| Situational factors … pertaining to patient and/or GP |
| Patient was from an older or younger age group (particularly <50 years or >75 years), or had comorbidities |
Some GPs paid closer attention to which direction they ‘coaxed’ patients in these age groups; for example, some would particularly emphasise false positives and the potentially harmful diagnostic pathway to younger men under 50 years (ie, GP more likely to use Do not be screened approach). Some GPs who usually communicated in Be screened mode provided comparatively less detailed information for older patients, particularly those with declining memory or those they perceived as being cognitively unable to ‘handle the information’, and ‘pick[ing] the details of the intricacies … and a lot briefer [conversation]’ (AGP17). Some GPs described defaulting to providing stronger recommendations with elderly men.
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| Patient had a family history of prostate cancer |
Conversations with men with family history of prostate cancer were described as being slightly different; some GPs said their interactions with these men would be more ‘considered’ and ‘gentle’ despite the majority of the men knowing their decision before coming to the doctor. Some GPs who generally communicated in a way to achieve screening (Be screened) or not screening (Do not be screened) changed their approach more towards Analyse and choose and As you wish in situations where a family history was implicated—for both those determined to be tested and those not wishing to be tested.
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| Patient requested to receive a PSA test or was perceived to be determined to have a test |
These patients were perceived to have positive preconceptions about PSA screening which pre-empt any GP discussion. Some GPs who would usually communicate with a particular goal in mind (Be screened or Do not be screened) said any conversation counter to the man’s beliefs was not a productive conversation because their intentions could not be changed; ‘they see it as their right to have it [a PSA test]’ (AGP15); ‘he was so definite he wanted it’ (AGP6). GPs tended to take the As you wish approach in these situations, even if this was not their preference. ‘I think that what changes in that situation is their determination to have the testing done, most of these men have made a decision before I’ve said anything, that they’re going to be tested, no matter what I say’ (AGP8).
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| Patient was interested in finding out more about screening |
Some GPs reasoned that a man’s interest in PSA screening would drive the discussion, ‘it tends to be very patient specific and tailored advice … and depends on what I think that they expect and hope to hear and are likely to do’ (AGP16). GPs who usually took an As you wish approach, so did not communicate, would in some situations be required to shift to one of the other three approaches (Be screened, Do not be screened, Analyse and choose) because the man requested information. Some GPs said the discussion would become ‘more complicated’ the more interested the patient was.
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| Situational factors … pertaining to service characteristics |
| Rural location with limited access to urology services |
Some GPs were influenced by their access to a urologist. Although they might prefer to recommend that men Be screened or Do not be screened, they described instead shifting their approach towards Analyse and choose when based in a rural location; I ‘just might try to explain the test, do a bit more pre-test counselling with the patient when I was in the country, just because I knew that I’d then be managing the result rather than just sending them onto a Urologist, like it’s easy to do in Sydney’ (AGP5). GPs described how in rural locations it is common for GPs to have to manage abnormal PSAs for a longer period before they can access urologists for a second opinion. Some GPs were uncomfortable with this situation and consequently aimed to involve men more in the decision from the beginning. Some GPs would talk to patients after PSA screening if it was abnormal but not before; that is, they would take either a Be screened or As you wish approach before testing, and provide counselling if needed after testing. These GPs perceived some men as resistant to seeing a GP at all, so thought it important to be seen to do a test because it was ‘something’ proactive for them while they were there, rather than simply talking.
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| Time available for the consultation (GP short of time) |
Some GPs who preferred an Analyse and choose approach engaged in less detailed discussion with patients about PSA screening when they were short of time. They described selecting out the information to include in discussions with men when they were time poor, more in line with the Be screened or Do not be screened approaches. Some GPs said it is often simply impractical to provide full information and support patients to develop detailed population-level understanding at each appointment so on occasions they ‘just haven’t had time to give a full spiel so I order it and I will have the discussion later with them, if it’s positive’ (AGP13).
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| Relational factors … pertaining to patient and/or GP |
| GP made a judgement that the patient ‘starting point’ in terms of grasping the information was low and it would be difficult for them to understand PSA screening |
Some GPs who usually favoured Analyse and choose, reverted to a Be screened or Do not be screened approach when communicating was difficult, ‘If I had a patient who is extremely unintelligent and I tried to explain it and I didn’t seem to be getting through to him, and I felt it was in his best interests, I might go ahead and do the test [or not do the test] anyway’ (AGP29). Some GPs tailored the content accordingly; ‘it really depends on the population you’re dealing with … what you perceive they are capable of understanding’ (AGP31); ‘You’ve got to target it at the level of the patient basically’ (AGP4). ‘If a man thinks PSA is just a blood test, then I mentally go oh dear, we need to go through this in more detail’ (AGP4).
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| Patient was perceived to be anxious, and so not receptive to information |
Sometimes GPs provided minimal information to manage anticipated patient anxiety; ‘if you put too much information out there…most of it doesn’t go in … there’s too much information … it’s not possible for people to take that stuff in, they don’t even want to’ (AGP7). In such cases, GPs who would usually communicate in Analyse and let choose mode, acted in what they saw as their patient’s ‘best interests’ (towards Be screened or Do not be screened), which could involve no communication, or being selective with the information they shared.
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| GP made a judgement that the patient was ‘very switched on’ and had ‘done their homework’ |
GPs were often more inclined to take the option of As you wish in situations involving well-informed men, regardless of the GP’s usual practice. Alternatively, GPs might take an Analyse and choose approach and tailor content accordingly; ‘it really depends on the population you’re dealing with … what you perceive they are capable of understanding’ (AGP31); ‘You’ve got to target it at the level of the patient basically’ (AGP4).
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GP aware of patient history of screening
(GP has screened patient in the past or has discussed screening with patient previously, GP knows patient’s screening preferences, or GP knows patient has been screened previously) |
Some GPs who would prefer the Analyse and choose approach said they ‘may not give a full spiel’ (AGP13) to men who have been screened before and ‘often do it [discuss] a little more quickly, because it is clear that they remember it from the year before. And if they are men who made the decision last year to have the test done, then they are often going to make the same decision this year … so it’s a quicker conversation, but it’s not a non-conversation. And it depends on the patient and how well I know them’ (AGP30). In these situations, GPs tended to shift to an interaction more like one of the other three approaches. Some GPs were more likely to initiate screening with men who had had PSA screening with them in the past or had had many PSA tests, because ‘generally a lot of my patients by now have had the spiel so many times that they often will, come in and say “It’s time for my yearly prostate test’ (AGP29).
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| Relational factors … pertaining to service characteristics |
| Patient was the usual patient of another GP, and patient asked for a PSA test |
Sometimes GPs who preferred an Analyse and choose approach were consulted by patients who were routinely tested by another GP. In this situation, the GP would assume that the man had heard the talk before. They responded to this situation in several ways: Some GPs shifted to either the Be screened or As you wish approach and ordered PSA tests without discussing it with the man, reasoning that the discussion could be revisited if the PSA was abnormal. Some GPs maintained Analyse and let choose mode and actively engaged patients in a discussion because they did not know what men had heard from previous GPs. This was sometimes with a view to changing the patient’s mind: for example, ‘I am trying to create permission and faith for me to open the discussion up again, rather than just keep redoing the test’ (AGP30). Some GPs found this position incredibly challenging if they preferred not to test (ie, Do not be screened); ‘because you have to undo the patient’s expectations … you’ve got to decide whether you just go with the flow … or you sit down and ascertain what their appetite for negotiating is. Some of them are just locked into it and it’s too late’ (AGP23).
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