Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Declare your interest
- Harry Hall (7 October 2008)
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Paternalism in disguise
- Owen P Dempsey, Hazel Hawker (10 October 2008)
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'Consider an offer' approach to communication requires more than making an offer
- Vikki A Entwistle, Stacy M Carter and Kathy Flitcroft on behalf of the original authorship group (19 October 2008)
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Normal practice for treatment?
- Peter M English (20 October 2008)
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History of communicating "The Facts" in the NHS Breast Screening Programme
- Hazel Thornton (20 October 2008)
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Opportunistic Testing
- Deborah L Brown (2 February 2009)
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Harry Hall, Retired Physician EX1 2HW
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To say in the table (last column, paragraph 4) that "The income we get from government to help run the practice depends in part on us doing some of these checks, but we recommend it because we think it can help patients" is misleading to say the least. The fact is that these payments had to be made to induce GPs to do the tests. An offer of a test should be accompanied by a clear declaration of financial interest if incentives are offered. Competing interests: None declared |
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Owen P Dempsey, GPwsi primary care education Huddersfield HD7 4LQ, Hazel Hawker
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Dear editor, Re: 'Communication about screening' by Entwistle et al (1). We read and discussed this paper as a group in an afternoon educational session, and have the following thoughts about it. The paper starts off with the implicit assumption that the consultation in general practice is the appropriate place for opportunistic screening as primary prevention. This is certainly not a view held by everybody, for example Getz et al, writing in 2003, discuss how such screening may be unethical as it can distract the GP from the patient’s primary reason for attending, and as many GPs feel unconvinced by the ‘evidence’ behind disease prevention programmes premised as they are on modelling and ‘ideal scenarios’ (2). The whole concept of ‘making an offer’ and incorporating the values and attitudes and beliefs of the GP into a final decision is not new at all, it has been called ‘shared decision making’ and has been extensively researched. However, even worse is the way, in the paper, that ‘making an offer’ subtly becomes either ‘recommending or offering’ a screening test. Well, it seems to us that ‘recommending’ the test falls into the paternalistic ‘be screened’ category. This interpretation is reinforced by the example given in the table of the screening for IHD risk , this fails to include any discussion of potential harms , and fails to mention serious doubts about such screening programmes held by eminent experts, including, Simon Capewell in the same issue (ironically) of the BMJ in the ‘Head to Head’ article (3). We also felt that the time required to discuss everything described would not be feasible in an average UK GP surgery. Is it time for such adult primary prevention activities to be taken out of routine general practice consultations? --------------------------------------------------------------------- ----------- [1] Communication about screening. Entwistle et al BMJ 2008;337:a1591 [2] Is opportunistic disease prevention in the consultation ethically justifiable Getz et al BMJ 2003;327:498-500 [3] Will screening individuals at high risk deliver large benefits. Capewell et al BMJ 2008;337:a1395 Competing interests: None declared |
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Vikki A Entwistle, Professor of Values in Health Care Social Dimensions of Health Institute, 11 Airlie Place, Dundee, DD1 4HJ, Stacy M Carter and Kathy Flitcroft on behalf of the original authorship group
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We write in reply to responses to our recent paper (1) from Harry Hall (2) and Owen Dempsey and Hazel Hawker (3), whom we thank for their interest and the opportunity they provide for clarification. Both responses were concerned in part with the place of screening discussions in general practice in the UK. Our paper did not set out to consider where or by whom particular screening tests should be provided, but to outline an approach to communication about screening that could be used in diverse health care contexts in both recorded information resources and interpersonal professional-patient communication. We agree that pay-for-performance schemes have raised new issues for screening discussions within general practice, and we think this makes attention to the challenges of communication more urgent. We acknowledged that our ‘consider an offer’ approach would require resources for its implementation. However the ‘analyse and choose’ approach is also resource intensive, and although the ‘be screened’ approach might be more time efficient, it remains ethically unacceptable. Both commentators expressed concerns about our illustrations of the ‘consider an offer’ approach in relation to screening for cardiovascular risk. These illustrations were envisaged as portions of hypothetical conversations, although this was not stated in the inevitably shortened version of our table, and we agree with Dempsey and Hawker (3) that more could usefully be said about the potential harms this screening may lead to. The congruence of any particular set of words with the ‘consider an offer’ approach depends on context. Hall (2) helpfully reminds us that some of the talk we presented as illustrative would be dishonest and inconsistent with ‘consider an offer’ if voiced by a GP who was sceptical about the clinical value of cardiovascular risk screening. ‘Consider an offer’ provides scope for GPs to explain their personal views, but also requires that they summarise current research-based guidelines, provide information about benefits, harms, financial incentives and other interests, and encourage more detailed consideration and discussion if required. It insists people are told it may be reasonable to decline screening (presuming a situation in which screening is not compulsory to avoid harm to others). Although our illustrations had limitations, the general features of the ‘consider an offer’ approach still make it a more appropriate model for first-line communication than either the ‘be screened’ or the ‘analyse and choose’ approaches. The overall intent of ‘consider an offer’ is always to support people so they can assess an offer, including its general basis and personal applicability. It does not reduce to ‘making an offer’ as Dempsey and Hawker suggest. ‘Consider an offer’ can accommodate the making of recommendations, but making recommendations is not necessarily paternalistic. We are not sure how Dempsey and Hawker define paternalism, but suspect they are equating autonomy with independence. We do not think autonomy is reducible to independence in decision-making. Autonomy is always exercised in the context of social influences and relationships, and health professionals’ recommendations may either undermine or support patients’ autonomy depending on how and in what circumstances (including the specific features of particular patient-professional relationships) they are communicated. Within ‘consider an offer’ communication, people are given help to (a) understand the basis of any recommendations and the types of situations in which they might not apply, (b) limit or expand the information they consider and discuss, and (c) trust they will be respectfully supported whether or not they accept a recommendation. Dempsey and Hawker were also concerned that the ‘consider an offer’ approach was the same as shared decision-making. Shared decision-making has been variously defined (4) and in our brief paper we did not discuss how the three approaches to communication might relate to it. Our typology of communication approaches covers mailed screening invitations as well as interpersonal professional-patient communication, and shared decision- making is not a relevant concept for the former. Consultations consistent with the ‘consider an offer’ approach could incorporate shared decision- making, but so too could consultations consistent with the ‘analyse and choose’ approach that we distinguished it from. Shared decision-making is often associated with the provision of detailed effectiveness data. We sought to provide a model of communication in which autonomy is respected but people are not necessarily required to work through detailed epidemiological evidence for themselves. The ‘consider an offer’ approach highlights the importance of features of health care organisation and reimbursement systems for personal consideration of screening offers. This consideration is also relevant in the context of treatment decision- making, and we hope our suggestions will contribute to thinking about shared decision-making and professional-patient communication more generally. 1. Entwistle VA, Carter SM, Trevena L, Flitcroft K, Irwig L, McCaffery K, Salkeld G. Communication about screening: a proposed new direction. BMJ, 2008; 337 (221) a1591. 2. Dempsey OP, Hawker H. Paternalism in disguise. BMJ rapid response, 10 October 2008. 3. Hall H. Declare your interest. BMJ rapid response, 7 October 2008. 4. Makoul G, Clayman ML. An integrative model of shared decision-making in medical encounters. Patient Education and Counseling, 2006; 60: 301-312. Competing interests: None declared |
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Peter M English, Consultant in Public Health KT22 7PL
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Thank you for this fascinating article. I think it articulated very clearly the way that we need to tailor our advice and guidance to the patient's needs. Some will want huge amounts of information; others will be happy to know that you recommend something; and many will fall somewhere between these extremes. As I read the article, I realised that you almost could substituted "treatment" for "screening" throughout. While purists might insist that we should inflict a detailed list of all the possible adverse consequences of our every recommendation on every patient (and record that we've done so for fear of subsequent claims based on "you didn't warn me"); most practitioners in the real world soon learn to recognise how much detail is appropriate for each patient. So the article became, for me, an interesting articulation of reasons - or perhaps a validation, or maybe even an excuse - for the way doctors normally work, despite impractical imprecations from the informed consent purists. Competing interests: None declared |
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Hazel Thornton, Honorary Visiting Fellow, Department of Health Sciences, University of Leicester. "Saionara", 31 Regent Street, Rowhedge, Colchester, CO5 7EA
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Perhaps it would be helpful to consider the new approach to communicating screening suggested by Entwistle and colleagues of` `consider an offer` [1] against the background of the 20yr history of communication about mammographic screening offered by the NHS Breast Screening Programme. (NHS BSP). During this time, it is unfortunate that the NHS BSP itself, (which needs to achieve a 70% minimum uptake target rate) has been responsible for providing the information leaflet, rather than a neutral, unbiased information source. In the year 2005/6 we are advised [2] that 1,782,381 women were invited. They will have been given the leaflet “Breast screening: the facts” [3] – a misnomer if ever there was one – it being very short on essential facts, particularly about potential harms. It also gives them the NHS Breast Screening Code that includes the coercive instruction “Go for breast screening every 3 years if you are over 50” – the antithesis of `neutral` information – leading women to believe that they have no option but to accept. This is no surprise. Dr. Joan Austoker, Director of Cancer Research UK`s Primary Care Education Research Group at the University of Oxford, reports in the NHS BSP Annual Review 2007[2]: “We`ve never had a comprehensive set of standards which outline the key information that should be included in every invitation letter, so we`ve never really been able to achieve a consistency in the messages we`ve been delivering.” It is time we did. The implementation of Entwistle and colleagues` new `consider and offer` approach (which might likely suit many people) will require thorough re-education of women to appreciate that they have a choice in the matter. Breast cancer support and information organisations have a responsibility to provide honest information.[4] The practicalities of who might be the best providers of better information, and the health practitioners best entrusted to help women decide,[5] require to be considered. It is time to formulate a comprehensive strategy. [1] Entwistle V, Carter SM, Trevena L, Flitcroft K, Irwig L, McCaffrey K, Salkeid G. Communicating about screening. BMJ 2008; 337:789- 791 [2] NHS Breast Screening Annual Review 2007 www.cancerscreening.nhs.uk/breastscreen/publications/nhsbsp- annualreview2007.pdf [3] NHS Cancer Screening Programme. Breast screening: the facts. 2007 www.cancerscreening.nhs.uk/breastscreen/publications/ia-02.html [4] Thornton, H. Breast cancer slogan reality check: “1 in 9” – if you`re 90! Misuse of “1 in 9” slogan defended by two leading organizations` directors on grounds of consistency and popularity. International Journal of Surgery. In press. October 2008. Online 14 October 2008. doi:10.1016/j.ijsu.2008.10.002 [5] Dempsey OH, Hawker H. Paternalism in disguise. bmj.com rapid response to Entwistle et al paper [Ref.1.] 10th October 2008. Competing interests: None declared |
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Deborah L Brown, Lawyer Consultant 3000
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I think it's disgraceful and unethical that women are unable to see their GP without being hassled and bullied about cervical screening. We are not children and are quite capable of deciding for ourselves whether we want to participate in cervical screening. GP's should NOT receive incentives to recruit women into these programs - IMO it deters the Dr from providing risk information and means Dr's often overstate the benefits of the Test - it also, encourages bullying and disrespectful behaviour. Cervical screening IMO has harmed thousands of women. As a young lawyer 30 years ago, my GP started to pressure me into the program. I asked for risk information - What? I did my own research and was shocked - I refused to have this Testing and still do... The risks for me FAR outweighed the benefits. Over the years I've watched women increasingly, live in fear of their own bodies - they hate having the Test, but fear not having it - they fear false positives, another colposcopy and biopsies - it's shameful IMO that women are treated in this way. The facts are clear - cervical cancer is an uncommon cancer (only 1.58% of an unscreened Aust population would get this type of cancer.....) L Koutsky in "Cancer Prevention" Fall 2004 Issue 4 states that almost 78% of women receiving regular screening will have a colposcopy in her lifetime, yet only a tiny number will have malignancy. The coloposcopy is an unpleasant and invasive test - many women find the experience traumatic and some are left with permanent damage - physically and mentally. The misleading information, the overstatements, the bullying must stop....too many women are being harmed....healthy women. I have just rejected mammograms as well - after doing my own research - I don't trust the medical profession to tell us the truth....too many vested interests. I understand the situation in the UK is even worse - if a woman refuses the Test, another Dr may join her Dr to jointly apply pressure - get the scare campaign happening - if she continues to refuse, she's asked to sign a disclaimer acknowledging she may be harmed as a result of her refusal and releasing the practice of any responsibility. Don't kid yourselves - there is no informed consent with cervical screening - it's high-handed tactics...(that story was related to me by an English woman who has also, declined to be screened) I would have handed back the Release form, left the surgery and reported the Dr's for their unethical behaviour. The unreliable pap smear should have been replaced by now - the Cervical Specific Antigen blood test was patented in 2004 in the States - unlike the smear, this is almost 100% reliable.... Why are women still waiting? I suspect there are too many snouts in the trough...reluctant to give up power, control and a rich source of income from screening and unnecessary follow-up... Women need to do their reading - make informed decisions and stay strong - Knowledge is Power... Women should also, demand access to the CSA Blood Test asap Thanks to Dr Angela Raffles for giving us some earth shattering facts - 1000 women need to be tested for 35 years to save ONE woman from cervical cancer - I wonder how many healthy women are harmed over that period of time. Also, Professor Michael Baum - brave enough to tell us the truth about cervical and breast cancer screening - exposing himself to the fury of the powerful screening industry. Thank you to the people brave enough to speak out.... Competing interests: None declared |
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