How physicians approach prostate cancer screening before and after losing a lawsuit

Abstract

Purpose: In 2004, a commentary by Merenstein was published in JAMA describing how he was sued for engaging a patient in shared decision making for prostate cancer screening. The article sparked considerable debate on the impact of litigation on medical care. A natural experiment (a study assessing shared decision making under way at the practice that was sued) enabled us to evaluate whether physicians changed their prostate cancer screening behavior after the lawsuit.

Methods: As part of a randomized controlled trial conducted between January 2002 and November 2004, patients and physicians completed exit questionnaires about prostate cancer screening discussions after health maintenance examinations. We compared responses before, during, and after physicians became aware of the lawsuit.

Results: A total of 432 of 497 patients completed questionnaires (180 before the practice became aware of the lawsuit, 87 as knowledge of the case diffused through the practice, and 165 after publication of Merenstein's commentary). Comparing patients' responses over the 3 time periods, there were no changes in the average locus of decision-making control, time spent discussing screening, number of screening topics discussed, knowledge scores, or decisional conflict. The frequency with which physicians reported performing prostate-specific antigen testing increased (before vs after: 84% vs 90%; P = .03), and physicians were more likely to report that they, rather than the patients, had made the screening decision (before vs after: 3.3% vs 11.1%; P = .003).

Conclusions: The physicians in closest proximity to this well-known legal case continued to engage patients in shared decision making and to let patients decide whether to be screened. Prostate-specific antigen testing increased during this period.

Figure 1.

Patient-reported locus of decision-making control in relation to the Merenstein case (N = 431 question respondents). Note: The figure shows patients’ responses to the survey question, “How was the decision made today on whether to do a PSA blood test? (A) I made the decision on whether to order a PSA test. (B) I made the decision about whether to order a PSA test after seriously considering my doctor’s opinion. (C) My doctor and I shared the responsibility for deciding whether to order a PSA test. (D) My doctor made the final decision about whether to order a PSA test after seriously considering my opinion. (E) My doctor made the decision whether to order a PSA test.” Before period = January 2002 through June 2003; diffusion period = July 2003 through December 2003; after period = January 2004 through November 2004. The differences across the 3 time periods are not significant (P = .54).

Figure 2.

Patient-reported elements of the prostate cancer screening discussion in relation to the Merenstein case (N = 432). PSA = prostate-specific antigen. Note: The figure shows temporal trends of measured elements of the prostate cancer screening process in relation to the Merenstein case (before, diffusion, and after periods) as reported by 432 patients who returned a completed questionnaire. The left-hand axis and black lines represent an ordinal scale from 1 to 10. The right-hand axis and gray lines represent a percentage scale from 0% to 100%. Comparing the before and after time periods, the differences are not significant for decisional conflict (P = .23), number of topics discussed (P = .37), time spent on discussion (P = .20), and knowledge (P = .86). The percentage of patients receiving a PSA test increased, however (84% vs 90%; P = .03).