utility of routine pelvic exams

[bashir]

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http://well.blogs.nytimes.com/2013/04/29/an-exam-with-poor-results/

I have to say I've questioned the utility of pelvic exams as a screening test for asymptomatic women (for reasons stated in the article), but never had the guts to voice such thoughts as a mere medical student. What do you guys think?

 

[JJMrK]

Gotta be kidding. This is like a urologist not doing a testicular exam, or cards not auscultating the heart. "Embarrassment for the patient" is not a valid reason not to do part of the exam if indicated.

 

[NickNaylor]

Gotta be kidding. This is like a urologist not doing a testicular exam, or cards not auscultating the heart. "Embarrassment for the patient" is not a valid reason not to do part of the exam if indicated.

No doubt. My guess is that 99.9% of people would rather be momentarily "embarrassed" if it meant that they, you know, don't die of cancer.

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[GUH]

It's certainly worth considering if there is evidence that such exams discourage women from seeking appropriate medical care.

 

[11MD2B]

Gotta be kidding. This is like a urologist not doing a testicular exam, or cards not auscultating the heart. "Embarrassment for the patient" is not a valid reason not to do part of the exam if indicated.

I think the article questions if there is indeed an indication. Based on the evidenced presented, there is no validated indication other than monkey see monkey do. Comparing pelvic exams on asymptomatic women to uro or cards is meaningless; the majority of these patients are not seeking care to address a gyn complaint but to refill their OCP scripts or have a validated screening test (pap). If you are at the urologists office, you were referred there or showed up to address a specific complaint related to your rocks. Same with cards and your ticker. Would you want a finger in you ***** every time you had wanted some pepto?

 

[Kaustikos]

Yes,
Let's do away with it when routine pelvic exams are what usually catch STD's like Chlamydia. And considering chlamydia leads to infertility, I'm sure women wouldn't be too happy to find out they're infertile because their Gyn didn't do that pelvic exam which would've caught it...

 

[calvnandhobbs68]

A woman undergoing the exam is bare below the waist. She lies on the examining table on her back with her knees bent and legs spread apart, her feet in stirrups and her buttocks near the end of the table. The doctor inserts a lubricated, gloved finger into her vagina and, with the other hand, presses down on her abdomen to check the shape and size of her uterus and ovaries.

Oh wow you mean the doctor is actually doing a physical exam to see if anything is wrong with you? Terrible I tell ya.

 

[TooMuchResearch]

Gotta be kidding. This is like a urologist not doing a testicular exam, or cards not auscultating the heart. "Embarrassment for the patient" is not a valid reason not to do part of the exam if indicated.

"If indicated."

 

[KnuxNole]

What a joke article. Someone needs to smack that author.

 

[Textbookversion]

Seems unwise in terms of liability. Better document well.

 

[theshellyb]

Yes,
Let's do away with it when routine pelvic exams are what usually catch STD's like Chlamydia. And considering chlamydia leads to infertility, I'm sure women wouldn't be too happy to find out they're infertile because their Gyn didn't do that pelvic exam which would've caught it...

Did anyone READ this article?

They're specifically talking about the *bimanual exam* portion of the pelvic and questioning its utility. They are not questioning STD screenings or pap smears.

 

[chopes31]

How important is this exam to a doctor’s income? Slightly more than half of those surveyed ranked “ensuring adequate compensation” as very important or moderately important.

Correlation is not causation, Jane Brody.

 

[11MD2B]

+1

And urinary and self administered swabs to test for GC/Chlamydia do just we well as MD administered swabs.
It is a good and healthy practice for docs in training to question these sorts of practices, and to do so throughout our careers. It even has a name; Evidenced Based Medicine.
Im sure our patients wouldn't mind us acknowledging their discomforts instead of scoffing at them so we can earn another 70 bucks and you know, detect no ovarian cancers.

 

[Barcu]

Did anyone READ this article?

They're specifically talking about the *bimanual exam* portion of the pelvic and questioning its utility. They are not questioning STD screenings or pap smears.

I agree. They really are just talking about about the bimanual exam.

The problem I see is this: the idea of evidence. Yes, I believe that doctors should be doing things that are based on evidence, and I'm guessing that the majority of patients would want that too. However, tests indicated based on evidence will not catch every single case (there will always be missed diagnoses even with evidence-based guidelines). Until people actually understand that, and we change the perceptions of medicine and the legal system accordingly, I would still want to do a pelvic exam as an OB.

 

[badasshairday]

Listening to heart and lungs leads to unnecessary echo and chest Xray. LIstening to carotids lead to unnessesary ultrasound too. As does palpating the abdominal aorta.

We should just stop the physical exam. It wastes too much money. Everything will look so much better because the population will be considered healthier since we won't ever find anything. Also healthcare costs will go way down. Stupid physical exam.

 

[ijn]

Yes,
Let's do away with it when routine pelvic exams are what usually catch STD's like Chlamydia. And considering chlamydia leads to infertility, I'm sure women wouldn't be too happy to find out they're infertile because their Gyn didn't do that pelvic exam which would've caught it...

Uh... no. We catch most chlamydia in women by screening their urine with nuclear amplification assays.

 

[Kaustikos]

Did anyone READ this article?

They're specifically talking about the *bimanual exam* portion of the pelvic and questioning its utility. They are not questioning STD screenings or pap smears.

And how would that not discern fallopian scarring or cervicitis? Asymptomatic women with a sexual history should definitely get this. Especially ones with multiple partners.

 

[Kaustikos]

Uh... no. We catch most chlamydia in women by screening their urine with nuclear amplification assays.

I never said don't do that. But we're talking (which I misspoke) about women with sexual history of multiple partners. I'm talking about asymptomatic. Correct me if I'm wrong - but annual pelvic examination would be more tolerably by insurance rather than urine screening.

 

[ijn]

I never said don't do that. But we're talking (which I misspoke) about women with sexual history of multiple partners. I'm talking about asymptomatic. Correct me if I'm wrong - but annual pelvic examination would be more tolerably by insurance rather than urine screening.

You're not going to use a pelvic exam to make the diagnosis of an asymptomatic chlamydia infection.

The urine test is cheap ($12.) We routinely screen all women below the age of 24 with it. And the patients I saw during my 8 weeks of OB/Gyn were all Medicaid/county insurance.

You would use a pelvic exam to make the diagnosis of PID since it's a clinical diagnosis. But that's an entirely separate situation from routine annual exams.

 

[Law2Doc]

It's generally never the patient who makes the argument about not wanting to have the exams. They want you to do whatever you need to to fix their problem or give them a clean bill of health. It's some doctor who doesn't want to do these exams, and is trying to make it sound less despicable by saying it saves the patient discomfort and embarrassment, or that they do without it in other countries. Ive seen similar arguments for almost all aspects of the physical exam. Some doctor just want yo order labs and imaging and let someone else tell them what is wrong with the patient. It's this kind of "practice" that is why NPs are having such an easy time elbowing into our field. Deplorable.

 

[theshellyb]

You would use a pelvic exam to make the diagnosis of PID since it's a clinical diagnosis. But that's an entirely separate situation from routine annual exams.

THIS. The article is not talking about trying to deny the utility of a bimanual on a symptomatic woman with suspected PID.

It's talking about the use of the bimanual exam as a screening tool- which we currently use in an attempt to detect ovarian cancer. But we are awful at doing so. http://www.uspreventiveservicestaskforce.org/uspstf12/ovarian/ovarcancerrs.htm

 

[theshellyb]

It's generally never the patient who makes the argument about not wanting to have the exams. They want you to do whatever you need to to fix their problem or give them a clean bill of health. It's some doctor who doesn't want to do these exams, and is trying to make it sound less despicable by saying it saves the patient discomfort and embarrassment, or that they do without it in other countries. Ive seen similar arguments for almost all aspects of the physical exam. Some doctor just want yo order labs and imaging and let someone else tell them what is wrong with the patient. It's this kind of "practice" that is why NPs are having such an easy time elbowing into our field. Deplorable.

I do not even know where to start with this.

The reason patients aren't the ones clamoring for the end of testing is because they trust that their doctors aren't doing anything that is medically unnecessary that would cause them harm. They trust that their doctors are following the medical literature and are only doing tests that have diagnostic relevance and are clinically useful.

Doctors aren't discarding clinically useful exams willy-nilly because "they just don't want to". Right now we're discussing discarding exams (AND LABS!) that have been proven to NOT effectively serve our patients.

All of the debates we have on these issues- PSA testing, self breast exams, bimanual exams- are because evidence has shown that more patients are HARMED by the invasive biopsies that these screening tools result in. If we ignore that and continue to do them, we're doing a disservice to our patients.

If you're talking about doctors ignoring the physical exam because they're being lazy and just want to go straight to labs, that's a different matter. And not what we're talking about here.

 

[ijn]

It's generally never the patient who makes the argument about not wanting to have the exams. They want you to do whatever you need to to fix their problem or give them a clean bill of health. It's some doctor who doesn't want to do these exams, and is trying to make it sound less despicable by saying it saves the patient discomfort and embarrassment, or that they do without it in other countries. Ive seen similar arguments for almost all aspects of the physical exam. Some doctor just want yo order labs and imaging and let someone else tell them what is wrong with the patient. It's this kind of "practice" that is why NPs are having such an easy time elbowing into our field. Deplorable.

Just because grandpa did a given part of a physical exam does not mean that aspect of the exam is appropriate when applied to everyone simply because they're living and breathing.

Physical exams should be subject to the same scientific study as any other medical practice. If it decreases mortality, then let's do it. If you can't prove the exam helps more than it harms through false positives and unnecessary surgical intervetion, then why the hell are we doing it?

 

[bashir]

I do not even know where to start with this.

The reason patients aren't the ones clamoring for the end of testing is because they trust that their doctors aren't doing anything that is medically unnecessary that would cause them harm. They trust that their doctors are following the medical literature and are only doing tests that have diagnostic relevance and are clinically useful.

Doctors aren't discarding clinically useful exams willy-nilly because "they just don't want to". Right now we're discussing discarding exams (AND LABS!) that have been proven to NOT effectively serve our patients.

All of the debates we have on these issues- PSA testing, self breast exams, bimanual exams- are because evidence has shown that more patients are HARMED by the invasive biopsies that these screening tools result in. If we ignore that and continue to do them, we're doing a disservice to our patients.

If you're talking about doctors ignoring the physical exam because they're being lazy and just want to go straight to labs, that's a different matter. And not what we're talking about here.

This. I was hoping that someone in the "pro-bimanual screening exam" camp might explain why they think the bimanual pelvic is useful as a screening test or even offer some evidence to that effect but instead all I'm seeing is the kind of knee-jerk reactions I'd hope to avoid in a forum like this.

 

[ijn]

This. I was hoping that someone in the "pro-bimanual screening exam" camp might explain why they think the bimanual pelvic is useful as a screening test or even offer some evidence to that effect but instead all I'm seeing is the kind of knee-jerk reactions I'd hope to avoid in a forum like this.

The physical exam is like a religion. Do. Not. Question. It's exempt from evidence based medical practice because we've inherited it from up high.

 

[NickNaylor]

I do not even know where to start with this.

The reason patients aren't the ones clamoring for the end of testing is because they trust that their doctors aren't doing anything that is medically unnecessary that would cause them harm. They trust that their doctors are following the medical literature and are only doing tests that have diagnostic relevance and are clinically useful.

Doctors aren't discarding clinically useful exams willy-nilly because "they just don't want to". Right now we're discussing discarding exams (AND LABS!) that have been proven to NOT effectively serve our patients.

All of the debates we have on these issues- PSA testing, self breast exams, bimanual exams- are because evidence has shown that more patients are HARMED by the invasive biopsies that these screening tools result in. If we ignore that and continue to do them, we're doing a disservice to our patients.

If you're talking about doctors ignoring the physical exam because they're being lazy and just want to go straight to labs, that's a different matter. And not what we're talking about here.

Just curious, beyond patient discomfort what risks are associated with bimanual exams? This isn't something like a complex surgical case with significant morbidity/mortality associated with it. It takes all of 30 seconds with zero chance of adverse effects unless you have someone who has no training doing the exam.

I'm all for not subjecting patients to needless tests, but you can't look at epi data in a vacuum. This is a test that essentially costs $0 and has insignificant risk associated with it (biopsy, etc. are another story). With that being in mind, I would say it's still worth it even if only 1/50 (or ~1/9000 per the link you posted) patients have an abnormal exam. If your goodies are already being palpated and examined during a normal gyn exam I really don't see the harm in doing a bimanual given the very minimal "costs" but potentially huge (if very infrequent) benefits.

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[Law2Doc]

Just because grandpa did a given part of a physical exam does not mean that aspect of the exam is appropriate when applied to everyone simply because they're living and breathing.

Physical exams should be subject to the same scientific study as any other medical practice. If it decreases mortality, then let's do it. If you can't prove the exam helps more than it harms through false positives and unnecessary surgical intervetion, then why the hell are we doing it?

The physical exam is being dismantled pretty methodically these days. I see doctors who don't examine the whole patient, doctors who avoid doing DREs, pelvic exams, etc. Maybe some of these things aren't ideally effective, (and all are "operator dependent" which i think is the big source of the problem), but I promise you that most of the people citing lack of evidentiary basis when they choose not to do an exam haven't even looked at the literature, they just don't want to do the exam, or they don't have the skill set to make it worth the trouble. Not that long ago, a good physical exam could actually diagnose things. These days they CT the patient first and wait for the read before they examine the patient. The news media seizes on overuse of imaging/radiation as it's headline, but misses the corollary of the demise of physical exam diagnosis. FWIW I've seen the physical exam of graduates from countries which don't have the imaging or lab resources we do here, and those exams are a heck of a lot more intrusive and diagnostic.

 

[Law2Doc]

Just curious, beyond patient discomfort what risks are associated with bimanual exams? This isn't something like a complex surgical case with significant morbidity/mortality associated with it. It takes all of 30 seconds with zero chance of adverse effects unless you have someone who has no training doing the exam.

I'm all for not subjecting patients to needless tests, but you can't look at epi data in a vacuum. This is a test that essentially costs $0 and has insignificant risk associated with it (biopsy, etc. are another story). With that being in mind, I would say it's still worth it even if only 1/50 (or ~1/9000 per the link you posted) patients have an abnormal exam. If your goodies are already being palpated and examined during a normal gyn exam I really don't see the harm in doing a bimanual given the very minimal "costs" but potentially huge (if very infrequent) benefits.

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Agreed.

 

[ijn]

Just curious, beyond patient discomfort what risks are associated with bimanual exams? This isn't something like a complex surgical case with significant morbidity/mortality associated with it. It takes all of 30 seconds with zero chance of adverse effects unless you have someone who has no training doing the exam.

I'm all for not subjecting patients to needless tests, but you can't look at epi data in a vacuum. This is a test that essentially costs $0 and has insignificant risk associated with it (biopsy, etc. are another story). With that being in mind, I would say it's still worth it even if only 1/50 (or ~1/9000 per the link you posted) patients have an abnormal exam. If your goodies are already being palpated and examined during a normal gyn exam I really don't see the harm in doing a bimanual given the very minimal "costs" but potentially huge (if very infrequent) benefits.

Sent from my SAMSUNG-SGH-I717

We could also pray with our patients every visit. And it'll have the same effect on ovarian cancer mortality as annual bimanuals.

 

[NickNaylor]

We could also pray with our patients every visit. And it'll have the same effect on ovarian cancer mortality as annual bimanuals.

Yes, clearly the same. 1/8000-9000 is essentially equivalent to the likelihood of prayer curing pancreatic cancer.

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[ijn]

Yes, clearly the same. 1/8000-9000 is essentially equivalent to the likelihood of prayer curing pancreatic cancer.

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Ah yes. Your intervention for benign ovarian masses is going to do zero harm to the patient? (No)

This has been studied buddy. There is a reason the USPSTF says routine screening of the general population for ovarian cancer does more harm than good.

 

[evilbooyaa]

If a woman is asymptomatic and doesn't need a pap smear or a pelvic exam, will she hold her appointment to wait an hour or more just to talk to the physician for 15 minutes about her lack of symptoms? Just my 2 cents. I haven't been to the doctor in at least 3 years, and if I don't need a physical for work, I don't plan to. I don't know how it is for women, but it sounds like everyone goes for their annual check.

Just something to consider. I think we should follow EBM, and ask the patient. If she doesn't want a pelvic, just needs a pap and just wants her OCPs refilled, then say "Bimanual: Deferred", give her the pap smear, and move on.

Also, who is going to an OB-GYN for a refill on asthma meds?

 

[kavorca]

My personal bimanual exam is almost useless. My patient is over 250 lbs 9 times out of ten. I am always impressed with myself if i can visualize the cervix. The bimanual part I could do without. It doesn't bother me to do it. I just do not get any info out of it. I am sure others do, but I don't.

 

[NickNaylor]

Ah yes. Your intervention for benign ovarian masses is going to do zero harm to the patient? (No)

This has been studied buddy. There is a reason the USPSTF says routine screening of the general population for ovarian cancer does more harm than good.

I explicitly separated the screening from the intervention. A reasonable compromise to me would be to give the patient the option to undergo more thorough testing.

But hey, what do I know. Can't argue with EBM amirite

Sent from my Nexus 7

 

[alpinism]

Did anyone READ this article?

They're specifically talking about the *bimanual exam* portion of the pelvic and questioning its utility. They are not questioning STD screenings or pap smears.

👍

“In my experience as a practicing gynecologist, I frequently have had to take patients into the operating room because I found an enlargement during a bimanual pelvic exam,” Dr. Sawaya, a professor of obstetrics at the University of California, San Francisco, said in an interview.

“I then follow up with a sonogram which shows a mass, but I can’t tell what the mass is without surgical exploration. Yet nearly always it’s benign.”

Dr. Sawaya says it’s time to change this practice, in which doctors “put patients in a perilous situation and then act like they’re rescuing them.” He admits that his position “won’t win any popularity contests, but I’m trying to do what’s right for patients.”

Dr. Westhoff and colleagues wrote in January 2011 in The Journal of Women’s Health, “Frequent routine bimanual examinations may partly explain why U.S. rates of ovarian cystectomy andhysterectomy are more than twice as high as rates in European countries, where the use of the pelvic examination is limited to symptomatic women.”

She and others say that the justifications gynecologists typically offer for doing the pelvic exam — screening for a sexually transmitted infection and cervical cancer, early detection of ovarian cancer, and evaluating a woman for hormonal contraception — either do not require a bimanual exam or are not supported by research.

Just curious, beyond patient discomfort what risks are associated with bimanual exams? This isn't something like a complex surgical case with significant morbidity/mortality associated with it. It takes all of 30 seconds with zero chance of adverse effects unless you have someone who has no training doing the exam.

I'm all for not subjecting patients to needless tests, but you can't look at epi data in a vacuum. This is a test that essentially costs $0 and has insignificant risk associated with it (biopsy, etc. are another story). With that being in mind, I would say it's still worth it even if only 1/50 (or ~1/9000 per the link you posted) patients have an abnormal exam. If your goodies are already being palpated and examined during a normal gyn exam I really don't see the harm in doing a bimanual given the very minimal "costs" but potentially huge (if very infrequent) benefits.

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Its not the exam itself that's the problem, its the (more often than not) harmful effects of doing the exam.

Unnecessary surgeries (cost $$$$)
Unnecessary surgical complications (morbidity and mortality)
Unnecessary procedures, labs, and follow up appointments (time and cost factor)
Unnecessary emotional stress

Also, there's a huge difference between 1/50 and 1/9000.

 

[alpinism]

The physical exam is like a religion. Do. Not. Question. It's exempt from evidence based medical practice because we've inherited it from up high.

Lol sad but true.

Sounds just like my PDS/clinical skills instructors.

 

[NickNaylor]

👍

“In my experience as a practicing gynecologist, I frequently have had to take patients into the operating room because I found an enlargement during a bimanual pelvic exam,” Dr. Sawaya, a professor of obstetrics at the University of California, San Francisco, said in an interview.

“I then follow up with a sonogram which shows a mass, but I can’t tell what the mass is without surgical exploration. Yet nearly always it’s benign.”

Dr. Sawaya says it’s time to change this practice, in which doctors “put patients in a perilous situation and then act like they’re rescuing them.” He admits that his position “won’t win any popularity contests, but I’m trying to do what’s right for patients.”

Dr. Westhoff and colleagues wrote in January 2011 in The Journal of Women’s Health, “Frequent routine bimanual examinations may partly explain why U.S. rates of ovarian cystectomy andhysterectomy are more than twice as high as rates in European countries, where the use of the pelvic examination is limited to symptomatic women.”

She and others say that the justifications gynecologists typically offer for doing the pelvic exam — screening for a sexually transmitted infection and cervical cancer, early detection of ovarian cancer, and evaluating a woman for hormonal contraception — either do not require a bimanual exam or are not supported by research.



Its not the exam itself that's the problem, its the (more often than not) harmful effects of doing the exam.

Unnecessary surgeries (cost $$$$)
Unnecessary surgical complications (morbidity and mortality)
Unnecessary procedures, labs, and follow up appointments (time and cost factor)
Unnecessary emotional stress

Also, there's a huge difference between 1/50 and 1/9000.

Beyond emotional stress, none of those things have anything to due with the bimanual exam itself (which is what I'm talking about). Why not give the patient the option of both getting a bimanual and, after giving them the prevalence data for ovarian cancer and accurately explaining the relative rarity of ovarian cancer, giving them the option of follow up?

And whether it's 1/50 or 1/9000 is somewhat irrelevant in my view for the reasons I mentioned.

Sent from my Nexus 7

 

[Kaustikos]

The physical exam is being dismantled pretty methodically these days. I see doctors who don't examine the whole patient, doctors who avoid doing DREs, pelvic exams, etc. Maybe some of these things aren't ideally effective, (and all are "operator dependent" which i think is the big source of the problem), but I promise you that most of the people citing lack of evidentiary basis when they choose not to do an exam haven't even looked at the literature, they just don't want to do the exam, or they don't have the skill set to make it worth the trouble. Not that long ago, a good physical exam could actually diagnose things. These days they CT the patient first and wait for the read before they examine the patient. The news media seizes on overuse of imaging/radiation as it's headline, but misses the corollary of the demise of physical exam diagnosis. FWIW I've seen the physical exam of graduates from countries which don't have the imaging or lab resources we do here, and those exams are a heck of a lot more intrusive and diagnostic.

I guess I'm a fan of old school exams. If patients aren't the ones complaining about them, then I don't see why any portions of physical exams should be dismissed. The diagnostic value and low cost associated with these exams probably work better than saying "Well, we're just going to do a CT... and here's the $10,000 bill for it" I prefer a physician who's competent in their examination abilities rather than just going to CTs. So I'm just wondering if people are complaining about them because they're just lazy and don't wanna do it. Like doctors that just order a CT for everything.

Also...

"“In my experience as a practicing gynecologist, I frequently have had to take patients into the operating room because I found an enlargement during a bimanual pelvic exam,” Dr. Sawaya, a professor of obstetrics at the University of California, San Francisco, said in an interview."

Can someone explain the logic in that one? So they're saying do away with bimanual exams unless they're symptomatic because they lead to operating room procedures? An ultrasound guided biopsy or lab test? Maybe I'm the out-liar, but a pathologists' consult in something like this seems really beneficial for these things after detecting an abnormality.

And that statement about the higher frequency of hysterectomies... I don't see that being necessarily causative from the bimanual exams. That makes it sound like we're just removing things left/right the second after we do bimanual exams


Also - the USPSTF changes their opinions on everything all the damn time. I don't think I've seen any moment where they don't change what they say about exams.

 

[ijn]

I guess I'm a fan of old school exams. If patients aren't the ones complaining about them, then I don't see why any portions of physical exams should be dismissed. The diagnostic value and low cost associated with these exams probably work better than saying "Well, we're just going to do a CT... and here's the $10,000 bill for it" I prefer a physician who's competent in their examination abilities rather than just going to CTs. So I'm just wondering if people are complaining about them because they're just lazy and don't wanna do it. Like doctors that just order a CT for everything.

Also...

""In my experience as a practicing gynecologist, I frequently have had to take patients into the operating room because I found an enlargement during a bimanual pelvic exam," Dr. Sawaya, a professor of obstetrics at the University of California, San Francisco, said in an interview."

Can someone explain the logic in that one? So they're saying do away with bimanual exams unless they're symptomatic because they lead to operating room procedures? An ultrasound guided biopsy or lab test? Maybe I'm the out-liar, but a pathologists' consult in something like this seems really beneficial for these things after detecting an abnormality.

And that statement about the higher frequency of hysterectomies... I don't see that being necessarily causative from the bimanual exams. That makes it sound like we're just removing things left/right the second after we do bimanual exams


Also - the USPSTF changes their opinions on everything all the damn time. I don't think I've seen any moment where they don't change what they say about exams.

You're still in your basic science classes and it shows. You'll get some more perspective soon enough. You have no idea if the ovarian mass is cancer or not until it's out of the body. The pathologist isn't going to help you. You don't do ultrasound guided biopsies on possible ovarian cancer. If it actually is cancer you just seeded the peritoneum with possible metastasis. The ovary must be taken whole. Most of the time the ovary you're removing has a benign mass. You just exposed the patient to an expensive procedure and associated mortality/morbidity.

How about ya'll bimanual exam advocates present some evidence for why the heck we're doing it. Prove that you're actually helping your patients with data instead of going off of gut instinct and professional traditionalism. That's all you have going for you so far in this thread.

The USPSTF makes recommendations based on reproducible evidence. The recommendations change when the evidence changes. Your side can't say the same thing. We do the bimanual annual exam because we've always done the bimanual annual exam. Why? Don't ask why. Just do.

 

[KinasePro]

"Blame the bimanual exam for over-treatment, not gynecologists & PCPs performing it. Blame the PSA for excessive prostatectomies, not hyper-vigilant urologists. Blame the self-taught breast exam for excessive biopsies, not the surgeons & radiologists interpreting the imaging studies. Blame the ECG for unnecessary admissions following angina presentation in the ED, not the ER & cards docs interpreting them." - USPSTF

This committee's recommendations have always bothered me. They put a tremendous amount of faith in what are often very imperfect studies, and are provided far too much influence with far too little expertise (not many active specialists/experts in the USPSTF... hence why their decisions are often controversial). It's odd to me that USPSTF tries to limit the clinician's decision making at every turn, rather than strive to improve the quality of those decisions.

I've met plenty of patients whose lives were saved by self-breast exams, PSA screening, and seemingly excessive ECG's (met at least one in each category in the past month). But they're each only 1/8000+ according to USPSTF... so not worth the false positives and extra $$, i suppose? .... My patients would probably beg to differ ...

 

[ijn]

"Blame the bimanual exam for over-treatment, not gynecologists & PCPs performing it. Blame the PSA for excessive prostatectomies, not hyper-vigilant urologists. Blame the self-taught breast exam for excessive biopsies, not the surgeons & radiologists interpreting the imaging studies. Blame the ECG for unnecessary admissions following angina presentation in the ED, not the ER & cards docs interpreting them." - USPSTF

This committee's recommendations have always bothered me. They put a tremendous amount of faith in what are often very imperfect studies, and are provided far too much influence with far too little expertise (not many active specialists/experts in the USPSTF... hence why their decisions are often controversial). It's odd to me that USPSTF tries to limit the clinician's decision making at every turn, rather than strive to improve the quality of those decisions.

I've met plenty of patients whose lives were saved by self-breast exams, PSA screening, and seemingly excessive ECG's (met at least one in each category in the past month). But they're each only 1/8000+ according to USPSTF... so not worth the false positives and extra $$, i suppose? .... My patients would probably beg to differ ...

Do understand the difference between an individual and a population?

You're quoting anecdotal evidence. The USPSTF draws upon thousands in a representative sample. Your handful of examples in no way begin to rebut their recommendation.

But hey, no one is forcing you to follow their recommendations. You can do whatever the hell you want out in practice. Just realize you don't have any evidence to justify what you're doing.

 

[KinasePro]

Do understand the difference between an individual and a population?

You're quoting anecdotal evidence. The USPSTF draws upon thousands in a representative sample. Your handful of examples in no way begin to rebut their recommendation.

But hey, no one is forcing you to follow their recommendations. You can do whatever the hell you want out in practice. Just realize you don't have any evidence to justify what you're doing.

Of course its anecdotal, that's precisely my objection. There's generally a strong opposition to USPSTF's recommendations, mainly because specialist's anecdotes disagree too frequently with the studies USPSTF are citing as gospel. So the question is, are the studies under-powered & not designed appropriately enough to catch these "anecdotes"? Or are all specialists just being cry-babies because they don't want to be told how to practice? Truth is probably somewhere between column A and column B.

My problem is that anecdotes that run counter to USPSTF's recommendations are far too easy to come by, even for a ******ed M3 like myself.

 

[ijn]

Of course its anecdotal, that's precisely my objection. There's generally a strong opposition to USPSTF's recommendations, mainly because specialist's anecdotes disagree too frequently with the studies USPSTF are citing as gospel. So the question is, are the studies under-powered & not designed appropriately enough to catch these "anecdotes"? Or are all specialists just being cry-babies because they don't want to be told how to practice? Truth is probably somewhere between column A and column B.

My problem is that anecdotes that run counter to USPSTF's recommendations are far too easy to come by, even for a ******ed M3 like myself.

And you nor any other specialist depending on said screening test for income is going to post on this forum or speak out about about the greater number of people harmed by unnecessary intervention. I'm sure that's some kind of bias that I long ago memorized and forgot.

Ovarian cancer sucks. If there was a good screening test for it the USPSTF would be all over it in a nanosecond. Unfortunately it doesn't exist. Ultrasound sucks. CA-125 sucks. OVA-1 sucks. But that doesn't mean we should cling to the historical precedent of bimanuals without critical question simply because there's no good way to lower mortality from screening for ovarian cancer.

 

[Law2Doc]

You're still in your basic science classes and it shows. You'll get some more perspective soon enough...

that's funny. I'm a lot further down the road than you both and I actually think you are the one whose perspective is going to change.

 

[KinasePro]

And you nor any other specialist depending on said screening test for income is going to post on this forum or speak out about about the greater number of people harmed by unnecessary intervention. I'm sure that's some kind of bias that I long ago memorized and forgot.

A) That's assuming there is a greater number harmed, which is often fiercely contested and difficult to quantify. (not sure what the case is for the bimanual)

B) doesn't that mean the emphasis should be placed in the intervention, not the screening? The interpretation of the screening results is a large part of the problem here. You don't have to sacrifice 1/8000 lives due to undetected cases of prostate cancer, simply because 10% of urologists are over-zealous. You need to still catch the 1/8000 by better defining treatment indications, not simply throwing out the screening tool.

 

[ijn]

that's funny. I'm a lot further down the road than you both and I actually think you are the one whose perspective is going to change.

So I'm going to start rejecting evidence based medicine and do **** in my practice simply because that's the way it's always been done?

I might start believing in God and start voting Republican too, I suppose. I wouldn't bet on it. 🙄

 

[Kevin Baker]

Listening to heart and lungs leads to unnecessary echo and chest Xray. LIstening to carotids lead to unnessesary ultrasound too. As does palpating the abdominal aorta.

We should just stop the physical exam. It wastes too much money. Everything will look so much better because the population will be considered healthier since we won't ever find anything. Also healthcare costs will go way down. Stupid physical exam.

They've posted a few articles recently advocating even that... at least the annual physical

http://www.nytimes.com/2012/06/03/sunday-review/lets-not-get-physicals.html?pagewanted=all&_r=0

http://well.blogs.nytimes.com/2012/10/22/thinking-twice-about-health-checkups/

 

[Stellar Clouds]

So I'm going to start rejecting evidence based medicine and do **** in my practice simply because that's the way it's always been done?

I might start believing in God and start voting Republican too, I suppose. I wouldn't bet on it. 🙄

Probably will once you actually have real money

 

[alpinism]

Beyond emotional stress, none of those things have anything to due with the bimanual exam itself (which is what I'm talking about). Why not give the patient the option of both getting a bimanual and, after giving them the prevalence data for ovarian cancer and accurately explaining the relative rarity of ovarian cancer, giving them the option of follow up?

And whether it's 1/50 or 1/9000 is somewhat irrelevant in my view for the reasons I mentioned.

Sent from my Nexus 7

If you didn't do the bimanual exam, you wouldn't be "discovering" all those benign masses which require further investigation and possible excision. Doing the exam directly leads to more surgeries. That's why the rates of cystectomy and hysterectomy are so high here compared to Europe.

In theory, giving the patient a choice would be the best option. However, the issue is more complicated than just "reading prevalence data".

Most medical students have a hard enough time understanding biostats and concepts like the NNT and RRR. Do you really want to sit every patient down for 15min and try to explain epidemiology concepts to women with a HS education in the hope that they can make an "informed" decision?

 

[Law2Doc]

They've posted a few articles recently advocating even that... at least the annual physical

http://www.nytimes.com/2012/06/03/sunday-review/lets-not-get-physicals.html?pagewanted=all&_r=0

http://well.blogs.nytimes.com/2012/10/22/thinking-twice-about-health-checkups/

Bear in mind that the NY times isn't exactly where doctors should be getting their info. there were a Couple of very good articles in the New England Journal a couple of years back bemoaning the death of the physical exam that are worth a read. That people aren't learning to do exams properly isn't a reason to dismiss them, it's an argument to teach them better. and the notion that exams are problematic because they can net actual findings which are "mostly" going to turn out to be benign and put people through biopsies is so bizarre I don't know if it even merits a response. A finding that turns out to be benign is okay as long as once in a while there is a finding that isn't, and saves someone's life. Most patients would undergo the discomfort of biopsy (which is an outpatient procedure, not surgery) to avoid even the very remote chance they have something bad. That the doctor is talking about taking patients to the OR is misleading.

We have more hysterectomies here because we have more extensive use of imaging and catch more cancers here. People go through life with undetected and/or indeterminate lesions elsewhere. Most won't kill you. Here you aren't playing the odds, and that's probably a good (albeit expensive) thing. A relatively small percentage of these hysterectomies in the US are completely benign and not related to symptoms.