I came across this case from JAMA in January, 2004. Here are the basics:
1) A third-year resident, Dr. Merenstein, saw an educated 53-yo man for the first time at his resident clinic. A PSA level had never been done before.
2) A documented discussion about the risks and benefits of screening was done, and the patient was enouraged to consider the information. He was never seen by Dr. Merenstein again.
3) The patient was later seen by an older doctor who, disregarding current clinical guidelines, ordered a PSA without discussing the risks and benefits.
4) The PSA came back high and the patient was diagnosed with incurable advanced prostate cancer.
5) Dr. Merenstein and the residency program were later sued, with Dr. Merenstein being “exonerated” and the residency found liable for $1 million.
The physician’s actions are supported by the USPSTF and the ACP‘s guidelines for prostate cancer screening.
Unfortunately, the concept of evidence-based guidelines did not stand up well in court:
. . . A major part of the plaintiff’s case was that I did not practice the standard of care in the Commonwealth of Virginia. Four physicians testified that when they see male patients older than 50 years, they have no discussion with the patient about prostate cancer screening: they simply do the test . . .
. . . It is often claimed that malpractice is a mechanism for holding physicians accountable and improving the quality of care. This case illustrates quite the opposite: punishing the translation of evidence into practice, impeding improvements to care, and ensconcing practices that hurt patients. In our legal system, the physicians who are slow to change are the winners . . .
. . . During closing arguments the plaintiff’s lawyer put evidence-based medicine on trial. He threw EBM around like a dirty word and named the residency and me as believers in EBM, and our experts as the founders of EBM. He defined EBM as a cost-saving method and stated his belief that the few lives saved were not worth the money. He urged the jury to return a verdict to teach residencies not to send any more residents on the street believing in EBM . . .
Think about that last statement for a moment. Do physicians tell lawyers how they should be trained? I find it disturbing that lawyers feel they are entitled to dictate how physicians are trained.
Dr. Merenstein sums up the moral of the story perfectly:
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.
