Expert: Communication Is Top Fix for Prostate Care Allegations

On today’s podcast, we welcome one of the foremost authorities on prostate cancer detection and staying out of court. Dr. Marc Garnick is Gorman Brothers Professor of Medicine at Harvard Medical School and a medical oncologist at Beth Israel Deaconess Medical Center in Boston. And we will also be joined by special guest Dr. Matt Germak, a med/peds primary care doctor in Boston and the Vice President of Patient Safety at CRICO in the Harvard medical community.

Matt, I’m so happy that you’re with us today and leading our discussion with Dr. Garnick. Welcome.

Matthew Germak, MD
Thank you, Tom, and thank you, Dr. Garnick, for joining us today.

Marc Garnick, MD
Thank you.

Matt
CRICO is the medical malpractice insurer for the Harvard Medical affiliated hospitals and organizations. At CRICO our primary aim is to learn from our malpractice data to support clinicians, improve patient safety, and mitigate malpractice risk.

For primary care clinicians, a top risk area is related to allegations of delayed diagnosis. The most common final diagnosis within these cases is cancer. The top three cancers we see are prostate, lung, and breast cancer.

Marc, you have a lot of experience in providing expertise on critical issues when a physician or organization is named in a malpractice issue related to prostate cancer screening and diagnosis. Where do you see the biggest challenges in malpractice cases with an allegation of a missed or delayed prostate cancer diagnosis?

Marc
Yeah. As you mentioned, the two largest categories are failure to diagnose a particular cancer, in this case prostate cancer, or a delay in the diagnosis. So for example, a patient will have a PSA value that will be outside the normal values. And either a physician doesn’t see it or he thinks that the patient’s primary care may be taking care of it. And it’s overlooked. And the patient comes back sometimes often with visits to that physician. And again, it’s overlooked and so over a period of time that PSA may go up and up and then the patient, unfortunately may be diagnosed with prostate cancer. And the allegation there is a failure to identify an abnormal PSA test which led to a potentially worse outcome.

The other one is that the physician doesn’t discuss the pros and cons of PSA testing, and a PSA test is not obtained. So that would be another allegation. And there are also nuances. For example, physicians may be named in a malpractice case even though the PSA may be normal, but the rate of change from one year to the next may exceed certain accepted standards.

Matt
And speaking of those standards, Marc, I know that it’s important that clinicians stay updated, with new and changing recommendations, which can be challenging at times given all the moving parts. Are there any key resources you might recommend to the primary care clinician audience, that they should be familiar with?

Marc
Yes. I think overall the one that has the largest influence is the United States Preventive Services Task Force. There are other guidelines, from the American Urological Association, the American Academy of Family Practice, the Canadians, the Europeans have their own guidelines. But for a primary care physician, I think it’s incumbent upon that person to be aware of what the US Preventive Services Task Force [says.] And I should mention that the last set of recommendations came out in 2018. And generally, what I referred to is the task force updates their recommendations every five to six years. So we are due at any moment for an update from the 2018 recommendations.

The other really important aspect is individual hospitals and institutions may have generated their own level of evidence to inform PSA screening decisions. And if that’s the case, I think it’s incumbent upon the physician to at least know that such guidelines have been proffered by the institution. And that physician may or may not agree with the particular guidelines that have been established by a large institutional organization. And that would be important in documentation, to say, I’m aware of the institution’s recommendation, and I’m going to do something slightly different.

Matt
That makes sense. Thank you Marc. And you mentioned documentation and its importance. And I want to return back to that in just a moment. But before we get to that, the communication with patients and their family members in these conversations is critical, just as important as communication between physicians and other team members.

And so, what can you say about how we engage our patients in their care, in the setting of prostate cancer screening and diagnosis, in which we assist patients to make informed decisions about this?

Marc
You know, this is one of the biggest challenges. I can’t tell you how many times the physician absolutely guarantees under oath that he or she had a discussion about PSA-based screening with the patient, and then the patient has a PSA test or does not have a PSA test. And then something untoward happens and the patient was questioned and the patient will say, and the patient’s family will say, the physician never, ever spoke to me about the PSA pros and cons of screening. And you go to the medical record and there’s absolutely no documentation of whether or not a discussion for the pros and cons and what’s the patient’s decision was took place. And that’s a very difficult position for everyone involved. And it goes to he said-she said or she said-he said and it’s an unending issue.

The simplest thing for the primary care physician to do is to use five or six words: PSA decision making discussed, and the patient either accepted or declined. As I talk about little later on, those five or six words can save five years of anxiety and angst and negative influences on the on the physician’s self-confidence and the way he or she ends up practicing.

Matt
That’s really important, Marc, and such a simple tool and reminder that can go a long way and has a lot of value in the malpractice setting. And there are tools that are based in the EHR nowadays. Most people are documenting within an EHR environment. Can you speak to tools, such as templates and dot phrases and other tools? And what are the implications? Can those help in these scenarios, or can they hurt in any way?

Marc
They can certainly help if they are utilized and they’re used as intended. If they’re there and they’re not utilized, that’s a higher level of vulnerability that a physician may have if he or she ends up being charged with a malpractice case in which the template was there, but it was not offered to the patient.

So, the other important aspect is it’s important that the physician, during a annual visit, not necessarily an acute visit for something else, document what the screening recommendations have been, whether be for colorectal screening, discussed; breast cancer screening, discussed; lung cancer screening, discussed; or PSA-based screening. And from my perspective, if the template is there, easily accessible during the clinic visit by all intents you use it. But also you should also just use the six or seven words that I mentioned previously. 

Matt
Yeah, because that’s a simple approach that hopefully is, is, relatively easy to remember and to do each and every time.

Marc
And physicians will often say, well, I don’t have enough time to discuss all the pros and cons. And I think as this discussion will go on, there are certain key areas of pros and cons relating to PSA-based screening that, in essence, take anywhere between 30 and 45 seconds to do.

And sometimes there are wonderful, you know, educational guides that can be provided to the patient ahead of time so he can read the pros and cons and, you know, come in with a more informed understanding of what the decision is: If I have a PSA, what does that mean? Will I automatically be referred to urology? Will I automatically have to have a biopsy? Will I automatically have to have my prostate taken out? I mean, so these are the concerns that patients have. And I think it’s very, very useful to give them some lay publications, of which there are many if the patient is so motivated to learn as much as he can and his family can about the pros and cons when the when the final decision is made.

Matt
That’s a great point. And, you know, in terms of efficiency and being mindful of time for the clinicians, I think there are tools that can be sort of deployed or sent to patients before office visits, for example, that they can help educate patients and make them aware of what you’re referring to.

Marc
Yes. And that was exactly the impetus for starting the Harvard Medical School Report on Prostate Diseases. It’s a lay publication. We also have an associated website on the Harvard Health website, which is user friendly for a lay audience, in which all of these issues, the pros and the cons and the nuances of what happens if you’re going to be tested with a PSA value.

Oftentimes physicians will say, well, I can’t spend the time and the person has not read all of the information before coming in the office. And so we have several simple things. We can say that the benefits of PSA-based screening is, for a thousand men over the age of 50, who get screened over 10 years, you’ll save one life over those ten years. For a thousand men screened starting at age 50 over ten years, you’ll decrease the likelihood of that patient developing metastatic disease in three of those thousand men. So those are the quantifiable benefits.

The potential harms are these treatments have consequences, whether it be erectile dysfunction and urinary incontinence secondary to surgery, or radiation damage to anterior portion of the rectal wall, the lower portion of the bladder. And, there’s also operative complications. And those risks are actually greater in patients who are over the age of 70 years old. So those are the sorts of the key factors that a patient would have to know about when he’s making a determination.

Matt
Thanks, Marc. Those are all very helpful learning points. This has been a really informative conversation. And, I really want to thank you for taking the time today. It’s been a pleasure to speak with you. Thank you.

Marc
Thank you.

Matt
Tom?

Tom
Well thank you, Matt. That was a great discussion. Dr. Germak is Vice President of Patient Safety at CRICO. And our special guest, Dr. Marc Garnick is Gorman Brothers Professor of Medicine at Harvard Medical School and a medical oncologist at Beth Israel Deaconess Medical Center in Boston.

I’m Tom Augello for Safety Net.

For an extended version of this conversation and an opportunity for online Category 1 CME, please visit www.rmf.harvard.edu/prostateCME