He told each new patient, “I have no insurance, and this place is mortgaged to the hilt. If you ever decide to sue me, there’s nothing to win.”

It may be coincidence, but he retired a few years ago never having been sued by a patient.

I have a graduate degree in health law and I understand that my chances of even having to take such a case all the way to a jury verdict are low and chance of actually losing while adhering to the guidelines of my professional society are even lower, but what I see in my professors and mentors who have been sued at one time or another makes the prospect so terrifying that when it comes time to discuss options with a patient and they ask for my view I might very well abandon all the EBM in favor of ‘peace of mind’ (the patients and mine).

Hopefully we will have an answer soon and put this finally to rest. So far the data is leaning towards early PSA screening and earlier biopsy.

“Anon at 1:43, and you also have a magic way to figure out which cases are overdiagnosis? You also don’t have your patient have a right to be informed of this potential serious risk?”

I agree that cases with well to moderately differentiated cancer in a single core of the biopsy in a young patient is a difficult situation to deal with. I strongly offer watchful waiting to a select group of my patients and some do choose this option. Of these patients, approximately half of them have seen a PSA progression and then went on to treatment and the other half are still watching their PSA. Unfortunately, prostate needle biopsy underestimates the grade of cancer in nearly 30% of patients. I inform all my patients about the potential for over treatment and the fact that they may have an “insignificant” cancer. However, lately, I have been diagnosing more frequent moderate to poorly differentiated cancer in younger and younger patients. A few years ago, I found a Gleason 3+3 cancer on biopsy in 2/12 cores in a 36 year old African American with a PSA of 7. After much discussion, he opted for a radical prostatectomy. His final pathology revealed Gleason 4+4 with extracapsular extension of the tumor beyond the prostate. His PSA recurred 6 months later. He then received radiation. Currently he is disease free 5 years out and has complete urinary continence (wearing no pads) and has erections with the aid of viagra. Thankfully, he chose treatment rather than watchful waiting. Cases like these and many others keep me going everyday, but you are right medicine is full of gray areas. That is why it is called the “art of medicine” and it is not a pure science. I suppose that is also why we go through 4 years of medical school and for an urologist a 6 year residency. I do have to admit though, after 6 years of practicing after residency, I am still learning every day.

“Defensive medicine is one of the most important drivers in rising health care costs today. There are few reliable studies to back this up. This is because defensive medicine is impossible to quantify.”

We can’t define it, but it’s definitely driving up costs significantly?