What is a Good Decision?

When I was asked to think about how patients make decisions and how we as health care providers assess these decisions, a recent encounter came to mind. A 36-year-old woman came into my office requesting a complete physical examination, "screening labs," a mammogram, and a Thin-Prep Papanicolaou (Pap) smear. She had read about Thin-Prep Pap smears in a women's magazine and wanted me to use this method to ensure that we were "not missing anything." Explaining her concern, she mentioned that her 76-year-old mother had recently died of "cancer all over her body" (which began in her breast) and that before dying her mother had a standard Pap smear that did not show any cancer.

I was glad she came in for a physical examination and was encouraged by her interest in prevention. I questioned, however, the value of a mammogram for her, given her family history (one first-degree relative who developed the disease in her mid-70s) and the limited sensitivity of the test in younger women. I appreciated her fear of missing cervical cancer because of an ineffective test. However, I also felt that her distrust of the standard Pap smear (because it did not detect her mother's cancer in an unrelated organ) was unwarranted and should be addressed.

As we talked, I learned that she felt generally well and had no significant medical history. She had divorced an abusive husband and was now happily dating another man and using Depo-Provera shots for birth control. Her last tetanus booster was "years ago." For the past 20 years, she had smoked two packs of cigarettes per day (and did not plan to quit); she also drank a six-pack of beer each night to improve her mood and help her sleep.