Vol 54: september • septembre 2008 Canadian Family Physician•Le Médecin de famille canadien
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The problem with choice
What my mechanic taught me about PSA screening
Roger Suss
MD CCFP(EM) FCFPW
hich fuel filter do you want?”The question took me aback. Why would my mechanic offer me a choice about which filter to use? My knowledge of automobile parts is quite limited.
But this morning I learned that Brand B fuel filter is cheaper than Brand A and performs equally well. I was confused. My mechanic clearly thought that B was a bet- ter choice and she knows I’m an automotive imbecile, so why did she ask? I went with Brand B but I asked why she gave me a choice. She shrugged and said, “Choice is good—right?”
I am not so sure that choice is always good. This morning I wanted my mechanic to choose for me. If I had picked my own fuel filter I would
have felt responsible for the con- sequences of my choice. If the fil- ter failed prematurely I would have blamed myself. Now if it fails I won’t even blame my mechanic. I trust her
judgment. I will blame fate and say that this particular filter happened to be a dud. Even if I didn’t think she was the best mechanic around (which I do) I would feel bet- ter trusting her judgment than trying to evaluate fuel fil- ters by their packaging.
What ends mean
This principle doesn’t just apply to mechanics. It applies to all experts. The whole point of consulting an expert is to leverage their expertise. We form a partnership of experts.
I am an expert on what I want and they are experts on how to get it. I tell them the ends and they tell me the means. It’s an ongoing discussion because choosing dif- ferent means sometimes changes the ends in unexpected ways—like side effects or complications. Communicating ends includes discussing the value placed on particular goals, the likelihood of achieving those goals, and the likelihood and negative value of undesirable outcomes.
My mechanic knows that I value saving money. And she does not believe that any other ends will be risked in choosing to save money on Brand B. Her question to me was entirely about means. To make it purely an ends question she would have had to ask whether I wanted to spend extra money for an equivalent product.
When I try to influence the means I generally cause problems. You might think it couldn’t hurt to ask my mechanic about Brand C that I had seen in a billboard
ad. But it might. Maybe my mechanic would lean toward Brand C just because I asked about it and not because she thought it was a good choice. I don’t really want her to do that. I care about making my car run well and saving money. I don’t care which fuel filter will achieve that end.
On the other hand, I would be concerned if my mechanic installed seat warmers without asking me.
Warm buttocks are an end (sorry, I couldn’t resist). When experts start answering ends questions on their own, it creates problems.
You might think that all of this only applies if I have confidence in my expert, and that is partially true. I need to feel confident that my expert both listens to my goals and puts my inter- ests first. But my expert doesn’t have to know everything. She doesn’t even need to know more than other mem- bers in her field. My mechanic knows more than I do and that is what matters. If I doubt her knowledge and abilities, my best strategy is to find a new expert, not to start telling her how to achieve my goals.
The end of means
Back in my office my first patient is in for a periodic health examination. I am about to ask him whether he wants a prostate-specific antigen (PSA) screening test when I pause. I know his goals. He is a healthy 50- year-old man. He wants to live as long as possible and has a very dim view of urinary incontinence and impo- tence. Why am I asking him about PSA screening? I don’t know whether a PSA screening test will increase his chances of living longer or better. I am just follow- ing the American Cancer Society guidelines which say:
“Information should be provided to patients about ben- efits and limitations of [PSA] testing.”1
On the other hand, the United States Preventative Services Task Force “found good evidence that PSA screening can detect early-stage prostate cancer but mixed and inconclusive evidence that early detection improves health outcomes … evidence is insufficient to determine whether the benefits outweigh the harms for a screened population.”2
Prostate-specific antigen screening is not controver- sial because of conflicting ends. It is a promising but unproven means.
Reflections
Choice is good—
right?
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Canadian Family Physician•Le Médecin de famille canadien Vol 54: september • septembre 2008Reflections
Most of my patients choose not to have PSA screen- ing. I attempt to present the pros and cons in a neutral fashion because of the American Cancer Society guide- lines, but I think my patients catch on to my opinion even if I don’t say it openly.
My anxious patients insist on screening anyway. I cringe before I ask them about it; PSA testing is very bad treatment for anxiety. They are hoping a negative test will reassure them that they won’t die yet. After years of experience I have learned to anticipate that if the test is negative, this specific anxiety will quickly be replaced by another one. Once I tried telling a patient that even if the test were negative he could still get hit by a bus. (I only tried that once.)
Some patients come to me specifically asking for the test after the personal recommendation of a highly qual- ified television talk show host. But others have not even considered the PSA choice until I bring it up. They must wonder why I raise the subject.
Of course, that is what brought to mind the bewil- dering discussion I had with my mechanic this morn- ing. Upon reflection, I don’t think it is a good idea for experts to ask their clients or patients to make choices about means. If thousands of doctors can’t agree on whether PSA screening results in any benefit, then it makes no sense to ask the patient to settle the dis- pute. I am perfectly willing to discuss the pros and cons of PSA screening if my patients raise the subject (and order the test if desired); but it is a big leap to suggest that I should raise the subject myself and then sub- liminally discourage the test—or attempt to be neutral
when I am not. There are many unproven interventions out there, and many interested parties who want me to discuss the pros and cons of their favourite interven- tions when the evidence is inconclusive. I have decided to stop doing this. I don’t want the experts in my life to ask me means questions and I am not going to ask them of my patients.
Dr Suss is an Assistant Professor in the Department of Family Medicine at the University of Manitoba in Winnipeg.
Competing interests None declared references
1. Smith RA, von Eschenbach AC, Wender R, Levin B, Byers T, Rothenberger D, et al. American Cancer Society guidelines for the early detection of cancer:
update of early detection guidelines for prostate, colorectal, and endome- trial cancers. Also: update 2001—testing for early lung cancer detection. CA Cancer J Clin 2001;51(1):38-75. Erratum in: CA Cancer J Clin 2001;51(3):150.
2. Agency for Healthcare Research and Quality. Guide to clinical preventative services 2007; recommendations of the U.S. Preventative Services Task Force.
Rockville, MD: Agency for Healthcare Research and Quality; 2007. Available from: www.ahrq.gov/clinic/uspstfix.htm. Accessed 2008 Jul 10.
Disclaimers
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Please disregard my willful misrepresentation of the views, behaviour, and sex of my mechanic.
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