Items in FPM with MESH term: Decision Making
ABSTRACT: Radiation therapy can be an effective treatment modality for both malignant and benign disease. While radiation can be given as primary treatment, it may also be used pre- or postoperatively, with or without other forms of therapy. Radiation therapy is often curative but is sometimes palliative. There are many methods of delivering radiation effectively. Often, patients tolerate irradiation well without significant complications, and organ function is preserved. To ensure that all patients with cancer have the opportunity to consider all treatment options, family physicians should be aware of the usefulness of radiation therapy.
ABSTRACT: Approximately 10 to 15 percent of all breast cancers are thought to be familial and about one third of these cases are due to an inherited mutation in a BRCA1 or BRCA2 breast cancer-susceptibility gene. The lifetime incidence of breast cancer in mutation carriers is above 50 percent, and carriers of BRCA1 mutation also have a substantially increased risk of ovarian cancer. BRCA1 and 2 mutations are associated with early-onset breast cancer, and some experts call for aggressive screening of affected persons. Monthly self-examination of the breasts beginning at age 18 and annual clinical examinations and mammography after age 25 have been recommended but are of unproven benefit. Prophylactic mastectomy and oophorectomy have been advocated by some authorities, but these interventions are disfiguring and for some carriers of the gene, they are unnecessary. The patient's decision to undergo genetic screening is complicated by the technical difficulty of the test, the substantial cost and the still incomplete understanding of the penetrance of disease in known mutation carriers.
ABSTRACT: Family physicians often encounter patients with acute knee trauma. Radiographs of injured knees are commonly ordered, even though fractures are found in only 6 percent of such patients and emergency department physicians can usually discriminate clinically between fracture and nonfracture. Decision rules have been developed to reduce the unnecessary use of radiologic studies in patients with acute knee injury. The Ottawa knee rules and the Pittsburgh decision rules are the latest guidelines for the selective use of radiographs in knee trauma. Application of these rules may lead to a more efficient evaluation of knee injuries and a reduction in health costs without an increase in adverse outcomes.
ABSTRACT: Psoriasis is characterized by red, thickened plaques with a silvery scale. The lesions vary in size and degree of inflammation. Psoriasis is categorized as localized or generalized, based on the severity of the disease and its overall impact on the patient's quality of life and well-being. Patient education about the disease and the treatment options is important. Medical treatment for localized psoriasis begins with a combination of topical corticosteroids and coal tar or calcipotriene. For lesions that are difficult to control with initial therapy, anthralin or tazarotene may be tried. The primary goal of therapy is to maintain control of the lesions. Cure is seldom achieved. If control becomes difficult or if psoriasis is generalized, the patient may benefit from phototherapy, systemic therapy and referral to a physician who specializes in the treatment of psoriasis.
ABSTRACT: Physicians assess the decision-making capacity of their patients at every clinical encounter. Patients with an abrupt change in mental status, who refuse recommended treatment, who consent too hastily to treatment or who have a known risk factor for impaired decision-making should be evaluated more carefully. In addition to performing a mental status examination (along with a physical examination and laboratory evaluation, if needed), four specific abilities should be assessed: the ability to understand information about treatment; the ability to appreciate how that information applies to their situation; the ability to reason with that information; and the ability to make a choice and express it. By using a directed clinical interview or a formal capacity assessment tool, primary care physicians are able to perform these evaluations in most cases.
ABSTRACT: To take the best possible care of patients, physicians must understand the basic principles of diagnostic test interpretation. Pretest probability is an important factor in interpreting test results. Some tests are useful for ruling in disease when positive or ruling out disease when negative, but not necessarily both. Many tests are of little value for diagnosing disease, and tests should be ordered only when the results are likely to lead to improved patient-oriented outcomes.
ABSTRACT: Prostate cancer is the second most common cancer in men, with a lifetime prevalence of 17 percent. Prostate cancer symptoms generally occur in advanced stages, making early detection desirable. Digital rectal examination and prostate-specific antigen testing are the most commonly used screening tools. The goal of screening is to detect clinically significant prostate cancers at a stage when intervention reduces morbidity and mortality; however, the merits and methods of screening continue to be debated. Prostate-specific antigen levels may be less than 4 ng per mL in 15 to 38 percent of men with cancer, indicating a high false-negative rate. The positive predictive value of the prostate-specific antigen test is approximately 30 percent; therefore, less than one in three men with an abnormal finding will have cancer on biopsy. These limitations of the prostate-specific antigen test have led to variations designed to improve its accuracy (e.g., age- and race-specific cutoffs, free prostate-specific antigen tests); however, none of these modifications have been widely adopted because of unclear benefits. Although treatments have improved in the past two decades, therapy for prostate cancer is not benign and may lead to urinary incontinence, sexual dysfunction, or bowel dysfunction. New evidence affecting screening recommendations continues to accumulate, and two large randomized controlled trials of screening will be completed in the next few years. Current guidelines recommend an individualized, targeted, patient-centered discussion to facilitate a shared decision about screening plans.
Prostate Cancer Screening: Let Patients Decide - Editorials
What My Brother Knew - Close-ups
Practical Considerations for Determining Patient Capacity and Consent - Curbside Consultation