Recent developments in PSA screening point out why policy truly does matter to residents, writes Alan L. Kaplan, MD, in this blog post.
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Dr. Kaplan is a urology resident at the David Geffen School of Medicine at UCLA.
At my very first urology residency interview, the department chair asked about my interests in the field. Hoping my dark suit was masking the nervous sweat spotting underneath, I explained I was interested in health policy. Lowering his head, squinting over a pair of retro horn-rims, he responded: “Pretty early in your career to be changing the field, isn’t it?”
I ended up matching into a different program where health services research and health policy are valued but found that the resident’s foray into health policy is both novel and ill defined. It turns out opportunities for-and interest level among-residents to get involved in health policy are few and far between.
Recent events in the urologic world are shaking the ground we walk on and highlight the fact that policy does matter to urology residents. Just as prostate cancer patients need to live long enough to derive benefit from treatment, the (practice) lifetime of the urologist dictates the degree to which health policy will affect her in the future. To that end, residents should care more about policy than anyone.
But residency is busy! Between learning endoscopy, open surgery, lap and robotics, journal clubs, teaching conference, and in-service studying, learning about the abstract world of policy is low on the totem pole.
Many of us read, or at least heard about, the two recent JAMA articles documenting the dramatically declining PSA screening rates since the U.S. Preventive Services Task Force’s (USPSTF) grade D recommendation in 2012. Perhaps you even saw the quotes from David Penson, MD, MPH, who discussed the studies’ implications in a New York Times article.
But what seems to be flying under the urology resident radar is the fact that the Centers for Medicare & Medicaid Services (CMS) is considering a proposal to make PSA screening a negative quality indicator. In simple terms, this means physicians will be financially penalized for providing PSA screening to any man, regardless of his risk factors. The 2012 USPSTF recommendations were just that, but they resulted in a significant decrease in screening rates nationwide. Attaching a financial penalty to those recommendations has an even more dramatic potential effect.
Our older faculty vividly recall days of cauda equina and emergent bilateral orchiectomy for men limping into the ER with metastatic prostate cancer, a foreign concept to most residents. Whether the current CMS proposal would drive a return to those proverbial dark days of prostate cancer remains to be seen.
But the effects of the USPSTF recommendations have already changed practice. Looking at the National Cancer Database, Dan Barocas, MD, MPH, and colleagues showed that incident prostate cancer diagnoses have decreased by 28% since 2012. Anecdotally, accrual to a prostate cancer shared decision-making trial I was a part of decreased dramatically, and a temporal decline in prostate cancer diagnoses at our VA and county facilities is palpable. Only time will tell whether these changes may turn out to be a good thing.
What is clear, however, is that health policy decisions being made in our state capitols and in Washington directly impact not only how we practice, but also how disease states play out. In 5-1/2 years as a urology resident, I have spent over 1,000 hours learning robotic prostatectomy, logged 25 open radical prostatectomies, performed 182 prostate biopsies, and read countless studies on PSA, PSA density, PSA velocity, etc. I have my “new diagnosis of early-stage prostate cancer” spiel down pat. It is said that up to 80% of what we learn in medical school will be obsolete by the time we reach practice. Will the same be said of residency?
When CMS considers making a recommendation against PSA-based screening a quality measure, urology residents should be actively thinking about how they can get involved in health policy at the local, state, or national level. As the old political adage goes, “You’re either at the table or you’re on the menu.”
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