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?

Sunday, June 28, 2009

Medical Malpractice: Tort for Sport

Physicians and plaintiff attorneys have philosophically divergent views on our tort system. I know the attorneys’ views on this issue well. There are lawyers in my family who have prosecuted physicians for alleged medical malpractice. Sometimes, there hasn’t been enough antacids in our house to douse my flaming heartburn after some of our discussions.

Obviously, one reason that lawyers support the current system is because it enriches them. However, there are purists among them who truly believe that the tort system, despite some flaws, is the best means available to pursue justice and to compensate injured people. They point out that the medical profession has been lax to monitor itself and to sanction incompetent physicians. Too many medical mistakes, they claim, are ‘buried’. Without aggressive legal advocacy, what recourse would negligently injured individuals have against the powerful and well financed medical profession? In addition, they argue that the system is a powerful deterrent, which improves medical quality.

While I concede there is a ‘white coat wall of silence’, the argument that our tort system improves medical quality is absurd. Indeed, there is no fair-minded individual who can possibly support it on its merits. It is not designed to narrowly target negligence. It is patently abusive and unfair to conscientious, competent and caring doctors across the country. The system ensnares scores of innocent doctors in order to capture a few rogue practitioners. It’s a hatchet job, when a scalpel should be the right tool.

As a statement of fact, the vast majority of true medical negligence never enters the tort system. These patients are never compensated and the medical perpetrators are never discovered. Additionally, most medical malpractice cases that plaintiff attorneys review are rejected because the lawyer does not feel that negligence has occurred or can be proved, or that the damages are insufficient to merit a legal proceeding. So, the current system only compensates a small fraction of negligently harmed patients. Can we defend a system that only provides relief to only a minority of those who deserve a legal remedy? Would we applaud our government if it provided food stamps to only 10% of those eligible, or would we demand a higher performance level or a new system?

In addition to its failure to reach most potential plaintiffs, the current system also punishes too many innocent doctors. Few other professions can truly empathize with our predicament. Most folks on the job do not fear that they can be successfully prosecuted for doing their job well. Do store clerks, cab drivers, teachers, entertainers, union workers, journalists, zookeepers or candle stick makers punch their time clocks in the morning and worry that they might be sued if an adverse event occurred that was not their fault? Doctors do.

Lawyers state that innocent physicians are ultimately dismissed proving that the system works well. A just outcome, however does not mean that the system is just. Recently, the U.S. government released several Guantanamo prisoners, who were cleared of being enemy combatants, to the island of Palau. Do these new islanders, who were captured in 2001 and endured years of misery, feel that our system is fair and true to American ideals just because they were ultimately exonerated?

I do not suggest that being wrongly sued is similar to being wrongly incarcerated, but there is a parallel theme. The innocent physician who is ultimately dismissed from the case or prevails in court does not feel like a winner. He emerges from his ‘victory’ as a battered and angry practitioner who returns to his practice with renewed cyncism and wariness. His relationships with his patients inevitably suffer and he practices more defensive medicine for legal protection. The current tort system fails in its mission to improve medical quality. Paradoxically, it diminishes quality by generating excessive and medically unnecessary care from worried doctors, which costs money and risks complications.

Lawyers don’t understand why we physicians take litigation on such a deeply personal level. If they lose a case, they shrug it off and move on to the next client. To them it’s just business. Not so, for physicians. When we are unfairly attacked, and our reputations are publically sullied, it becomes a wrenching personal ordeal.

How would lawyers feel if they feared a lawsuit after every case they lost? Would it be fair if innocent attorneys had to spend years and money defending against an outcome that was not their fault? Perhaps, then, they might understand better why we physicians are so hostile to the present system. Of course, if this sweet ironic turnaround occurred, there would be dividends. Attorneys and physicians would then finally be alligned. We could commiserate with each other. We could plot joint strategy for tort reform. We could be allies. And, we could share antacids.

Sunday, June 21, 2009

Obama’s Health Care Program: Breaking Loose or Breaking the Bank?

Would you be comfortable buying a house if you didn’t know the price or weren’t sure you could obtain financing? Of course not, but this is exactly the kind of purchase the government is asking us to support. This past week, the non-partisan Congressional Budget Office threw the Obamians off balance with health care reform cost estimates that were beyond the stratosphere. None of reform plans on the table credibly explain how they will be funded. The public is becoming wary of buying into their Grand Plan on credit. Credit card purchases are easy to make and can seduce us to buy more than we can afford. As many American are learning, these purchases can haunt us and ultimately bury us in debt. President Bush was rightly criticized for signing the Medicare Part D prescription drug program, which deepened our debt. Imagine how reforming the entire health care system could affect the nation’s balance sheet.

First, show me the money. Then, show me the whole pie, not a different piece of it each month. I don’t want to support the June piecemeal proposal when I don’t know what the July, August and September offerings will be. For example, since funds are finite, should I support universal health care coverage today to discover later that there won’t be enough money remaining to pay primary care physicians more money or to fund a cancer vaccine? This incremental approach may be an effective political strategy in the short term, but it risks collapse when the fragile tower collapses.

The administration strategy seems to be to be forge relationships and deals with various stakeholders. The risk is that these deals may not survive when future deals with other interest groups threaten the earlier agreements. This divide and conquer approach can doom the whole effort as interest groups pull back or overtly oppose the president. Despite all of the smiles in front of the cameras and warm handshakes, these groups are all keeping their powder dry. The dilemma is that this gradual contruction of a coalition may not endure, but that presenting the complete health care product now won’t sell.

We have seen how quickly the medical industry groups who were singing Kumbaya at the White House last month started walking away from their ‘commitment’ to decrease medical costs by 1.5% annually for the next decade. Last week we saw the AMA offer a marriage of convenience to the president if he would ‘adjust’ the public option program. Let’s see how cooperative these physicians will be in the coming months when other aspects of the Obama plan come into view. Will the doctors still be under the tent when they realize that there won’t be meaningful tort reform and that that they will be forced to participate in the public option in order to remain a Medicare provider? Other groups - hospitals, insurance companies, the pharmaceutical industry, employers - who are extending the olive branch now may be swinging a club in the future. Obviously, there’s politics on all sides here. No group wants to appear to be an impediment in achieving health care reform. Some of them who are playing nice now are really playing make-believe.

One might have predicted that with a Democratic president, Democratic congressional majorities, a bloated and wasteful health care system and a public that demands reform that the president could push through his plan over a weekend. The obstacles that he is facing, and those yet to come, reinforce the enormous complexity of health care and the power and influence of its players. I wonder whether any other issue, save the Middle East quagmire, is as vexing for the administration.

Some months ago, Tom Daschle gave the president 50-50 odds on achieving health care reform this year. As the president’s approval rating ebbs, and the astronomical costs of reform increase, I think that the odds are getting longer. True, the political stars for Obama on this issue may all be aligned, but the lights are dimming.

Obama has promised to deliver us the whole health care pie. At the end of it all, will he be serving us only some crumbs?