Saturday, April 18, 2020

More Disrespect For Primary Care Docs - NEJM Article On PSA Screening

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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