Smearing and Scheduling

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.

14 Replies to “Smearing and Scheduling”

  1. VERY interesting. I’ve suffered through two colposcopies for nothing. Had two abnormal paps, but the colposcopy results were always normal. Every other year or so I tend to get an abnormal pap result and then end up with 3-5 per year, ALL NORMAL. Sigh.

  2. Elita, I have a few friends with the same problem. I’ve (luckily) never had an abnormal pap but it sounds really scary to go through, and to have it be for nothing…and of course to have that smouldering in your file like a ticking time bomb for an insurance company to use to deny coverage later…

  3. I learned this when I was living in Australia! I had been there for about 6 months, or whatever (I lived there 3 years), and was like “oh, time for my annual pap!” So I went to the doctor and told them I needed a pap, and they asked me when my last one was. I said “about a year ago” and they looked at me like something weird was growing out of my face, and said “uh, you don’t need one then.”

    So, I argued with them, and eventually got my test. Being an 18-year-old American — read “arrogant know-it-all” — I thought for some time that the Aussies were just doing it wrong. I learned a couple years later that no, actually, we are, and have been annoyed at getting my annual pap in order to continue my BC prescription here in the U.S. ever since.

    The really funny thing is that a lot of Americans would think, as a much more naive and ignorant version of myself did, that these countries with universal health care are just cutting corners and putting people’s health at risk in order to save money. But in fact, I’m now fairly convinced that it’s really at least partially about the U.S.’s profit-driven system finding more ways to suck money out of people who don’t have it.

  4. I’m delighted to have a doctor who only requires them every 3 years for women under 45. If one comes back abnormal, you’re in for the following year, but otherwise, it’s exams only in the intervening years, no paps.

  5. I start birth control for a number of young women without an internal exam, though I do like to do one in the first six months as a baseline and to check for STDs. As far as abnormal paps, in my age group (teens), they generally self-resolve which we didn’t know a decade ago.

    The scarier thing is that paps are not regulated. A couple decades ago, paps were enormously full of errors. Big errors causing death and unnecessary surgeries. There was a big outcry and CLIA came into being, designed to regulate all lab tests (and make it difficult for me to do any, even the easy ones, in my office) except, surprise, paps. Still unregulated. Read about it sometime.

  6. Thanks for the tip, Vicki, I’ll have to do some reading; do you have any particular sources you’d recommend?

  7. Vicki says I should join this discussion (or else?) and I am nothing if not dutiful. I think this discussion, and all the discussions about specific problems in the US health care system are actually a case of mistaking the symptom for the cause. Granted and regranted, the system is royally copulated. Pick any issue relative to the system and it is like going down a rabbit hole with Alice. It can easily be demonstrated that almost nothing makes sense on close examination. Aditionally, everyone’s head so full of artificial framing of the various issues, think of thinking in slogans, that rational dialog becomes impossible. For instance, with the pap smears, never really liked doing them much, the question becomes a question not of medicine but of automation. Taylorism is in full tilt when we talk about “routine tests,” much less rules about which demographic gets what. Medicine as something that emanates from a black box, metaphorically more like the auto repair shop than any description of an actual human relationship. In fact, according to the golden rule of medicine, do unto others as you would do unto members of your own family, such “rules” should be rejected by the ethical physician who always retains a responsibility to act, according to her experience and understanding, in the best interests of her individual patient primarily and inclusive of that individuals community. Practice guidelines and protocols were always meant to be a suggestion, but the corportization of medicine have turned them into inhuman rules serving the interests primarily of the profit statements of the corporations. With the issue of pap smears, for instance, not all sub-populations of individuals of a given age are at the same risk of cervical cancer. In my practice in juvenile halls I was both responsible for the quality of care and for the budget expended on that care. I was not spendthrift. However, especially with the Hollywood crowd, I sent a lot of pap smears. Turns out that if you are very active the cervix looks like it may be brewing active cancer. A lot of the young women got Paps. A lot of them were abnormal. None were referred for cuposcopy. All of the abnormal tests returned to normal after six months of incarceration, but if it looks like cancer, you should test.

    Every human is exquistely unique. It is one of the very strange things about our species. So uniform genetically. So unique phenotypically. When I taught medicine I often suggested that the student ask herself first what she would do with the information she received from the proposed test. If nothing was planned, if it was just a “fishing expedition” it should not be done. So called “routine” screening tests are just tests that would be expected to be commonly ordered by a well informed physician, doing a careful exam and history, that are “indicated” (as opposed to “routine”) for that particular patient given their unique history, age and sex. For instance celibate women probably, baring other considerations, less frequent exams than their age mates. It is all about being conscious of the patients reality and not treating them like industrial livestock, not like you would want your family treated.

    So the way medicine is supposed to be, the way it has often been in many places at least since the Hippocratic school, is that the doctor encounters the patient in an honest and unexploitive relationship and abjures doing harm, including, in our discussion not doing tests that may end up resulting in harm through false positives. Someone needs to assess the risk vs. benefit ratio whenever humans are subjected to any kind of test. Would that it were that those assessments were being made by the wisest rather than the greediest.

    herb

  8. hi mel,
    as per usual – great post. Not attempting to de-rail here (if I am – would love to discuss over email) but one of the things I love about your approach is that you don’t take the, “as a woman, you should adore every aspect of your reproductive health. Don’t complain – rejoice!” I love that about your approach in general – and here in particular. I am one of those women who has found pap smears to be incredibly uncomfortable. In fact, I am overdue. While I will get it done – I really, really do not want to. The last time I had it done, the CIS woman doctor stuck the swap up me, and jabbed incessantly. When I said, “You’re hurting me,” I was told that there are no nerves there and that I was imagining the pain. To link this back – I had only had a pap smear 9 months before (in Australia, BTW). And was sent for one on the basis of suspected endometriosis. Because – naturally, even after pelvic ultrasounds – let’s do another pap smear searching for a cause of something that existed long before the last one. hmm = not too sure of my entire point – apart from the fact that it is so nice to read the thoughts of someone else who can actually relate to my thoughts on the matter.

  9. Grk, Natalie, that sounds extremely uncomfortable. They always act like you can’t feel the swab and, uhm, yes you can.

    It’s hard to find a doc who respects boundaries/will actually listen to you when you say “stop, this is hurting.”

    One thing which might make it more comfortable for you is a side-lying exam, a tip recommended to me by one of my FWD co-contributors; it might be worth finding a doc who will agree ahead of time to do one. Both because it will be more comfortable, and because advance agreement would suggest that the doc will actually be respectful.

  10. I suspect most of the problem with discomfort is the ancient implement called a vaginal speculum, and the only device I and every other physician has been trained to use. It really is a dinosaur with respect to most procedures and something, probably incorporating fiber optics would be better.

    A good short term political goal would be to find funding to develop such a thing and do the clinical trials to establish its role in common procedures (alas, for some things, the speculum will still have a role) where discomfort is a significant risk leading to exam aversion and less than optimal care for many.

    I would imagine the female membership of Congress could be enrolled in support, or even arrange funding. If feminist leaning non-profits ended up with the patents, in the long run, more money would be available to put towards solving the real problem, the symptom causing disease, behind all these symptoms of systematic dysfunction in all aspects of health care. Not to mention the exotic degree of dysfunction in ALL our institutions, the dysfunction in the health care system can be directly traced to domination and exploitation of health care by a cabal of criminal mega-corporations.

    herb

  11. Before I do a first internal exam (with or without the Pap test), I describe it at length to the young woman involved. One of the things I tell her is that it is frequently somewhat uncomfortable (those foot holders!) but that it should not hurt. If it hurts, one of three things is true. You are tense, your doctor is not being careful, or something unusual such as an infection is going on. In any case, you should speak up immediately and the enterprise should pause until you and the doc figure out which problem it is. If you are tense, work on relaxation or reschedule. If your doc is rough or careless, he (or me) should apologize and you can decide if you want to continue or find someone else. If it is neither of those, then we really need to know what is going on. PID, endometriosis, what. Oh, and make sure the speculum is the smaller one, not the huge one they say is for the grand multip.

  12. I still remember the first time I was informed that speculae (speculums?) came in SIZES.

    And that you could request a SMALLER ONE.

    It was a lightbulb moment.

  13. I find it amazing (in a sad way) that a woman’s right to control her reproduction via hormonal birth control is contingent on an invasive (often irrelevant) medical procedure. As an Australian, I can see my GP for BC pills and paps, but one is not dependant on the other. By the pills being contingent on the pap it sets up a coercive situation, which by its very nature impedes ethical informed consent for the consultation (specifically the pap).

    I have also had abnormal pap results and had to have medical treatment. Annual testing would not have changed this, nor identified it sooner in my circumstances.

  14. I am an American male and find it appalling that woman in this country are forced and even coerced into this on an annual basis. The statistics show that there is a very low chance of cervical cancer overall, even lower than the risk of becoming pregnant while using the birth control pill. Of course, there are chances of ovarian cancer, but according to a gynecologist at gynotalk the pill reduces your chance for those cancers which are already very low. In reality based on the many things I’ve read some woman can even skip them if them and their spouse were virgins and have been together since (as is my case) due to the extremely unlikely chance of HPV. Other woman as mentioned above can have them every 3-5 years and still be fine. There is a huge discussion at blogcritics regarding this issue which started me, as a male, reading on this subject.

    There are a few options including one mentioned at the New York Times regarding DNA testing for woman instead of pap smears which is more accurate. The test works “acceptably well” for woman who elect to swab themselves due to modesty reasons. Of course, doctors would rather see you yearly for a test and BC instead of one time for it.

    Another option is the HOPE program at planned parenthood (go to one listed on the planned parenthood site, some places claim they are planned parenthood but are not) which allows birth control without a pelvic exam if you do not have high blood pressure and other symptoms which require an exam.

    Recently, there have been updates to the recommendations of number of pap smears by ACOG. Considering ACOG and ACS now recommend them at longer intervals you should consider pressing your doctor about not requiring them yearly or based on when you feel they are necessary. Since cervical cancer screening is unrelated to birth control a patient may make an informed consent to still get birth control without an exam. If the doctor refuses, many recommend getting a lawyer to send a letter and usually that’s all it takes to set things right.

    Men are not forced to get cancer screenings at 50; we’re strongly encouraged though. Woman are coerced in to cancer screening with doctors making woman feels as though they are not responsible when refusing an exam (seen it first hand). If woman want this changed, stand up for your rights, tell the doctor you will not do the exam and mention that you’re giving your informed consent to receive BC.

    Remember, it’s your body TAKE CONTROL OF IT!

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