What to do with abnormal PSA results in a young man

A 45-year-old man in excellent health with no family history of prostate cancer had a screening PSA done three years ago which was in the range of 4.0 ng/mL. He has been followed by a urologist, and the test was repeated several times without much change.

In June of this year, his PSA was 4.6 and the free PSA was 0.6 for a ratio of 0.13. He was given a course of antibiotics for presumed prostatitis, and repeat testing a month later showed a PSA of 3.8 with a free PSA of 0.5. Because the PSA was less than 4, a ratio was not calculated.

The patient obtained copies of the reports. The from June one states the following: "When total PSA is in the range of 4.0-10.0 ng/mL, a free PSA/total PSA ratio of less than or equal to 0.10 indicates a 49% to 65% risk of prostate cancer depending on age. A free PSA/total PSA ratio of greater than 0.25 indicates a 9% to 16% risk of prostate cancer depending on age." It does not comment on the significance of a ratio of 0.13, which I have looked up. The cancer risk is in the area of 20%-25%. However, no source gave estimates for men under the age of 50.

On examination, his urologist can feel no nodules. He has recommended that the patient undergo an MRI of the prostate.

Stating that an MRI is not indicated in a man of his age with his history, the patients insurance company will not pay for the test and suggested a trans-rectal ultrasound. The urologist advised the patient not to have an ultrasound due to his age and the potential for complications. A hospital quoted him an out-of-pocket price of $2500 for the MRI.

The urologist has told him that random biopsies may not be accurate and there is a risk of complications.

When he had his first PSA done three years ago, I had expressed surprise and wondered why it had been offered to him. The patient said his internist told him he should have the test.

He is concerned about these recent results and has asked me for advice which I am not qualified to give.

What would you advise?

Follow-up August 6, 2014

Numerous urologists responded on Twitter with more than 60 tweets about this post. Suggestions for the next step were as follows: trans-rectal ultrasound (TRUS) and biopsy as mentioned by Dr. Cooperberg below; going ahead with the MRI; repeating the PSA in 3 months; go for a second opinion by a recognized expert in prostate cancer.

One urologist emailed me to point out that even if the patient has cancer, it is probably not an aggressive type because his PSA has not risen in 3 years.

Another urologist gave me the name of an expert in the patients geographic area. 

The patient has already scheduled an appointment for a second opinion.

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Do surgeons still do postop care

Heres an email I received the other day (edited and posted with the authors permission):

I am a recently retired internist. I have noticed some evolving trends over time and had an interesting experience that illustrates this issue.

A 77-year-old friend went for check up due to urinary incontinence. He was found to have a large prostate and a PSA of only 2 so was given Flomax . This helped somewhat.

At the time, an asymptomatic hernia was found. He was immediately scheduled for surgery which went well. His Foley was removed, and he was sent home.

At home he could not void, called the surgeon, and was told to go to the ER, There the Foley was replaced, and he was to see his urologist in 2 days. The urologist removed the Foley. Later he was in agony and walked the floor all night. He called the urologist and the service said that the office was closed. He was told to drive to the other office in the next town only 15 miles away. They replaced his Foley again.

Two days later he went to the surgeon who did the hernia repair and explained his postop adventures. The surgeon said, "Those things have nothing to do with the surgery. Your wound looks fine."

Things have changed. IN THE OLD DAYS:

• After surgery, patients were not sent home until they could eat, void, and walk. Those days are history. 
• Surgeons took care of their patients post op. Those days are gone.
• Urinary retention was a recognized complication of hernia repair, especially in someone with known BPH. Are those days gone too?
• If you sent someone home after pulling the Foley, you waited till the patent had voided being aware that massive urinary retention has the potential to induce damage to the bladder muscle itself (He had retained over a liter of urine) as well as cause great pain and distress.

I am aware that surgeons are not paid for postop care, but the global fee includes the surgery and the postop care (Follow the money). Hospitals need beds for new patients (Follow the money). [Dont forget that third-party payers wont fund any extra time in hospital.]

Are surgeons no longer trained in post op care? Are surgeons not exposed to the concept of surgical complications? Isnt it interesting how things change for the worse and nobody notices?

I wondered if the friend had really needed the herniorrhaphy. The writer replied:

I looked up that question and found that only 1% of hernias need surgery by becoming symptomatic. I mentioned this to my friend, but he had been "seduced" by the authority of the surgeon who acted as though not operating was inconceivable.

I once had an echocardiogram for occasional PVCs (probably not indicated). The tech discovered gallstones. Within an hour, a surgeon stopped me in the hall and wanted to remove my GB. (So much for privacy!) As luck would have it, I had had the experience of caring for patients who had had GB surgery and had terrible results involving damage to the hepatic duct resulting in liver failure and jaundice. I looked it up and found that asymptomatic gallstones may not need surgery. I have done fine for 30 years. (Knock on wood.)

I think no postop care by the surgeon is "THE NEW NORM."

As a hospitalist, I was assigned to care for surgeons postop patients—one reason I finally retired. This was challenging at times. For example, one day a lady had a tummy tuck by a plastic surgeon. I was "consulted" to follow her and noticed her Hct had dropped. After investigating, I concluded that she must be bleeding into her wound. The surgeon never saw the patient post op. A nurse practitioner saw her but was clueless. I called the surgeon but no response came. When her Hct got down to 25, I gave her some blood and she stabilized and went home. A month later the surgeon stopped me in the hall and said when he had taken out her stitches, a huge amount of black gook plopped out. "She had a wound hematoma," he said. "Thanks for taking care of it." He was not embarrassed at all. I guess my caring for this was the new norm.

Stuff like this happened too often. If I called another surgeon for help they always refused. There was nowhere to turn.

In my fairly extensive experience, postop care by the surgeon is now seen as optional. Hospital employed surgeons are expected to operate, and NPs and/or hospitalists [Dont forget the PAs.] are assigned to do the postop care. This permits more surgeries (revenue).

On a more philosophical note, I am fascinated how "standards" change right before our eyes, but the process goes on unnoticed, slowly, almost invisibly. Then a few people speak up. They notice things. But it doesnt pay to agree with those people. Eventually, the process becomes obvious, and everyone says, "You know what? Health care in America really sucks. When did this happen?"

Are surgical residents being trained in postop care? Do surgeons no longer take care of their patients? I think this is true in orthopedics and plastics. Has it spread to general surgery too?

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Should radiologists tell patients their test results

Radiologists discussing test results with patients, a subject that has been lurking under the radar for a while, recently came to light because of an article in the New York Times. The idea is that patient anxiety while waiting to find out a test result could be alleviated by an immediate discussion with a radiologist.

That would be very nice, but there are potential problems, some of which are detailed in a post that appeared on the website of The Advisory Board and others in an editorial by radiologist Saurabh Jha accompanying a paper on the subject..

In the Times, Dr. Christopher Beaulieu, chief of musculoskeletal imaging at Stanford, said, “[T]he radiologist may be capable of transmitting the information but the obvious next question for the patient is, ‘What do I do now?’ which, as nontreating physicians, radiologists are not trained to answer.”

Both The Advisory Board and Dr. Jha speculated about the potential liability exposure of a radiologist whose advice might differ from that of the referring doctor causing concern for the patient and hostility from the doctor.

Unless the radiologist performs a history and physical examination, he will not know much about the patient. A lack of clinical context might cause a radiologist to misinform the patient.

Heres a scenario. A radiologist tells a patient she has a suspicious mass in her adrenal gland on a CT scan but cant tell the patient what should be done about it. Instead of anxiety about not knowing the test result, the patient would then have anxiety about having a mass and no plan to deal with it.

What about incidental or equivocal findings? Dr. Jha wrote, "Such findings, for example, could potentially, albeit immensely improbably, turn out to be cancer. Radiologists will find that the burden of ‘clinical correlation’ will fall upon them, and this task will be all the more challenging at a single time point."

A study found that a radiologists discussion with the patient about a CT scan took a little more than 10 minutes. Would that time be reimbursed and if so, how? Dr. Jha pointed out that the discussion would have to be documented and the decrease in radiologist productivity would have to be made up somehow.

Since they rarely, if ever, talk to patients, radiologists may be extremely uncomfortable with this new role. Ive known a few radiologists who are not even comfortable talking to other physicians. Many radiologists dont choose a career being sequestered in a dark room because they are "people persons."

The Times article described one patients interaction with a radiologist. He said the radiologist "seemed physically afraid of me."

The real solution is for radiologists to communicate more rapidly with referring physicians and for those physicians to communicate more rapidly with their patients.

Here is what needs to happen. 1) A critical or unexpected result of radiologic examination should always be immediately discussed in a telephone call from the radiologist to the doctor who ordered the test. 2) Every doctor or her staff must promptly communicate the results of any radiologic test to a patient.

If those actions occurred on a regular basis, radiologists wouldnt need to talk to patients, and litigation due to overlooked important findings could be avoided.

So what I really would like to see is pathologists talking to patients.

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Improving the M M conference

"Surgical pathology works more than 80 hours per week, has no regard for your gender or your life situation, and can be devious and sneaky in its presentation."

The following is a guest post by Dr. Leo Gordon, a surgeon from Los Angeles.

A recent paper in Annals of Surgery found that 24% of graduating surgical residents "were unable to recognize early signs of complications." One possible solution is a redesign of the morbidity and mortality (M&M) conference .

I have spent a significant part of my professional life in an effort—at this point it is a crusade—to change the nature of the M&M conference. For 11 years, I moderated 495 conferences, 1485 presentations, and 30 written examinations based on the error and complication-reducing points raised during the discussions.

If properly implemented, a redesigned M&M conference can satisfy the ACGME core competencies, the suggestions of the Institute of Medicine, and the publics demand for a reduction in medical errors.

What I have dubbed the "M&M Matrix" converts the weekly conference into a vibrant educational effort and creates a constantly updated patient safety curriculum for the resident and attending staff.

If the M&M Matrix is such a valuable idea, why hasn’t it been widely adopted?

Here are the reasons:

1. Implementing the M&M Matrix is a ton of work.

Setting up this program and changing the culture of a traditional conference requires acceptance at all levels of the department. It is a week-long effort, not a one-shot Tuesday morning flirtation with surgical education. To pull this off, someone is going to have to be paid, which is a stumbling block. The residents have to buy into this program. It is more work for them, but think of the benefits of the cautious analysis of a complication. Most departments look at the concept, realize how much work it will take, and revert to the traditional conference.

2. The M&M Matrix requires a moderator with specific talents.

Effective moderation of this conference requires a certain set of skills that not every attending surgeon possesses. The moderator has to select educationally valuable complications to discuss. The moderator has to…well…moderate the conference, focus on worthwhile comments, recognize the difference between a legitimate statement and the sweet reverie of surgical anecdote, and do it in a respectful manner. The moderator has to summarize the conference in a HIPAA compliant manner, distribute the teaching points, and construct an examination based on the conference.

3. The M&M Matrix relies on a structure of classic surgical education, a structure suffering advanced erosion.

I am entering my 36th year of practice. My view of surgical education is inconsistent with work-hour restrictions, life-style considerations, hand-offs, and current methods of patient care. I view the discipline of surgery as an effort to eradicate surgical pathology. Surgical pathology works more than 80 hours per week, has no regard for your gender or your life situation and can be devious and sneaky in its presentation. The method of assessing the effects of surgical pathology should be just as rigorous. I hate to fall back on a military analogy, but the M&M conference should be a boot-camp or basic training for the real war.

4. There is no statistical proof that the M&M Matrix decreases the incidence of complications.

The academics and statisticians have got me here!

How do you get inside the head of a senior resident as he is digging out the left colon in a tough diverticulitis case and show that in that fecund mind, because of this educational format, the resident is thinking:

"Gee, we discussed a lacerated ureter a few months ago. Remember the techniques of assessing the ureter that we discussed at the Matrix Conference? Didnt the outline we got and the test questions suggest that we should identify the ureter above and below and make sure we stay close to the colon?"

How does one quantify that a complication was avoided because of an educational effort?

These four reasons for lack of wider adoption can be overcome by a thoughtful analysis of the benefits of a redesigned conference. Given the current problems confronting surgical education, I believe that the idea will be re-evaluated and will eventually be adopted.

Time will be increasingly valuable in upcoming 60-hour work week. The hour allotted for the analysis of surgical complications has to be leveraged into a durable learning experience.

The incoming president of the American College of Surgeons, Dr. Andrew Warshaw, has chosen Dr. Ernest Codman as the subject of his presidential address. Dr. Codman invented the M&M conference. He conceived and implemented it, and in so doing improved surgical care. I hope that Dr. Warshaw’s remarks will spark a renewed interest in a re-design of the M&M conference.

I have a viable plan. Now I need the support to implement this plan. Perhaps I can complete Dr. Codman’s work!

If you have an opinion about the M&M Matrix, please comment below or contact the author—LeoGordonMD at gmail.com

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