I have a hard time accepting “no” when the answer, in my opinion, should be the opposite, or when every guideline says “yes.” Nevertheless, my parents have prevailed in their complete rejection of undergoing colonoscopies, and, in the case of my mom, a mammogram as well. I have no insight into their future well-being, no warning about whether they wake up each morning and go to work carrying precancerous lesions slowly morphing into malignant masses. I have no idea if a hidden lesion might quietly spread into another organ until, one day, my parents notice that something is wrong.
The majority of medical tests physicians order do not ask a person to enter a vulnerable state in quite the same way a colonoscopy and a mammogram demand. However, to me, it is 100% worth the chance that the procedure has a pertinent finding. To be diagnosed with cancer before it is considered terminal is an incredible feat that the healthcare system offers its patients. It is something I offer my patients at the student clinic at every appointment as indicated. Regardless, something my mom refers to when pressed on why her answer is a firm “no” is a friend who was distraught over what turned out to be a false-positive blip on her mammogram and a Facebook post relaying a personal story of a woman’s life after a gastroenterologist perforated her bowel. In an attempt to educate myself, I looked up the statistics. I found that overdiagnosis of breast cancer in a population offered organized mammography screening was estimated at 52%. In addition, the risk of perforation was 0.57 per 1,000 procedures, or 1 in 1,750 colonoscopies.
Accepting these points on their merit, though, has been quite difficult for me. Medical school trains us to believe in the power of early detection, in the number of lives saved by catching disease before it fully declares itself. What it does not train us for is the emotional tension that appears when evidence-based guidelines directly oppose a patient’s wishes. Then, the line between recommending and coercing becomes blurred. According to my parents, their clinicians explain the guidelines, speak briefly about the risk-benefit ratio of preventive screening, send an annual Cologuard box to our house upon refusal of colonoscopy, document said refusal, and move on. There is no prolonged attempt at convincing based on experience with prior patients, no fear mongering along the lines of wanting to be around for their kids to have kids, no sign of frustration. Year after year, they simply ask why the test was not performed, state the importance of the test, and order a Cologuard box. Rinse, recycle, repeat. Box on top of box in our garage. It is not personal, and while I am not happy with the result, ultimately they are respecting patient autonomy. My parents’ doctors are turning away from paternalistic medicine, instead opting for a shared-decision making model. And when I put it that way, I know that I will do the same one day.
Moreover, I am also realizing that far fewer people undergo preventive screenings than my ongoing medical school training has suggested. Without intervention, adherence ranges from 5–59% for colonoscopies across all ages, and mammography adherence is about 59% among women aged 40–49 and 76.5% among those 50–74. The reality is that refusal is not a statistical anomaly, thus requiring physicians and daughters alike to learn how to live with it.
I still hold hope that one day something will stick, and I will cancel whatever I have going on to drive my mom and dad to their respective appointments. Until then, I am learning that offering no resistance does not equal indifference. It means trusting that patients, even when they are my parents, are entitled to weigh risk differently than I do.
How do you walk the line between recommendations and coercion for your patients and family? Share in the comments.
Marta Majewski is a third-year medical student at Cooper Medical School of Rowan University in Camden, New Jersey.
Image by DrAfter123 / Getty
