A Foucaultian encounter with a GP

I’ve put up a similar post on my Facebook wall a few days ago. It just repeated the same story, but I sprinkle the story with a little bit of social theory here. 

In September, after getting the Medicare card, I walked into a clinic in Holland Park near Griffith and wanted to get a doctor’s prescription for my neck’s eczema. The cream I need is not an over-the-counter medicine because it contains steroids. I didn’t think too much about which GP is good, but as long as he/she got available slots and I don’t have to wait, I’ll just go. I happened to see a lot of slots from this GP, Dr B, who is rather senior and got an MD and an Order of Australia. So, I chose him.

As usual, during the consultation, I explained to him my condition and how long I’ve been infected. Everything seems fine. Then, he said that I should do a blood test and fungus test the next day. Alright. Since I didn’t need to pay, I’ll just do as he instructed. I haven’t heard from the GP about the results, until last Tuesday in November.

The GP called me on the 6th November, last Tuesday, during the writing retreat with colleagues at Ship Inn in South Bank campus. ‘This is Dr B. You came to my clinic in September. I’ve got to tell you something serious.’ Yeah, I remember him, but why didn’t he call me immediately after he got the results of the test? I have no idea but that’s alright, I’ll make an appointment with him as I also want to know what happened.

I went to the clinic the next day. Then, he went through all the results. Everything seems normal, except one item. ‘Your PSA level is very high, it’s 5.5, much higher than the level of your age. It could be prostate cancer. ‘ said Dr B in a grim voice, which sounds very alarming to me. He also asked me two embarrassing questions, e.g. ‘do you have a lot of sex? did you masturbate before you did the test?’ Well, I actually had no idea about what PSA is (i.e. prostate-specific antigen). Then, this GP asked me to do another blood test on Friday. And I did. Meanwhile, during this period, I did my homework and checked what PSA is, and whether PSA is a reliable indicator of prostate cancer. I always rely on NHS for the best medical knowledge. Here is what the NHS said:

The PSA test is a blood test to help detect prostate cancer. But it’s not perfect and won’t find all prostate cancers.
The test, which can be done at a GP surgery, measures the level of prostate-specific antigen (PSA) in your blood.
PSA is a protein made only by the prostate gland. Some of it leaks into your blood, but how much depends on your age and the health of your prostate.
There’s currently no national screening programme for prostate cancer in the UK because the PSA test is not always accurate.
Before deciding to have the PSA test, you may want to talk to your GP and practice nurse, as well as your partner or a friend or family member.
You have a higher risk of prostate cancer if you: have a family history of prostate cancer, are of black ethnic origin, are overweight or obese
What’s a raised PSA level?
The amount of PSA in your blood is measured in nanograms of PSA per millilitre of blood (ng/ml).
If you’re aged 50 to 69, raised PSA is 3ng/ml or higher.
A raised PSA level in your blood may be a sign of prostate cancer, but it can also be a sign of another condition that is not cancer, such as: enlarged prostate
prostatitis, urinary infection
How accurate is the PSA test?
About 15 out of every 100 men with a normal PSA level have prostate cancer. About 75 out of every 100 men with a raised PSA level do not have prostate cancer.
Pros and cons of the PSA test
Pros:
it may reassure you if the test result is normal
it can find early signs of cancer, meaning you can get treated early
PSA testing may reduce your risk of dying if you do have cancer
Cons:
it can miss cancer and provide false reassurance
it may lead to unnecessary worry and medical tests when there’s no cancer
it cannot tell the difference between slow-growing and fast-growing cancers
it may make you worry by finding a slow-growing cancer that may never cause any problems
Before having the test
If you’re having a PSA test, you should not have: ejaculated in the past 48 hours
exercised heavily in the past 48 hours, a urinary infection, had a prostate biopsy in the past 6 weeks
Each of these may give an inaccurate PSA reading.

from the NHS website

That means, statistically, it doesn’t even reach 95% of confidence level to determine if PSA is an absolutely reliable indicator for prostate cancer. Then, I googled the PSA reading again and found the following description from the National Cancer Institute in the US:


What is a normal PSA test result?
There is no specific normal or abnormal level of PSA in the blood, and levels may vary over time in the same man. In the past, most doctors considered PSA levels of 4.0 ng/mL and lower as normal. Therefore, if a man had a PSA level above 4.0 ng/mL, doctors would often recommend a prostate biopsy to determine whether prostate cancer was present.
However, more recent studies have shown that some men with PSA levels below 4.0 ng/mL have prostate cancer and that many men with higher levels do not have prostate cancer (1). In addition, various factors can cause a man’s PSA level to fluctuate. For example, a man’s PSA level often rises if he has prostatitis or a urinary tract infection. Prostate biopsies and prostate surgery also increase PSA level. Conversely, some drugs—including finasteride and dutasteride, which are used to treat BPH—lower a man’s PSA level. PSA level may also vary somewhat across testing laboratories.
Another complicating factor is that studies to establish the normal range of PSA levels have been conducted primarily in populations of white men. Although expert opinions vary, there is no clear consensus regarding the optimal PSA threshold for recommending a prostate biopsy for men of any racial or ethnic group.
In general, however, the higher a man’s PSA level, the more likely it is that he has prostate cancer. Moreover, a continuous rise in a man’s PSA level over time may also be a sign of prostate cancer.

from the National Cancer Institute

OK, that means, no matter what the result of the new test is, I’m pretty sure it’s rather meaningless. This Monday, I went back to the clinic and checked the results. ‘No good. It’s even higher. 5.7 now. You’d better do an MRI scan.’ That old GP told me. Then I asked him whether I can do the MRI scan for free as I’m just a PhD student and don’t want to spend A$500 for a test which might turn out to find nothing inside my body. I even argued with him, using the medical knowledge quoted above, that I’d better have urinary test because it’s more likely that I have urinary tract infection (UTI) than prostate cancer. I don’t have any symptoms of both illnesses. However, that GP refused my request, and I’d better choose another doctor and seek second opinion.

My mum’s friend here happened to know a family of doctors who originally came from Hong Kong. The father is a very experienced psychiatrist, and the kids are both doctors working in Brisbane now. Once I told them the story, they immediately know what’s going on. They didn’t ask me to do the MRI scan, which can only find out if I have prostate cancer but cannot determine if I have other infections.

The whole incident is super Foucaultian – medical power/knowledge. As Basil Bernstein said, pedagogic communication is not just happening between teachers and students, but it happened in the clinical context between GP and patient. Here, the boundary between sacred medical knowledge and everyday knowledge is weakened as a result of the Internet, where I can access a lot of reliable, proper medical knowledge. As Bruno Latour said, the old structures safeguarding the old knowledge are increasingly coming under pressure and frontal attacks from all sides, and therefore, we have such ‘post-truth’ moments such as alternative medicine, New Age, etc. because medical power of the previous generation of GPs, such as the doctor in the Holland Park clinic, who had an MD in Vietnam should be very well respected and could perhaps be regarded as a demigod in his generation, is now challenged by the laymen like me. I don’t think the GP is cheating the Government for bulk-billing me relentlessly.

Isn’t the whole incident familiar in the political debates over NAPLAN, ranking, TSA? What does it mean to be ranked No.1 in the Freedom Index by the Heritage Foundation? All knowledge, which may sound authoritative, is somehow unstable.

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