10.1177/0272989X03256010 ARTICLE MEDICAL DECISION MAKING/JUL–AUG 2003 SORUM, SHIM, CHASSEIGNE, BONNIN-SCAON, COGNEAU, MULLET DECISION PSYCHOLOGY WHY ORDER PSA TESTS? Why Do Primary Care Physicians in the United States and France Order Prostate-Specific Antigen Tests for Asymptomatic Patients? Paul Clay Sorum, MD, PhD, Junseop Shim, PhD, Gérard Chasseigne, PhD, Sylvie Bonnin-Scaon, Joël Cogneau, MD, Etienne Mullet, PhD Purpose. To understand why many primary care physicians in the United States and France order prostate-specific anti- gen (PSA) tests routinely for their asymptomatic male pa- tientsdespite“evidence-based”recommendations. Methods. Thirty-two U.S. general internists and family practitioners and 33 French generalists judged, for 32 hypothetical male patientsseenforroutinepreventivecare,theprobabilitythat thepatientshadasymptomaticprostatecancerandthelikeli- hood that they would order PSA tests. They were also asked about beliefs, attitudes, and knowledge related to prostate cancer. Results. The significant predictors of ordering more PSA tests in the scenarios were physicians’ higher ratings of regretifuntestedpatientswerefoundtohaveadvancedcan- cer, their greater discomfort if they suspected that patients had illnesses but could not know for sure, and their percep- tionsofofficialrecommendationsasfavoringroutinetesting. Implications. Nonrational factors can impede physicians’ adoption of “evidence-based” recommendations. Key words: prostate-specific antigen; practice guidelines; pros- tatecancer;decisionmaking;judgmentanalysis. (Med Decis Making 2003;23:301–313) W hether primary care physicians should rou- tinelytestmenovertheageof50forasymptom- atic prostate cancer by measuring the serum level of prostate-specificantigen(PSA)hasbeenhighlycontro- versial. The issue illustrates how difficult it is for the makers of evidence-based practice guidelines to change physicians’ behavior. 1–4 The American Cancer Society (ACS) 5,6 and the American Urological Association 7 advocated in the early1990sthatallmenovertheageof50receivePSA testsannually.Theroutinetestingofasymptomaticpa- tientswas,however,opposedbytheUSPreventiveSer- vices Task Force (USPSTF) 8 and subsequently by the specialtygroupsofprimarycarephysicians,theAmer- ican College of Physicians (ACP) 9 and the American AcademyofFamilyPhysicians(AAFP). 10 TheACPand the AAFP recommended instead that primary care physicians discuss the pros and cons of PSA testing with each patient and allow the patient to make the choice.InFrance,theAgenceNationald’Accréditation etd’EvaluationenSanté(ANAES),thenationalagency charged with formulating practice guidelines for all French physicians, came in 1998 to the same conclu- sions as the USPSTF, the ACP, and the AAFP. 11 Nonetheless, large numbers of primary care physi- cians in both countries—general internists and family practitionersintheUnitedStates 12–14 andgeneralprac- titioners in France 15,16 —have been ordering PSA tests routinelyorfrequentlyfortheirasymptomaticmalepa- tients over the age of 50. Indeed, between 1993 and MEDICAL DECISION MAKING/JUL–AUG 2003 301 Received 11 February 2002 from the Departments of Medicine and Pediatrics, Albany Medical Center, Albany, NY (PCS); the Center for Policy Research, University at Albany, Albany, NY (JS); Département de Psychologie, Université François-Rabelais, Tours, France (GC, SBS); St. Avertin, France (JC); and Ecole Pratique des Hautes Etudes (EM).Preliminaryversionpresentedatthe22ndannualmeetingofthe SocietyforMedicalDecisionMaking,Cincinnati,Ohio,September27, 2000. Revision accepted for publication 19 May 2003. AddresscorrespondenceandreprintrequeststoPaulClaySorum,Al- bany Med Primary Care Network, 724 Watervliet-Shaker Road, Latham, NY 12110; telephone: (518) 783-0312; fax: (518) 782-7485; e-mail: sorump@mail.amc.edu. DOI: 10.1177/0272989X03256010