Screening for cancer is like Mom and Apple Pie. Who would be against it? Intuitively, early detection should allow for early treatment and higher survival rates.

Vinay Prasad is an oncologist and professor of epidemiology at UCSF. His provocative thesis is that cancer screening is over-rated – or at least is based on flimsy evidence. He argues that identifying a cancer on biopsy does not equate with a full understanding of its long-term behavior. He makes several important points in his podcast on EconTalk with Russ Roberts.

“And, some of these lesions that we find are definitely the sort of lesions that are going to kill you. Some of the lesions are the sort of lesions that are going to kill you were it not for cutting it out in that moment. So, if you catch it early and cut it out, now it’s not going to kill you.

Some of them, they’re going to kill you regardless of whether or not you cut it out. It’s already spread, the damage is already done.

And then some of them are lesions that might not cause you harm in the rest of your natural life. And, that’s a very counterintuitive idea and something people called over-diagnosis.

And, the problem with screening is that it has to have the right balance of these things. You have to catch a lot of the cancers that, if you didn’t find it would’ve done something bad, but now that you found it, we have a good outcome; and not so much of the ones that they’re going to do something bad anyway. That’s just adding extra time, anxiety, to your life and not so much of the ones that aren’t going to do anything.”

So, it’s complicated.

“The metaphor is a barnyard metaphor. And, the metaphor is basically, like, imagine you’re a farmer and you have a barnyard and you have lots of different animals in your barnyard, and you want to find a way to keep the animals in your barnyard. And, that’s, I think–the idea of catching the animal before it leaves the barnyard is the metaphor for catching the cancer before it causes a problem.

And, one can imagine there’s three types of animals in your barnyard. There are rabbits, turtles, and birds. The thing is the fence, it’s going to be really good at catching those rabbits. They are hopping, they’re jumping, and when they get to the fence, they’re going to be stopped and they’re going to come right back to your yard.

The turtles–actually turns out you probably didn’t even need the fence. They’re moving so slowly that even in the next year or two, they’re not going to get outside your yard. This is how the metaphor goes.

And, the birds, meanwhile, are moving so quickly that no fence can stop them. They’ve already flown right out of your yard. And, those are also cancers.

So, the idea is that the turtles, the birds, and the rabbits are all cancers. Some cancers are so aggressive that even when you screen people, they have already spread.

And, in fact, Russ, I would just say that when you look at all of the screening tests we’re going to talk about today, and maybe the ones we’re not going to talk about, one thing to point out to the listeners is that no screening test reduces death from that cancer to 0%. So, we debate how well they work. We debate the benefits and harms.

But nobody debates the fact that you can get all the colonoscopies you want and there’s still a risk of dying of colon cancer. You can get all the breast cancer screening you want. There’s still a risk of dying of breast cancer. Typically, that risk is 80% of the risk. I mean, even the proponents think it only lowers cancer death by 20%. What that means is there’s a lot of birds. There’s a lot of birds.

And then the other thing, Russ, is we should have some humility in medicine. We don’t know how many turtles there are. And turtles matter a lot. Because, every time you find a turtle, you’re going to treat that person as if they had a rabbit or as if they had a bird. They’re going to get the full-court press of treatment. But they may not have needed much of that treatment or even any of that treatment. And so, that’s just harm being inflicted on someone. So, this is the delicate balance of screening.”

Most patients with prostate cancer die WITH prostate cancer; not of prostate cancer.

Some of our treatments have become so good, that screening may not even make sense. He uses testicular cancer as an example. Should men examine their testicles every month in the shower? Dr. Prasad argues no.

“As one example, in testicle cancer since the 1970s and 1980s, we can cure testicle cancer even when it’s spread everywhere. Like Lance Armstrong. Our cure rates are like 95%, 96%, 97% for metastatic testicle cancer. So, actually, because we can cure it so well when it’s advanced, there’s no longer an impetus to find it early.

And the USPSTF–United States Preventive Services Task Force–says: Don’t examine your testicles every month in the shower. It’s USPSTF Grade D because you’re only going to find incidental things that lead to losing a testicle, which is the way we actually–we don’t biopsy a testicle; we actually just remove it. And, even if it presented late, you still have an excellent result. So, there’s no differential to exploit.

And finally, the thing I’d say is our treatments are getting better for breast cancer, prostate cancer, etc., and the advanced disease, which many of us believe is eroding whatever benefit of screening was there in the first place.”

What harm is there with screening? Of course, all screening tests have risks. If we use colonoscopy as an example, there’s a risk of bowel perforation, including death. But the risk is low. The main risk is the inconvenience of the bowel prep. Dr. Prasad continues:

“What I would say about colon cancer screening is that until this year, this last year, there were zero randomized studies of colonoscopy; and many European nations did not recommend colonoscopy as that was the intervention that went beyond available data. The United States has been doing colonoscopy for a long time–based largely on some of the other considerations we’ll talk about, and our financial biases–but other nations weren’t.

So, what was the data? The original colon cancer screening was something called Fecal Occult Blood Test or FOBT. It’s basically smearing feces on a card and looking for occult blood–little bits of blood in it that you didn’t feel or see. And that was the original test. And, that has multiple randomized trials that show reduction in dying from colon cancer. So, you’re less likely to die of colon cancer, but you’re no less likely to die for any reason.

The Minnesota FOBT study has absolutely super-imposable survival curves for all-cause mortality. You look like you did the same.

We switched maybe about a decade and a half ago to the fecal immunohistochemical test or FIT. That’s a different kind of card technique that you poop on a card. It looks for different things, but it has slightly better test characteristics–a little more sensitive and a little more specific. And so, people can say it’s a reasonable extrapolation to use the FIT card versus the FOBT. And, I’m okay with that, too.

We do have randomized trials of sigmoidoscopy. What’s a sigmoidoscope? A sigmoidoscope is a way to screen the left side of the colon. There’s a big difference: it’s a shorter scope. It doesn’t go all the way in. The GI [gastrointestinal] doctors will tell you that screening the left side and not the right side is like getting a mammogram on just the left breast, not the right breast.

But, there are a lot of reasons why that’s a false analogy because the left side of the colon is different than the right side. The stool is more solid and the cancers that occur there have different mutations and fundamentally do differently with treatment.

And, because of those differences, some of us believe that sigmoidoscopy actually does work. In fact, sigmoidoscopy has a reduction in colon cancer death. And if you do a meta-analysis of all the studies, there is a small reduction in all-cause death.

So sigmoidoscopy has cleared the highest bar. That might be the only thing I consider doing for myself.

Colonoscopy has always been thought to be–it’s at least a sigmoidoscopy. At least we look that far, and then we look a little bit further. So, it has to be at least as good. That’s the logic.

But, the recent NordICC [Nordic-European Initiative on Colorectal Cancer] Study found that–it’s still early, so it may find a benefit with time–but so far it’s failed to find a reduction in colorectal cancer death from colonoscopy. This is a study that came out of Europe–Norway–and in multiple European countries like Norway, Sweden, and Poland.”

Dr. Prasad on mammography:

“If you look at all-cause mortality in all of the mammographic screening trials put together, you will find there’s just no signal there. It’s just not budging all-cause mortality. It looks pretty null. Confidence intervals crosses[?] one; the actual effect size is like 0.99. It’s as close to just totally null as it gets.

Now, proponents of mammography say, ‘Well, that’s unfair. You don’t have the power to find a difference. I mean, there could be a difference that exists. The studies just aren’t designed and sized for that. And, in fact, we’ve done some power calculations. I had a paper on a few years ago. You’d probably need, like, 3 million women randomized and there are usually in the tens of thousands. Put together, maybe it’s like 300,000, 400,000 women. You need 3 million.

But, the point I want to make is: if you need 3 million women randomized to see the effect, maybe it’s a small effect. I mean, maybe it’s something that might not be worth a $100-billion medical campaign. That’s something that we could think about.

The next thing I’d say is: if you look at just the reduction in death from breast cancer, I always like to separate the trials into this thing you’ve alluded to, which is what we call adequately randomized or suboptimally randomized studies. This is not my nomenclature. This comes from the Cochrane Group–that is the independent research group looking at the studies.

And, it’s exactly as you say: they look for some endpoints that they think are implausible, implausibly related to screening. So, they look at dying from something other than breast cancer. And, if there’s severe imbalances between the two groups, they think there’s something a little bit odd about randomization. And, in fact, that’s true for some of the very older studies.

And I guess listeners may not know this, but in the history of medicine, the first randomized controlled trials came out in the 1940s; and now in 2023, it’s a juggernaut of randomized studies. I mean, we are putting out maybe tens of thousands of random, maybe a hundred thousand randomized studies a year. It’s just a machine. We’ve gotten a lot better at randomization. We used to have envelopes that you would randomize people and open the envelope. Sometimes people would hold them up to the light to try to subvert randomization.

Now we have computer-generated automatic telephone randomization. Pretty much everything about the design and conduct of studies is better today than it was when many of these trials were run–when these mammographic screening trials were run. Many of them use things like Mailer. So, people are invited by mailed invitation to participate in the program. There can be some biases because the group of people who didn’t show up, but the group of people who was assigned to the control arm may include some people who are already deceased, for instance. That’s been cited as a problem with some of these older studies.

This is a little bit long-winded, and so I’ll just cut to the point. The point is that even the biggest optimist about mammographic screening would probably cite a 20% reduction in dying from breast cancer. They can’t claim a reduction in dying for any reason.

And, that means 80% of breast cancer deaths are not avoided. And, this is largely using studies that happened decades ago. And, probably a lot of the changes in breast cancer treatment have eroded that benefit. So, I think that’s what proponents would say.

A critic, like me, would say, is that I truly have no idea if I advise a woman to undergo this screening test if she’s going to live longer. I just don’t know. And I don’t know if she’s going to live better. And, I have to ask myself, what are we doing as a profession that we cannot answer that most basic question?”

These are all reasonable questions to ask. Care, though, does not occur in a vacuum. If a doctor is advising against screening (against the recommendations of medical specialty organizations), and the patient does develop a cancer that causes death, will litigation ensue? Will the family argue that this cancer could have been prevented had the screening test been performed? While the metaphor of turtles, rabbits, and birds makes eminent sense, I suspect it will fall on deaf ears with a jury.

Unless and until the screening recommendations are updated per medical specialty organizations, it will be a bold medico-legal move to persuade a patient that cancer screening is not supported by the data.

What do you think?

Medical Justice provides free consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. If you are navigating a medico-legal obstacle, visit our booking page to schedule a free consultation – or use the tool shared below.

Jeffrey Segal, MD, JD

Chief Executive Officer and Founder

Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.

Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.

Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.

In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.

Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. Byrd Adatto was selected as a Best Law Firm in the 2023 edition of the “Best Law Firms” list by U.S. News – Best Lawyers. With over 50 combined years of experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.

Physicians discriminate against patients all the time. Pediatricians discriminate against the elderly. Ob-gyns discriminate against men. Urologists specializing in male infertility discriminate against women.

But you cannot illegally discriminate against patients.

There are federal and state laws against illegal discrimination. California’s Unruh Act is instructive.

The Unruh Civil Rights Act (California Civil Code Section 51) provides protection from discrimination by all business establishments in California, including housing and public accommodations, because of age, ancestry, color, disability, national origin, race, religion, sex and sexual orientation. 

The Unruh Act permits disparate treatment that is not “arbitrary, invidious or unreasonable.”

Many aesthetic practices limit their treatment based on certain patients they focus on – the aging face (so, they discriminate against the young), Asian rhinoplasty (so, they discriminate against non-Asians), African American skin treatment (so they discriminate against non-African Americans). What allows such practices to do what they do is they have a reason. Their background, training, and experience is limited to a narrow domain. Their results in their domain of excellence will be better than when they stray outside of that domain.

Many surgeons were trained to do a range of procedures. If they have not performed procedure X in 30 years, they likely are rusty. Perhaps it would be better to refer that patient to someone else. That someone else will get a better result. And the reason must be objectively true.

If you do not want to perform a superficial surgery on a patient with hepatitis C because of your perceived risk of sticking yourself with a needle, good luck with that. You may have a valid subjective reason to turn the patient away. But objectively, you would lose a case alleging disability discrimination. Just double glove.

Not surprisingly, in California all types of lawsuits are propelled, alleging discrimination.

Here are California cases where claims of age and gender discrimination were pushed back.

Pizarro v. Lamb’s Players Theatre, 135 Cal. App. 4th1171 (4th Dist. 2006) (theater did not violate the Act by offering discount prices to “baby boomers” to attend a musical about that generation, inasmuch as it allowed greater access to the theater); Sargoy v. ADR Tr. Corp., 8 Cal. App. 4th 1039 (Cal. App. 2d Dist. 1992) (age-based preferences are justified by compelling state interests and are consistent with the public policy favoring assistance to the elderly). In Frye v. VH Prop. Corp., B246991, 2014 WL 69126, at *4 (Cal. App. 2d Dist. Jan. 8, 2014), the Court of Appeal in an unpublished decision affirmed the dismissal of gender discrimination claims against a golf course, for its offering of discounts and free gifts during Breast Cancer Awareness Month. The court noted that the public policy of promoting breast cancer awareness was “more compelling” than it was in Pizarro.

Third, courts have rejected claims of gender discrimination where the activity uses gender as a proxy for a different category of people—such as mothers or people at risk of breast cancer. In Cohn v. Corinthian Colleges, Inc., 169 Cal. App. 4th 523, 86 Cal. Rptr. 3d 401 (2008), for example, the court held that the defendant’s Mothers’ Day promotion, in which female attendees at a baseball game received a free tote bag, did not violate the Unruh Act because “the giveaway was based on motherhood, with gender only a secondary consideration.” That is, the intent of the promotion was not to honor women above men, but mothers against the rest of the population, and giving tote bags to adult females was a practical alternative to taking the time to verify that each woman who received a tote bag was in fact a mother. The court reasoned that because only women can be mothers, the discrimination did not emphasize an irrelevant difference or perpetuate an irrational stereotype.

So, discrimination against patients is permissible if it is not illegal discrimination. Disparate treatment is allowed so long as it is not “arbitrary, invidious or unreasonable.” There must be an objectively valid reason. This can include your medical background, training, and experience. You are not required to stumble through a procedure and deliver questionable results if it’s been years since you operated on a specific type of patient and if specific training and experience are required to deliver excellent results to THAT type of patient.

What do you think?

Medical Justice provides free consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. If you are navigating a medico-legal obstacle, visit our booking page to schedule a free consultation – or use the tool shared below.

Jeffrey Segal, MD, JD

Chief Executive Officer and Founder

Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.

Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.

Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.

In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.

Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. Byrd Adatto was selected as a Best Law Firm in the 2023 edition of the “Best Law Firms” list by U.S. News – Best Lawyers. With over 50 combined years of experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.

Insurance policies are contracts. You pay a premium. In exchange, the carrier covers a specific risk.

Life insurance is the simplest example. You pay a premium and the carrier pays a set amount to your beneficiaries if you die. Whether you die or not is easily determined. (At least most of the time it is easily determined…We won’t get into the unusual circumstance of a person who goes missing and is declared “dead” – for insurance purposes – after many years.)

Of course, the carrier may still deny coverage. There are terms and conditions. It covers the risk based on certain representations. If you have a history of cancer and do not disclose that detail to the carrier – when asked in the application-  and you later die of the same cancer, expect the carrier to deny coverage. The decision to accept the risk is based on specific representations.

If a carrier denies coverage when the policy suggests it should do otherwise, the policyholder may have a claim for bad faith. And the amount of money at play can dwarf what the carrier may have been on the hook for originally.

To be sure, a policyholder also has specific obligations.

For example, you must timely notify the carrier of a high-risk event. Assume you have a claims-made policy with an anniversary date of July 1^st. You perform a wrong level surgery on a patient April 15^th. (I know. Two unhappy events on the same day.) You take the patient back to the operating room the next day. You are aware of the high-risk event. You get a letter from a lawyer asking for records on April 22^nd. (I know, couldn’t the patient have at least waited until the sutures were removed?) You notify your carrier August 1^st, well after the policy’s anniversary date. Your claims-made policy has started a new year. This lawyer files a lawsuit On September 1^st.

Can the carrier deny coverage? It depends upon in which state you live. But, yes, the carrier likely can and will deny the claim. They will argue that they manage their reserves annually and you missed the deadline to report a reportable event.

If you learn one thing from this post, it is this. If you experience a high-risk event, strongly consider notifying the carrier ASAP. It will preserve your rights for the carrier to pay for a lawyer to defend the claim and pay a settlement/judgment if that is the ultimate outcome.

Sometimes, a carrier will scratch its head, writing that they are not sure, at this point, whether a claim is covered. Still, they will pay for an attorney to investigate and defend the claim. But they will reserve their rights to not pay a settlement or judgment (or if paid, claw back what they paid on the claim from you). Their duty to defend is broader than their duty to pay for a loss.

Now for the $52M verdict.

This story begins in 2012.

Dr. Pawankumar Jain, of Las Cruces, was accused by the New Mexico Medical Board of overprescribing opioids resulting in the death of at least 17 patients. Two of the 17 patients were Ruben Bonilla, Jr. and Serina Clark. Bonilla died from Dr. Jain’s injudicious prescribing of morphine in August 2010. He was 43 and was survived by 11 children. Days later, Clark died from Dr. Jain’s injudicious prescribing of opioids and other medications. She was 28 and was survived by three young children.

The doctor’s license was suspended by the Medical Board. The carrier learned of these high-risk events from someone other than the doctor – the insurance broker.

In 2012, [the doctor’s] insurance agent saw a television news story about the physician being accused by the state medical board of overprescribing opioids, resulting in the deaths of 17 patients. The next day, the agent obtained copies of documents from the state medical board, including a summary suspension order and a notice of contemplated action.

The notice of contemplated action specified that [the doctor] had deviated from the standard of care through injudicious prescribing, leading to approximately 17 patient deaths due to drug toxicity. Because the agent realized that lawsuits could be filed against [the doctor]  for the deaths, she sent the insurance company the paperwork from the medical board so the insurer would be aware of the potential claims.

However, when the insurer received the information, it did not investigate or seek more information as it was required to do. The insurer failed to get medical records or specific patient names, and none of the 17 deaths were recorded in the insurance company’s claims system (a failure to follow company procedure). Instead, the insurance company decided to cancel [the doctor’s] policy effective the following month.

The company sent [the doctor] a cancellation letter advising him that his policy was being terminated due to “license suspension, nature of allegations, and practice profile,” and offered him a tail policy to purchase.

The insurance company did not advise [the doctor] that he should ensure all potential claims were reported, including the 17 deaths, before his policy expired. The company also did not advise him that he had a claims-made policy and what that meant regarding future lawsuits that might be filed after his policy period expired.

About a year later, two of these 17 patients sued the doctor for the opioid-related deaths. When he was served with the summons, the doctor notified his carrier, PULIC. The carrier denied the claims.

The doctor’s life went from bad to worse. He and his wife of 35 years filed for divorce. He then filed for bankruptcy. The bankruptcy trustee filed a lawsuit against the carrier for failing to defend and pay claims related to the two deaths. This trustee then settled the case with the two plaintiffs by paying the families $680k from the bankruptcy estate. And by assigning the bad-faith lawsuit against the carrier to the plaintiffs.

The doctor was done with this case. The two plaintiffs could continue forward as if they were the policyholder.

The case continued into 2020, when a New Mexico District Court held that PULIC (the carrier) owed Dr. Jain a defense and indemnity for the Bonilla and Clark wrongful death lawsuits in 2013, that PULIC breached its insurance contract with Dr. Jain, and it violated New Mexico’s Unfair Insurance Practices Act. Early in 2023, an Albuquerque jury determined that PULIC also willfully violated the Unfair Practices Act and engaged in punitive conduct, resulting in a $52 million verdict for punitive damages.

Had Dr. Jain settled the case on his own (outside of bankruptcy), arguably he would have been the recipient of the $52M verdict. That would have been quite a payday. But those funds now belong to the plaintiffs.

Will PULIC file an appeal? Presumably. They may also negotiate with the plaintiffs, settling the case for an amount it can live with.

In this case, the carrier was aware of the high-risk events. While the doctor had a duty to notify the carrier of the high-risk events, it already knew about the cases, and their potential for litigation. Carriers say they need to be timely notified so they can properly allocate reserves to pay for such claims. The prior knowledge made it harder for the carrier to justify the denial of coverage.

What is not clear is whether the doctor actually purchased tail coverage. The reporting suggests he did not.

The second take-home point is this. If you terminate coverage with a carrier, and you have a claims-made policy, you should either purchase tail coverage or make sure the new carrier will cover any claims that pop up down the road for past medical care (nose coverage). You do not want a window of time lingering where no carrier is covering your risk for medical events that have not yet surfaced as bona fide legal claims.

If a carrier denies a claim, and you believe the policy language supports that they should cover, and you have met all your obligations, you may have a claim for “bad faith.” As you can see from Dr. Jain’s circumstances, a jury may award a sizable sum, well beyond policy limits.

What do you think?

Medical Justice provides free consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. If you are navigating a medico-legal obstacle, visit our booking page to schedule a free consultation – or use the tool shared below.

Jeffrey Segal, MD, JD

Chief Executive Officer and Founder

Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.

Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.

Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.

In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.

Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. Byrd Adatto was selected as a Best Law Firm in the 2023 edition of the “Best Law Firms” list by U.S. News – Best Lawyers. With over 50 combined years of experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.