Shared decision-making for screening, explained
Some screenings come with the words "talk it through with your doctor" or "shared decision-making". It means you and your clinician decide together, using the evidence and what matters to you. Here is what the USPSTF and Medicare mean by it, which screenings it matters most for, and what to weigh.
What it means
The USPSTF describes shared decision-making as patients and clinicians making health decisions together, so that patients are informed and involved in their preventive care. It says the role differs by grade: (USPSTF, JAMA 2022)
| USPSTF grade | Role of shared decision-making |
|---|---|
| A or B (substantial net benefit) | Lets each person decide whether to accept the service, based on their own values and preferences |
| C (small net benefit) | Critical: each person decides whether the benefit is worth it for them |
| D or I (no net benefit, or evidence insufficient) | Clinicians should be ready to discuss it if you ask |
Source for the table: USPSTF, JAMA 2022. More on what the letters mean: USPSTF grades explained.
For clinicians, the Agency for Healthcare Research and Quality teaches a model called the SHARE Approach, built around exploring the benefits, harms and risks of each option and what matters most to the patient. (AHRQ)
Screenings that are explicitly a shared decision
| Screening | Who | What the source says |
|---|---|---|
| Prostate (PSA) | Men 55 to 69 | An individual decision after discussing benefits and harms; do not screen men who do not want it (grade C) (USPSTF, 2018) |
| Colorectal | 76 to 85 | Offer selectively, weighing overall health, past screening and preferences (grade C) (USPSTF, 2021) |
| Lung (low-dose CT) | 50 to 80 with a 20 pack-year history | Shared decision-making is important (grade B); Medicare requires a counseling and shared decision-making visit before the first scan (USPSTF, 2021) (CMS NCD 210.14) |
| Aortic aneurysm | Men 65 to 75 who have never smoked | Offer selectively, not to all (grade C) (USPSTF, 2019) |
| BRCA testing | Women with a positive family risk check | Genetic counseling first, then testing only if indicated after counseling (grade B) (USPSTF, 2019) |
PSA at 55 to 69: the clearest example
The USPSTF says screening offers a small possible benefit, a lower chance of dying of prostate cancer for some men, while many men will meet its possible harms: false-positive results that lead to more tests and possibly a biopsy, overdiagnosis and overtreatment, and treatment side effects such as incontinence and erectile dysfunction. It asks patients and clinicians to weigh these with family history, race and ethnicity, other health conditions and the man's own values. (USPSTF, 2018)
Lung screening: the Medicare visit
Before your first Medicare-covered low-dose CT, Medicare requires a counseling and shared decision-making visit that checks you are eligible, uses one or more decision aids, covers the importance of yearly scans, how other health problems and your willingness to have diagnosis and treatment affect the choice, and covers quitting or staying quit. (CMS NCD 210.14) Who qualifies is on screenings if you smoke.
What to weigh
- The benefit for someone like you: your age, health and risk, not just the average.
- The harms: false positives, follow-up tests and procedures, and finding something that would never have caused trouble (overdiagnosis); the numbers by test are on their own page. See what usually happens after an abnormal result.
- What matters to you: how you feel about uncertainty, procedures and possible treatment side effects.
- The options: a different test, a different interval, or not screening for now.
Write your questions down before the visit. Ready-made lists by age are on questions to ask your doctor about screening.
Questions people ask
What is shared decision-making in PSA screening?
For men 55 to 69 the USPSTF says PSA screening should be an individual decision: before deciding, a man should be able to discuss the possible benefits and harms with his clinician and weigh his own values. Clinicians should not screen men who do not say they want it. (USPSTF, 2018)
Is a shared decision-making visit required for lung cancer screening?
For Medicare, yes. Before the first low-dose CT, Medicare requires a counseling and shared decision-making visit that uses at least one decision aid. The USPSTF also says shared decision-making is important for lung screening. (CMS NCD 210.14) (USPSTF, 2021)
Does shared decision-making mean the doctor decides?
No. The USPSTF describes it as patients and clinicians making health decisions together, so the patient is informed and involved. For C grade services it calls this critical, because the benefit for any one person is small. (USPSTF, JAMA 2022)
Can I still say no to a grade A or B screening?
Yes. The USPSTF says shared decision-making lets each patient decide whether to accept even a strongly recommended service, based on their own values and preferences. (USPSTF, JAMA 2022)