Clinical
Communication for
Male Cancer Screening
Comments for PA Programs
Funded
by National Cancer Institute
#5R25 CA82320
Copyright 2003
Male
Cancer Screening Curriculum
Review Comments from Bob McNellis, MPH, PA-C.
"As a PA with training in public health I have always believed in the important role of clinicians in preventive medicine. For many years, I was a PA working in a urology practice, providing many of the services covered in the curriculum. As a faculty at the local PA program I specifically taught PAs, PA students and medical students about men’s health and the clinical epidemiology of male genitourinary cancers.” (Bob McNellis, MPH, PA-C, 2003)
For Physician Assistant Programs: We asked Bob McNellis from the American
Association of Physician Assistants to review the Male Cancer Screening
curriculum. Below are comments from him that you may find helpful when
using these curriculum materials in your teaching program.
Video Discussion Cases - These cases are not meant to present a “gold standard” for the interaction, but the positive role modeling here will be useful in helping students adopt appropriate practices.
Specific Comments about Video Cases:
Video Discussion
Case #2 (Shared Decision Making and PSA Testing)
• In group discussion about this video, I would be cautious not
to favor the ACS guidelines over the U.S. Preventive Services Task Force
guidelines on prostate cancer screening.
Video
Discussion Case #3 (Communication During the Male Genitourinary Examination)
• When combined with the later clip on the testicular exam, students
can see how to examine the genitals in both the supine and standing positions.
Here are some issues that might come up in discussion:
- Should you explain the rectal exam to the patient as a “cancer
screen” while doing it?
- Many practitioners allow patients to clean up immediately after the
rectal exam. Should you hand the patient a tissue? What might this communicate
to a patient?
- Alternative methods for the hernia exam: Most experts suggest asking
the patients to bear down rather than to “turn your head and cough.”
It decreases the false positive rate of the test by diminishing the sudden
movement that can be misinterpreted as a hernia.
Video Discussion
Case #5 (Testicular Examination and Teaching Testicular Self-Exam)
• What was the style of this interaction? Paternalistic? How appropriate
or inappropriate is this approach with an adolescent male patient? How
did you feel about the description of the testicles (“soft and squishy”)?
What are some alternatives to this wording? The hernia exam in this video
was simulated to avoid patient discomfort -- Assess the hernia exam maneuvers.
How should these maneuvers be improved?
Curriculum
Materials – Suggestions for Specific Modules
All of the module materials can be changed and customized for your use.
Here are some suggestions from Bob McNellis:
Module 1 (Topics
in Men’s Health)
• In Handout #2, adding rates to the disorders presented would help
put them in perspective.
Module 3 (Principles
of Cancer Screening)
• The presentation nicely lays out the classic 2x2 table. Be sure
to point out that the presence of disease (the top categories) is determined
by a “gold standard.” (Of course, even that is problematic
in a broader sense!) The test result (the left side categories) is of
course from the screening test.
• Handout #1 provided a nice examination of testing issues. Implicit
in the discussion is the fact that most screening tests do not have dichotomous
results. The PSA for example has that pesky 4-10 range.
Module 4 (Testicular
Cancer: Screening and Recommendations)
• I have some biases against having the patient cough to increase
intra-abdominal pressure. I would prefer to see the clinician asking the
patient to bear down.
Module 5 (Male
Genitourinary Exam: Communication During the Clinical Encounter)
• Currently, the correct term for BPH is benign prostatic hyperplasia,
not hypertrophy.
• I like the standardized patient training guide. I think that is
very valuable. Please note that in certain places it states “you
will examined by a 2nd year medical student.” Since this has application
to all kinds of student examinations, you will want to change this wording
to suit your teaching situation.
Module 6 (Colorectal
Cancer Screening)
• There is a reference to www.uptodate.com
in this module. This service requires a subscription. You may want also
want to check the USPSTF recommendations which are more recent. They are
also available on-line at www.guideline.gov:
Module 7 (Issues
in Colorectal Cancer Screening)
• Be aware that, in this presentation, there are several references
to the “physician’s role” and “physicians and
other healthcare providers.” I recognize that this curriculum was
originally designed for medical students, so be sure to watch for these
references and change them before you use the materials for teaching.
Module 8 (Digital
Rectal Examination)
• If you have access to a handout on the male anatomy of the rectal
exam, this would be a nice addition to this module. I can specifically
think of some drawings done from posterior view of the prostate that would
help demonstrate just how little of the prostate and which zones are examined
with the DRE.
Module 9 (Prostate
Cancer Screening and Recommendations)
• I am not a particular fan of using the abbreviation CaP for prostate
cancer. It is used more commonly community acquired pneumonia. In my experience
PCa is a more often used abbreviation. You may want to change this abbreviation
when you use these materials.
• Handout #3 is very helpful. I would suggest adding links to the
National Guidelines Clearinghouse (www.guidelines.gov).