Sit patientes estote cave (Let the patient beware)
Shared decision-making is supposed to involve an honest conversation between a patient and clinicians to help the patient make difficult decisions about screening and diagnostic tests as well as treatments.
In the case of prostate cancer, it may involve low-risk patients deciding between radiation, surgery, or active surveillance (AS). 60% of these patients in the U.S. now choose AS, while 40% opt for more aggressive approaches.
These discussions can be confusing as we seek second opinions from urologists and radiation oncologists.
The patient is meant to be the decider, who weighs all the facts and chooses a course that best meets his needs.
But research is showing that doctors, especially urologists, are biased toward steering patients to surgery.
Give a urologist a surgical robot or scalpel, and he or she is likely to recommend a radical prostatectomy to remove the gland.
Give a radiation oncologist a medical linear accelerator, and he or she will want to radiate the gland.
I call this the rule of the tool. It’s the inherent bias based on physician training and preferences that leads many doctors to recommend a particular treatment.
American psychologist Abraham Maslow called it the law of the instrument or the law of the hammer, a cognitive bias that involves an over-reliance on a familiar tool.
Maslow wrote in 1966, “If the only tool you have is a hammer, it is tempting to treat everything as if it were a nail.”
Urology Today on Feb. 1 ran an interview about shared decision-making and bias with cognitive psychologist Angela Fagerlin, chair of the Department of Population Health Sciences at the University of Utah School of Medicine, Salt Lake City.
Not surprisingly perhaps, Fagerlin found doctors were biased in favor of their own treatment approaches. But urologists were more prejudiced than rad oncs.
Fagerlin said, “What we found is that when a urologist and a radiation oncologist saw the same exact patients —this is a real patient in the clinic, just like in the studies—urologists were more likely to recommend surgery, and radiation oncologists were more likely to recommend radiation.”
But there was a difference between the specialists.
Urologists recommended surgery for 79% of the patients that they saw. Radiation oncologists recommended surgery for 57% of the patients.
Patients need to be on alert for the bias from the rule of the tool.
Fagerlin urged “urologists really think about their biases.”
If they’re honest about it, urologists can gain patient confidence—maybe too much—by admitting bias.
Fagerlin said, “In a number of cases, we’ve seen urologists say, ‘Hey, I’m biased. I’m a surgeon. I was taught that this is a great method. You need to go talk to my colleagues who are radiation oncologists, just so that you can balance this out.”
Fagerlin did a study that found that when physicians fess up to their bias, “patients actually trusted them more because they acknowledged that they have this potential bias.”
She found urologist admission of bias often made patients trust them so much that they didn’t go to see the radiation oncologist. “It really suggests that before you make these recommendations—because of this underlying potential for bias—it’s important to ask the patient questions that get at what they want.”
Another approach is fielding multi-disciplinary teams including urologists, medical oncologists, and possibly nurse practitioners, to present options to patients at the same time. The evidence is that doctors are less likely to recommend their own tools.
Too bad multi-disciplinary teams for prostate cancer are not widely available.
As they said in ancient Rome, per Google translate, sit patientes estote cave (let the patient beware).
Jake Remaly, a writer for Medscape Medical News, reports on the Movember conference calling for dropping digital rectal exams, those unpopular “finger waves” that yield so little, and greater reliance on MRI imaging before biopsies.
I participated in that panel as a rep for TheActiveSurveillor.com and the AnCan Foundation, along with my colleagues Joe Gallo for AnCan and Active Surveillance Patients International, Jim Schraidt for ZERO—The End of Prostate Cancer, Phil Segal for Prostate Cancer Support Canada and Anthony Henry, of the Walnut Foundation in Toronto.