Saturday, July 25, 2009

Prostate Cancer Screening: Stop The PSA Train!

About 10 years ago, my dad was to see his general internist. I have always refrained from giving medical advice to my family, for all of the reasons why doctors should not treat or advise their relatives. But, on this occasion, I did give Dad some unsolicited advice, particularly as I knew that his physician fired the diagnostic testing trigger readily.

“Dad, please make sure that he doesn’t check the PSA (prostate specific antigen) test.” Dad indicated that he would convey my concern to his doctor, who ran the test on him anyway. Apparently, he includes the PSA test as a matter of routine on all men over a certain age.

Twenty-five years ago as a curious, but skeptical medical student, I learned about prostate cancer. I learned that every man will develop it if he lives long enough. I learned that most cases of prostate cancer remain silent and never interfere with the individual’s life. I learned that the treatment for these cancers involves either major surgery or radiation, both of which can markedly diminish the quality of mens’ lives by causing urinary leakage, chronic diarrhea and rectal bleeding and sexual dysfunction. These lessons are just as true in 2009, yet they are largely ignored by a juggernaut of physicians, medical societies and hospitals, who have conflicts of interest on this issue. These PSA proponents are not corrupt, they are just blinded by their biases.

Men are strongly urged to pursue early diagnosis of prostate cancer under the false premise that this will lengthen and improve their lives. The PSA test, which is championed by so many physicians, has achieved exactly the opposite results. It has been an entry point for men who are pushed down a slippery slope into a medical minefield. Like many medical cascades, it is very difficult to change the course of this journey once it has begun. Once a PSA value is abnormal, it becomes almost impossible for patients and physicians to resist the pressure for prostate ultrasounds and biopies. The time to discuss prostate screening with patients in detail is before the blood test is done, not afterwards when the result is elevated or borderline.

The treatments for prostate cancer harm thousands of men across the country, most of whom would never have been disturbed by their silent cancers. This is a true medical travesty. Urologists and others dispute my views and earnestly believe that they are saving lives. I believe they are sincere and properly motivated. Yet, while they may be saving a few men, this must be balanced against the direct harm, financial cost and anxiety of patients and their families that are ultimate PSA casualties. Personally, I am mystified why the PSA screening test wasn’t banned from medical practice years ago.

Here’s what a study published in the prestigious New England Journal of Medicine concluded earlier this year. In order to save a single life from prostate cancer, about 1400 men would have to be screened. How do those odds sound? Read on. About 50 of these men would endure prostate cancer treatments, as I described above, that would not benefit them, either because the disease would have remained silent or was already too advanced to be helped medically. Still interested in getting a PSA test?

It’s a tragedy when a patient suffers chronic complications from a treatment that was not necessary. If comparative effectiveness research, which aims to scientifically determine which medical treatments are supported by evidence, ever gets airborne, I hope that PSA becomes a very high priority item.

PSA testing is a complex issue and calls for discussion between patients and physicians before any testing is undertaken. It should not be casually added to a panel of blood tests, deferring the conversation until afterwards, when it may be too late to derail the prostate locomotive.

The PSA is more accurately a Physician Scam Activity, than it is a lifesaving screening test, even though the physicians’ intentions may be pure.

When your doctor advises any test, particularly the PSA, make sure that you understand where the result could lead you. Regrettably, many men like my dad have the test sent off without their knowledge. Fortunately, his PSA result was normal. Otherwise, the prostate train may have taken him into a tunnel with no way out.

Saturday, July 18, 2009

Tort Reform: Lawyers -vs- Doctors

Over the past week or so, I have been engaged in a colloquy with a presumed lawyer on tort reform on KevinMD’s blog. It has been a frustrating and unsatisfying exchange. I have had many discussions with attorneys over the years, and I am always struck by the gulf that separates us on this issue. I regard myself as a fair-minded individual. I believe that I can separate my own self-interest from the public interest. Indeed, many Whistleblower postings take aim at my own profession and have generated some spirited responses from my colleagues, some of them delivered offline. Although I am a gastroenterologist, I will not defend the value of colonoscopy when a better option for patients emerges. I admit and write that our health care system is riddled with excesses and inefficiencies and that we physicians deviate from evidence based medicine regularly.

Lawyers, at least those who I’ve spoken with, express an unwavering fidelity to the tort system. This is why the dialogue between the professions is so strained. I don’t believe that they put the public’s interest ahead of their own. Would they defend the current system as vigorously as they do now if it didn’t enrich them personally? Using my colonoscopy example above, if we created a tort system that provided more fairness and justice to the parties involved, would lawyers support it if their incomes would suffer as a result?

When an organization or a profession claims that no reform is needed, despite an avalanche of evidence to the contrary, then the credibility of the institution erodes. Yet, lawyers defend even the most glaring defects in the tort system as essential elements that require no remedy. When physicians argue that innocent doctors are unfairly drawn into the legal vortex, lawyers respond that their innocence cannot be assumed and must be established. When innocent doctors complain that they remain attached to lawsuits for years before dismissal, they are told that the legal process is a methodical process. In this instance, they point to the physicians’ ultimate dismissal as evidence that the process is fair. When physicians state the the tort system fuels uneccessary and defensive medicine, they counter that they provide an important deterrence function over the medical profession. When we point out that the tort system misses most true medical negligence, they respond that this is evidence of lax physician oversight over its own practitioners. I could easily extend this paragraph with additional examples.

In my mind, this dispute is not a true controversy where two reasonable viewpoints are juxtaposed. One profession admits its own failings and asks the other for relief and understanding. The other, in contrast, claims it needs no reform and should be preserved, if not strengthened. How can you talk with someone who is always right? You can’t dialogue with an idealogue.

Sunday, July 12, 2009

Medical Malpractice Strikes Home: A Time to Serve

For a while now, I’ve been in between lawsuits. I am now pleased to report that I am a defendant again. Such good fortune, like a lottery win, descends upon doctors without warning or invitation. Nothing else can leaven a physician’s morale more than opening that thick envelope delivered by certified mail. We should not regard a medical malpractice lawsuit as a personal legal assault, but rather as an opportunity to promote truth, justice and the American way of life. (If I had the technical skills, an audio of the Star Spangled Banner would now begin.) We physicians, through our involuntary participation and testimony, can shed light in the darkened corners of the medical world. This is no time for physician anger. This is a time to give back and make others whole. Litigation is a natural extension of our professional mission to serve humanity. When viewed from this perspective, sitting in the courtroom or giving a deposition are important opportunities to heal our injured patients. That’s why, as a defendant again, the sun shines a little brighter, the songbirds sing a little sweeter…

Doctors, like everyone else, have to fully accept society’s prevailing ethos:

Every adverse outcome has a responsible perpetrator who must be sought out and punished.

When I perused the complaint against me, I was struck by how many defendants would be joining me in this important humanitarian endeavor. Here are the players, withholding their true identities.



Physician 1
Physician 2
Health Center
Surgery Center
Physician Practice 1
Physician 3
Physician 4
Physician Practice 2
Physician 6
Physician Practice 3
Physician 7
Physician 8
Hospital 1
Hospital 2
Coroner’s Office
Physician 9

I certainly wasn’t going to be lonely. I had more team members than a football squad.

I won’t discuss any of the clinical particulars, so my lawyers won’t suffer apoplexy. I admit that I am puzzled why I was called to serve humanity in this instance. My professional involvement with the patient was brief and I successfully addressed the clinical issue at hand. Follow-up appointments were advised, scheduled but did not occur.

I have no opinion on the merits of the case with regard to the numerous other defendents, since I never saw the patient again. My staff advised me that the current plaintiff attorney firm is the 4th so far. I presume that the first 3 didn’t believe that my conduct merited inclusion. In tort law, there’s no ‘3 strikes and you’re out’ provision. The current law firm managed to find a physician who was willing to sign an affidavit of merit, an Ohio requirement since 1995, affirming that my care and treatment were negligent. I can only imagine how effortless it is to cross this legal threshold. Tort reform, a necessary response to an oppressive legal system, does not address the front end, lawsuits filed without merit.

If I am dropped from the case, as I expect, the ride will be an expensive journey. Add up the number of defendants above and then estimate the aggregate cost for all of our legal defenses. This will be a staggering amount of cash. If the physicians, et al prevail, then hundreds of thousands of dollars will vaporize, and this is only one single lawsuit. Imagine what we are spending across the country every single year against innocent doctors and other defendants. Does this give you an idea where we might look for the health care dollars that we so desperately need?

Sunday, July 5, 2009

Tort Reform and Medical Malpractice: Ready! Fire! Aim!

We’ve already had a little fun presenting ‘tort for sport’ for your entertainment, describing a system that is nearly exclusively advocated by trial lawyers and their minions. Beyond their tendentious rhetoric, however, are the inescapable hard facts that the tort system misses most cases of true medical negligence and wounds too many physicians as friendly fire casualties.

Let’s put this issue in medical terms. As lawyers so often say, ‘let’s consider a hypothetical’. A pharmaceutical company launches a new medical screening test to diagnose pancreatic cancer at an early stage when the disease is curable. The test can accurately detect the condition in only 5% of cases. Unfortunately, the test causes side effects in most patients, who experience severe fatigue, muscle aches and joint pains. These symptoms last for several months and then gradually resolve. If this screening test were widely adopted as a routine test, then 95% of early pancreatic cancer patients would be missed and most of the country – the healthy folks - would be suffering severe side effects. Would the F.D.A. ever approve such a test that performed so miserably? Let’s hope not. Yet, this is analogous to the tort system that physicians and the public endure.

In fact, when government health experts review screening test data, they are focused on these two specific issues.

What percent of afflicted individuals will be correctly identified by the test?
What percent of healthy individuals will identified as normal and not be harmed by the test?

The current tort system shoots a fusillade of arrows into crowds of doctors. Sure, a few negligent pracitioners are picked off, but what about the rest of us? Why should I be in the line of fire if I haven’t missed the mark? Shouldn't we prefer a tort system that doesn’t just fire, but actually aims?

There are many alternatives to the current system, nearly all of which would be fairer to physicians and the public. Frankly, I think if you put half a dozen reasonable people in a room for an afternoon, they could create a proposal that would remedy most of the tort system’s deficiencies. Of course, as in every other aspect of health care reform, there will be winners and losers. What is our objective? Should we aim for a new system that truly serves the public or retain the one that serves trial lawyers?

If a new medicine or medical test were harming more patients than it cured, would physicians still demand that we use it, just because it served our financial interests? If so, we would be properly chastised and vilified. Yet, the tort system as practiced serves legal interests over justice. Where’s the outrage?