The many problems in the American health care system are so numerous that it almost seems silly to try and profile individual issues, but this is an issue particularly dear to my heart, so I’m going to go ahead and go for it. I think it’s a perfect example of the storm of circumstances which is causing such problems right now; you have fear of a malpractice suit, the need to generate reasonably easy income for a practice, and the desire to at least try and keep up with patients who will not set foot in a doctor’s office unless it can’t be avoided, because of the expense.
I’m talking about the Pap test, also known as the smear test.
Here in the United States, Pap tests are given annually. During the annual exam, as a matter of fact. Having a conversation with a friend from another region of the world recently, this topic came up, and she was astounded that Paps are given so frequently. So, I started poking around, and I found that guidelines in other countries recommend screening every three to five years, and that screenings stop after age 60 if a woman hasn’t had any abnormal results.
Here in America, we like to think that our health care system is best, even as we are bemoaning how broken it is. Something like an annual screening for cervical cancer is touted as an example of how terrific our system is. We don’t cut corners. We’re better than everyone else. We make sure that our women get routine screenings for a very serious disease so that it can be caught early. I’ve even bought into this to some extent; I hate the smear test, I would like to not have it every year, but I submit “for my own good,” because I’ve been told that this is the best way to do it.
Except that I actually started reading the studies used to justify a three to five year schedule, and I found that, uhm, we’re doing it wrong. These studies showed that doing smear tests annually increases interventions, which sounds like a good thing on the surface but actually isn’t, because sometimes cells are abnormal and there isn’t a problem. Indeed, women have been subjected to very invasive procedures for, well, for nothing. The same issue arises with mammography. While it seems like a good idea to screen a lot, it actually increases the rate of false positives, and when you get a positive on something like a mammogram or a Pap, you are definitely going to consent to invasive procedures like biopsies “just to be sure,” and that exposes you to risk.
Other nations use evidence-based medicine to decide on guidelines for things like this. They conducted a lot of studies, and they found that a three to five year interval was actually optimal. Not because they didn’t want to pay for annual screenings, but because a three to five year schedule hits the sweet spot. It’s not too frequent to get false positives, it’s not too infrequent to catch cervical cancer early. In other words, this interval is best for women.
But if I approached my gynecologist and asked to have tests less frequently, or exercised informed dissent and asked that a smear not be conducted during my annual exam, she would refuse. She would probably refuse to write me a prescription for birth control (which is, yes, why I bother to go every year), because she would be concerned about liability. She may well agree with me that smear tests happen too frequently, but if I got cervical cancer, I might find some way to blame it on her, and she can’t take that risk.
So she has to do it every year. Because, if she doesn’t, she’s at a financial risk. Indeed, it’s probably a practice policy; even if she was willing to space my smear tests out more, she might not be allowed to, because she has to follow the standards of the practice. Even though conducting a smear test every year endangers my health. In this case, quite literally, the status quo trumps my health and bodily autonomy.
This is a problem. We should not be endangering women’s health. We should be revising the guidelines for the smear test to make it clear that it does not need to happen annually. I won’t deny women who want an annual Pap the right to get one, but I would like to exercise the right to make informed decisions about my medical care, based on evidence-based studies which clearly demonstrate that my desire to get a smear every three to five years, rather than every year, is actually better for me.
This is a country in which concerns about bureaucracy override the rights of patients. Doctors perform smear tests annually because, well, because the patient is a captive audience. She has to get the test to get her birth control, and she’s been told that she needs the test for her safety. So she submits. It’s easy money for the practice, it covers the doctor in terms of legal liability, and it allows the doctor to make a connection with a patient; at least, if someone comes in once a year, a doctor can identify signs of medical problems early and perhaps intervene.
Annual wellcare visits are pretty critical. But we need to change the structure of those visits, to shift the focus onto preventative care rather than using unnecessary procedures to get people in the door. We need to shift the way Americans think about going to the doctor. You shouldn’t go because there’s a problem, or because you have to in order to access medication that you need. You should go because regular checkups are a good idea, because early intervention can make a big difference.