Dr. David Merenstein’s Journal of the American Medical Association article (“Winners and Losers”, JAMA. 2004;291:15-16, reprinted here), first noted here Jan. 14, continues to be the source of discussion in the medical community.
To recap: prostate-specific antigen (PSA) tests for prostate cancer have well under 100% accuracy. A majority of men with an “elevated” level of PSA do not have prostate cancer, and, for some, the only possible follow-up is a discomforting biopsy that often results in complications. Because of the high rate of false positive results, the questionable accuracy of the test, plus the expense and uncertain impact of drastic treatment on survival of prostate cancer, medical experts differ on whether PSA screening should be routine: the American Cancer Society says yes, the American College of Physicians, National Cancer Institute and U.S. Preventive Services Task Force say no.
Dr. Merenstein saw an educated 53-year-old who had never had a PSA, and discussed the risks and benefits of PSA screening with him. The patient left, and never saw Merenstein again. Later, another doctor simply ordered a PSA for the patient, and the patient was eventually diagnosed with incurable advanced prostate cancer. A lawsuit ensued, with the plaintiffs’ lawyer convincing a jury that “evidence-based medicine” was grounds for a $1 million verdict against Merenstein’s residency program. As Merenstein notes,
During that year before the trial, my patients became possible plaintiffs to me and I no longer discussed the risks and benefits of prostate cancer screening. I ordered more laboratory and radiological tests and simply referred more. My patients and I were the losers.
The risk of course, is that doctors could be held liable if they take advantage of new evidence for the care of patients if, in hindsight, a more traditional course of treatment could be argued to have given a different result.
Doctors are understandably outraged; there is even commentary in Germany. (Robert L. Edsall, “The Evidence-Based Medicine Heresy”, Family Practice Management, Feb. 2004; J. Michael Pontious, “Profoundly Disturbed”, Oklahoma State Medical Association Journal, Jan. 2004; “Kevin, M.D.” blog, May 20). Dr. Merenstein briefly follows up in response to a number of letters to JAMA. (“Evidence-Based Medicine on Trial?Reply”, JAMA. 2004;291:1698).