Table 2

Practice, conditions and consequences of the four general practitioner (GP) heuristics for dealing with prostate-specific antigen (PSA) testing

  Dominant practice orientation
  GPs engaging with overdiagnosisGPs not engaging with overdiagnosis
  GP prioritises avoiding underdiagnosisGP thinks about underdiagnosis and overdiagnosis case by caseGP prioritises avoiding overdiagnosisGP avoids thinking about overdiagnosis or underdiagnosis
Routine PracticeHow did GPs approach communication?GPs inclined not to talk about overdiagnosis. The information they provide is “next to none” (GP9). Communication style characterised by advising men to have a PSA with emphasis on benefits of early detectionGPs inclined to talk about overdiagnosis and underdiagnosis, tailored specifically to the personal circumstances of each patient and what they are perceived as being capable of understanding. GPs agreed that it is never a particularly easy discussion to have, because the information is complex and “the figures are so—are quite hard to explain” (GP16), with the discussion described by some as becoming “more complicated depending on how interested the person is” (GP4)GPs inclined to talk about overdiagnosis and emphasise the harms of PSA testing when giving advice. Most of these GPs try to talk patients out of having the test, and many had patients who did not go ahead with a PSA test following discussionGPs do not talk about overdiagnosis or underdiagnosis; general information about the PSA test as a screening tool sometimes provided. GPs happy to leave discussion up to the specialists; “I wouldn't go ahead, two steps ahead and discuss that they might find a cancer that they—that wouldn't have killed them; I don't go and—I don't go there. I think, I mean, that's sort of a urologist can do that” (GP7). For some, it was easiest to just do the PSA test with no explanation at all
How did GPs approach PSA testing?Mostly test. Testing is perceived to be an absolute obligation. These GPs feel their primary duty is to prevent prostate cancer death, and save men's lives wherever possible. “To not screen somebody, I don't know, it seems cruel, it's cruel and irresponsible…to not at least make an attempt to avoid the misery of a person getting prostate cancer, to me, seems unbelievably cruel” (GP29). “We have to diagnose them if they have a problem. What if it couldn't wait? How would you know it won't affect them?” (GP11)Variable testing practice. Testing decisions and ‘rules’ shifted according to the patient, and factored in such things as the patient's risk profile (eg, age, family history), life expectancy, interest in and reason for wanting a PSA test, motivation to have the test, anxiety around cancer, understanding, and intention and ability to follow up any abnormal test results. For some GPs, [It's] “really one of those tests in medicine that you order with the hope that it will be low or negative, and the sort of dread that it will be positive because you know that, it being positive creates a whole lot of problems for you and the patient” (GP17)Prefer not to test or will test only under duress because of uncertain benefit and potential harms caused by overdiagnosis. GP tries to minimise the likelihood of overdiagnosis by minimising PSA testing. Overdiagnosis described as “bad. It's like sin” (GP19), and “makes us very thoughtful about what preventive care and what screening we would recommend to patients” (GP19). These GPs believed the harms of overdiagnosis were too great to justify testing, “Even though we—in the long term you might save someone's life, if you do an awful lot of harm along the way, it's just not worth it” (GP18)Mostly test. GPs seemed disengaged from the overdiagnosis debate and tended to default to testing, doing what they had always done without any further consideration
How did GPs respond to patient requests for a PSA test?GPs will test if requested. These GPs valued the knowledge produced by the test which can reassure patients and the GP. “I believe there is no case for saying you shouldn't take PSAs…how can knowledge not be a good thing?” (GP29)GPs will test if requested. These GPs particularly emphasised being responsive to patient preferencesGPs try and talk patients out of it, but will test if requested, despite convictions that PSA is “a very concrete example of where doctors can help mess things up” (GP8)GP will test if requested
Practice rationaleDid GPs draw on first-hand experiences to reason about PSA testing?Yes. Witnessing the horrors of prostate cancer deaths was enough to motivate GPs to do everything in their capacity to prevent further deaths. For some, having a man alive following a prostatectomy was a powerful anchor and confirmation for PSA testing; “for me that was worth it. Even his side effects are, I don't know if he thinks it, but he's still alive” (GP26)NoYes. It is a difficult balance for these GPs to practise according to the evidence while not being influenced by personal and professional experiences; “it's certainly a—hard to be, treating dying people who are young and not to worry about all of this and I, but I try not to change my practice based on my own personal experience of one or two people dying of prostate cancer. I have to still have confidence in the advice I get from, the population screening advice I get from bigger experts than me” (GP8)No
Did GPs express medicolegal concerns about PSA testing?Yes. Many GPs were preoccupied with concern of legal risk. “I never want to get caught out really, by someone having asked for a test and you refusing it, and then in fact, they did have an abnormality” (GP15). This influenced more defensive practice; “you are so open for being sued by anything but it's very easy to want to lean towards the screening everyone because…I know it's the wrong thing to say because it's meant to be let's not do the PSA but I think if I wasn't concerned about being sued then maybe I'd say let's do it less…I definitely think it's hard not to think legally” (GP6). Some of these GPs felt legally covered putting men on their practice recall systemNo. Either GPs believed their patients had made an informed choice following discussion or they felt they practised from a defensible positionNo. Perceived themselves to be covered by the guidelines of their medical college. They engaged patients in detailed discussions about potential harms and resisted medicolegal fears. “If I did that…I think I would be a more paternalistic doctor who ordered a lot more tests. And I don't see that would be good medicine. I think it would do more harm to more people for practicing defensively like that” (GP30)Varied. “It's very unclear for GPs, what it is [why there is an onus to discuss testing]. And, I mean, on one hand we are being told to, you know, to try to, you know, basically discuss the—the downside of PSA screening and things with patients…But then pretty much, they all go on and have the test anyway…and part of that is probably fuelled by my anxiety about missing something. Ah, and I guess part of that anxiety comes from medico-legal anxiety” (GP3)
Did GPs draw on practice guidelines, recommendations or their interpretation of the evidence?Many of these GPs were following the guidance of specialists (urologists). Many also believed they were following their medical college guidelines. They tended to be sceptical of the evidence. “it's fine for the people in their…universities and stuff like that to—to give us figures and say, you know, we are only going to lose this number of individuals if we do all this testing…but those individuals, some of them are young men, with lots of productivity and stuff” (GP24) These GPs were likely to agree that population statistics do not, or cannot, apply to individuals, and sometimes had difficulty translating population-based information; “applying knowledge from an epidemiological study to one person is not easy…it's so hard to apply” (GP28). “I don't think, a doctor should ever be guided by mathematics, you know, humans aren't machines” (GP29)GPs trusted the evidence to guide their decisions and practised according to population-level statistics and the guidance of most professional recommendations (particularly their medical college); “we must stick to the epidemiological rigor behind screening” (GP23); “I worry that there are men, young men who probably will get prostate cancer and die of it because I'm not doing enough screening, but I'm not prepared to, to not follow the evidence and I think that the evidence says you don't do it” (GP8). However, it was extremely challenging for GPs to balance guidelines against anecdotal experiences; “even though you know the statistics, you are influenced by what you are dealing with at the time…if you hear the story instead of just the statistics, it makes a lot more powerful a case” (GP27)No
Practice outcomeGP experience of personal burdenBurden moderated by belief in the PSA test as life-saving. Some GPs were so convinced that testing to save lives was the right thing to do that they did not feel burdened. Other GPs were somewhat burdened by the experience of the patient's side effects but rationalised this using their belief in preventing prostate cancer death. “Oh, well, it happens. I mean unfortunately no matter how good a doctor, now and then this is going to happen” (GP19). “We all live with that fear of, kind of, missing a cancer in somebody that is clinically significant” (GP3)Burden shared with patients.“It's a difficult area for GPs because there is this debate…about what should be done. You're trying to do the best for your patients, you're trying to avoid, you know, being sued for missing something” (GP5)Heavy personal burden reported. Many GPs carried the burden of hoping they had protected their patient from the harms of overdiagnosis while witnessing prostate cancer death. “I'm fully aware of the fact that prostate cancer kills my patients and that by not testing for it, I won't find it…it's an incredibly difficult situation” (GP8). GPs recalled cases of patients who had suffered with aggressive/metastatic cancers and spoke of how hard it is to see men suffering (from potentially missed cancers) but to continue to practise according to their own values, the evidence and recommendations. “But I did what you were meant to do and that's what's going to happen sometimes, so it's just hard to take” (GP27)Personal struggles about what is the right approach to PSA testing were not a significant feature. GPs did not have to grapple with the ‘what ifs’ because they weren't engaging with issues of overdiagnosis.For some it was about performing according to ‘good’ GP ideals.For example, one GP's understanding was that a large majority of people would think he was neglectful if they were 45 years and above and he wasn't offering PSA testing. This GP believed patients would compare him with other GPs who were screening and think they were much better than him. Satisfying patient expectations meant no burden on the GP