George F. Sawaya, MD; Vanessa Jacoby, MD, MAS
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1205.
Requests for Single Reprints: George F. Sawaya, MD, Department of Obstetrics, Gynecology and Reproductive Science, University of California, San Francisco, San Francisco, CA 94143.
Current Author Addresses: Drs. Sawaya and Jacoby: Department of Obstetrics, Gynecology and Reproductive Science, University of California, San Francisco, San Francisco, CA 94143.
Sawaya G., Jacoby V.; Screening Pelvic Examinations: Right, Wrong, or Rite?. Ann Intern Med. 2014;161:78-79. doi: 10.7326/M14-1205
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Published: Ann Intern Med. 2014;161(1):78-79.
In the modern era, many routine practices are being reevaluated through a lens of not only evidence, but also value. In this issue, the American College of Physicians discusses the screening pelvic examination and gives a “strong” recommendation against it being done in asymptomatic, nonpregnant adult women (1). The recommendation is based on a systematic review (2) that found “no data in support of the examination” but did find evidence of harms ranging from distress to unnecessary surgery.
This recommendation will be controversial. Pelvic examination has long been considered a fundamental component of the well-woman visit, and 62.8 million were done in the United States in 2010 (3). The examination has been closely linked with cervical cancer screening, but with current guidelines recommending less-than-annual testing, the need for asymptomatic women to return annually for this examination has been questioned. In 2012, the American College of Obstetricians and Gynecologists (ACOG) published a committee opinion describing the content of the well-woman visit and continued to recommend annual pelvic examinations, including speculum and bimanual examinations, in all women aged 21 years or older (4). According to a recent survey (5), obstetrician-gynecologists in the United States universally conduct pelvic examinations across a lifespan in asymptomatic women and believe that lengthening the interval between examinations would decrease patient satisfaction and overall health and well-being (6). Ending such a prevalent practice with widespread support among women's health providers will be met with formidable challenges.
Paolo Vercellini, Carlo Liverani
Department of Obstetrics and Gynecology, University of Milan, Italy and Fondazione Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
July 26, 2014
Screening pelvic examination: follow the money
Sawaya and Jacoby (1) comment on the clinical practice guideline from the American College of Physicians on screening pelvic examinations in adult, asymptomatic women, (2) efficaciously describes methodological issues lying beneath this medical ritual associated with overdiagnosis, and politely suggest that clinicians that continue to offer the examination may not be cognizant of the uncertainty of benefit and the potential to cause harm owing to the consequences of a false positive test result. However, the authors do not appear to have openly considered conflict of interest (COI) as an alternative or additional explanation for the insistence on well-women visits. In-office care generally influences the income of most physicians, but there is probably no other specialty like gynecology where healthy people have been accustomed to think that yearly examinations, independently of symptoms, are essential for disease prevention. The resulting considerable increase in ambulatory clinical activity has economically benefitted not only gynecologists, but also cytologists, pathologists, radiologists, pharmaceutical companies, and manufacturers of medical devices that can earn from care of the large proportion of well-women. Additionally, it seems unlikely that gynecologists still are unaware of the needlessness of yearly pap smears in women with previously negative cytological testing. Clinicians appear to ignore this evidence too, and continue to perform Papanicolaou tests sooner than needed, (3) potentially reinforcing women’s conviction that screening pelvic examination and pap smear are inseparable components of a single preventive intervention. Also this unsubstantiated attitude contributes to "physician self-referral", that is, «the practice of a physician ordering tests on a patient and that are performed by either the referring physician himself or a fellow faculty member from whom he receives financial compensation in return for the referral». (http://en.wikipedia.org/wiki/Physician_self-referral) The ability to self-refer is an incentive for physicians to order more tests than they otherwise might. The American College of Obstetricians and Gynecologists continue to recommend annual pelvic examinations, including speculum and bimanual examinations. (4) Members of the Committee on Gynecologic Practice, as gynecologists, are subject to COIs by definition. A recommendation against screening pelvic examination in asymptomatic women would have important economic implications for the gynecologists they represent. Although COIs do not necessarily result in bias, they resemble a screening test for bias, with imperfect sensitivity and specificity (5). Thus, in order to minimize the risk of undue influence, the evaluation of the effect of screening pelvic examinations by non-gynecologists appears as a healthy initiative despite predictable controversies. 1. Sawaya GF, Jacoby V. Screening pelvic examinations: right, wrong, or rite? Ann Intern Med 2014;161:78-79.2. Qaseem A, Humphrey LL, Harris R, Starkey M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2014;161:67-72.3. LeFevre ML. Swimming upstream: doing less in health care is hard: comment on "No Papanicolau tests in women younger than 21 years or after hysterectomy for benign disease" and "Cervical cancer screening intervals, 2006 2006 to 2009". JAMA Intern Med 2013;173:856-8.4. Committee on Gynecologic Practice. Committee opinion no. 534: well-woman visit. Obstet Gynecol 2012;120:421-4.5. Lo B, Ott C. What is the enemy in CME, conflicts of interest or bias? JAMA 2013;310:1019-20.
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