Here's a personal story about medical overuse and willful ignorance. Stay tuned for the punchline. First, a little background: a couple of weeks ago I came across a great study on medical overuse, specifically adherence to national recommendations published in 2012 regarding the use of the PSA (prostate specific antigen) blood test to screen for prostate cancer.
Here's the PSA story: In 2012 the United States Preventive Services Task Force (USPSTF) updated its guidelines to recommend that men generally not be PSA screened for prostate cancer. The recommendation was made after the committee weighed the effectiveness of the screening in reducing mortality from prostate cancer versus the consequences of treating an working up a bunch of red herrings. The guidelines note:
Subsequently, the Clinical Guidelines Committee of the American College of Physicians (ACP) recommended that clinicians inform men ages 50 to 69 about the limited potential benefits and substantial harms of prostate cancer screening and only screen men who express a clear preference for being screened. The guidance statement also recommends against screening for prostate cancer in average-risk men under the age of 50 and against screening in men over the age of 69 or with a life expectancy less than 10 to 15 years.
from the nation's blockbuster guidelines groups? In the April 2016 JAMA Internal Medicine, authors found something interesting: The study, performed by Brigham and Women's authors, Michael Zavaski and colleagues, used a national dataset to examine PSA testing in 2010 (before the guidelines) and 2012 (after). They included all visits for men ages 50 to 74 who went to urologists or primary care physicians for a preventive care visit. The authors found that
(not significant). Here are the the results.
I've heard a range of explanations, from the suggestion that the urologic guidelines were a bit more lenient than the USPTF and ACP, to the old saw about how when you're a hammer everything looks like a nail, to the JAMA author's own diplomatic conclusions:
My thinking on this "practice variation" issue has evolved. In 2014, I commented on Jack Wennberg's findings on practice variation, commenting on how deeply held physician belief systems guide particular therapies.
Last year, in American Healthcare post, I commented on the on growing use of prophylactic coiling for cerebral aneurysms despite indications that it wasn't doing anything for the incidence of subsequent sub-arachnoid hemorrhages from burst aneurysms. My take at the time: physicians are far more sensitive to missed badness than overaggressively pursued nothingness.
Doctor Gil Ross at the American Council of Science and Health offers a third hypothesis for the PCP/ urologist discrepancy:
What a shame I didn't read the USPTF guidelines before visiting my urologist last month. I periodically visit a private-practice urologist who has monitored a chronic condition for a couple of years. On my last visit I was seen by the urology PA, who at the end of the visit recommended that we perform
.
I looked at him skeptically: I'm in my 40's with no risk factors. Is this really indicated, I asked?
I could make any decision I wanted, the PA explained, but their office sent PSAs and did prostate exams on almost all patients. He would recommend that I get tested "just in case."
In all candor: this was one of those times when I wished that I had read the instructions in advance. But, in the rush of a busy afternoon (and convinced that the urologist must know more than me about urology issues), I hastily agreed. We sent a PSA and did a prostate exam. Both were normal.
Now, of course, the problem is that no single consensus document that I could find, anywhere, endorses screening PSA (or prostate exams) in average-risk men in their 40s. Remember, this isn't about controversy in screening older adults, where a urologist could
disagree with the guidelines. This was
Which is a disappointing reflection on my urologist's professional competence, and which gets us back to Dr. Ross's suggestion that this is all about the cash.
More than you'd think: It turns out that the urologist has the Quest lab in the building's basement do venipuncture and to run a couple of samples. But, curiously, they also ask Quest to send send several tubes blood back to the urologist's office to be run on the office's point of care lab machines. I simply can't come up with a clinical reason why the office would insist on running the labs internally rather than have Quest do it more cheaply.
According to my insurance company, here are the invoices and payments made for the 20 minute visit: You can see how profitable office-run labs (including PSA) are.
Imagine the cash that flows when the PSA is abnormal and biopsies need to be done.
In the absence of reasonable specialist self-regulation,
: either as a system we migrate to a risk-bearing payment models where primary care physicians are incentivized to advocate for their patients and who select specialists on the basis of their thoughtful practice of medicine. Or, we need to insist that the insurance company refuse to pay for un-indicated tests and for things like point of care labs. Absent that, the system of misaligned financial incentives under fee-for-service seems to irreparably affect specialist's judgement.
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