Recommendations for the routine screening pelvic examination: Could they have a negative effect on physician competence?

Roger Ladouceur

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Re:Recommendations Against Routine Pelvic Examinations: Could they have a negative effect on physician competence and women's health?
Ainsley Moore

Published on: 18 July 2016
routine screening pelvic exams have a negative effect on patients
Robert W. Shepherd

Published on: 21 June 2016
The E-spot; considering Ethics in maintenance of competency and evidence based medicine. A response to: Recommendations for the routine screening pelvic examination: Could they have a negative effect on physician competence?
Colleen Fuller

Published on: 15 June 2016

Published on: (18 July 2016)

Re:Recommendations Against Routine Pelvic Examinations: Could they have a negative effect on physician competence and women's health?
Ainsley Moore, Associate Professor of Family Medicine
The Canadian Task Force on Preventive Health Care (CTFPHC) strongly recommends against routine pelvic examination screening among asymptomatic women for non cervical cancer, pelvic inflammatory disease, or other gynecological conditions.(1) These recommendations are based on moderate quality evidence that there would not be benefit to women from pelvic screening examinations.(2) Indeed the Prostate Lung Colorectal and Ova...
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The Canadian Task Force on Preventive Health Care (CTFPHC) strongly recommends against routine pelvic examination screening among asymptomatic women for non cervical cancer, pelvic inflammatory disease, or other gynecological conditions.(1) These recommendations are based on moderate quality evidence that there would not be benefit to women from pelvic screening examinations.(2) Indeed the Prostate Lung Colorectal and Ovarian Cancer Trial involving 78,000 women, included pelvic screening for the first 5 years, and dropped the screen when no cancers were identified as a result of this intervention.(3) There was, however, evidence of harms from other studies, reporting that 1.5% of women received unnecessary surgery (open or laparoscopic) as a result of routine screening pelvic examinations (4) and over 1/3 of women report fear, embarrassment, anxiety, pain or discomfort associated with the pelvic examination.(5-19)
Dr. Ladouceur laments the possibility that family physicians and residents who follow this recommendation will lose their pelvic examination skills. He further speculates that this loss of skill will reduce compliance with cervical cancer screening in Canada, ultimately affecting women's health.
For any busy family physician in an academic or community setting, the need for appropriate pelvic examinations and opportunities for teaching are abundant. As the CTFPHC report specifies, "the pelvic examination is appropriate in other clinical situations, such as diagnosing gynecologic conditions when women present with symptoms or for follow-up of a previously diagnosed condition."
Concern that these recommendations would lead to declining skills and therefore poor uptake of cervical cancer screening is not based on evidence and seems tenuous at best. Studies on the topic have found that barriers to cervical cancer screening in Canada, are related to ethnocultural, language and socioeconomic factors among indigenous and immigrant women, as well as preference for female health care providers, rather than provider skill.(20)
Dr. Ladouceur appeals for a return to "artful care...where evidence does not interfere with clinical judgment". We remind Dr. Ladouceur that evidence-based care occurs at the intersecting triad of clinician judgment, best available evidence, and patient values and preferences, all of which underlie the shared decision making paradigm. In mourning the loss of a pointless and potentially harmful routine examination, despite clear values and preferences expressed by women and evidence that it would harm, but not benefit women, Dr. Ladoceur is not making the case for clinical judgment versus evidence. Rather he has made a case for his personal judgment -- which does not appear to be shared by patients or by guideline panels in Canada and the U.S.
References 1. Tonelli M, Gorber S, Moore A, Thombs B. Recommendations on routine screening pelvic examination. Canadian Task Force on Preventive Health Care adoption of the American College of Physicians guideline. Can Fam Phys 2016; 62(3): 211-14.
2. Qaseem A, Humphrey H, Harris R, Starkey M, Denberg T, et al. Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline From the American College of Physicians. JAMA 2014; 161(1): 67-72.
3. Buys SS, Partridge E, Johnson CC, Lamerato L, Isaacs C. Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial. JAMA 2011; 305(22): 2295-303.
4. Adonakis G, Paraskevaidis E, Tsiga S, Seferiadis K, Lolis DE. A combined approach for the early detection of ovarian cancer in asymptomatic women. Eur J Obstet Gynecol Reprod Biol 1996; 65(2): 221-5.
5. Golomb D. Attitudes toward pelvic examinations in two primary care settings. R I Med J. 1983; 66:281-4.
6. Harper C, Balistreri E, Boggess J, Leon K, Darney P. Provision of hormonal contraceptives without a mandatory pelvic examination: the first stop demonstration project. Fam Plann Perspect. 2001; 33:13-8.
7. Bourne PA, Charles CA, Francis CG, South-Bourne N, Peters R. Perception, attitude and practices of women towards pelvic examination and Pap smear in Jamaica. N Am J Med Sci. 2010; 2:478-86.
8. Hesselius I, Lisper HO, Nordstr?m A, Anshelm-Olson B, Odlund B. Comparison between participants and non-participants at a gynaecological mass screening. Scand J Soc Med. 1975; 3:129-38.
9. Wijma B, Gullberg M, Kjessler B. Attitudes towards pelvic examination in a random sample of Swedish women. Acta Obstet Gynecol Scand. 1998; 77:422-8.
10. Armstrong L, Zabel E, Beydoun HA. Evaluation of the usefulness of the 'hormones with optional pelvic exam' programme offered at a family planning clinic. Eur J Contracept Reprod Health Care. 2012; 17:307-13.
11. Osofsky HJ. Women's reactions to pelvic examination. Obstet Gynecol. 1967; 30:146-51.
12. Hoyo C, Yarnall KS, Skinner CS, Moorman PG, Sellers D, Reid L. Pain predicts non-adherence to pap smear screening among middle-aged African American women. Prev Med. 2005; 41:439-45. 13. Taylor VM, Yasui Y, Burke N, Nguyen T, Acorda E, Thai H, et al. Pap testing adherence among Vietnamese American women. Cancer Epidemiol Biomarkers Prev. 2004; 13:613-9.
14. Fiddes P, Scott A, Fletcher J, Glasier A. Attitudes towards pelvic examination and chaperones: a questionnaire survey of patients and providers. Contraception. 2003; 67:313-7.
15. Yu CK, Rymer J. Women's attitudes to and awareness of smear testing and cervical cancer. Br J Fam Plann. 1998; 23:127-33.
16. Broadmore J, Carr-Gregg M, Hutton JD. Vaginal examinations: women's experiences and preferences. N Z Med J. 1986; 99:8-10.
17. Haar E, Halitsky V, Stricker G. Patients' attitudes toward gynecologic examination and to gynecologists. Med Care. 1977; 15:787-95.
18. Petravage JB, Reynolds LJ, Gardner HJ, Reading JC. Attitudes of women toward the gynecologic examination. J Fam Pract. 1979; 9:1039-45.
19. Kahn JA, Goodman E, Huang B, Slap GB, Emans SJ. Predictors of Papanicolaou smear return in a hospital-based adolescent and young adult clinic. Obstet Gynecol. 2003; 101:490-9
20. Redwood-Campbell L, Fowler N, Laryea S, Howard M, Kaczorowski J. Before You Teach Me, I Cannot Know': Immigrant Women's Barriers and Enablers With Regard to Cervical Cancer Screening Among Different Ethnolinguistic Groups in Canada. Can J Public Health 2011; 102(3):230-34.
21. Sackett DL. Evidence Based Medicine, what it is and what it isn't. BMJ 1996; 312:71.
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (21 June 2016)

routine screening pelvic exams have a negative effect on patients
Robert W. Shepherd, physician
DS Jones et al stated that researchers and doctors should not harm patients, and should work with patients to help the individual patient, not patients in general. (1) In 2016 the Canadian Task Force on Preventive Health Care (CTFPHC) recommended not performing pelvic exams in asymptomatic women. R Ladouceur proposes that discontinuing routine pelvic exams "could have a negative effect on physician competence, and by ex...
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DS Jones et al stated that researchers and doctors should not harm patients, and should work with patients to help the individual patient, not patients in general. (1) In 2016 the Canadian Task Force on Preventive Health Care (CTFPHC) recommended not performing pelvic exams in asymptomatic women. R Ladouceur proposes that discontinuing routine pelvic exams "could have a negative effect on physician competence, and by extension, on women's health..." (2)
A pelvic exam takes time, causes embarrassment and discomfort, and worst of all initiates the diagnostic cascade: if the doctor finds something, he or she or she feels compelled to order more tests, including biopsy. The likelihood that 2 pathologists will agree on the interpretation of a slide is 80%. (3,4,5,6,7) This means that if a woman is diagnosed with ovarian cancer, there is a 20% chance that another pathologist would say that the patient did not have cancer.
Last week a 65-year-old woman asked if I would consider helping her die. She has chronic pain from multiple vertebral fractures due to severe osteoporosis. When she was 26 years old she was found to have an ovarian cyst. The first 2 pathologists who studied the tissue weren't sure what to call the pattern. The third pathologist said "it's cancer." The patient had bilateral oophorectomy.
I agree with the recommendation of the CTFHPC that we should not do a pelvic exam on an asymptomatic woman. If a doctor wants to maintain competence in a skill, the doctor should take a course in which the human subjects know they are being used for training.
sincerely, Robert Shepherd, Victoria BC daytime tel 250-477-9100
references:
1. Jones DS, Grady C & Lederer SE, "Ethics and Clinical Research" -- the 50th Anniversary of Beecher's Bombshell, NEJM, Vol 374, June 16 2016, page 2395
2. Ladouceur R, Recommendations for the routine screening pelvic examination Could they have a negative effect on physician competence? Canadian Family Practice, Vol 62, June 2016, p 460
3. Baak JPA et al, Disagreement of Histopathological Diagnoses of Different Pathologists in Ovarian Tumors, Europ. J. Ostet. Gynec. Reprod. Biol., 13 (1982), 51-55
4. Eriksson H et al, Interobserver Variability of Histopathological Prognostic Parameters in Cutaneous Melanoma, Acta Derm Venereol 2013; 93: 411-416
5. Farmer ER, Gonin R & Hanna MP, Discordance in the Histopathologic Diagnosis of Melanoma and Melanocytic Nevi between Expert Pathologists, Hum. Pathol 27, 1996, 528-531
6. Paech DC et al, A Systematic Review of the Interobserver Variability for Histology in the Differentiation between Squamous and Nonsquamous Non-small Cell Lung Cancer, J. Thoracic Oncology, Vol 6, 2011, 55-63
7. Presant CA et al, Soft-Tissue and Bone Sarcoma Histopathology Peer Review: The Frequency of Disagreement in Diagnosis and the Need for Second Pathology Opinions, J. Clinical Oncology, Vol 4, 1986, 1658-1661.
Thanks to the library service of the Island Health Authority for finding the articles about the inter observer variability among pathologists.
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (15 June 2016)

The E-spot; considering Ethics in maintenance of competency and evidence based medicine. A response to: Recommendations for the routine screening pelvic examination: Could they have a negative effect on physician competence?
Colleen Fuller, Family Physician
As a woman myself, with all the particular body parts pertinent to Dr. Ladouceur's commentary on the utility of the female pelvic exams, I was dismayed by the message conveyed by this article.
In as much as physicians do need to continue to practice physical exam manoeuvres in order maintain certain competencies, I was astonished that Dr. Ladouceur would raise an alarm over competency in this particular context,...
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As a woman myself, with all the particular body parts pertinent to Dr. Ladouceur's commentary on the utility of the female pelvic exams, I was dismayed by the message conveyed by this article.
In as much as physicians do need to continue to practice physical exam manoeuvres in order maintain certain competencies, I was astonished that Dr. Ladouceur would raise an alarm over competency in this particular context, and especially by the lack of ethical analysis of the subject his view seems to indicate.
Firstly, and of not to be understated importance, I want to highlight the dire lack of consideration of the patient perspective within this commentary. This is important because, if pelvic examination of asymptomatic women is continued under the guise of using it as a learning tool, or even a tool of very marginal potential diagnostic use, we absolutely have to consider on whom the burden of negative effects such a procedure falls - and it is on asymptomatic women. From personal experience both as a female family physician who provides primary care gynecological services and as woman seeking primary care from others, I can assure Dr. Ladouceur that helping to maintain the bimanual exam dexterity or cervical swab technique of the physician do not enter into the average woman's considerations when she is finding herself clothed by what is essentially an extra-large Kleenex on a vinyl bed with a cold piece of metal or a person's index and third fingers pushed inside of her vagina. This is not the benign exam that is suggested by Dr. Ladouceur's comments, "greeting a patient, observing his gait, deciphering his affect, listening to his heart and lungs, and palpating his abdomen are all part of what a physician does."* Instead, this is a physically and emotionally invasive exam that is uncomfortable at best and downright painful and mentally injurious at worst. This is clearly an inappropriate distribution between who takes on the burdens and who stands to benefit.
Secondly, following the guideline to conduct this exam only for symptomatic women, pregnant women and for those getting a Pap test, still quite definitely yields a high enough volume of exams to maintain the competencies required. The parallels drawn to IUD insertion, sutures and injections are poor choices for comparison as owing to Pap tests and STI screening alone, these 3 procedures are an order of magnitude less common in typical family practice then the gynecological exam.
Thirdly, the premise that hundreds of normal patients would need to be examined in order to maintain competency should be rejected. No one would suggest a dermatologist would be less competent to diagnose a melanoma if she did not examine the normal skin of hundreds of individuals per year. Better she would examine hundreds of skin lesions!
Finally, Dr Ladouceur should be aware of the many medical models that exist to simulate the female pelvis, and that these can be used to increase familiarity with normal anatomy and to maintain competencies, in the rare occasion they cannot be maintained in the course of practice, just as models are used to practice for IUD insertion, joint injections and endotracheal tube placement. If increasing access to such resources was all that he meant to suggest would be needed because of this recommendation, he should have said as much. Instead he suggests that women's health may ultimately suffer from the supposed lack of foresight of the CTFPHC in recommending against this practice and inadvertently crippling doctors ability to have sensitive fingertips.
We further read his assertion that "there are things that we do that simply make good sense and that no scientific evidence will ever prove. After all, we do not need a comparative study to prove the efficacy of a parachute!" Aside from being blatantly untrue (I'm sure there are several laboratories of engineers out there who could reassure us that they in fact frequently conduct experimental testing on parachutes in order to optimize their design), as discussed earlier, comparing the experience of having a pelvic exam conducted on one's body under the assumption that it is probably not valuable to the person's own health but just maybe once in awhile could be to the experience of having a parachute while free-falling simply does not fly with women, nor with anyone who has an appropriate sense of a risk-benefit ratio.
Guidelines are not dictates. They are useful tools that we develop through consensus and study and apply judiciously to encounters with individual patients. Reading Dr. Ladouceur's opinions here is a salient reminder of simply how important it is to have such tools to guide physicians towards the course of action that is most likely to benefit their patient and to establish standards of practice.
*Of note that Dr. Ladouceur chooses to use the masculine gender in this piece ostensibly on women's health.
Conflict of Interest:
None declared
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Competing Interests: None declared.