Thursday, July 3, 2014

The screening pelvic examination: not annual, not ever

The Dispute Over Annual Pelvic Exams, an editorial in the New York Times July 3, 2014, highlights an issue about which I have written before, including Primary Care Contributes More than Money...., June 2, 2013 and President Bush's stent: inappropriate screening and care for the rich, nothing for the poor, September 7, 2013. The Times has also had articles on the same subject, notably Questioning the pelvic exam, by Jane BrodyApril 29, 2013. The impetus was a recent guideline recommendation from the American College of Physicians (ACP), the specialty society for internal medicine physicians, that recommended against doing this test on an annual basis.[1]

This examination is not to be confused  with the Pap smear screening test for cervical cancer (although it regularly is). The Pap smear involves obtaining cells for cytological examination from the cervix by means of a spatula and/or small brush. The Pap smear is not perfect, but it is probably the best of the cancer screening tests available to us; the US Preventive Services Task Force (USPSTF) recommends them in women 21-65 years of age every 3 years. The pelvic exam, the part where the doctor puts her/his hands inside a woman and feels around, is often done in conjunction with the collection of the Pap, thus the basis for the confusion among many women. It is not recommended by USPSTF at all, at any frequency[2], but the American College of Obstetricians and Gynecologists (ACOG) recommends it on an annual basis.

I have long been a teacher of family medicine, and for many years have told my students and residents that there was no indication for this examination, at any frequency, for screening. I do this despite the fact that I know they are taught to do so on their OB-Gyn clerkships and rotations, and not because I believe I am more experienced in providing women’s reproductive health care than are the OB-Gyns. I can, however, read the evidence. By definition screening occurs in asymptomatic people; should a woman present with symptoms referable to the pelvic region (for example, pain, bleeding or discharge) the examination may be indicated. However, in the absence of symptoms it is a screening test, and should not be done because there is nothing that it can screen for. Years ago, an argument for doing it was screening for ovarian cancer, but many studies have demonstrated that it is not effective for this purpose, because by the time an ovarian cancer can be felt by the examiner, it is very far gone. These are essentially the same reasons that USPSTF and ACP recommend against it.

And, yet, ACOG, as noted, continues to recommend it (”Annual pelvic examination of patients 21 years of age or older is recommended by the College.”). The Times editorial notes that
…the gynecologists group argues that the “clinical experiences” of gynecologists, while not “evidence-based,” demonstrate that annual pelvic exams are useful in detecting problems like incontinence and sexual dysfunction and in establishing a dialogue with patients about a wide range of health issues.

This defense ranges from the indefensible (that it is not evidence based) to the absurd (that it is the way to find problems like incontinence and sexual dysfunction). If a woman has incontinence or sexual dysfunction, she knows it and the way to discover it is not by a pelvic exam, but by asking her. Clearly, the same is true of “establishing a dialogue with patients about a wide range of health issues.” I strongly doubt that most women would feel that having the doctor put his/her hands inside her vagina is the best way to open such a dialogue!

Why, then, would ACOG continue to recommend it? Long ago, when I was in medical school and residency, almost all OB-Gyns were men, and lack of empathy could be a possibility, but this is far from the case now or in recent decades. There is also the fact that such an examination, as a procedure, is reimbursed at a much higher rate than simply talking to a patient. This is true also for family physicians and other primary care providers (such as general internists, which explains the ACP’s interest in the issue), but for OB-Gyns it is a much greater percentage of their practice and thus their income. It is hard to break with tradition, to change the way that you have always been taught, and it is probably harder when there is a concrete disincentive (loss of income) for changing.

But women, and all people, need to be able to trust that their doctors are recommending and doing procedures, particularly invasive and uncomfortable procedures like the pelvic examination, only when they are indicated by the evidence. They need to have confidence that those physicians are not motivated, consciously or not, by a conflict of interest (e.g., financial gain). One step is for physicians to honestly look at the evidence, and avoid prioritizing their anecdotal experience over that evidence.

More profoundly, however, our society, our health care system, needs to eliminate perverse incentives for doing “more” even when it is not indicated, still less when it is also unpleasant for the patient (like a pelvic exam), and least of all when it is also dangerous (as other procedures are). Physicians should be paid for maintaining and increasing the health of their patients, not for “doing things”. If talking to the patient about “a wide range of health issues”, including but not limited to incontinence and sexual dysfunction, is the right way to find out about these problems, and if it takes a long time, then this is what needs to be reimbursed, not a procedure.

We are currently a long way from this sort of reimbursement, for spending the time needed to provide the best health care for a person. It is good that ACP has added its voice to recommending against screening pelvic examinations, but it is unsurprising that doctors do what they are paid to do. We need system change.

[1] Qaseem A, et al, “Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline From the American College of Physicians”, Annals of Internal Medicine 2014;161(1):67-72. doi:10.7326/M14-0701.

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