How about this Twitter story?

[thegenius]

I hope you guys can read this. A story about a person getting a prostate biopsy that resulted in septicemia when all along he felt it wasn't necessary, but went along with it nonetheless.

These kinds of stories irritate me. The notion that "I know my body and I don't have 'X'", "I should have listened to my gut instinct" when doctors have gone to school, residency, and have taken care of thousands of patients with the same complaint and have tremendous, advanced experience dealing with possible prostate cancer. Three urologists recommended a prostate biopsy. What if the pt got 5 second opinions? 10? What if the pt talked to 50 Urologists and 47 of 50 recommended a prostate biopsy?

On the other hand, the system is set up so poorly in that I believe we often don't treat the whole patient. We are super-subspecialized. Time-crunched. Incentivized by procedures (and I don't believe that decisions on an individualized basis are overtly subjected to this bias.)

This guy was so sure of himself...yet he even quoted a 70% chance of not having prostate cancer. That's it. 30% chance he did.

I also loved reading the comments....so many people are pissed off at the health care system. Only a few said "I'm glad I got a biopsy becuase I caught prostate cancer early."

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[VA Hopeful Dr]

This is basically the reason that PSA screening recommendations are somewhat controversial. I don't know the exact numbers, but in residency a urology attending said that around 1 in 30 people who get a prostate biopsy will end up septic. There's also a not insignificant number of people who will die with prostate cancer, not of it.

As for the general health care comments, this is why we need to improve primary care. We're generally pretty good at not hyper focusing on a single area (anyone who has seen an internist referee between nephrology and cardiology on a patient with CHF and AKI has witnessed this). FM residency programs are growing at a pretty fast rate, so hopefully we'll see some movement in this direction in the next handful of years. Here in SC, for example, in the 10 years since I finished residency the number of programs in the state has doubled.

 

[GonnaBeADoc2222]

Meh.

Medicine is constantly evolving and we don't know everything.

What was done here, and what our jobs are, is a recommendation was made based on current evidence, and rhe patient made a choice Everything has risk.

Physicians are upper middle to lower upper class working people. The crabs in the bucket will try to pull us down always. Plebs gonna pleb.

 

[wareagle726]

I mean his primary stream of revenue is selling workout routines and alternative health/diet courses. This just gets him more clicks and dollars.

 

[Siggy]

It doesn’t help that the evidence for PSA screening is bad and, absent a family history or specific genetic markers, PSA isn’t really recommended in the first place. Checking it is likely something done because that’s how we’re trained and doing something feels better than doing nothing.

 

[GonnaBeADoc2222]

It doesn’t help that the evidence for PSA screening is bad and, absent a family history or specific genetic markers, PSA isn’t really recommended in the first place. Checking it is likely something done because that’s how we’re trained and doing something feels better than doing nothing.

The converse of this story is:

"Bratty Keto man who knows medicinezzzz doesn't get biopsy because the mean doctors said not to, and now has cancer." everywhere."

 

[PikminOC]

I hope you guys can read this. A story about a person getting a prostate biopsy that resulted in septicemia when all along he felt it wasn't necessary, but went along with it nonetheless.

These kinds of stories irritate me. The notion that "I know my body and I don't have 'X'", "I should have listened to my gut instinct" when doctors have gone to school, residency, and have taken care of thousands of patients with the same complaint and have tremendous, advanced experience dealing with possible prostate cancer. Three urologists recommended a prostate biopsy. What if the pt got 5 second opinions? 10? What if the pt talked to 50 Urologists and 47 of 50 recommended a prostate biopsy?

On the other hand, the system is set up so poorly in that I believe we often don't treat the whole patient. We are super-subspecialized. Time-crunched. Incentivized by procedures (and I don't believe that decisions on an individualized basis are overtly subjected to this bias.)

This guy was so sure of himself...yet he even quoted a 70% chance of not having prostate cancer. That's it. 30% chance he did.

I also loved reading the comments....so many people are pissed off at the health care system. Only a few said "I'm glad I got a biopsy becuase I caught prostate cancer early."

He talked about taking a ketone supplement....
And if he had cancer he would have sued the physician for not making him do the biopsy...

 

[PikminOC]

"I know my body" translates to "I don't have cancer" ????

 

[bravotwozero]

The converse of this story is:

"Bratty Keto man who knows medicinezzzz doesn't get biopsy because the mean doctors said not to, and now has cancer." everywhere."

No win.

 

[VA Hopeful Dr]

It doesn’t help that the evidence for PSA screening is bad and, absent a family history or specific genetic markers, PSA isn’t really recommended in the first place. Checking it is likely something done because that’s how we’re trained and doing something feels better than doing nothing.

I do it because:

Patients want it and patient satisfaction is king.

If I don't and a patient gets metastatic prostate cancer, unless I have documented detailed shared decision making then I am screwed.

 

[Brigade4Radiant]

I do it because:

Patients want it and patient satisfaction is king.

If I don't and a patient gets metastatic prostate cancer, unless I have documented detailed shared decision making then I am screwed.

We are under a lot of liability the guidelines are nice but they don’t protect in a lawsuit

 

[RustedFox]

If I hear you say: "the whole patient" again, I am coming to NorCal to effing slap your hippie ass.

 

[WilcoWorld]

Starting with "I don't like doctors. Some of my best friends are doctors" would be hilarious if he was making that reference on purpose, but I suspect he wasn't.

Through Palliative fellowship I have special training in treating "the whole patient" and I do find it valuable. But I still struggle with folks who feel specially educated in "alternative" treatments. You want to explore non evidence-based treatments? It's your body, go ahead, but don't expect me to be able to manage that - I specialize in evidence-based medicine!

That said, if you want to take shots at modern medicine in the US, prostate cancer is an excellent target to pick.

 

[Siggy]

I do it because:

Patients want it and patient satisfaction is king.

If I don't and a patient gets metastatic prostate cancer, unless I have documented detailed shared decision making then I am screwed.

I'm trying to remember if it was The Expert Witness Substack or another site where the PCP ordered a PSA, never got the results, and was sued. The analysis was that it would have been more defensible to not order it in the first place than to order it and assume the patient never had the test done.

Outside of the "you could be sued for anything" aspect, isn't there a legitimate cause for action for recommending a procedure based on a screening exam that isn't recommended for? Similarly, if there's an adverse outcome by working outside of the guidelines, I don't see how that's more defensible just because guidelines tend to be "do less" than standard practice.

In the end it's easy enough to find an expert to say that they would have done something different... thanks to hindsight.

 

[VA Hopeful Dr]

I'm trying to remember if it was The Expert Witness Substack or another site where the PCP ordered a PSA, never got the results, and was sued. The analysis was that it would have been more defensible to not order it in the first place than to order it and assume the patient never had the test done.

Outside of the "you could be sued for anything" aspect, isn't there a legitimate cause for action for recommending a procedure based on a screening exam that isn't recommended for? Similarly, if there's an adverse outcome by working outside of the guidelines, I don't see how that's more defensible just because guidelines tend to be "do less" than standard practice.

In the end it's easy enough to find an expert to say that they would have done something different... thanks to hindsight.

I don't recommend a procedure, I refer to urology and let them discuss options. If the procedure goes bad its on them. Same way I am fairly safe from referring someone to a surgeon and their surgery has complications or referring to oncology and the patient has a bad reaction to chemotherapy.

Not following up on results is a common thing PCPs get sued for. My favorite I read about in med school was a patient with an abnormal mammogram, PCP recommended a surgery referral, patient refused. 2 years later diagnosed with metastatic cancer, sued PCP for not making it clear how bad an abnormal mammogram could be. PCP lost, but this was also in Florida so make of that what you will.

You also should really look up what the current prostate cancer screening guidelines say:

Men aged 55 to 69 years

For men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one. Before deciding whether to be screened, men should have an opportunity to discuss the potential benefits and harms of screening with their clinician and to incorporate their values and preferences in the decision. Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of family history, race/ethnicity, comorbid medical conditions, patient values about the benefits and harms of screening and treatment-specific outcomes, and other health needs. Clinicians should not screen men who do not express a preference for screening.

If you heavily document the shared decision making, you're probably safe not ordering a PSA. That's what I did at first and I did not have a single man say "you know what, I don't want to check my PSA" so now I bring it up as a thing I'm going to order and if they don't want it they can say so.

 

[Brigade4Radiant]

A lot of pcps will fire you if you don’t get ultrasounds or the tests they order

 

[VA Hopeful Dr]

A lot of pcps will fire you if you don’t get ultrasounds or the tests they order

Yep. You're going to see it more and more as many of our quality metrics are for getting tests done (mammograms, colon cancer screening, eye exams in diabetic patients, so and on).

Speaking for myself, quality went from being around 10% of my total pay to now being more like 30-40%. I routinely have to tell patients to either get X done or find a new doctor.

 

[Siggy]

I don't recommend a procedure, I refer to urology and let them discuss options. If the procedure goes bad its on them. Same way I am fairly safe from referring someone to a surgeon and their surgery has complications or referring to oncology and the patient has a bad reaction to chemotherapy.

Not following up on results is a common thing PCPs get sued for. My favorite I read about in med school was a patient with an abnormal mammogram, PCP recommended a surgery referral, patient refused. 2 years later diagnosed with metastatic cancer, sued PCP for not making it clear how bad an abnormal mammogram could be. PCP lost, but this was also in Florida so make of that what you will.

You also should really look up what the current prostate cancer screening guidelines say:

Men aged 55 to 69 years

For men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one. Before deciding whether to be screened, men should have an opportunity to discuss the potential benefits and harms of screening with their clinician and to incorporate their values and preferences in the decision. Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of family history, race/ethnicity, comorbid medical conditions, patient values about the benefits and harms of screening and treatment-specific outcomes, and other health needs. Clinicians should not screen men who do not express a preference for screening.

If you heavily document the shared decision making, you're probably safe not ordering a PSA. That's what I did at first and I did not have a single man say "you know what, I don't want to check my PSA" so now I bring it up as a thing I'm going to order and if they don't want it they can say so.

I saw the various society recommendations. Anytime you see a recommendation that's "shared decision making" vs "you should do X" it's a rather weak recommendation. Take the inpatient stroke guidelines. For spontaneous hemorrhagic strokes, it's listed as "It may be reasonable to start DVT PPx 24-48 hours after admission" (2A recommendation IIRC). Saying something along the lines of "Please engage in shared decision making on the risks/benefits of DVT PPx" would be absurd.

 

[VA Hopeful Dr]

I saw the various society recommendations. Anytime you see a recommendation that's "shared decision making" vs "you should do X" it's a rather weak recommendation. Take the inpatient stroke guidelines. For spontaneous hemorrhagic strokes, it's listed as "It may be reasonable to start DVT PPx 24-48 hours after admission" (2A recommendation IIRC). Saying something along the lines of "Please engage in shared decision making on the risks/benefits of DVT PPx" would be absurd.

In this case it was a fight between the urologists and primary care and this was the compromise.

 

[wareagle726]

I thought this was the EM forum. What's a PSA? /s

 

[Birdstrike]

My interpretation of that Twitter story is simple. The guy has a product to sell. The more distrust of the medical system he can tap into, the more he can sell of his book and diet system that goes against the grain.

I have plenty of criticisms of the current medical system. But people also need to be more skeptical in general, rather than buying into and I’m enriching every social media charlatan hawking the latest “life hack.”

Fortunately for these types, there’s a sucker born every minute.

 

[thegenius]

My interpretation of that Twitter story is simple. The guy has a product to sell. The more distrust of the medical system he can tap into, the more he can sell of his book and diet system that goes against the grain.

See...I'm so naive that I didn't even recognize this. Pisses me off even further that I didn't recognize that

 

[RustedFox]

I thought this was the EM forum. What's a PSA? /s

This would have gotten me to laugh hard out loud, but I don't want to wake the sleeping wife.

It was very very very hard not to do that.

 

[TooMuchResearch]

It doesn’t help that the evidence for PSA screening is bad and, absent a family history or specific genetic markers, PSA isn’t really recommended in the first place. Checking it is likely something done because that’s how we’re trained and doing something feels better than doing nothing.

Just get an outpatient MRI.

 

[WilcoWorld]

Just get an outpatient MRI.

Oh man, insurance prior authorization is going to be nearly impossible for that!

 

[PikminOC]

Oh man, insurance prior authorization is going to be nearly impossible for that!

He can afford ketone capsules

 

[WilcoWorld]

He can afford ketone capsules

Oh yeah, that guy. Totally!