Male docs over-order PSAs

Urologists more likely to feel "prostatempathy"

By Owen Dyer

Male doctors, especially older ones, are more concerned about prostate health than other physicians — perhaps a little too concerned, according to new research in the July 9 Archives of Internal Medicine.

A team led by Dr B Price Kerfoot of the Veterans Affairs Boston Healthcare System and Harvard Medical School found that older male doctors, especially urologists, were more likely to order inappropriate prostate-specific antigen (PSA) screening tests than women and non-specialists.

By inappropriate, they mean not recommended by guidelines. "The various guidelines differ on who should be given PSA screening," Dr Kerfoot tells NRM, "but there's remarkable unanimity about who shouldn't be screened." All guidelines agree that PSA screening is not appropriate in men aged under 40 or over 75.

NOT APROPOS
The researchers analyzed data from 181,139 male patients who were treated at Veterans Health Affairs (VHA) facilities in New England from 1997 to 2004. During this period, 232,302 PSA tests were ordered by 4,823 clinicians including nurses, physician assistants, general practitioners and urologists.

The study excluded PSA tests that were not for screening purposes, such as those in symptomatic patients and patients with diagnosed prostate cancer. Of the PSA screening tests, 16.1% were given to patients younger than 40 (0.8%) or older than 75 (15.3%), thus meeting the criteria for "inappropriateness" according to all current guidelines.

But the various categories of clinician were by no means equal sinners. Perhaps unsurprisingly, nurses and physician assistants hewed closest to the guidelines, while urologists, more confident in their own knowledge, strayed furthest.

Women physicians, overall, stuck closer to guidelines than men did. But this tendency was not apparent in the younger age groups. Rather, as women aged beyond 45, they seemed to order progressively fewer inappropriate tests, while men ordered progressively more. In the 55-plus age group, men were ordering twice as many inappropriate tests as women were.

GENDER IMBALANCE
Dr Kerfoot has a theory to explain the older men's behaviour. He calls it "prostatempathy." Essentially, these clinicians are sympathizing more with patients who might have a condition that they can picture themselves having.

Asked if he has a theory to explain why women prescribe more appropriately over time, he laughs. "No, I'll have to throw my hands up on that one and say we have no explanation."

The men's behaviour follows trends that have been identified before. A 2004 study in the Journal of Women's Health found male doctors ordering significantly more PSA tests than women, though they were also more likely to recommend an office visit for vaginal itching. A 1990 study in the journal Medical Care found women doctors outperforming men on Pap smears and breast exams.

A whole slew of studies have looked at the effect of age on physicians, and in almost every case has found them straying further from guidelines with increasing age. A very few studies produce "concave" results, where appropriateness of treatment rises for several years after qualification then begins to decline. No study has shown adherence to guidelines improving consistently with age.

ME OR THE GUIDELINES?
There is lively debate, of course, about how appropriate these guidelines are. Dr Kerfoot is himself a little doubtful about some elements of the guidelines, arguing that they "shy away" from complicated questions such as the greater significance of slightly elevated PSA in younger men, and the whole question of PSA velocity. They are also mute on whether a man should be screened after 75 if his results up to then were climbing. "The American Urological Association will be replacing the 2000 guidelines pretty soon," he adds, "but I'm not sure what new information they have to bring to the table since last time."

Nevertheless, he has no doubt that the guidelines are right, given our current knowledge, in advising against screening in the over-75s and under-40s. "No actual survival benefit has ever been shown from PSA screening even within the 40-75 age group most likely to benefit. So it seems strange that people think it would be helpful outside that group."

He adds, "People say 'it's only a minor blood test, how bad can it be?' But there's plenty of evidence to suggest unnecessary PSA screening carries a heavy burden in terms of unnecessary additional procedures."