Recently my wife, who is a cancer doctor, took care of a middle-aged woman with cervical cancer. As someone whose job it is to treat cancer, my wife took at face value that the woman had cervical cancer and focused her efforts on how to best help the patient overcome her terrible disease. As someone interested in preventive health, I took a different focus — how is it that this woman got cervical cancer at all? With appropriate screening, cervical cancer is almost entirely preventable (see http://beyondapples.org/2009/05/03/pap-smears-re-examined/). Since the advent of Pap smears rates of cervical cancer have plummeted, taking it from the number 1 most common malignancy in women to not even being in the top 10. These days, the 11,000 or so cases of cervical cancer annually almost exclusively occur in women who have never gotten a Pap smear or who get them infrequently. And sure enough, this patient was no different — her last Pap smear was during her last pregnancy over 20 years ago.
In considering the patient further, I naturally assumed that she had no primary care doctor. As we hear about almost daily on the news, there are millions of people in the United States today who because of lack of insurance and lack of access have no primary and preventive care. It is these people who are most at risk for preventable diseases such as cervical cancer and who sadly bear a disproportionate amount of the disease burden. But this patient HAD a primary care doctor. In reviewing her past medical history, my wife noted that the patient had high blood pressure and depression for which she was taking chronic medications. I stopped her right there: “You mean to say that this patient has a regular doctor and yet hasn’t had a Pap smear in over 20 years!?”
How could this be? How could a woman with a regular doctor not get a routine Pap smear — a universally accepted, life-saving preventive health measure – in over two decades? This past week an illuminating study was published in the Annals of Internal Medicine that evaluated how good primary care doctors are at following the screening guidelines for cervical cancer (see http://www.annals.org/content/151/9/602.abstract). In the study, primary care doctors were mailed a questionnaire with four common clinical scenarios and asked what the appropriate screening step would be. As an example, in one scenario, participants were presented with an 18-year old girl with first sexual intercourse 1 month ago and asked if she should get no Pap, Pap every 3 years, Pap every 2 years, Pap annually, or other. Although the guidelines from every major expert group state that cervical cancer screening should at age 21 or 3 years after first sexual intercourse, whichever comes first, almost half the doctors surveyed recommended Pap smear. Overall only 22.3 percent of clinicians answered all 4 clinical scenarios correctly. Put bluntly, the study found that less than 1 in 4 doctors know and practice the guidelines.
In many ways, this information is not a surprise. We already know that people consistently do not receive proven preventive health services. Thousands of people are not taking aspirin to prevent first heart attacks, getting routine mammograms, or receiving vaccines against common adult diseases. I started BeyondApples.Org to help tackle this very problem, to help get the word out among doctors and patients about the preventive health services we all need. But at the same time, this study was sobering and discouraging. This study was performed under artificial “test-like” conditions that if anything give doctors the benefit of the doubt. One could look at the statistic that less than half of Americans are getting appropriately screened for colon cancer and rationalize it in any number of ways: the doctor concluded that the guideline did not apply to the individual patient, the patient refused screening, the patient couldn’t afford to pay for the test. But you can’t make these excuses for the results of this study. Clinical vignettes such as the one used in this study are in many ways optimal settings to test clinical knowledge because they circumvent all these real-world confounders. The simple conclusion we are left with is that doctors just don’t know enough about preventive health.
We can argue about why this is the case. Clearly not all the blame falls on doctors. The science of medicine changes daily, different expert organizations put out conflicting guidelines, the health care system is broken. We can also debate solutions — we need better point-of-care decision support, better continuous medical education, better reimbursement for health maintenance. But from the patient’s perspective arguing about causes and debating solutions seems inadequate. For the patient that my wife is caring for these discussions are too late.
For the person out there wondering whether he or she is getting the right preventive care, I offer a simple solution. Get informed. Use the checklist we developed (www.beyondapples.org/checklist). Find out what preventive health services are recommended for you. And then partner with your doctor to make sure you are getting the best preventive health care possible.
- Shantanu Nundy, M.D.
I'm an internal medicine doctor passionate about keeping people healthy and out of the hospital. For a brief bio 