Medicine
An American College of Physicians practice guideline has garnered attention for recommending against clinicians performing screening pelvic examinations in asymptomatic, nonpregnant women. Although the new guideline has been called "controversial," its findings should not be a surprise to readers of American Family Physician. An editorial and blog post published in AFP early in 2013 argued that this longstanding tradition is "preventive time not well spent," since the pelvic examination doesn't actually prevent anything (screening for ovarian cancer does more harm than good and accurate testing for chlamydia and gonorrhea can be done on urine samples) and is associated with increased cost, inconvenience, and patient discomfort. With Pap smears only recommended every 3 to 5 years in most women, it also seems prudent to redirect time saved from not performing extra pelvic exams to effective preventive services such as counseling for tobacco and alcohol misuse.
But why stop at the pelvic examination? Last September, the Society of General Internal Medicine included the following item in its Choosing Wisely Top 5 List of potentially unnecessary tests or procedures: "Don't perform routine general health checks for asymptomatic adults." They cited a Cochrane review of 14 randomized controlled trials that found that the annual physical increases new diagnoses but "do not decrease total, cardiovascular-related, or cancer-related morbidity or mortality."
The physical examination may not improve outcomes in asymptomatic patients, but what about the cardiovascular risk assessment and lifestyle counseling that goes along with it? A randomized trial published this year in BMJ casts doubt on the benefits of this preventive service. In nearly 60,000 residents of Copenhagen, Denmark between the ages of 30 and 60 years, four or more sessions of individual lifestyle counseling over a 5-year period produced no effect on rates of coronary artery disease disease, stroke, or mortality after 10 years of followup. In an accompanying editorial, the Cochrane review authors state flatly: "General health checks don't work. It's time to let them go."
As the U.S. faces a worsening shortage of primary care clinicians, are today's family physicians prepared to abandon annual pelvic examinations and well-adult checkups in general? If not, why not?
**
The post originally appeared on the AFP Community Blog.
- The Screening Pelvic Examination: Not Annual, Not Ever
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Medicine
Skip the annual pelvic examination? How about the whole checkup?
An American College of Physicians practice guideline has garnered attention for recommending against clinicians performing screening pelvic examinations in asymptomatic, nonpregnant women. Although the new guideline has been called "controversial," its findings should not be a surprise to readers of American Family Physician. An editorial and blog post published in AFP early in 2013 argued that this longstanding tradition is "preventive time not well spent," since the pelvic examination doesn't actually prevent anything (screening for ovarian cancer does more harm than good and accurate testing for chlamydia and gonorrhea can be done on urine samples) and is associated with increased cost, inconvenience, and patient discomfort. With Pap smears only recommended every 3 to 5 years in most women, it also seems prudent to redirect time saved from not performing extra pelvic exams to effective preventive services such as counseling for tobacco and alcohol misuse.
But why stop at the pelvic examination? Last September, the Society of General Internal Medicine included the following item in its Choosing Wisely Top 5 List of potentially unnecessary tests or procedures: "Don't perform routine general health checks for asymptomatic adults." They cited a Cochrane review of 14 randomized controlled trials that found that the annual physical increases new diagnoses but "do not decrease total, cardiovascular-related, or cancer-related morbidity or mortality."
The physical examination may not improve outcomes in asymptomatic patients, but what about the cardiovascular risk assessment and lifestyle counseling that goes along with it? A randomized trial published this year in BMJ casts doubt on the benefits of this preventive service. In nearly 60,000 residents of Copenhagen, Denmark between the ages of 30 and 60 years, four or more sessions of individual lifestyle counseling over a 5-year period produced no effect on rates of coronary artery disease disease, stroke, or mortality after 10 years of followup. In an accompanying editorial, the Cochrane review authors state flatly: "General health checks don't work. It's time to let them go."
As the U.S. faces a worsening shortage of primary care clinicians, are today's family physicians prepared to abandon annual pelvic examinations and well-adult checkups in general? If not, why not?
**
The post originally appeared on the AFP Community Blog.
- The Screening Pelvic Examination: Not Annual, Not Ever
The Dispute Over Annual Pelvic Exams, an editorial in the New York Times July 3, 2014, highlights an issue about which I have written before, including Primary Care Contributes More than Money...., June 2, 2013 and President Bush's stent: inappropriate...
- President Bush's Stent: Inappropriate Screening And Care For The Rich, Nothing For The Poor
One of the recurrent themes of this blog has been the importance of everyone having access to necessary medical care, and how the US compares poorly to other developed countries in that it does not cover everyone. Another recurrent theme has been that...
- Choosing Wisely: Learning To Leave Asymptomatic Bacteriuria Alone
Outside of pregnancy, antibiotics for patients with asymptomatic bacteriuria - that is, a positive urine culture in a patient with no signs or symptoms of a urinary tract infection - do more harm than good. Consequently, comprehensive guidelines...
- Can Treating Mild Hypertension Be Too Much Medicine?
As part of a plan to improve our practice's quality of care for patients with high blood pressure, my office's nurse announces at every morning huddle which patients on that day's schedule had a blood pressure measurement of greater than 140/90...
- Why You Should Just Say No To "routine Blood Work"
You're at your family doctor's office to have a complete physical. Maybe you're starting a new job, or have recently joined a wellness program in your community, or it's been more than a few years since you've had a checkup and you...