Mr. Smith walked into the tiny exam room for his annual check-up. His doctor walked in the door after him, gave the usual pleasantries and then turned to him and said, “your prostate test was a little high this year, Dan”. And Mr. Smith replied, “Okay, so no what, doc?” The doctor sat and thought, looked up and simply said: “nothing, we’ll check it again next year.” Mr. Smith, without hesitation replied, “whatever you say doc, you’re the boss.”
No other institution in our country demands as much scrutiny as healthcare. No other profession has so much expected of one individual as medicine. We, as a community, require that our physicians and our health institutions meet standards. Rightfully so, these bastions of education and expertise make decisions that are, for lack of a better phrase—life and death. We, as patients, trust that the highest quality care possible is being given because of the systems in place, the rigorous checks and balances, require our medical care meet the highest standards in the world.
Inside the safe confines of the academic medical center a patient is near guaranteed to receive the most up-to-date medical care. We, as patients, seek out institutions with greater reputation with the assumption that our life is safe in their hands. And, for the most part, it is.
Our government ensures that hospitals, and to some degree, physicians are incentivized to “do the right thing”. They have built entire systems of measurement to track hospital data and change hospital reimbursement based on performance. To a similar degree, physician performance is rated as well. Almost everything is fair game. Practices that do not even have strong medical evidence can be incentivized. For example, hemoglobin A1C, a measurement of the sugar levels in your blood to detect diabetes, is a quality metric. Physicians are paid based on how many of their patients can be below a certain benchmark, specifically 9%. But the data has born out, time and time again, that a target A1C is less important than a relative. That is to say, it is more important for someone with an A1C of 14% to reach 11% or even 10% because of diminishing returns rather than reach 9%.
But what is not fair game is the sanctity of the so-called “Doctor-patient relationship”. Any infringement by the government on The Relationship frightens the medical community. Even in the face of bad medicine. We, as a society, regulate the rest of our medical care to ensure evidence-based medicine is practiced, to our benefit. But we let doctors make decisions, or offer outdated tests, in direct contradiction to best practice, so long as it involves “patient centered decision making”.
The example is Mr. Smith’s elevated prostate test, or PSA as it is known in the medical world. The data has been present for nearly two decades. The United States Preventive Services Task Force has given annual PSA screening for men a letter “D” recommendation, or, more commonly referred to as the “Don’t Do” category. Researchers have determined that by giving the test a physician is more likely to harm their patient than they are to help them. As in the case of Mr. Smith, many physicians still order this test because their patient’s ask or because it was how they were trained. When it is positive, they often do nothing about it because they know it is not a great indicator for the presence of disease. Or they do send a patient to the urologist, where invasive testing is performed, where harm is a real possibility.
In November of 2014 the Center for Medicare and Medicaid Services attempted to create a payment structure that would subtract from a physician’s payment for the annual visit if they offered their patient a PSA test. The resulting backlash from the medical community forced CMS to retract the payment method. Physician’s believed that the change would be an infringement on The Relationship a physician has with their patient. Even physicians who believe in removing useless tests from medicine reprimanded CMS for this policy. They argued that only a doctor could know what is best for their patient, not the government.
The day of paternalistic medicine is long gone. Patient’s are savvier about their health than ever before and should be playing a greater role in their own medical decision-making. But why, in such a regulated, patient safety oriented, society are we allowing physicians to offer detrimental, outdated testing in the name of a relationship between two people centered around the mutual understanding of maximizing the health of the patient?
Physician’s, as a culture, are afraid to say they do not know the answer to a question. Medical literature has grown exponentially over the past 30 years. And we expect our physicians to stay up-to-date on all of the new data. This is an unrealistic task for a primary care physician who sees 30 patients a day with barely enough time to finish charting and eat lunch. We are setting physicians up to fail. The easy solution to prevent needless medical error would seem to be to prevent the harmful practice from occurring in the first place. Take the decision out of the physician’s hands; remove the possibility of non-evidence based medicine from clinical practice by eliminating outdated care, do it for the sake of The Relationship.
American Academy of Ophthamology. (2017). Measure 1: Diabetes: Hemoglobin A1c Poor Control . Retrieved 2017, from American Academy of Ophthamology: https://www.aao.org/practice-management/regulatory/mips/quality-reporting-measure/1-diabetes-hemoglobin-a1c-poor-control
Mathematica Policy Research. (2015). Non -R ecommended PSA -Based Screening. Retrieved 2017, from Mathematic Policy Research: https://talkaboutprostatecancer.files.wordpress.com/2015/11/psa-screening_framing-document_measure-specification_hqmf-header3.pdf
USPSTF. (2012). Prostate Cancer: Screening. Retrieved 1017, from U.S. Preventive Services Task Force: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/prostate-cancer-screening
Wlech, G. (2016, January 7th). Why Doctors Shouldn’t Be Punished for Giving Prostate Tests. Retrieved 2017, from The New York Times: https://www.nytimes.com/2016/01/07/opinion/why-doctors-shouldnt-be-punished-for-giving-prostate-tests.html?_r=1