PSOTBLOG

An Ode to PSA

Ah yet, why should they know their fate
Since sadness never arrives too late
And happiness too quickly flies
Clarity would destroy their paradise
For, when ignorance is bliss,
'tis folly to be wise
 
Out, out brief candle
PSA tis a poor player that struts and frets his hour upon the stage
And, then, is heard no more
'tis a tale full of sound and fury
signifying nothing
 
Slighlty abridged in the witness protection program
El Vez de la endoscopia
Siguiendo el sueno en Memphis
 
The previous post generated a long string which is below [partially]:

England doesn't screen for prostate cancer.  Men who get prostate cancer in England are 25 percent more likely to die from prostate cancer. Most men I talk to still want to be screened for prostate cancer. My favorite author died of prostate cancer at 76 in England. I am befuddled.

MD

I think everyone has concern that men should know and we all go through a conversation with them about screening but since the issue and recommendation are so diverse we all put our slant on it based on our understanding and personal practice experience. I usually have the discussion once and once they have chosen the screening route i just briefly review yearly that they haven't changed their mind- no need to do the 10 minute conversation yearly. I talk to them extensively at a level i think they can understand ( engineer vs McDonald worker) and make sure that they understand we dont' know the correct way to go with this like we know other things ( ex PCN for strep throat) and that the decision is theirs i am only providing the info.

Raff Thomas, MD

Does anyone have concern that the patient should know about this information. They can then make up their own minds to treat or not treat, conservatively manage, evaluate treatment options. From conversations I've had with hundreds of thousands of patients over the years. Most would like to know all the information they can about themselves and their potential illnesses, what their options and risks are and then make appropriate decisions for themselves once they feel comfortable they have found out and had answered all the questions that they need info on.

Most of my patients would rather be screened. I know screening has saved the lives of a good number of my patients over the years. I also know some that had higher risk for certain things, that chose not to be screened or do some various preventive measures and sure enough they endured complex and sometimes difficult terminal events.

Falball

All of your assertions are correct but the issues is that most men that are screened for cancer would never be those men who ended up getting cancer anyway.  Most of the cancers diagnosed currently with screening would never have gone on to become the relatively small cohort that became symptomatic like your author. Many men screened for cancer will have small cancers that would never become clinical yet they get treatment and a fair proportion (up to 30% for Erectile dysfunction and incontinence) will suffer morbidity and a few will even die of complications of treatment.

The real question for England is- if they screened for cancer what will happen to the large number of men who would have never developed prostate cancer when they are suddenly diagnosed with microscopic asymptomatic cancer. Most men certainly do want screening but this is due to what they have heard from us, the media, and their friends but that doesn’t mean what they heard was correct only what our current thinking is on the subject.

I think of the benefits of vitamin C, E, encainide, Darvocet,  and a host of other medical therapies that we used in the past which everyone agreed were beneficial until we learned more.

The fundamental problem with screening is we took a clinical tool ( PSA ) and made it a diagnostic screening tool before we had adequate information on the longterm implications. And lest you think I live in  a vacuum I am 50, live in the U.S.  and my father has prostate cancer so the implications of this question are very real to me.

Raff Thomas, MD

I think the bias we all have is hard to get around but unfortunately for us-There is one correct answer (Just Like PCN really does kill strep bacteria).

The real true answer is that screening with PSA does not prevent death.  This is not the same as saying it does prevent death but the work ups are hell for the no cancer guys. Screening with PSA does not prevent death.  It does not prevent all cause mortality and it does not prevent prostate specific mortality.

The less than one year survival benefit noted for screened vs non screened is explained entirely by lead time bias. 

Similarly but not exactly so is the survival risk for screening mammography. Screening mammography does not prevent death. It prevents breast cancer specific death but patients who chose to get mammograms die the same year as the women who do not participate in screening (on average). 

Many sensible things are not true upon proper study.

One of my favorites is Beta blockers are not dangerous in diabetics they prevent mortality.  How many times did we tell each other not to use beta blockers in diabetics?

John Bucek

Am I incorrect in recalling recent report of valid, well done European or Scandavanian study showing minimal survival increase in psa screened and detected vs symptom presenting prostate cancers? Isn’t there good evidence that a significant of psa detected cancers are treated and they would not have affected qol or shortened survivial?

I discuss this with my patients. Most decide to have the psa knowing that we together can decide to monitor vis free/total psa IF no DRE nodule and decide if/when to involve urologist. This is different than mammograms with immediate radiologist’s involvement.

I’m 68yo, my psa’s thankfully have been <1.0 over a dozen years.

Earl J. Carstensen, MD, MHS

Earl C:

I agree with you and I do the same. That being said, in Stamford, CT was one of the largest Malpractice Cases ever awarded with a Physician who "missed" Prostate Cancer by not pressing the patient to do a PSA. And for not following up on that decline to screen, then decline to treat. The patient died, the family/estate sued.

The Physician couldn't get malpractice insurance, was put out of business and had a heart attack.

Oh well, that's just anectodotal, no studies have been done.

So it's just like it didn't happen.

Falball

Biggest and most common payouts in OB are for failure to do a timely cesarean resulting in brain injury. There is no data that the tripling of the cesarean rate in this country has reduced CP or neonatal brain damage or seizures. Liability claims care not for cause and effect.

If you take care of your patients to prevent lawsuits ignore the meta analysis and do the PSA.  If you take care of your patients to prevent death and preserve life then you must tell them what the research shows. 

There was a failure to prevent prostate cancer lawsuit in which a resident carefully documented the informed consent discussion where he outlined the pros and cons and the patient CHOSE to forgo PSA.  He was discovered to have aggressive prostate cancer soon after and died within two years.  The estate sued the resident and attending and won a million dollars for failure to prevent prostate cancer.  If you practice medicine trying to avoid this kind of outcome you will harm patients. 

Just to evolve this discussion a bit, Genetic advances are going to challenge the already tenuous hold we have on these issues.There is a company called “23 and me” that evaluates your DNA for many health related conditions.

What do we do when patients come to us with the results of these tests?

I had my DNA analyzed and found that I was more likely than average men to get prostate cancer (which is remarkable because 80% of men get prostate cancer) I was told I cannot get Mad cow disease because I do not have the brain protein sequence that leaves one susceptible to the prion.

I was told what my susceptibility to certain medications is.

I was told that I have fewer than average fast twitch fibers in my muscles.

And so on.

I could send my kids DNA to be analyzed and they could present their strengths and weaknesses to future bosses and partners.

John Bucek

John B:

""If you take care of your patients to prevent lawsuits ignore the meta analysis and do the PSA. If you take care of your patients to prevent death and preserve life then you must tell them what the research shows""

I do both, and help the patient make the choice they are most comfortable with.

I tell them basically I don't have a crystal ball, I can use the research and studies and help follow them up as best I can, knowing what we together need to watch for in all things.  Incorporating the patient into the decision making process.   Always.   Though there certainly are times when patients make stupid decisions and are passive-aggressive, Fearful, resistent and sometimes just plain dumb, and I work hard to lay our a flow chart of best options to worst options.

It's a lot of work, but I've done it pretty well for a lot of years.

Heck, I've lost patients who's families insisted on treating 92-95 year olds Dx with prostate cancer,

when I advised them it was not advisable nor necessary.   Whole families and the patient picked up

and left to go elsewhere, found someone who would agree with them.

All this always needs to be kept in mind.

Falball

I tell patients that the issue is controversial – I tell them that I do not think it is beneficial based on my interpretation of the large scale studies.  I ask them if they have heard about the issue anywhere else.  If they have and they want to get it we order it.  If they ask me what we should do I tell them I do not want to order it.

My anecdote is as follows; my dad asked me when I was an intern what he should do at 60 to be healthy.  I told him to get a a few things including a DRE.  The doc thought he felt an irregularity.  Biopsy showed prostate cancer.  Very low Gleason’s score.  Pathologist and oncologist recommended watch and wait.  Urologist said cut it out.  My dad had a radical prostatectomy because he did not want to think he had bad cells in him every day.

He was incontinent for 6 months and he had erectile dysfunction ever since.  My dad is now 80.  He has not had a day in the hospital since.

John B

My dad is happy because he has found medical solutions for the impotence and he is alive 20 years after diagnosis. One of the reasons I can resist the urge to overgeneralize his example to my patients is that he did not have a PSA before the DRE. The thing that haunts me is that he lives in a part of the NY/NJ area which is notorious for procedures and over treatment. I have rarely heard of a prostate with a palpable finding and a PSA as low as his and a Gleason’s score as low as his. Did he get told “ I think I felt something” in order to justify a PSA (because your son is a doctor) which was just high enough to justify a biopsy, which found a tiny nest of cells. Maybe I caused the cascade of interventions?--John
But do you think getting a annual screening PSA saves lives?

When we give balanced counseling in a condition where we really believe one of the two options is untrue then we are being dishonest with ourselves or dishonest with the patient. 

We use hyperbole in ethics arguments to make a point but for the sake of argument:

If you think PSA does not save lives why would you offer it to a patient? If you think the research is wrong then do the PSA. 

If you think PSA does not save lives but you think the patient believes the opposite, then the counseling is a comparison of your belief and the patients belief. 

I find a patient centered path to decisions often in cases where the patient believes the opposite of what I believe.

John Bucek

Index--Med4  Uninsured, Medicos No Fly Zone
Love Affair with expensive and unnecessary testing continues

Sacred Cow Down For The Count

Medicos NO Fly Zone 2001. Medicos faculty got grief from the medical students and residents when we refused to fall in line with conventional academic wisdom at that time. One gave a poor rating based on unscientific teaching.... But things appear different in 2011
 
Sacred Cows may be Bull.
 
USPSTF Finds Little Evidence to Support Advising PSA Screening in Any Man
Anita Slomski
JAMA. 2011; 306:2549-2551.

Index--Screening fallacies, PSA

OB Compensation Rates

This was sent from a friend of mine who is looking for a job.
 
"Do you know where to find going compensation rates for FP w/OB and FP w/OB w/C-sections?"
 
Can anybody help?

S Forman
 

CMS has a site where you can look up physician fee schedules based on CPT
codes, ie NSVD no prenatal care, NSVD with PP care, C/S etc. He just needs
those codes and he can look up what CMS pays. This isn't private payor
and usually that is a little more. Here is the link:
(https://www.cms.gov/apps/physician-fee-schedule/overview.aspx)

Dolores

Family Medicine Obstetrics

There are so many intangibles associated with family medicine obstetrics and surgical family medicine obstetrics, that base salary is poor surrogate for the evaluation of any particular position. There are other professional assets and risks which should to be tallied.

Guaranteed-in-writing OB privileges based on current training,education,and proven ability before you move--If not STOP

Who covers the ectopics, bladder perf's, others? Is FP allowed to do them, do you transport, or is there a friendly surgeon? No emergency plan--STOP

Family practice group with at least one FP with Cesarean privileges--add 2 points
working for an OB-Gyn take away a point
working for a corporate hospital= neg
NHSC= neg 2 points
Will you glorify your spiritual goals--Priceless

Obtain data on last year's delivery volume--take away points for too many and too little; latter will not be sustainable and you will be sad to learn of hospital's plan to close OB in 2014.

Obtain data on the average reimbursement per delivery for the last year? Do the arithmetic.

Does the practice utilize coding savvy strategies about V23.89 situations? Are you allowed to manage GDM within family medicine or must they be referred?

call group too 1-3::: --take away points contingent upon your family situation, ambition, and health; or add points if total delivery volume is 120-150 per year. Goal 50 deliveries per year per MD; top end varies but you need to know your limits. Average pure OB in the USA does 11-12 per month.

Incentives for productivity with a clear system of accounting=+
Incentives for each delivery and Cesarean=+
No fair incentive for after hours and weekends = neg

Factor in physicians right to collect on ancillaries--office surgery, ultrasound scope of practice issues; No rights for revenue sharing of ancillaries = negative

Do have the right to manage the subsequent well child product or do these kids go to the corporate pediatrician-- if so your revenue is less= negative

What state are you in and what is the cost of average insurance with and without OB; you need to know what is paid for the margin needed to cover the OB portion; Do you expect $1M/3M annual or will you demand more coverage? Will the group require that you pay for more coverage?

Who pays the tail and what does it cost after 3,5, and 10 years?

And more

With best wishes for your professional success
Witness Protection Program
El Vez de la Noche
Memphis, Nashville, and International

 
I would like to, respectively disagree with one score . . . the neg 2 for NHSC.  I work for the CHC in Salt Lake City.  We have had NHSC loan repayment most of the 22 years I have worked here.  It is a great place to work, and we have a long hx of long tenure amongst our docs.  I am sure there are places that would not fit this description, but a blanket score making NHSC the single largest negative score seems over the top.
 
One benefit of working for a CHC (with or without loan repayment) is that it is the one place where, with FTCA as malpractice coverage it is possible to do OB part time!  With no direct malpractice insurance it is possible for folks with young families or slowing down, or for whatever to do "enough" ob for clinical skills without having to do "enough" to cover a malpractice annual differential and there is never a tail.
 
Keith Horwood, MD

WMR Replies:
 
Fair enough, and I agree that NHSC is a noble endeavor, but, 1990--2010, of 8 NHSC-bound physicians we trained to be capable of surgical family medicine obstetrics, only two could be placed in a location where they were allowed to do any Cesareans.
 
Last year our NHSC placement did a total 3-4 deliveries for the year. This occurred after a lengthy written process in which many things were promised, but not delivered. I would welcome a list of NHSC assignments where our graduating fellows can indeed do all of the things we train them to do. I would be the first to help recruit for these places.
 
Could you tell me the name of a malpractice company in Utah,and what they charge for an average FPOB policy?

I have personally shopped for and purchased OB malpractice policies for people who work part time. I bought one this year. Physicians without any incentive to investigate options, particularly those bound by corporate[not NHSC] contracts, make poor shoppers.
 

How It's Done--Profit For BigPharma

Yesterday I saw another tragic  uninsured patient who had been given a $500 per month prescription for Vicoza by the nurse practitioner who works for an endocrinology specialist. She thought is was "insulin" and "vital" to her Type 2 DM [HgbA1c = 7.2]. Bipolar and in tears.

 Today another bipolar with 4 subspecialists. She had been given Zenpep samples for her chronic dyspepsia/abdom pain with no pathology after multiple endoscopies and a hysterectomy.

Her medicaid will never cover this, and they are correct not to cover it. She also received an Implanon for the possiblity of endometriosis. Nice touch by her Gyn specialist who found something "new" to do.

 The pharma reps continue to wine and dine the subspecialists leaving behind a trail of incredibly expensive meds with little documented value for the patient. But it is "new", and hope springs eternal for these chronically suffering patients. The subspecialists disavow any responsibility for the chronic psychosocial comorbidities since it belongs to the patient's "primary care provider".

 

Science can be "purchased inside the university. The Abramoff lobbying of congress story demonstrates how health care expenses are made mandatory. This was one of the big drivers of wasteful spending 1990-present. Fragmented Care is a profit center, and many Memphis patients lack the sophistication to understand these issues..

 

The Texas governor's chief of staff received a triple digit salary with Merck after he juiced legistlation making Gardasil purchases mandatory for all Medicaid children in the state(subsequently repealed).

 

WMR

 

 

 

 

60 Minutes ----CBS 2011[original  article abridged and changed by wmr--editor of what follows]

Shocking story of former super political lobbyist Jack Abramoff in which he explains how he influenced Congress for years; was caught breaking the law and sent to federal prison. He shares many of the dirty secrets that he and other lobbyists use to steal the government away from you. Since he already served prison time for this, he can’t go back to jail for what he reveals

The pharmaceutical industry is the largest lobby in the U.S. Last year, the industry spent over $244 million lobbying for favorable legislation and tax breaks The most effective strategy employed by industry and lobby groups is the promise of extremely lucrative jobs once their service on the Hill is over. Similarly, revolving doors between industry and the federal agencies that oversee them have caused untold harm by hampering health freedom and promoting corporate interests According to Abramoff, to curtail this type of corruption within the halls of Congress, members of Congress and their staff must be prohibited from ever becoming lobbyists once they leave office

CBS News correspondent, Lesley Stahl, was visibly shaken,...angry...with the system he represents.

Interestingly, 60 Minutes ....showed how many in Congress perform insider trades from privileged information they have access to. And it's legal for them to do so. Any other private citizen would serve serious prison time for doing this, but Congressmen get to brag as to how much they made from their insider trades.

By plying Congressmen and their staffers with gifts, from meals to use of private jets, Abramoff was able to have significant influence over about 100 congressional offices—a failure, according to his own standards, as there were still 355 offices that he did not control.

In return for gifts and special treatment, the Congressional members he had pocketed would vote yes for legislation and tax breaks that were favorable for his clients.

It was easy—and lucrative. Abramoff made about $5 million per year during his lobbying heydays. Then, five years ago, it all caved in. After a very public scandal, he pled guilty to corrupting public officials, tax evasion and fraud.

He served three-and-a-half years in a medium security prison in Maryland. He now blames his unscrupulous actions on being so far into debt that he lost his ability to discern right from wrong. In fact, at the time, he believed he was one of the more honest lobbyists around. He claims he was "blinded" by what was going on, and states that virtually all Congressmen are able to rationalize their behavior as well. They don't necessarily feel guilty at all about the fact that what they're doing is undermining the basic structure of the United States.

If this doesn't disturb you, I don't know what will—especially when you consider that as of 2011, there are an estimated 12,220 other Abramoff's out there lobbying Congress and federal agencies for various industries.

Which Industry has the Greatest Control on Capitol Hill?

The pharmaceutical industry is the BIGGEST political lobby in the US. There should be no doubt about the power the drug industry wields in shaping the U.S. health care system, and political lobbying is one of the primary reasons why the drug companies are controlling nearly the entire the health industry.

Last year, the pharmaceutical industry as a whole spent over $244 million on lobbying, and that's just the dollars-and-cents influence that what was reported. As Abramoff explains, there are other methods that are FAR more effective for getting desired results, which I'll get to in a moment. In addition, federal candidates received over $15 million in political contributions last year.

The lobbying expenditures and political contributions for the top three pharmaceutical companies for last year were as follows:

Company	Pfizer	GlaxoSmithKline	Sanofi-Aventis
Lobbying expenditures	$13.3 million	over $6 million	nearly $7.6 million
Election cycle political contributions	over $1.1 million	$606,000	$87,000

 

Compare this to the biotech industry giant like Monsanto, which spent about $5 million on their lobbying efforts in 2010.

All of this adds up to some serious cash. In just one decade, from 1998 to 2008, the pharmaceutical industry alone spent $1.5 BILLION on lobbying for legislative favors and tax breaks. And that's just one industry, albeit the most generous one!

The pharmaceutical industry's power and influence over government and the field of conventional medicine is in a class of its own. Most people don't realize the staggering magnitude of their financial influence and massive marketing efforts. Similar to the medical profession,there are saints and sinners. Although there are genuine contributions, most of the new drugs and vaccines are marketed to create a perception that the industry is "helping mankind." The genuinely helpful new drugs are in the minority.

Lobbying Pays Off BIG Time

Although the dollars the pharmaceutical companies spend on lobbying are astronomical by most people's standards, they pale in comparison to the profits this industry generates. And there can be little doubt that their stratospheric profits are in large part due to the financial influence and control they wield over Congressional members and other federal agencies.

As of 2009, the global market for pharmaceuticals was worth more than $837 billion, and is expected to reach $1.1 TRILLION in 2014.

A trillion dollars is one million million…

To put these mind-boggling numbers into a more comprehensive perspective, the pharmaceutical industry is worth more than the gross domestic product (GDP) of 168 different nations on this planet (individually, not collectively). That's right—if Big Pharma's global market was compared to the GDP—the market value of all the output produced in a nation in one year—then Big Pharma would rank # 15 on a list of 183 nations.

That's how BIG a $1.1 trillion dollar industry is!

The MOST Effective Lobbying Does Not Involve Money…

The vast amounts of money spent on lobbying, however, is not the most effective lobbying strategy. The ultimate "weapon" doesn't involve gifts or money exchanging hands at the time. No, according to Abramoff, the BEST way to get a Congressman or Senator to do his bidding was to extend a lucrative job offer. For example, promising a staffer a job once they were done serving the Hill—which could triple their salary—would always seal the deal. As Abramoff says, from that point on, he "owned" them, and whatever he wanted done for his clients was done… and then some.

Lobbyists often craft purposefully nebulous language to change the US code to specific ends of industry, and these amendments are then snuck into various bills, which no one read before passing.

The same shenanigans occur between other federal agencies and drug companies. For example, the revolving door between the U.S. Food and Drug Administration (FDA) and various drug companies and other industries, such as the biotech industry, has done untold damage to public health and health freedom. It is very common for high-ranking FDA officials to get lucrative consulting positions with the drug companies after they quit.

The converse is also very common. Federal officials can get paid millions by the drug companies before they make the switch over to the FDA, like the current FDA Commissioner Margaret Hamburg did with Henry Schein.

Is There a Solution to This Travesty?

"Our system is flawed, and has to be fixed," Abramoff says. "Human beings populate our system, and human beings are weak."

And lobbyists are masters at preying on those weaknesses. After the scandal that sent Abramoff to jail, Congress instituted a package of reforms to stop this kind of bribery and corruption.

But according to Abramoff, nothing has changed.

"They're faux reform efforts," he says, because the people making the reforms are the ones affected by them! For example, you can no longer legally take a Congressman out to dinner or lunch—as long as it's a sit-down meal. But if the meal is consumed standing up, it's still perfectly legal. So a lobbyist can take a Congressman to a fancy fundraiser serving finger-food, and hand them a large check, and it's perfectly within the law.

According to Abramoff, in order to have even a remote chance of ending this kind of corruption, we must first prohibit all members of Congress and their staff from ever becoming a lobbyist after their service on the Hill is over…

The good news is that increasing numbers of people are now waking up to these harsh realities, and you, being among those who are informed, can help share this knowledge with others. Remember that the definition of fascism is a government system that has complete power in regimenting all industry and forcibly suppressing opposition and criticism. What we have here is a hybrid—a sort of corporate fascism, where industry has powerful control over government, and forcefully suppresses anything that threatens their monopoly on profits.

This is one of the reasons I was so surprised to see this interview on CBS. I was fairly convinced that the government had more control over the media and would prevent the airing of this type of information.

Index--Big Pharma, vaccine profit, Med4 Uninsured

Sedation/Analgesia

Question:

There is a shortage of fentanyl and versed and I am exploring alternatives for endoscopy. My thought is to try valium 10 mg IV 30 min prior to procedure then use morphine in 2.5 mg IV increments during the procedure. Or possibly dilaudid in 0.2 mg  IV increments. Any thoughts or experience with this?

Thanks
Ernie

WMR Replies:
 
Medicos recommends  2.5 mg increments of diazepam concurrently with the 25 mg increments of merperidine. Colonosocpy is started concurrently with the 2nd increment and we lose no time. EGD  takes 5-10 min before we are ready to go. Usually I am doing  paperwork in the Office OR , and no time is lost while the physician actively supervises the administration of these drugs.
 
Special issues---BUT, Surgical Family Medicine is vastly different than surgical GI endoscopy in that FP's are regularly uncovering previously undiagnosed issues such as latent alcoholism, anxiety neurosis, off label uses of xanax from the street, domestic abuse, etc. Then again there are the bipolar patients who must have their sedation/analgesia and recovery carefully tailored to their unique biochemistries.
 
 
What's your opinion on propofol?  Rapid onset, rapid recovery.  Easy to dose.  Low side effects.  Wide margin for "error".  I've begun to use it frequently for procedural sedation.

Omar L. Hamada, MD, FAAFP, FACOG, FICS
Vanderbilt MBA, 2012

 

WMR Replies:

Good drug whose reputation has been contaminated by the Michael Jackson case. What does it cost you to use it?

No idea.  :-) Mainly in ED.

Omar

WMR Replies:

Propofol and alternatives are discussed below. Note physician who uses it but does not have any idea of cost. We hope that physicians will find positions where they are vital to the review of efficacy, effectiveness, availalbility and cost.
 
The disconnect of physicians from cost is one of the reasons that we are skeptical of recommending common USA methods for our brothers and sisters in developing countries. At Medicos we are always asking if we should teach this method or another.
 
Propofol is a poster child for this dilemma. ESSURE is another problem child for international efforts. The tubal occlusion devices cost $1400 and the follow-up is incredibly difficult. Propofol is not something we would pack when travel restrictions limit the weight and space of supplies.
 
Science is one consideration, but cost and availability frequently cause us to teach methods which are adequate even when other methods are possible.

Index--GI endosocpy, sedation/analgesia, office anesthesia