Thursday, March 14, 2013
QD: News Every Day--It's tough to convince older patients not to undergo screening
It's tough to tell seniors not to undergo screening, researchers found, and physicians who discourage unneeded tests may face resistance or disbelief when they do.
"These attitudes are similar to those seen in Americans more generally; most Americans surveyed see screening as an undisputed good and fail to recognize how screening tests can be harmful or nonbeneficial," the authors wrote. "Positive attitudes may help motivate individuals to undergo screening when their health status or age makes screening tests beneficial, but when they are older or ill, these same attitudes and limitations in understanding may make it hard for them to accept recommendations to stop screening."
To learn about older adults' perspectives on stopping screening cessation and their talks with clinicians about this topic, researchers interviewed 33 older adults (median age, 76; range, 63 to 91) presenting to a senior health center affiliated with an urban hospital. Results appeared online at JAMA Internal Medicine.
Interviewers started with open-ended questions about patient perceptions and recent experiences with screening decisions, and then outlined a list of potential decision-making factors, such as physician recommendations, statistical data about the test, and hypothetical conditions such as living in a nursing home. Interview transcripts were analyzed to identify themes and illustrative quotes.
Some patients see screening tests as morally obligatory. One 84-year-old woman told interviewers, "I think I should, because [stopping] would be the same as me taking my life. And that's a sin."
Some patients also see screening tests as mandatory. Another 91-year-old woman said, "Whenever we were told we were supposed to do something, I just, you know, did it."
Others accepted the need for screening with little discussion by physicians.
Researchers summarized that many patients saw continuing screening as a default decision, and stopping screening as a major one. Some patients were upset or expressed disbelief when physicians recommended stopping, and said they would get a second opinion.
Still more lacked confidence in government panels and recommendations, or in the need for statistics as part of a decision-making process. They were more agreeable about stopping because of the balance of risks and benefits, complications or test burdens.
Researchers concluded, "Just as the public health and medical message to patients is that screening is a wise and admirable choice when they are middle aged and otherwise healthy, so must messages explain why not screening, and focusing on other aspects of care, may be wise and admirable when patients are older or ill."
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
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Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
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Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
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