Men's health: The rules of patient engagement

Ask a primary care physician (PCP) to name the most common health challenges adult male patients face, and chances are that he or she will tick off a familiar list, ranging from prostate cancer to diabetes. But before they can begin addressing those problems, PCPs face a more basic challenge, which is persuading men just to come in at all.

The reasons why men are reluctant to seek medical care are not entirely clear, but are probably tied to notions of masculinity and fears of vulnerability. A study titled “‘Macho Men’ and Preventive Health Care,” published in 2011 in the Journal of Health and Social Behavior found that “men with strong masculinity beliefs are half as likely as men with more moderate masculinity beliefs to receive preventive care.”

“Trying to get men to come in for a routine physical is next to impossible because they think they’re going to live forever,” says William Silverman, DO, an internist in solo practice in Seminole County, Florida.

“When they’re younger, men think they’re invincible, they don’t need to go to the doctor,” he says. “Then when they hit 40, they start thinking about the future and working their tails off, but they get so focused on their work they don’t want to take time to come in.”

Whatever the reasons, men appear to be paying a price in terms of life expectancy. In 2010 it stood at 76.2 years for men, compared with 81 years for women, according to the National Center for Health Statistics.

Next: How women influence men's healthcare decisions

The role of women

Even when a man does come in, there’s a good chance he’s only doing so at the behest of a spouse, girlfriend, or significant other.

“In my practice I see that the woman in the family tends to drive the healthcare decision-making process,” says David Fleming, MD, FACP, an internal medicine practitioner in Columbia, Missouri, chair of the department of internal medicine at the University of Missouri School of Medicine, and president of the American College of Physicians. In part, he says, it’s because women are more accustomed to seeing a doctor regularly for procedures such as Pap tests and mammograms, and because women are more likely to see to childrens’ health needs.

Fleming adds that while some of his male patients do come on their own, “there are many who just don’t because they are preoccupied with work or other activities that take more precedence. So often in the family it’s the woman who forces the issue.”

Silverman puts it more bluntly: “The man only goes if his wife pulls him by the ear because he’s ignoring his health and having chest or stomach pains. He’s too busy working to pay attention to himself and he ignored everything else.”

His observations are bolstered by a 2007 American Academy of Family Physicians (AAFP) survey, which found that 29% of adult men wait “as long as possible” before seeking medical help when they feel sick or are in pain or otherwise concerned about their health.

Why men go to the doctor

When men do decide to visit a PCP, their health issues usually fall into one or more of three categories:

• male-specific issues, mainly those concerning the prostate, erectile dysfunction (ED), low testosterone levels; and loss of libido

• chronic conditions that aren’t gender-specific but occur more frequently in men, such as diabetes and cardiovascular disease, and

• injuries or complaints stemming from sports and “lifestyle” activities

Among these, the male-specific issues probably are cause the greatest angst for patients, due to the potentially life-threatening consequences of prostate cancer and the feared loss of sexual potency.

Next: Why patients are confused by PSA testing guidelines

In addition, changes in recommendations for the use of the prostate-specific antigen (PSA) screening for prostate cancer, especially for men under 50 with no family history of the disease, has created confusion among some patients. “When the PSA first came out I thought it was fantastic,” says Fleming. “It gave us an early detection mechanism that was very easy to do, and the initial recommendation was that we do it every year.”

The problem, he adds, is that the PSA test also results in a relatively high number of false positives, leading to unnecessary treatments that frequently carry side effects ranging from incontinence to loss of sexual function. As a result, Fleming says, he has gone from giving the test every year to men over 60 to doing it only once, so long as the patient has no other risk factors and their rectal exam is normal. (See below, "Screening for prostate cancer: a guidance statement from the American College of Physicians.")

In most cases where there are no other risk factors, the preferred method of treatment now is “watchful waiting.” But persuading patients to take that course often presents its own challenges, because their initial reaction on hearing a diagnosis of cancer is to want to do something to get rid of it. In those cases, the best approach often is shared decision-making-presenting the patient with his options and the possible consequences of each, then discussing with the patient how best to proceed, says Reid Blackwelder, MD, FAAFP, president of the AAFP and a family practitioner in Kingsport, Tennessee.

“It isn’t about me deciding what the right treatment has to be and how I’m going to get the patient there,” Blackwelder explains. “It’s more about me asking you, as the patient, ‘what are your thoughts about this?’ I’m not going to point you in a certain way.”

If the patient decides on a course that Blackwelder feels is risky, he will make sure the patient is aware of the risks. “But if the patient says, ‘I hear you, doc, but this is really what I want to do,’ then I need to respect your opinion even though I may not agree with it.”

Fleming says he approaches prostate cancer treatment as a question of risks and benefits, especially among patients with low-grade cancer.

“I’ll usually say, ‘let’s just keep an eye on it and see how you do. Because there’s a 30% to 40% chance you’ll have some kind of complication resulting from surgery, and the risk may be more than the benefit you’d derive from it,” he says.

Next: ED, low T, and men's health

Erectile dysfunction and testosterone therapy

Issues of ED and testosterone replacement have become a larger part of the discussions around men’s health since the advent of direct-to-consumer pharmaceutical advertising in the late 1990s.

“The marketing [around testosterone replacement] has been brilliant, and it’s creating a good discussion for a lot of men,” says Marc Childress, MD, a family practice and sports medicine physician in Fairfax, Virginia. “The number of prescriptions for testosterone replacement over the last five years or so has ballooned.”

On the other hand, PCPs have to be cautious about inferring a “linear relationship” between a symptom or condition and a specific medication. “Certainly men can have problems with ED or low testosterone, but it doesn’t mean everyone should immediately be treated with a particular pill,” he says. 

Blackwelder says he has seen an increase in the number of men asking about testosterone and ED remedies in recent years, a trend he attributes to TV advertising about these issues.

Most PCPs generally prefer to discuss testosterone/ED/libido concerns in the context of health and lifestyle issues. “It’s easy for us to play ‘patch and plug’ medicine, but it’s never that simple,” says Childress. “It’s not a matter of a man coming to me and describing ED and me prescribing a medication for that. There’s a lot that needs to be talked about.”

Fleming says he will try testosterone replacement on patients found to have low levels and complain of impotency or other associated symptoms.

“If their symptoms improve then it’s an indication we should continue doing it. If they don’t respond it’s up to them whether they want to continue or not. But it’s really patient specific,” he says.

Next: Difficult lifestyle changes

Treating chronic diseases

Treating the chronic diseases men face, such as diabetes and cardiovascular disease, usually requires difficult lifestyle changes.

The key in those cases, PCPs say, is to establish a strong relationship with the patient, built on good communication, trust, and presenting information in ways that patients can digest. And while building such a relationship is not easy within the limits of an evaluation and management visit, it’s by nomeans impossible.

“We all struggle with how to get our patients to follow our recommendations,” says Matthew Ajluni, DO, a family physician in Ann Arbor, Michigan and medical director of an urgent care center. “I think each physician has his or her own tools, but mine are listening, and being empathic, and supportive. It sounds common sense, but it works.”

Fleming emphasizes a team-based approach to helping patients, one that includes pharmacologists, nurses, dieticians, and other resources the patient requires. He also strives to educate patients about their disease or condition.

“Health literacy is still one of our most common concerns as it relates to compliance and clinical outcomes. It is the single most predictive variable for health outcomes,” he says. “If you can pull all that [patient education and team-based care] together, you have a much better chance of the patient keeping their appointment and taking their medication as prescribed.”

Blackwelder says he use any visit by a patient as an opportunity to begin establishing a relationship, a process that he compares to negotiating a business deal-right down to the handshake.

“We’re kind of negotiating an agreement, and that’s important, to give them some say but hold them accountable, especially if they say they’re willing to change their diet or give up smoking,” he says. “When they get to that point I almost always shake their hand and tell them I’m going to follow up on this. I’m willing to try all those little tricks to cement that relationship and create that sense of collaboration.”

Next: The American College of Physicians' cancer screening guidelines

ACP guidance statement for prostate cancer screening

In 2013 the American College of Physicians (ACP) issued the following guidance statements regarding screening for prostate cancer using the prostate-specific antigen test. The statements are based on a review of guidelines developed by the American College of Preventive Medicine, the American Cancer Society, the American Urological Association, and the U.S. Preventive Services Task Force:

Guidance statement 1

“ACP recommends that clinicians inform men between the age of 50 and 69 years about the limited potential benefits and substantial harms of screening for prostate cancer. ACP recommends that clinicians base the decision to screen for prostate cancer using the prostate-specific antigen test on the risk for prostate cancer, a discussion of the benefits and harms of screening, the patient’s general health and life expectancy, and patient preferences. ACP recommends that clinicians should not screen for prostate cancer using the prostate-specific antigen test in patients who do not express a clear preference for screening.”

Guidance statement 2

“ACP recommends that clinicians should not screen for prostate cancer using the prostate-specific antigen test in average-risk men under the age of 50 years, men over the age of 69 years, or men with a life expectancy of less than 10 to 15 years.”