A whole lotta' Pap smears going on (too many!)

It's hard for most of us to imagine that our physician(s) may be going against scientifically-drafted guidelines when it comes to screening for diseases and/or their treatment. But, this seems to be the case for cervical cancer screening. 

Researchers from the Centers for Disease Control and Prevention (the CDC) recently conducted a survey on whether or not docs would do a Pap smear on 3 different imaginary, yet low risk patients (defined as a woman in a monogamous relationship with one partner having a current negative HPV test or 2 consecutive normal Paps), and 2/3 of them recommended another smear in one year. This goes AGAINST the clinical guidelines that recommend spreading these screenings out for low risk patients. Not only do these extra tests cost us all more health care dollars, but they also increase frequency of pain and anxiety for the women undergoing them. And trust me, that discomfort and anxiety can be significant.

This doesn't mean that 2/3 of doctors are setting out to cause harm to their patients or order needless tests. For the most part, I do not believe that physicians are bad people looking to take vengeance out on their patients. I believe the confusion lies, well...in the confusion of clinical guidelines. Guidelines change constantly. One day, physicians are supposed to teach monthly breast exams to women for breast cancer detection and the next, they are supposed to recommend "breast awareness". One day, vitamin E is good for preventing heart disease and the next it's actually harmful! Etcetera, etcetera. The contradictions are endless.

But such is the nature of the beast. Medicine is dynamic, not static. It changes just as the seasons change, our moods change, our lives change. It is a process. With more and more technology and research, researchers are trying to figure out how to become more efficient and less costly with providing medical care to the aging masses. However, this is not an easy task nor is it simple. For one, it COSTS money to study cost-effectiveness...lots of it and secondly, it takes TIME to conduct a good study and obtain the results.  The average randomized clinical trial lasts over 5 years which is often not enough time to make long-term predictions.  Funders of studies want results asap, thus putting even more pressure on researchers.

Thirdly, doctors are constantly bombarded with information and often do not have the time or the patience to read the latest, most credible journals and research updates (which, in my opinion, is a product of the system). They then defer to practicing medicine the way the person(s) who trained them did. In doing so, non-evidence-based traditions (and there are MANY) are practiced and taught to future practitioners. As such, tradition has a great influence on the practice of medicine. Until this issue is addressed, costly medicine will persist and not without it's risks. 

Potential ways to address this issue are investments in electronic medical records that automatically schedule the next screening according to the most recent guidelines and physician audits during which random chart are extracted from a physicians' caseload and the physician is held accountable and liable for not adhering to current recommendations (although I would not be a fan of either of these options if I were in private practice as the former is very expensive and time-consuming to implement and the latter is very regulatory).

Changing the pay structure for docs would also help. Instead of the current fee-for-service structure in place now where payments are made for procedures, not necessarily for quality time spent with a patient, physicians are financially inclined to do more procedures (including Pap smears). This flies in the face of ethical medicine - no matter how ethical a person is, finances rule all and we, despite what some of our own think, are only human. 

So, my proposal to my readers is - be an astute patient and question your physician (in a nice way) as to whether or not you really need that cat scan or the annual Pap smear. After all, it most likely will not extend your life but it may make it less enjoyable (think anxiety, discomfort, etc). And if you question them and end up changing their practice, you can claim the cost-savings with pride! 

Happy Wednesday,
Dr. M