Must clinicians who believe PSA tests are unnecessary and unreliable let liability fears override their clinical judgment?
For more than 30 years, most of the patients in Dr. R's thriving primary care practice had been of retirement age. Now that he was 62, they were his contemporaries. Dr. R treated patients the way that he wanted to be treated— with respect and without unnecessary tests.
PSA tests fell into that category. While his regular check-ups for male patients included digital rectal examinations, he did not order PSA tests routinely. He had seen too many false positives resulting in uncomfortable and stressful prostate biopsies that usually turned out to be negative. In addition, Dr. R believed that if prostate cancer did develop in his geriatric patients it would most likely be slow-growing and not fatal.
Many clinicians share these views. Dr. R never expected that they would result in a lawsuit, but that's exactly what happened.
The plaintiff, Mr. U, was a former patient, an African American who had seen Dr. R for routine physicals and diabetes care for about seven years. Their doctor-patient relationship had been good. When at age 63 Mr. U moved away, Dr. R was sorry to see him go.
A year after his last office visit with Dr. R, Mr. U went to a Veterans Affairs clinic. There, he was given a PSA test for the first time, and the results indicated a PSA level of 74. A week later a second test showed a PSA level of 85. The subsequent biopsy was positive for prostate cancer.
The clinic doctors told Mr. U that a prostatectomy was not an option because the cancer was too advanced. He was offered either radiation or hormone therapy. Mr. U chose the hormones. While this treatment initially worked, his PSA levels began to rise again after a year, indicating that the cancer had become hormone refractory. The clinic doctors informed Mr. U that his prognosis was poor, predicting two years of survival at most.
Distraught at this devastating news and angry that the cancer had been diagnosed too late for effective treatment, Mr. U and his wife consulted a plaintiff's attorney. She hired a physician who concluded that Dr. R had been negligent. Armed with that opinion, the lawyer launched a malpractice lawsuit.