Thursday, May 12, 2005

Pap smears and the women who aren't getting them

I am not surprised by this at all. According to a study by the CDC, the number one reason women cite for not getting Pap smears is that their doctor never recommended it.

Certainly with survey data, one is never sure whether the responses truly charactorize the respondent's true experience. But in this case, I've no reason to think that it does not.

At Harbor-UCLA, our patient population is an extremely difficult one. In general, they are poor, speak little English and have very poor educations. Yet with all of these difficulties, chart reviews of our health screening indices stack up extremely well when compared to national averages.

In other words, despite all the obstacles to care that our patients experience because of their socioeconomic status (and by the fact that their doctors are doctors in training), in many instances, they are followed more meticulously by their physicians then the average suburbanite by his or her private doctor! To me this suggests that nationally, primary care providers (PCP's) just aren't doing their job even under far more optimal conditions than those of our disadvantaged patients.

Yet, there's no magic here. At Harbor-UCLA (presumably as in most residency programs), prevention is hammered into our residents throughout their outpatient clinic experience. Health screening is part of each attending's (supervising physicians) assessment of virtually every intern and resident clinic encounter.

When one of our female patients hasn't been scheduled for her Pap, pelvic and breast exam her resident's attending is surely going to ask why. Likewise, we routinely check our diabetics for the quality of their blood sugar control, kidney function, lipid profiles, etc. They are routinely sent to the ophthalmologist for diabetic eye checks and/or retinal photos. With every clinic visit, we make sure we've talked to them about smoking cessation or checking their feet for diabetic ulcers and whatever else they need to stay healthy. This goes on in a manner tailored to each patient's medical conditions.

These are things all PCP's should be doing for all of their patients.

This survey points to a particularly poignant failing on our roles as healers. We should be encouraging Pap smears in all appropriate patients (not all women need them). Essentially no one in the United States need die from cervical cancer. Pap smear screening has been proven to be just that good.

All of us PCP's need to get our acts together!


Blogger Henry Stern, LUTCF, CBC said...

Dr Ford:

Would you agree that perhaps this post and the last one ("PCP brain drain") are connected?

May 12, 2005 10:02 AM  
Blogger The Medicine Man said...

What can I say? The topic is on my mind!


May 12, 2005 11:57 AM  
Blogger Henry Stern, LUTCF, CBC said...

Not meant as criticism; I just inferred a relationship between the shortage(?) of PCP's and the low PAP smear rate.

It seemed to me that the next logical step was to draw a line between the two posts (metaphorically): there is a shortage of PCP's, they're overburdened, so they don't have time to stress the importance of these screenings, therefore a lot of women patients don't understand how critical these tests are (sorry for the run-on sentence).

May 12, 2005 2:52 PM  
Blogger The Medicine Man said...

Henry, I didn't think you meant it as criticism. I thought they were linked as I was writing the second one. (Used some of the same language in fact).

I think one of the ways PCP's can increase their value (per my previous post) is to get on top of health screening (per this post).

Take care,

May 12, 2005 6:10 PM  
Blogger DrTony said...

Unfortunately, so many PCP's are overwhelmed by acute care that the preventive medicine goes by the wayside. Having done locums tenems for docs on vacation, I can tell you that health care maintenance (HCM)ain't what it should be.

I am a huge advocate of flow sheets and have found that my office staff was an incredible asset in HCM. With a good flow sheet and staff trained to check it, it requires a positive effort to miss these items.

May 17, 2005 10:19 AM  
Blogger The Medicine Man said...

I definitely agree Dr Tony. My moment of clarity came when I learned to accept that Rome wasn't built in a day.

It is impossible, under the constraints of modern office practice, to address all HCM in a single visit. We have to address the chief complaint and then perhaps discuss ONE HCM issue at a time.

HCM has to be an ongoing dialogue. No cramming for exams in one encounter!


May 17, 2005 10:41 AM  
Blogger Dreaming again said...

How many of those women had the test recommended by the doctor, but the recommendation went in one ear and out the other? Never really hearing it, therefore not realizing that they needed to actually DO something about it?

May 17, 2005 11:55 PM  
Blogger The Medicine Man said...


A lot. But as docs, we need to keep after our patients about stuff like this. Patient noncompliance is a MAJOR problem. A LOT of it (not all) is our fault though.


May 18, 2005 10:23 AM  

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