifically John Rawls’ “Theory of Justice as Fairness.”
Unfortunately, not all doctors understand the statistics, or even know them - not just for PSA screening, but mammograms, PAP tests, routine blood work, etc. There is a lot to know, and I don't fault them for not knowing every statistic off the top of their heads, especially as they change when new studies come out.
To Diana's point, not every person is a rational being. In fact, I would say most of us aren't (I don't have statistics to back that up though). The minute you use a number in a sentence, my sister stops listening because numbers aren't her thing.
I don't think balance comes from the patient and physician having the same exact information. I do think that the physician or practitioner needs to have time to listen to the patient and help them through the decision. Does that mean throwing numbers at them? Maybe, maybe not. By listening to the patient, allowing them to ask questions, maybe even suggesting a second opinion, hopefully, it helps keep the relationship from being too unbalanced.
I'll give your script a try next time I have a PSA discussion and report back.
My usual prostate cancer spiel starts by explaining the idea of screening. I'd guess somewhere around 2/3 of my eligible patients who get physicals opt for a PSA which is quite high, I see, compared to national averages a quick search produces. Hmm. I wonder if I'm overselling it.
I agree with Diana. In addition, if you spout numbers to a patient in an exam room to see if you should order a PSA, they’re not necessarily going to be that meaningful in the moment. They require reflection. Usually a patient is going to ask what you recommend, occasionally they just want to “make sure” they don’t have cancer (no matter what you say), and they don’t care about the numbers.
These arguments would work in a world dominated only by reason, where all patients and all doctors understand completely the evidence presented and the risk of each next step in the treatment plan. If you follow this, then all current evidence should be presented for all medical decisions - not only those for screening. It would mean every time a doctor recommends Ibuprofen for muscle aches or fever he/she should explain in detail that 1 in about 100,000 people taking ibuprofen can develop acute renal failure, and list of all the other complications that could appear with their associated risk. In the spirit of justice, it should also be included in all our daily activities - because health is a whole person and entire day thing. For example a reminder every time you start your car that the risk of death is about 1 in 100, and the risk of an accident in the next 1,000 miles is 1 in 366 people, and then all the relevant statistics for how much money the average car accident costs. All of this is evidence is reasonable and needed to make sure people make an adequate and informed decision about driving to work that day, weighing the benefits and risks involved.
The problem with a purely rational view of life and medicine is that we are not all rational beings. Even Plato recognized that there’s spirit and appetite also, apart from reason. The reality is that no matter how smart someone is, or how much knowledge they have, the perception of risk for their own person is intrinsically connected to emotion, experiences, values and beliefs. None of these are stagnant - because unlike the absolute numeric risk of an adverse event - but are changing constantly, sometimes even from one day to the next. The numbers on PSA screening might mean something for me today, but tomorrow, after my 50 year old brother in law got diagnosed with a very aggressive, thankfully still incapsulated, prostate cancer based on a random screening PSA - these numbers will mean something different, because I’ve seen and felt what being that 1 in 366 is.
The other problem is that your average patient doesn’t want to make all healthcare decisions themselves. Part of a good doctor patient relationship is the partial transference of some autonomy that comes with trusting the doctor, and allowing him/her to make some decisions, while sharing some others. This is a crucial component of medicine, that is implicitly understood by all. Me as a patient (even very well informed one as a physician myself) could not bear the weight of being responsible for the entirety of every single medical decision based on EBM, without having a trusted doctor who makes recommendations in a more qualitative way.
In the end, the core of shared decision making is not to communicate rational facts, but to do it in the context of the values and preferences of the patient. That context, the relationship with the doctor and human connection that allows SDM to occur are important and, in my opinion, is one of the reasons physicians won’t be replaced by AI, at least not for the foreseeable future.
Yes, in an otherwise excellent comment that number is a head scratcher. Diana missed a few zeroes there. The risk of death of driving an automobile in the USA is around one per 70 million miles.
Joe Biden apparently was not even informed of whether he would like to continue with PSA testing beyond 70. He now has advanced prostate ca with mets. I am sure he would disagree with the original premise expounded in this article.
I agree with this analysis and the need for epistemic justice, but rather than looking to antiquity for guidance based on an abstract, vague and fanciful notion such as “harmony in a tri-partite soul” sensible practitioners of medical science in the modern era would be better served by contemporary empirically grounded philosophy, specifically John Rawls’ “Theory of Justice as Fairness.”
Unfortunately, not all doctors understand the statistics, or even know them - not just for PSA screening, but mammograms, PAP tests, routine blood work, etc. There is a lot to know, and I don't fault them for not knowing every statistic off the top of their heads, especially as they change when new studies come out.
To Diana's point, not every person is a rational being. In fact, I would say most of us aren't (I don't have statistics to back that up though). The minute you use a number in a sentence, my sister stops listening because numbers aren't her thing.
I don't think balance comes from the patient and physician having the same exact information. I do think that the physician or practitioner needs to have time to listen to the patient and help them through the decision. Does that mean throwing numbers at them? Maybe, maybe not. By listening to the patient, allowing them to ask questions, maybe even suggesting a second opinion, hopefully, it helps keep the relationship from being too unbalanced.
I'll give your script a try next time I have a PSA discussion and report back.
My usual prostate cancer spiel starts by explaining the idea of screening. I'd guess somewhere around 2/3 of my eligible patients who get physicals opt for a PSA which is quite high, I see, compared to national averages a quick search produces. Hmm. I wonder if I'm overselling it.
I agree with Diana. In addition, if you spout numbers to a patient in an exam room to see if you should order a PSA, they’re not necessarily going to be that meaningful in the moment. They require reflection. Usually a patient is going to ask what you recommend, occasionally they just want to “make sure” they don’t have cancer (no matter what you say), and they don’t care about the numbers.
These arguments would work in a world dominated only by reason, where all patients and all doctors understand completely the evidence presented and the risk of each next step in the treatment plan. If you follow this, then all current evidence should be presented for all medical decisions - not only those for screening. It would mean every time a doctor recommends Ibuprofen for muscle aches or fever he/she should explain in detail that 1 in about 100,000 people taking ibuprofen can develop acute renal failure, and list of all the other complications that could appear with their associated risk. In the spirit of justice, it should also be included in all our daily activities - because health is a whole person and entire day thing. For example a reminder every time you start your car that the risk of death is about 1 in 100, and the risk of an accident in the next 1,000 miles is 1 in 366 people, and then all the relevant statistics for how much money the average car accident costs. All of this is evidence is reasonable and needed to make sure people make an adequate and informed decision about driving to work that day, weighing the benefits and risks involved.
The problem with a purely rational view of life and medicine is that we are not all rational beings. Even Plato recognized that there’s spirit and appetite also, apart from reason. The reality is that no matter how smart someone is, or how much knowledge they have, the perception of risk for their own person is intrinsically connected to emotion, experiences, values and beliefs. None of these are stagnant - because unlike the absolute numeric risk of an adverse event - but are changing constantly, sometimes even from one day to the next. The numbers on PSA screening might mean something for me today, but tomorrow, after my 50 year old brother in law got diagnosed with a very aggressive, thankfully still incapsulated, prostate cancer based on a random screening PSA - these numbers will mean something different, because I’ve seen and felt what being that 1 in 366 is.
The other problem is that your average patient doesn’t want to make all healthcare decisions themselves. Part of a good doctor patient relationship is the partial transference of some autonomy that comes with trusting the doctor, and allowing him/her to make some decisions, while sharing some others. This is a crucial component of medicine, that is implicitly understood by all. Me as a patient (even very well informed one as a physician myself) could not bear the weight of being responsible for the entirety of every single medical decision based on EBM, without having a trusted doctor who makes recommendations in a more qualitative way.
In the end, the core of shared decision making is not to communicate rational facts, but to do it in the context of the values and preferences of the patient. That context, the relationship with the doctor and human connection that allows SDM to occur are important and, in my opinion, is one of the reasons physicians won’t be replaced by AI, at least not for the foreseeable future.
No, the risk of dying every time you start your car is not 1 in a 100. If that were true, no one would drive.
Yes, in an otherwise excellent comment that number is a head scratcher. Diana missed a few zeroes there. The risk of death of driving an automobile in the USA is around one per 70 million miles.