I don't
get no respect!
Thanks
for that mantra, Rodney Dangerfield. Primary care doctors, regarded
as the heart of the health care system by the enlightened, still get
no respect from their specialist brethren, and the New England
Journal of Medicine editors allow it to continue.
Screening
for prostate cancer with a PSA test is a difficult and contentious
issue. Opponents have several issues, but I have always gotten the
test personally, on the recommendation of my urologist, because we
think we can handle the results intelligently, not leaping blindly to
unwarranted biopsy and other measures. In short, my urologist Joel
is smart, I am smart and a doctor, and we can handle it. Most of the
objections center around poor decisions made by those less informed,
so we just go ahead and get the test, which has always had a
reassuring result. Simple reassurance has its own value.
The NEJM
article, Reconsidering
Prostate Cancer Mortality -- The Future of PSA Screening,
considers what doctors should do if they insist on getting the PSA
test. It is here that they stumble into insult. Here's my letter I
sent in the NEJM:
The
authors of this well-reasoned article perhaps inadvertently impugn
the abilities of primary care physicians when they patronize them in
searching for an “approach … (that) is simple and easy to
remember,” suggesting that they refer the patient when the PSA gets
to 10. Specialists are more capable, they imply, so they can pay
attention to the rate of increase of the PSA, the age of the patient,
and perhaps even order a free PSA and an MRI.
How
insulting to generalists! The authors should be reminded that all
primary care is not (yet) dispensed by unsupervised PA's at CVS.
It looks
to me as though advocates for primary care still have a long way to
go.
Budd
Shenkin
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