Posted by: notdeaddinosaur | November 16, 2011

Guidelines are in the Eye of the Beholder

Cancer. Just the word is scary. Actually, that’s the problem. Once you say that word, the average American will do anything — ANYTHING! — to just get it out of my body!!! Whether or not they have it, whatever the actual numerical chances of their ever developing it, no chance for detecting or treating it should ever be neglected. EVER! Ask any Med-mal lawyer. Better, ask any twelve average people off the street (ie, the ones who are going to wind up on a jury). “The doctor didn’t do every possible test/procedure, and now the patient has CANCER? String him up!”

Hence we have the new guidelines for PSA testing. (Given that many patients with prostate cancer have normal PSAs and lots of patients with high PSAs don’t have prostate cancer, it doesn’t seem semantically correct to call it “prostate cancer screening”.) Surprise! Turns out that not only does PSA testing not save lives, but that urologists don’t really care. Certainly not enough to stop recommending PSAs to just about everyone they can get their hands on.

Nor do breast surgeons have any intention of modifying their recommendations, not only in light of new understandings of the limitations of mammography, but even as their own treatment recommendations contract, becoming ever more targeted and less invasive. I recently heard a local surgeon speak about the progression from radical mastectomies to partial mastectomies to lumpectomies; from axillary node dissections to sentinel node sampling; from whole-breast radiation to intra-cavitary seeds. Listening to him, breast cancer therapy is becoming downright minimalist. Yet at the end of the talk, when asked about the new recommendations for biennial mammography, his response was, “Every woman should have an annual mammogram starting at age 40. I mean, there are no downsides to mammography.” Never mind the psychological stress of extra views, ultrasounds, and false positives, not to mention the bruising and even skin tearing that I see far more often than I’d like. “No downsides”? Not for him, that’s for sure. When will they realize that mammography catches slower-growing cancers that would be treated just as easily if they were found a year later? Women die of aggressive tumors that pop up between annual mammograms, which by definition would not be detected by standard screening.

The gynecologists are no better. They all still insist on annual visits for paps to find cancers that take 10 years to grow (and then only in the presence of HPV) and pelvic exams that detect, well, nothing. Whether driven by legal concerns or patient insistence, scientifically unnecessary medical care is running rampant in this country, playing a pivotal role in bankrupting us in the Orwellian name of “the best medical care in the world”.

What to do, though?

First, stop asking the foxes what they think of the new hen house alarm system. What do you think a urologist is going to say about PSAs? Why would a surgeon ever recommend against a mammogram? And whatever you do, don’t even think about questioning the need for an annual gynecological exam. Goodness. What’s a poor doctor to do without providing all that care? Starve?

Actually, you might be able to get an appointment with a urologist in less than six weeks for a kidney stone if they weren’t so booked up with annual rectal exams and PSAs on every asymptomatic man over 50. Think about getting in to see a gynecologist for heavy bleeding in less than 3 months. Not only would the care be more appropriate, but those same specialists worrying about their empty appointment books would probably be making more money by seeing patients who actually need their specialized skills and procedures.

So if you shouldn’t ask the specialists about screening guidelines, to whom should patients turn? How about me. Why not discuss these complex issues with your family doctor, who doesn’t make any money off your PSA or your pap or your mammogram. Believe me, my schedule is plenty full with sick people and the worried well (defined as those patients I cannot talk out of all those inappropriate interventions. Yes, they’re out there. Yes, I try to explain it to them. Am I always successful? Of course not, though it’s not for lack of trying.)

I’m more interested in seeing that the care you get is medically and scientifically appropriate, especially when deciding which screening interventions to forgo. “Watching and waiting” is often as viable a strategy for cancer as it is for lesser ailments. Let us family physicians educate you, our patients, so that you don’t end up with irreparable harm from treatments intended to cure something that would never have killed you. Sometimes “just getting it out of  my body” leaves you much worse off than leaving well enough alone.

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Responses

  1. As always, well put.

  2. I have the discussion with my men about PSA. I’d say about 2/3 decide to get it even after I describe it as a poor test that tells me almost nothing. I know that I personally will not be getting it when I turn 50 unless evidence changes.

    I discuss with women at 40 about mammograms. If there is any family history I rec them(not that I could convince them otherwise anyway). I do not actively recommend against mammograms before 50 but I do suggest doing them less often unless symptoms or family history.
    I do breast exams at annual exams. I am aware there is little evidence for it. I ignore a lot of clearly fibrocystic disease in young women during those exams.

    PAPs I do not do until 21(though I do have one patient who had first intercourse at age 12 that I wonder about) and then do them Q2years through 30 and then Q3(all assuming normal) and I test for HPV after 30. I believe this is in line with ACOG(the GYN organization that no Gynecologist follows). I do still do pelvics at the same time but freely admit I have never had a positive finding of consequence in an assymptomatic patient.

    I still think ‘annual exams’ are worth doing but hardly ever need to be done annually. For the 28 year old who only comes in every 12-18 months for minor injuries/colds/etc I think coming in for a physical every 3-5 years is reasonable to make sure you take the time to discuss general health, check cholesterol and screen for diabetes, update family history, focus on smoking and other health behaviors, etc.
    I think for the middle-aged to older person who multiple medical problems who comes in 6-12 times a year it is good to have a physical on occassion to make sure you are not always dealing with the acute issue but actually sit back and make sure everything, including general screening and follow-up on everything, is being done.

  3. The head of the USPSTF gave grand rounds today at my hospital. She said EXACTLY what you’ve outlined above. She’s a pediatrician and it was very nice to have someone in a position like hers that understands both medicine and policy. I wish that the rest of the people that make policy decisions understood medicine as well as she does.

  4. Once again you’ve written an important and thoughtful post that sparked one of my own–from a patient’s point of view: To Test or not to Test? What’s a Primary Care Physician to do? http://cushielife.multiply.com/journal/item/47/47

  5. yes, ‘tincture of time’ can be an effective strategy in much of life – gives you time for thinking before doing – and slowing down enuf to ask ‘what information are we going to gain from this test?” and “what will we do with this information?” Our whole American culture is so speeded up that it is hard to stop the rush to action!
    my internist is a good one for ‘thinking out loud’ so i understand his decision making and I know he incorporates my input. I’m a nurse, he’s paid a salary in a setting that is invested in quality of care/EMR/shared decision making. It’s an uphill struggle to get people to be PARTNERS in their own health, moving out of the “doc is god” and the “just fix it now” patient modes.

  6. I like the term “active surveillance” instead of “watchful waiting” when describing our newer modified monitoring practices.

  7. Well done.
    A talented surgeon once told me he did his best work with his hands in his pockets.
    Above all do no harm remains central.

  8. […] blog post was originally published at Musings of a Dinosaur* Related […]

  9. I think I love you.

    To JustADoc: I absolutely refuse to have another pelvic exam, for the rest of my life, unless I’m having symptoms. It’s beyond unpleasant, and I’m outraged that I’ve been forced to submit to them in the past for no good reason.

  10. AJ,
    Just to clarify as I find many many women do not know the difference between a pelvic and a PAP.
    A PAP is the scraping and the brush. Being male, I don’t know how that feels but I would imagine uncomfortable. The speculum has to be used to this. When women complain about the exam, it is generally centered around the speculum and the scraping in my completely non-scientific, non-randomized, non-controlled experience.
    A pelvic is simply 1 or 2 fingers in the vagina, with lubricant, to feel for any abnormalities or unusual pain. 99.9% of the time that I am doing one on an asymptomatic patient it is because I just did a PAP.
    As stated previously I do not recall many significant positive findings that mattered at the moment. I have documented some early cystoceles/rectoceles/ovarian cysts. Did this matter? Well, that is debateable for sure. But a pelvic exam at 68 is much easier than at 78 and if I knew you had a small cystocele at 68 than I can guess you have a larger one at 78 that is causing your recurrent UTIs and save you at least one additional exam when you have a bad hip and use a cane.
    But I do extremely few pelvics without PAPs in asymptomatic patients. In fact, I cannot think of an example where it was not requested by the patient.
    If I am doing a pelvic on a symptomatic patient, it is not a screening test.

  11. >>Just to clarify as I find many many women do not know the difference between a pelvic and a PAP.>>

    Thanks for your condescending, but completely unnecessary explanation. I know the difference between a pelvic and a Pap.

    >>A PAP is the scraping and the brush. Being male, I don’t know how that feels but I would imagine uncomfortable.>>

    I don’t find this particularly uncomfortable, as long as the physician chooses an appropriately sized speculum. Some women do find the brush painful, but it doesn’t bother me.

    >>A pelvic is simply 1 or 2 fingers in the vagina, with lubricant, to feel for any abnormalities or unusual pain. 99.9% of the time that I am doing one on an asymptomatic patient it is because I just did a PAP.>>

    Yes. It’s invasive and offensive, especially if the only reason it’s done is because “I just did a Pap”, which is NOT a good reason. WTH? I will continue to refuse this test.

  12. AJ(I presume, name changed but response seems to be so directed),

    I am glad you are informed. I was merely saying many aren’t. Since a wide range of people read this site and not just those who are fully educated on the wide range of medical procedures and tests, I wanted to clarify that PAPs remain recommended, though at a much less frequent schedule. I have done PAPs on hundreds, possibly thousands of women. A small minority complain. I am sure most don’t enjoy the expereince. Those complaints remain centered as above. As noted above, YMMV.

    I am sorry if I offended. I am just a doctor trying to do the best I can when pulled in 9 different directions by the patient, the patient’s insurance, 12 different competing guideline makers and of course the ever present lawyer who does not give a toot that pelvics are not very sensitive or specific for finding disease(‘Wouldn’t you have noticed the vaginal cancer if you had bothered to look, good Doctor?’)

    There was an article in JAMA several years ago. Resident physician discussed pros/cons of PSA with his asymptomatic patient. Patient decided not to get PSA. Down the road patient has prostate cancer. Pt sues resident and the residency. Standard of care was determined to be what is actually done by the majority of the local community, not what is scientifically valid. The doctor who practices the most up-to-date scientifially supported medicine treads on thin ice if there is a poor outcome. Is this horrible and wrong? Absolutely. Is it what occurs? Yes.

  13. JustADoc:

    Is it any wonder that patients are suspicious of physicians who, like you, order tests and procedures for no good reason other than “everyone else does it” and “to protect myself (the physician)”? The former is intellectual laziness; the latter, selfish and irrational, if you actually look at the number of patients who actually sue and win vs. the number of patients with actual malpractice cases who don’t sue or win and the actual amount of financial harm to most physicians who lose suits. It’s kinda like being afraid of a commercial airplane crashing: a highly unlikely, and therefore irrational, fear that still causes some people to take a train or drive cross-country instead.

  14. I will leave it at walk a mile in someone’s shoes. Clearly we are not communicating well. I order far far less tests than all my partners. But your opinion is decided.

  15. >>I will leave it at walk a mile in someone’s shoes.

    Ditto. Clearly, the thought that women who have consented to a Pap smear might prefer not to have a stranger’s finger inserted into their vaginas without good reason has never occurred to you.

  16. Now, now, boys and girls. Let’s play nice. Lots of merit in everyone’s position. I know it only seems logical not to perform an exam shown not to be necessary, but simply omitting it runs the risk of being seen as “less than thorough” by patients who have come to expect certain procedures, however unpleasant. AJ, you’d be surprised at how many women insist that they want “everything checked out”, despite the discomfort/humiliation/etc.Believe me, I’ve lost patients trying to talk them out of unnecessary screenings. Hard to tell who’s going to be pissed off by what (as this comment thread shows).

  17. […] *This blog post was originally published at Musings of a Dinosaur* […]

  18. My PCP was very much in favor of the PSA when I started going to him about 10 years back. Then about five years ago, he told me that the latest studies weren’t showing all that much benefit. He gave me all the facts and left the choice of a PSA or digital rectal exam to me.

    Somewhat reluctantly, I chose the digital rectal exam because I believed (and believe) that he has a better understanding of the science than I do.

    Maybe some day we’ll have a reliable alternative to the rectal exam. Until then, men should just tolerate the momentary discomfort.


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