Shared decision-making (when you’re wearing the paper gown)

I offer screening mammograms to my patients starting at age 40. I have developed a little script to explain that I recommend them routinely by age 50, but at younger ages, individual decision-making is required because the science to support breast cancer screening has more tradeoffs in younger patients.¹ Some patients have questions; many immediately know their preferences.

“Well, do it, don’t do it, but I recommend it,” the radiologist said. The conversation was over.

For me, personally, I felt comfortable waiting until sometime after age 40 to start screening. I have a reassuring family history; my mother has 5 sisters, without any breast or ovarian cancer among them. When, in my mid-40s, I told a doctor that I preferred to wait until I was closer to age 50 to get a mammogram, she urged me to begin screening immediately. Even as a physician, the drive to be a “good patient” was strong. I made the mammogram appointment.

Like many patients, my first mammogram was not normal.^2,3 After a second round of tests, and then a third, the radiologist gave me the results: Everything is fine. It is just normal breast tissue. To be on the safe side, you should do a follow-up mammogram and ultrasound in 6 months.

I asked why I needed to do follow-up imaging if the only thing that multiple diagnostic tests had shown was normal tissue—not a cyst, nor a fibroadenoma or any other abnormality.

“Well, do it, don’t do it, but I recommend it,” the radiologist said. The conversation was over.

My experience as a patient came to mind when I read this month’s article on shared decision-making by Mackwood et al.⁴ The authors discuss principles and techniques for shared decision-making in practice, which include enlisting the patient as the expert in their own values, and putting forth the health care professional as a source of reliable information when the evidence supports more than one reasonable strategy in a health care decision.

Aligning values, science, and action can be challenging, to be sure. It can be made easier through long-term relationships, such as the ones that family physicians have with their patients. One of the benefits of longitudinal practice is coming to know what our patients prefer instead of having to start from scratch with each visit. The belief that our values will be mutually respected is part of what builds trust in a doctor–patient relationship. We can use tools to support information delivery at the patient’s health literacy level to make the science more understandable. This in turn makes it easier for patients to integrate the science into their own value system.

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