He knew he was a defeated man, succumbing to the power that he loved, and now had him sitting in my office waiting for the self-imposed doom that had weighed on his mind for over a decade.
The power that he loved, his wife, sat next to him. Just making sure EVERYTHING was done for him. “Yes, he’s here for a physical. A FULL physical. I want him checked out completely,” she said.
Not just any physical. He had just turned 50. It was that physical. The one every man flinches, and then puckers a little, when he thinks about it.
In her mind his prostate had a date. She was there to see it through. She had dutifully had PAP smears and pelvic exams over the past thirty years as a routine, birthed their babies buck naked and displayed to the world in the birthing room, and, by golly, it was now his turn.
And he knew it, too. He had learned, as most wise husbands do, that he wasn’t going to win by posturing, avoidance or denial. So he summoned the wise courage to have no stupid courage, and agreed to her request.
She had her list of his problems for me to address, offered him one more look, and left us to go back to her work. He just wanted out. Little did he know she wasn’t up to date. The Task Force had changed their recommendations.
Per their website, “U.S. Preventive Services Task Force (USPSTF or Task Force) is an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, or preventive medications.”
This is the source of the majority of guidelines that primary care physicians will use to guide their choices and treatment plans for detecting, treating and preventing illness. This is the group that stated within the past year that the old standard of the prostate blood test (PSA) and yearly rectal exam was no longer recommended as a screening tool for asymptomatic or low risk men. At any age.
Therefore, if a man didn’t have a strong family history or any symptoms suggesting prostate issues, a rectal exam (finger test) and blood work (PSA) was not recommended.
I was reminded of this at my conference last week in Atlanta. (Incidentally, driving I-75 across I-275 in Atlanta provokes a certain level of adrenaline. Driving into Atlanta with heavy sleet, snow and ice is entire new level of peachy fear. Atlantans, remembering the snow-ice debacle on their roads from 2014, were exiting their city early in a manner probably not seen since Sherman. It was memorable.)
Not many of my fellow physicians agreed with this recommendation and likely will still continue offering both to their male patients. It is a challenge to explain the reasoning of the Task Force, especially when it is so personal.
The reasoning of the Task Force is similar to the old phrase that “more men die with prostate cancer than from prostate cancer.” This, of course, is only comforting if it is someone else’s prostate.
Statistically, the risk of cancer and the potential harm that can come from testing suspicious blood tests and exams were weighed by the committee. Their comments are as follows -
“The reduction in prostate cancer mortality 10 to 14 years after PSA-based screening is, at most, very small, even for men in the optimal age range of 55 to 69 years.” Translation: a few will die, but it’s only a few.
“The harms of screening include pain, fever, bleeding, infection, and transient urinary difficulties associated with prostate biopsy, psychological harm of false-positive test results, and overdiagnosis.” Translation: there are some short term complications in pursuing a cancer that may take your life.
“Harms of treatment include erectile dysfunction, urinary incontinence, bowel dysfunction, and a small risk for premature death.” Translation: some men would rather face prostate cancer than living with erectile dysfunction and urinary leakage. Well, yes, but I’ve seen untreated prostate cancer do the same thing when it spreads. And with a lot of excruciating bone pain, too.
“Because of the current inability to reliably distinguish tumors that will remain indolent from those destined to be lethal, many men are being subjected to the harms of treatment for prostate cancer that will never become symptomatic.” True, but what if it is symptomatic? What if it is yours?
I will explain these recommendations to my male patients and their wardens, sorry, wives, and then also offer the blood work and exam if they wish to have it. Thankfully, at least to this point, we as physicians still have some choice in how we manage the care of our patients. The day of the cookbook, impersonal, data-driven medical care is upon us and rapidly taking over. Some days I feel I am a modern day blacksmith looking at the first Model T Ford rolling into town.
The simple reason I will do this is based on the one thing, the very thing that is crucial here, that all of the data, documents, digital dividing and doctoral discussions on committees cannot measure - fear. The fear of the unknown. Is it there? Is it not? Is it possible?
My experience is that patients fear the unknown much more than they fear the known. Given a challenge with an abnormal result, I have seen the most anxious patients courage-up and want to know if it is good or bad. I cannot recall one patient telling me “I don’t want to know.”
My male patient? His fear of his wife overcame his fear of blood work and exam. He’s already preparing his researched defense for next year, though.
Eric J. Littleton, M.D. (@DrEricLittleton) is a Family Physician in Sevierville, TN. His office is in the UT Regional Health Center Sevierville at 1130 Middle Creek Road. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com
