Communicating about screening

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