title: Doctors' approaches to PSA testing and overdiagnosis in primary healthcare: a qualitative study.
abstract: OBJECTIVE
  (1) To explain general practitioners' (GPs') approaches to prostate-specific antigen (PSA) testing and overdiagnosis; (2) to explain how GPs reason about their PSA testing routines and (3) to explain how these routines influence GPs' personal experience as clinicians.
  
  
  METHODS
  Primary care practices in Australia including men's health clinics and rural practices with variable access to urology services.
  
  
  METHODS
  32 urban and rural GPs within Australia. We included GPs of varying ages, gender (11 female), clinical experience and patient populations. All GPs interested in participating in the study were included.
  
  
  METHODS
  Data were analysed using grounded theory methods to determine how and why GPs provide (or do not provide) PSA testing to their asymptomatic male patients.
  
  
  RESULTS
  We observed patterned variation in GP practice, and identified four heuristics to describe GP preference for, and approaches to, PSA testing and overdiagnosis: (1) GPs who prioritised avoiding underdiagnosis, (2) GPs who weighed underdiagnosis and overdiagnosis case by case, (3) GPs who prioritised avoiding overdiagnosis and (4) GPs who did not engage with overdiagnosis at all. The heuristics guided GPs' Routine Practice (usual testing, communication and responses to patient request). The heuristics also reflected GPs' different Practice Rationales (drawing on experience, medicolegal obligations, guidelines and evidence) and produced different Practice Outcomes (GPs' experiences of the consequences of their PSA testing decisions). Some of these heuristics were more responsive to patient preferences than others.
  
  
  CONCLUSIONS
  Variation in GPs' PSA testing practices is strongly related to their approach to overdiagnosis and underdiagnosis of prostate cancer. Men receive very different care depending on their GP's reasoning and practice preferences. Future policy to address overdiagnosis will be more likely to succeed if it responds to these patterned variations.
authors.affiliation: Centre for Values, Ethics and the Law in Medicine, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.
authors.forename: Kristen
authors.initials: K
authors.lastname: Pickles
authors.affiliation: Centre for Values, Ethics and the Law in Medicine, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.
authors.forename: Stacy M
authors.initials: SM
authors.lastname: Carter
authors.affiliation: Centre for Values, Ethics and the Law in Medicine, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia.
authors.forename: Lucie
authors.initials: L
authors.lastname: Rychetnik
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D001315:Australia / Q000453:epidemiology; D055088:Early Detection of Cancer / Q000379:methods* / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D010820:Physicians / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000379:methods*; D017430:Prostate-Specific Antigen / Q000097:blood*; D011471:Prostatic Neoplasms / Q000175:diagnosis* / Q000453:epidemiology; D036301:Qualitative Research; D012017:Referral and Consultation
chemical_list: D017430:Prostate-Specific Antigen
keywords: INTERNAL MEDICINE; PUBLIC HEALTH; QUALITATIVE RESEARCH