Wednesday, August 6, 2014
Should you get an annual pelvic exam?
There are many common practices in medicine that are completely useless. For example, it was once common for patients to get a chest X-ray as part of their yearly physical. Someone finally questioned this practice and studied its utility. It turned out that chest X-rays used to screen for cancer failed twice. They often detected non-cancerous abnormalities that led to extensive work-ups, and they failed to catch cancers. The practice has fallen into disuse.
The yearly physical exam has been a medical tradition for many decades. It is another procedure whose utility is questionable. Studies have shown it to increase costs with little benefit. But most internists still recommend them. Are we doing it just for the money?
We try to base our practice on good scientific evidence. Some things are easier to study than others. It’s relatively simple to design a study that looks at whether a pill prevents heart attacks. Figuring out how to evaluate something like the annual physical is more problematic. It’s hard to find endpoints, and many outcomes are vague: how many marriages were saved by impromptu counseling? How many people felt less depressed by being able to talk to their doctor? How many people treated their blood pressure better by getting praise from the doctor?
And as long as you’re in my office, should I stop at just checking your blood pressure and cholesterol? Why not take the time to talk to you and examine you? Yes, I may find things that should have been left alone, but I may be the one who first detects your skin cancer or leaky heart valve.
Deciding what medical procedures are “worth it” isn’t a simple matter, but it is important. This week the American College of Physicians (I am a member) issued a policy statement on pelvic exams. The policy is simple. In otherwise healthy women, don’t do them.
A pelvic exam consists of examining the external genitalia, placing a speculum in the vagina, inspecting the cervix and vagina, usually collecting a Pap smear, then inserting 2 fingers while feeling the belly with the other hand. This allows the doctor to feel the ovaries and tubes, uterus and bladder.
There is no magic to the pelvic exam. Since the vagina is part of the body, it gets examined. Skipping the genitals seems about as smart as skipping the lung exam. What is so special about the genitals that we should skip them?
In the ACPs new recommendations they looked at existing studies to try to assess the benefit of the pelvic in preventing disease and death. Not surprisingly, they did not find much benefit, but when doing a “study of other studies” this sort of thing isn’t easy to measure.
They also looked at the potential harm of the pelvic exam. The “harms” they looked at were those due to the exam itself, and the extra tests that an exam can lead to:
“The evaluated harms included fear, anxiety, embarrassment, pain, and discomfort.
Most studies included only women in their reproductive years. The overall quality of the studies was low.
Harms of pelvic examination include unnecessary laparoscopies or laparotomies, fear, anxiety, embarrassment, pain, and discomfort.”
I find the “emotional” component idiotic in this sense: it assumes that women are too psychologically fragile to have their genitals examined, and it assumes that gynecologists have no training or common sense in dealing with survivors of abuse, assault, and rape. This is an argument for better doctoring, not for abandoning an exam altogether.
The harms seem a bit overblown, and weren’t quantified all that well. How many pelvic exams does it take to diagnose one patient with ovarian cancer? How many does it take for a patient to disclose to her doctor a history of unsafe sexual practices, difficulties with intercourse, or a history of rape?
It’s important to note that the guidelines to not address Pap smears or exams on women with symptoms associated with the pelvis.
I find the recommendations put out by internists to be paternalistic and premature. The data aren’t sufficient to draw conclusions. It seems arbitrary to leave out a particular body part from a physical exam. If good studies are done in the future, ones designed specifically to evaluate the best way to approach women’s health, we should use that data to change our practices. For now, I see no good reason to eliminate the female genitals from the physical exam.
Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.
Contact ACP Internist
Send comments to ACP Internist staff at email@example.com.
- How and when is the physical exam useful?
- The Sunshine Act and Open Payments
- Professionalism in wartime: Arab and Jewish medica...
- GME funding report offers new recommendation, chan...
- Looking for the pony
- Eating breakfast neither helps nor hinders weight ...
- QD: News Every Day--'5 a day' fine, but more than ...
- QD: News Every Day--Middle age alcohol misuse may ...
- Update for Lyme disease
- Colonized patients (but not infected patients) con...
Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.
Reflections of a Grady
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
Technology in (Medical)
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
Peter A. Lipson,
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.
Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.