Helping patients understand

The public uproar over the recent recommendations of the U.S. Preventive Services Task Force seems to have taken them by surprise.  Apparently, in a Gallup Poll of 1,136 women, 76% of women say they disagree or strongly disagree with their recommendations. (Source:  http://www.usatoday.com/news/health/2009-11-24-mammogram24ONLINE_ST_N.htm)

So what did the task force say?  Here’s a synopsis:

November 2009 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for breast cancer.

Summary of recommendations:

• The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.

• The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.

• The USPSTF recommends against teaching breast self-examination (BSE).

Source:  http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm

Interesting, the task force did not get the same reaction from men when they released their recommendations for prostate cancer screening last year:

August 2008 U.S. Preventive Services Task Force (USPSTF) recommendation on Screening for Prostate Cancer

Summary of recommendations:

• The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years.

• The USPSTF recommends against screening for prostate cancer in men age 75 years or older.

Source:  http://www.ahrq.gov/clinic/uspstf/uspsprca.htm

In both cases, for mammograms and prostate screenings, the U.S. Preventive Services Task Force based their recommendations on the research available.

So what does this mean for patient education?

Patients hear and read things.  Some of these are facts, some rumors.  Some are advertisements.  Some are isolated pieces of research that should not be generalized.  Some are summaries of the research available, interpreted into recommendations.

Patients come to us with knowledge and opinions.  They are not empty vessels for us to fill.  We need to assess what they already know and believe before we begin to teach, so we can tailor our message so it makes sense to them.  Otherwise it will be rejected.

I suspect almost every woman knows a woman who has had breast cancer.  Women have been told that they have a 1 in 8 chance of developing breast cancer in their lifetime.  They’ve been told that women who get breast cancer when they’re under 45 years of age have a lower 5-year survival rate than those who develop it later in life.  So when they hear recommendations that say they don’t need to be screened until they are 50, it doesn’t make sense.  It is our job to give them information in context, so it makes sense to them, so they can make informed decisions.

As we strive toward an evidence-based practice, we need to remember:

“[Evidence] needs to be considered in light of the patient’s concerns and preferences.  The patient’s concerns and preference are crucial because most clinical situations are underdetermined (i.e., knowledge and information are incomplete, and the particular patient and circumstance are changing across time.  The patient’s diagnosis may be imprecise and the degree of pathophysiology uncertain, and the patient’s responses to particular interventions will vary.”

Source:  Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare:  A guide to best practice. Philadelphia: Lippincott Williams & Wilkins.  Page 164.

So ask your patient what she’s heard, knows, and believes.  Then teach.