Wednesday, 3 September 2014

Pelvic Examination in Healthy Women.

The American College of Physicians recommends against performing screening pelvic examinations in asymptomatic, nonpregnant, adult women. This is a strong recommendation based on moderate-quality evidence of harms outweighing benefits. Screening for sexually transmitted infection can be performed by urine testing or vaginal swabs. This recommendation applies only to the pelvic examination; the guideline does not address screening for cervical cancer using the Papanicolaou (Pap) test.
      This, believe it or not, was what arrived in my continuing medical education program recently.
      I trained many generations of medical students and residents to be competent, well trained family physicians.  The basis of that training was to take a detailed complete history, including family history and a history of the patient's current and past life.  This was considered important in those days and I recall telling my students that if one took a good history one usually had the diagnosis, or something close to it at the end of the process.  In other words, the patient told you what was wrong, at least from his point of view.  Then the physician did a complete physical examination to look for clues and search for evidence that would enable him to arrive at a definitive diagnosis.   The physician would then decide what tests or further investigations to order to either confirm or reject the working diagnosis and decide what further evidence was required.  It was not coincidental that Mr Sherlock Holmes was based on a real live physician.
     Part of that complete physical examination was a pelvic examination and a pap smear and although these were usually normal as were most of the findings in a general practice population, there were certainly unsuspected abnormalities discovered frequently enough to be worth the effort  in an era where we are emphasizing preventive medicine and wellness.   Although uncommon I have found ovarian cysts and tumours of various types, cervical erosions and evidence of infection, among other abnormalities in asymptomatic patients.
     Patients endure some discomfort but I have never known a patient to suffer any harm as a result of the procedure.
      So why is this recommendation which has implications far beyond the simple examination being made?  I believe it is part of an initiative to move away from time consuming history and physical examination, to free up physician time to make Obama Care feasible and affordable and to prepare patients for an automated less personal heath care system.   This it is hoped will enable the provision of health care to the increased numbers by the existing numbers of U.S. physicians.      Abandoning a painstaking history and physical examination, the traditional foundation of any medical encounter is surely not going to enhance the standard of medical practice.

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