Across 38 years in tobacco control, I have been asked countless times in media interviews if I ever smoked. It’s often an early question. I always unhesitatingly explain that I did: I stopped in my mid 20s. The tone of the interview immediately relaxes because the sub-text of the question is about authenticity. If this person has never smoked, what would he really know about quitting? If I chose to stammer something about it being private or “not the point here”, most would become preoccupied with my evasiveness. Fudging and equivocal replies tend to suggest disingenuousness or lack of personal conviction about the information being given.
Clinicians tell me they’re frequently asked by patients “what would you do, doctor?” The question might mean either “what would you do if you were me?” But it might also be an invitation to a doctor to explain their own personal health decisions. The question can refer to anything from diet, dietary supplement use, organ donation, beating jet lag, travel medicine or exercise. It’s normal to ask friends and family what they do in health matters, so when you come face to face with someone who’s supposed to know a lot about health, wanting to know if they personally practice some behaviour is an obvious question.
Many health-related practices are openly observable. So if you know or associate with health workers, you can see if they are wear a hat in the sun, walk or cycle to work, take the elevator when stairs are available, or hit the drink at social events. But many health practices are not obvious and require disclosure if we are to know what someone does.
Few would ask their doctor about his or her alcohol intake, and even fewer would ask about their sexual behaviour (condom use or contraception) because these questions cross obvious privacy boundaries. A corpulent doctor is unlikely to be asked about their diet or the extent of their exercise regimen but a lean doctor might well be because of differences in the social meaning of body size. But it’s not obvious that screening tests, check-ups, and dietary practices and supplementation cross privacy boundaries, particularly when patients are likely to have read conflicting information and material inviting them to discuss testing with their doctors.
But when it comes to prostate cancer screening, men in the medical profession – with rare exceptions – keep their heads well down from public disclosure. In 2003, the then head of the Cancer Council Australia Professor Alan Coates (then aged 59) told Jill Margo, health reporter at the Australian Financial Review, that he had not personally been tested for prostate cancer and did not plan to be. Despite there being no government position on prostate specific antigen (PSA) testing and considerable professional criticism of the practice, Coates was subjected to astonishing vilification, including a vicious spray on national television from senior Labor politician Wayne Swan, who had personal experience of the disease.
I know that many people privately thanked Coates for his frankness which did much to open up much needed public discussion of prostate screening in Australia.
With two other colleagues, I wrote a book in 2010 Let sleeping dogs lie: What men should know before getting tested for prostate cancer. The free-download book has had a remarkable 26,500 downloads. Knowing it was likely that I would be asked if I had been tested, I decided to be open about it and explain why I had not when the book was published.
Discussion about the book with colleagues in my own faculty quickly revealed that many men past their fifties had also chosen not to have a PSA test. Several had not consented to be tested, but were given their PSA result after their GP had taken the decision for them and added PSA testing to a blood sample drawn for other reasons. I suggested to some that they might do men’s health a service by explaining publicly why they have chosen to not be tested.
About five years ago, the Clinical Oncology Society of Australia allowed me to survey its members about their personal cancer prevention and screening practices. Confidentiality was assured, but the response rate was so low that the data were unusable. The most recent information I know about Australian doctors own prostate screening practices is now 18 years out of date (1997). Then, 55% of a sample of Victorian male GPs aged over 49 had chosen to not have a PSA test themselves.
With widespread publicity being given to problems of unnecessary over-diagnosis and the very serious problems that can follow from this (anxiety or depression in living with a cancer diagnosis, permanent impotence and incontinence), it is possible and even likely that an even higher proportion of Australian doctors today will have elected to not be tested. But we don’t know.
The recent draft report from the Prostate Cancer Foundation and Cancer Council Australia recommends men and their doctors fully explore the risks and benefits of prostate testing. In that spirit, if the subject comes up when you are next seeing your (male) doctor, ask him whether and why he has chosen to be tested or not. What you hear (or don’t hear) might be very revealing.
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