Yup. My primary care physician waited far longer, until my PSA doomed me to
a tenfold increase in my likelihood of dying OF my PC, according to one
recent study. But given the large number of docs who say PSA testing is
unwarranted alarmist pap, ignoring PSAs of any level, let alone a "measly"
4.6, is within the bounds of sound practice. Malpractice requires rock-solid
proof a doc was acting WAY outside ANY acceptable norms, and establishment
of exactly how and how much his extreme negligence ruined your life.

All I could do was "fire" him as my primary care physician, file a complaint
with the local VA patient advocate, and write a letter to the VA explaining
this and other gross errors he had made. My other docs, asked about my
specific PSA history, just said, "Yup. I'd have acted much sooner. But did
he harm you? There's no way to know."

I.P.

So, you had a enlarged prostate gland six years ago.  From what I've
read and experienced, BPH has nothing to do with prostate cancer.
There seems to be no connection between the two.  At age 55, I too had
an enlarged prostate, but the psa was normal for that age.  

You were 63 when the doc recorded a psa of 4.6 - just a little higher
than normal, but I believe still within the normal range, and he
obviously didn't feel anything with his DRE.  You admit he "checked it
closely for 18 months" which seems to be very prudent.  When he
noticed a rise, he sent you to the uro.  I see no malpractice here.
In fact, I think your doc served you well.

Dave

Pete,

PSA use, as a diagnostic tool, has gone through several iterations in its
relatively short history.  And each time, the golden standard of use is a
phased in affair.  First, a researcher discovers it, then a few doctors
accept it, then it is published, etc., etc., etc.  At some point it becomes
widely adopted by all medical resources and universally used.

I am told by an Estonian that the upper limit for PSA at one time in the US
was 10.  I know through the 90s, the upper limit was 4.  I still hear today,
of doctors using that as their yardstick.  And, I guess for the first time a
man is checked for PSA, the standard is still solid.

However, during 1999, it was not widely accepted that an increase in PSA
meant anything if the level had not reached 4.  Or, if it was widely
accepted, and even if widely published, it was not inculcated by the vast
majority of the primary care physicians until later.  During October 2000, I
was told that 4 was the milestone.

So, did he wait too long?  If you had a steady progression of PSA, in
hind-sight, yes, he probably waited too long.  Did he know that a steady
progression of PSA even though under 4.0 was indicative of cancer?  Probably
not.

I teach my PCP about the newest things in PCa and I consider him to be one
of the finest PCPs around (based on anecdotal evidence of my experience and
that of my extended family).  I learn so much from this newsgroup that I
even think I can stump my uro every now and then.  I haven't after 4½ years,
but I keep trying.

As long as you read this NG and as long as your PCP has to keep up to speed
with an infinite number of maladies, you will always know more than he about
one -- Prostate Cancer.

I probably don't have a case here but let me add a few more details.

In 1999, 2000, 2001, and 2002 my annual DRE showed an enlarged prostate
and my PSA was elevated (don't know the values but I could get them
from my medical records). My doc recorded BPH but there is no way for
him to know if its BPH or cancer without doing a biopsy. My DREs in
2003 and 2004 continued to show an enlarged prostate (which doc
recorded as BPH) and my PSA varied from 4.6 to 5.8.

I'm not a doctor, but it seems to me that the combination of an
enlarged prostate plus elevated PSA is cause for a biopsy.

Pete

The Partin Tables are one way to gauge how much more risk.  They show
your case to be very weak.

http://urology.jhu.edu/prostate/partintables.php

You need a better argument if you hope to burn that doctor.

jimhoney

 Does

I agree with the others that there's no case for a
charge of malpractice here.

One of the problems of health care is that primary
care physicians are required to know about such a
huge range of problems that they don't know enough
about each one.

A doctor may see 40 patients in a day, one with flu,
one with breast cancer, one with AIDS, one with
congestive heart failure, one with ingrown fingernail,
one with hemmorhoids, one with a pain in her hip,
one with a chronic headache, and on and on.  The next
day may bring 40 patients with completely different
problems, and the next day 40 more.

In your particular case, the doctor was at least
knowledgeable enough to know that your PSA was
high and needed watching.  And he did send you
to a specialist when it got clearly above the national
guidelines for a normal reading.  It would be
nice if he did that earlier, but he could well
be in the top half of doctors for doing it at
all.  Many doctors don't even give PSA tests to
their patients.

My doctor saw a PSA reading of 3.7 (I probably had
cancer then) and said, "it's normal".  She didn't
even tell me to come back for another test in a year.
When I came back for a physical 2 years later, she
didn't even request a PSA test for me - an alert
lab tech added it.  I too wound up with a Gleason
4+3 when it probably could have been caught two
years earlier at a much more treatable stage.

In the best of all possible worlds, your doc would
have done better and you would have been diagnosed
earlier, with a somewhat higher chance of a cure
(though your chances are probably still pretty
good.)  But unless you see other ways in which
the guy has not done a good job, I'd cut him some
slack on this one and chalk up the cancer to the
luck of the draw.

   Alan

hi pete - while you may feel that you MIGHT have a case.  the only thing
i could find that would support your case was that if you died from
being failed to diagnose the disease.  well, the doctor did his job,
and for that reason, can not be sued for what he is paid to do.  you had
a problem,  he found the problem.  if you check the strong example cases
for malpractice, you might find some of them interesting.

hope this helps.

~ curtis

From the 'Lectric Law Library's stacks
What Is A Strong Malpractice Case


Examples of strong cases.

It is most important that a plaintiff's medical malpractice lawyer
screen cases and accept only those that are worthwhile. (In some states,
the lawyer must certify that he has reviewed the matter with a qualified
physician who states that the case is "meritorious.") Often the
experienced lawyer can tell if the case is worthwhile from the first
contact with the client. If it is not, the client should be informed
immediately; the legal and medical systems should not be cluttered with
the prosecution of worthless cases.
True medical malpractice consists of negligent conduct that causes
damage. There may be "malpractice" from a theoretical point of view, but
if the conduct has not caused injury it is not a matter for the legal
system. Sometimes there may be true "malpractice" but no residual
damage. These are not strong cases. Juries are not all interested in a
past history of damage; they do become interested when a plaintiff can
show permanent injury. (1) The following are examples of such cases.
Anesthesia
A patient underwent surgery with Halothane (fluothane) as the anesthetic
agent, even though he had suffered previous biliary tract disease, which
made the use of this anesthetic contraindicated. The patient died as a
result of liver necrosis due to the effects of the anesthetic.
A trainee anesthesiologist ran out of oxygen before the operation was
completed, causing the patient to suffer a fatal cardiac arrest.
A patient who underwent surgery for the repair of a pilonidal cyst under
epidural anesthesia ended up with permanent uncontrolled movement of the
lower extremities.
Angiography
A patient underwent angiography (dye study of the arteries). The
procedure was improperly performed, and the patient suffered brain
damage.
Burn treatment
A patient suffering from severe third-degree burns received inadequate
and improper "burn therapy."
Childbirth
A child was born with a blood problem-Rh incompatibility-antibodies
developed by the mother were destroying the blood in the baby. The
attending physicians and hospital personnel failed to detect the child's
condition.
A mother who was a diabetic gave birth to a child suffering from "large
baby snydrome," and proper care was not excercised in delivering the
child. The baby suffered a shoulder-brachial plexus injury.
A newborn baby with a metabolic disorder was improperly diagnosed and
monitored by the attending physician and hospital nurses. The child
suffered permanent brain damage.
A pregnant patient was improperly evaluated and monitored during
pregnancy and labor; a difficult delivery ensued, and the baby was born
with permanent brain damage.
A patient in labor suffered prolapse of the cord. An emergency Cesarean
section was delayed, and the baby suffered permanent brain damage.
A patient's obstetrician was twenty minutes late, and delivery room
nurses had to deliver her child. Then, although the infant was suffering
from respiratory distress, a pediatrician was not called for several
hours. The child is brain-damaged and requires life-long care. (See
§6.4 herein.)
Diabetes uncontrolled
An attending physician failed to control a patient's diabetes and
potassium deficiency; the patient died. Diagnostic ERCP - Negligent
injection of dy
During an endoscopic retrograde cholangiopancreatography (ERCP), an
inexperienced nurse injected the dye too forcefully and caused the
patient to develop pancreatitis and other debilitating injuries. (See
§4.3 herein.)
Diet error
An accident victim's operation to repair a skull fracture was delayed
twenty-four hours because the patient was fed a regular diet by nursing
personnel, despite a physician's order that the patient was to receive
nothing by mouth. The patient suffered permanent brain damage.
Drug addiction
A patient underwent unnecessary surgery that resulted in severe pain for
which addictive medication was prescribed. The patient became a drug
addict.
Drug reaction
A patient with a minor infection repeatedly was given sulfa medication
without proper indication. The patient suffered Stevens-Johnson syndrome
and permanent eye damage.
Errors in diagnosis generally
A child swallowed foreign metal material, and the attending physician
failed to diagnose the trouble. The child died.
A child ingested an alkaline solution and at the hospital emergency room
the physician used the wrong antidote. The child suffered permanent
esophageal injury.
A child was born with congenitally dislocated hips, but the attending
obstetrician and pediatrician failed to diagnose the condition. There
was permanent disability.
A patient suffered from cancer, but the attending physician failed to
diagnose the disease. The cancer spread and the patient died.
A patient ingested insecticide. His physician incorrectly diagnosed his
condition, and failed to administer the proper antidote. The outcome was
permanent brain damage.
A patient suffered from ulcerative colitis of the sigmoid colon. His
attending physicians failed to perform a sigmoidoscope examination, and
the condition progressed, finally requiring removal of a large part of
the colon.
A patient suffering from appendicitis was misdiagnosed; the appendix
ruptured, and the patient developed fatal peritonitis.
A woman had a cancerous condition of the leg, but an inaccurate
diagnosis was made, and the patient was subjected to heat and ultrasonic
treatments. The cancer spread and the patient died.
A patient who fell was taken to the hospital emergency room where a
diagnosis of inebriation was made. The patient actually had a fractured
spine and a severed spinal cord. The result was permanent paraplegia.
Following surgery, a patient complained of difficulty in swallowing and
pain in his throat. His neurosurgeon mistook the symptoms for a sore
throat and did not come to see him. The patient died the next day from
aspirating vomit. (See §9.5 herein.)
An on-call ophthalmologist, without seeing the patient, diagnosed his
eye pain, sensitivity to light, and nausea as sinusitis, when in fact it
was acute angle closure glaucoma. The patient lost sight in the eye.
(See §14.2 herein.)
A urologist who visually inspected and palpated a patient's suspected
testicle tumor by surgically pulling it up through the inguinal canal
concluded that it was only an inflammatory process when in fact it was
malignant. (See §17.4 herein.)
Experimental therapy
A patient complaining of low back pain received an injection of an
experimental enzyme into a vertebral disc, causing a neurological
deficit.
An experimental implantation of a muscle in the spinal cord resulted in
quadriplegia.
Fractures
A patient suffered a fracture of the forearm that was improperly set,
resulting in Volkmann's contracture and permanent disability.
Even though a patient with a hip fracture was under a physician's care,
X-rays of the hip were not made for nine days, during which time the
patient was allowed to walk. The patient suffered severe narrowing of
the hip joint and permanent disability.
Heart surgery
A patient with coarctation of the aorta underwent surgical repair, but
the heart-lung by-pass machine was not in operation, and the patient
suffered nerve damage and paraplegia.
A patient underwent an unnecessary heart catheterization and developed a
blood clot in the leg that was improperly evaluated. The patient
suffered permanent disability.
Hemorrhage uncontrolled
A patient suffered from hemorrhage of esophageal varices. He was not
given prompt and adequate treatment, and he died.
A patient was admitted to a hospital for minor surgery and was allowed
to suffer from an uncontrolled nose bleed, causing shock and
irreversible brain damage.
Hysterectomies
During an hysterectomy the patient suffered a severance of the ureter
that went unnoticed. The patient lost a kidney.
A patient underwent an hysterectomy and experienced severe bleeding.
Later a severe infection developed, as did other disabilities that
required additional surgeries and transfusions.
Kidney operation
A child suffered from a kidney disorder. During surgery the wrong
technique was employed and the kidney was lost. Laboratory erro
A laboratory report stated that a small growth removed from a patient's
arm was simply a benign inflamed mole, when in fact it was malignant
melanoma. (See §16.3.)
Medication inadequate
A child suffering from meningitis was sent home with a prescription that
was inadequate and inappropriate. The disease progressed, and the child
suffered permanent brain damage. Pap smear not followed-u
A Pap smear taken from a patient who was complaining of vaginal bleeding
showed "extremely suspicious cells," but her HMO gynecologist did not
follow up with a later test, and her cervical cancer was not diagnosed
for another two years. Also, the laboratory report was insufficient.
(See §16.3.)
Priapism
A male patient suffering from an earache was given a diagnostic spinal
tap, after which he experienced a painful erection of the penis
(priapism). Treatment was delayed, and when finally accomplished,
bandages were applied too tightly, causing the patient to suffer
permanent partial impotency and strictures of the urethra.
Spinal surgery
A patient complained of low back pain and underwent removal of a disc.
There was nerve injury, causing the patient severe pain. Thereafter he
had to undergo various operations on the spinal cord, all of which were
unsuccessful.
A patient was injured in a serious automobile accident and underwent
back surgery. A tear in the dura was not diagnosed, and the patient
developed meningitis and died.
A patient underwent low back surgery for the removal of a disc. During
the approach, an instrument accidentally went through the spinal canal
and into the patient's abdominal cavity. A major blood vessel was
lacerated, which almost took the patient's life.
A patient underwent low back surgery following a minor fall. There was
no objective medical evidence whatsoever to justify surgical
intervention. The patient suffered emotional and physical disability,
and attempted suicide.
A patient undergoing a cervical laminectomy suffered from a preexisting
osteophytic condition that contraindicated extension or flexion of his
head or neck more than ten to twelve degrees. The nurse anesthetist who
intubated and anesthetized him was never told of this condition.
Following the operation, the patient awoke from the anesthetic a
quadriplegic. (See §1.2 herein).
During an elective lumbar laminectomy, an orthopaedic surgeon caused a
tear in the dura that resulted in a complete evacuation of cerebrospinal
fluid, which in turn caused a brainstem herniation and death. (See
§8.6 herein.)
Stomach surgery
A patient underwent surgery for removal of a portion of the stomach.
Anastomosis (joinder of parts) failed, and the patient required further
surgery with prolonged disability.
Unnecessary stomach surgery was improperly performed, requiring three
additional major operations, and a prolonged period of disability.
A patient underwent surgery for the repair of a duodenal ulcer. He
suffered duct damage during the procedure, and required four additional
operations. He was permanently disabled.
Surgical infections
An orthopaedic physician improperly reduced a fracture and failed to
take adequate precautions to prevent infection. When the infection
occurred, it was improperly treated. The patient suffered extended
disability.
A child suffered from a congenital defect in a lower extremity. Surgery
was performed without proper drainage, and the child developed infection
that went unnoticed. There was a delay in treatment, which necessitated
further surgery, and resulted in permanent damage.
Tracheostomy injury
A tracheostomy was performed at an incorrect level, then the tube was
improperly attended by hospital nurses. The patient suffered erosion of
the innominate artery, and bled to death.
Transferred without consent
A patient suffered from pancreatitis. While being transferred to another
hospital without consent, she suffered severe brain damage and remained
in a comatose condition until she finally died several years later.
Treatment delayed when patient not accepted
An attending physician failed to diagnose coronary occlusion and the
patient was not hospitalized. When the patient's condition deteriorated,
and he finally was ordered into a hospital, the hospital refused to
accept him. He was transferred to another hospital but did not survive.
§ 25.6 Fee arrangement-Advancing costs.
Most medical malpractice cases for the plaintiff are handled on a
contingent fee basis. Ordinarily this ranges from 331/3 to 50% of the
recovery after costs are deducted "off the top."
Medical malpractice cases are such that usually there will be no
settlement, nor even negotiations toward settlement, until the lawsuit
has been filed and all essential depositions have been taken. In most
well-prepared cases, there is virtually a trial through the discovery
process before the actual trial in court. Therefore, "sliding scale"
contingent fees (i.e., 25% before the suit is filed, 331/3/% after the
suit is filed, 40% if the case goes to trial, 50% if the case goes on
appeal, etc.) are not in vogue. But, of course, this is a matter of
individual negotiation between you and your client, and should be in
accordance with your local custom and practice. Some states now have
statutes limiting contingent fees in medical malpractice cases. 2
After the first interview with your client, you may deem it necessary to
have him or her sign a contingent fee agreement, subject, of course, to
your right to withdraw should you find the case unmeritorious after
additional investigation.
This fee agreement may provide, if permissible in your jurisdiction,
that you have the right to advance costs on behalf of the client (and
the right to be reimbursed). Ordinarily, the victim of medical
malpractice has been plunged into a financial abyss, and is unable to
undertake the cost of the investigation and prosecution of the case. The
matter will move much more expeditiously if you are in a position to
advance the necessary expense of investigation and litigation. These
advances usually do not include any sums for medical care and treatment,
however, and are limited to the necessary expenses for medical reviews
and examinations, and costs of investigation, depositions and the like.
--------
Excerpted from Medical Malpractice, Third Edition, § 25 by David M.
Harney Copyright 1993, The Michie Company, 1-800-446-3410
http://www.michie.com

knowledge is power - growing old is mandatory - growing wise is optional    
"Many more men die with prostate cancer than of it. Growing old is
invariably fatal. Prostate cancer is only sometimes so."
http://community.webtv.net/PALMER_ENT/doc