In my specific role in healthcare, there is no better example of relationship-centered care than in the decision-making that both physician and patient face in dissecting the incomprehensible dilemmas of prostate cancer screening and prostate cancer treatments. In very few others cancers do we agonize about the key issues related to this very important health problem. The relationship is what drives decisions — and ultimately it is the physician whose main responsibility is to provide information in a compassionate and objective fashion to the patient so the “relationship” can arrive at the most appropriate and “correct” answer. In the case of prostate cancer, physicians may decide not to offer screening in the first place, making the discussion regarding next steps in the screened patient that much more problematic.
The issue underlying the dilemma is the finding that, despite hundreds of thousands of patients who have been enrolled in randomized screening studies for early detection of prostate cancer, there is woefully little data that those individuals who are screened, diagnosed with and treated for prostate cancer as a result of a PSA test actually do any better than their colleagues who have never been tested in the first place. It is easy to say, “Don’t be tested,” but the patient wants to know if there is cancer in his body and what can be done about it.
When faced with caring for a patient who is dealing with these issues, I try with my deepest concern for the patient and his family to outline the major findings of studies that direct and govern how we practice medicine. The hardest aspect of these discussions is to neutralize the “emotional” aspects of a cancer diagnosis. While the primary care physician is often the front-line provider who advises about getting or not getting a PSA test in the first place, I am the one charged with facing the patient who has been diagnosed with the disease, often diagnosed as a result of the test.
These discussions often take several visits for the patient and his significant other to fully grasp the magnitude of the decision that he will be making. To think that my body has a cancer and I am being told that I may not need to do anything about it is, at initial hearing, a calamity. Over several visits, with counseling, the patient, his significant other, family members and me, the provider — which constitutes the relationship — can come to a consensus decision that makes sense to all involved. It is through this type of objective discussion, answering questions, delving deep into research technologies that may shed additional light on the subject, that a decision can be reached — with full understanding by the members of the relationship that nothing is immutable — but rather dynamic — in terms of future decision-making.
One parting comment: With the advent of ever-increasing medical record transparency allowing patients to gain access to their lab results almost in real time, I urge the patient to take a deep breath and simply be patient. I am of the opinion that more harm is done to patients than good when patients, as educated as they are, gain access to lab values even before their physician has had a chance to review them. The patient’s lack of ability to fully appreciate the nuances of lab values results in an avoidable anxiety-provoking episode. It is difficult, I know, but very valuable to have the patience to wait for your physician to provide the results in a comprehensible fashion, even though it may take a few days.
Marc B. Garnick, MD
Gorman Brothers Professor of Medicine, Harvard Medical School
Director of Community Cancer Services, Beth Israel Deaconess Medical Center
Editor-in-chief, Harvard Medical School’s Annual Report on Prostate Diseases
