Health News Review

From MedPageToday:

Average-risk, asymptomatic women do not benefit from pelvic exams as part of routine care and face potential harms from false-positive results, according to a new clinical guideline.

When screening for cervical cancer, clinicians should limit the physical examination to visual inspection of the cervix and use of cervical swabs for cancer or human papillomavirus, said a panel of clinical specialists convened by the American College of Physicians (ACP).

A review of more than 60 years’ worth of medical literature did not produce compelling evidence that the benefits of routine pelvic exams outweigh the potential harms, the panel concluded in a statement published online in Annals of Internal Medicine. Instead, the authors of the guideline found that screening pelvic exams have a low diagnostic accuracy for both cancer and infections.

“Our guidelines really have to do with women who do not have symptoms, who do not have a discharge or bleeding or pain,” guideline panelist Russell Harris, MD, of the University of North Carolina in Chapel Hill, told MedPage Today. “Those women clearly need a pelvic examination, and that’s fine.”

“Our guidelines talk about screening of asymptomatic women who are not pregnant. Those women simply don’t need the exam. It’s not something that is useful for them.”

There was a great deal of news coverage of the Annals publication. But the commentary by one “journalist” caught my attention.

Here is ABC News Senior Medical Contributor Dr. Jennifer Ashton, an ob-gyn. on ABC’s Good Morning America.

ABC News needs to think about what they’ve done by putting an Ob-Gyn front and center as the “reporter” on this study, and without an independent perspective as part of the story.

It is perhaps unavoidable that there would be controversy and debate over such recommendations, but does that mean your network’s only voice in the debate is one that is firmly entrenched on one side of the debate?

Would the network allow a drug rep to double as a journalist and then give opinions about the benefits of certain drugs that he/she promotes?

Would the network allow a politician to double as a journalist and then give opinions about legislation that he/she introduced?

There is an inherent conflict of interest here, and it comes out in some of what Dr. Ashton said on the air:

  • “it’s important to see an ob-gyn every year”
  • “These (recommendations) came from internists not ob-gyns”

So internists are chopped liver?  They’re not capable of evaluating evidence?

On ABC World News Tonight, the anchorman asked her, “What are you telling your patients tonight?”   Did they ask the political reporter, “Which candidate are you supporting?” What makes her opinion – and what she tells her patients – more important than what any other source would say on this topic?  ABC:  this is a problem.

On Twitter, Dr. Ashton seemed to scoff at the description of tests causing anxiety as a potential harm.  She wrote:

“I agree with the ‘first do no harm’ premise of medicine. I have a problem with the paternalistic view that tests cause “anxiety” in women….”

Paternalistic?  It could be argued that it’s paternalistic to scoff at anxiety as a harm.

The Annals paper authors cited data from their research:

“…limited evidence suggests that screening pelvic examinations may be associated with pain, discomfort, fear, anxiety, or embarrassment in about one third of women and can lead to unnecessary, invasive, and potentially harmful diagnostic procedures.”

Those numbers would suggest it’s an issue.  I’ve talked with women who’ve had a false positive and who describe the anxiety they experienced as a very real harm.

ABC’s website picked up an AP story that included an independent perspective which Ashton’s reporting did not:

Dr. Ranit Mishori, a family physician and associate professor at Georgetown University School of Medicine, said the new guideline “gets rid of an unnecessary practice” that takes up valuable time that could be put to better use.

“Many women will be happy to hear that, and I think also, frankly, many physicians will be happy to hear it. Many of us have stopped doing them for a long time,” said Mishori, who wasn’t involved with the recommendations. …

…editorial coauthors Drs. George Sawaya and Vanessa Jacoby of the University of California, San Francisco, said that whether the new guideline changes doctors’ practice or not, it could lead to better evaluation of what “has become more of a ritual than an evidence-based practice.”

“Clinicians who continue to offer the examination should at least be cognizant of the uncertainty of benefit and the potential to cause harm through a positive test result and the cascade of events that follow,” they wrote.

I’ve written many times about concerns about MD-journalists.  But the inherent conflicts came out quite clearly in this latest example.  And it’s another example of the screening test bias that exists in much of health care journalism.

Addendum:   When a mammography debate was stirring 3 years ago, Dr. Ashton publicly displayed her advocacy for the Komen Foundation on the air.  She was with CBS at the time. The networks who hire physicians to act as journalists should consider providing at least a crash course in journalism ethics.

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Comments

williamtheconquerorworm posted on July 1, 2014 at 10:09 am

Spot on! I recall an NBC report scoffing at the idea of “gluten sensitivity” in the general public, followed immediately by an ad for Panera Bread. The sooner we stop diefying doctors and TV newscasts the better.

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Lauren Streicher, MD posted on July 1, 2014 at 10:11 am

This is not a conflict of interest! This is an expert opinion from a practicing, board certified OB-Gyn who happens to also be a journalist. The thinking behind this recommendation is flawed and dangerous. See my blog. http://www.everydayhealth.com/columns/lauren-streicher-midlife-menopause-and-beyond/why-new-no-pelvic-exam-recommendation-flawed/

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    Gary Schwitzer posted on July 1, 2014 at 12:17 pm

    Dr. Streicher,

    With all due respect, I won’t lecture you on the Hippocratic Oath if you don’t tell me – with 40 years of journalism experience – what is a journalistic conflict of interest.

    From the Statement of Principles of the Association of Health Care Journalists – the leading professional organization in the field:

    “Distinguish between advocacy and reporting. There are many sides in a health care story. It is not the job of the journalist to take sides, but to present an accurate, balanced and complete report.”

    Expert opinion is not only low on the hierarchy of evidence. It is low on the hierarchy of journalism ethics when it’s an opinion voiced by someone who is supposed to report with balance, not with personally-conflicted perspectives.

    This is pretty basic stuff in undergrad journalism ethics education. When you choose to hang out your shingle as a journalist, you’re expected to know it and act accordingly.

    Reply

    Tazia K. Stagg posted on July 4, 2014 at 8:55 am

    Dr. Streicher, if you’re willing to cancel and retract your blog, I can explain why you certainly should.

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ken yonb posted on July 1, 2014 at 10:13 am

I was shocked at the poor choice of a commenter. Of course, she still wants women to show up every year at her office for a pelvic exam. That is how she makes her money, Her comments completely undercut the very important findings that were the real news story. This is typical of what passes for journalism on TV.

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K.Moore, MSN, ANP posted on July 1, 2014 at 10:23 am

Actually, she didn’t even state the recommendation correctly! She stated that the recommendation is now from annual to triannual, but it is NOT RECOMMENDED IN THE WELL WOMAN! and also she refers to the old Annual Physical coverage that OB/GYNs provide as a service to women who don’t see anyone else…that also has been RECOMMENDED TO BE SCUTTLED

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jessica c corbes posted on July 1, 2014 at 10:55 am

I dread to take the pelvic exam. The 1st one I had was not completed because I could not take the pain any more. My primary physician is encouraging me. But I could not take the severe discomfort or pain that I go through.
I’m 45 yo not married, not sexually active, no vaginal discharges, pelvic pain or vaginal bleeding.
I would like to take this side that if a woman is not symptomatic then she shouldn’t be subjected to such horrible exam. I would love to see one day there is another way of doing screening for cervical cancer. less painful.

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S. Fitzgerald posted on July 1, 2014 at 11:18 am

Yo, Gary, your post made the Google News cut in the Health section! Here’s hoping lots of people see it, and come back to visit you.

Thanks for calling this out. I learned about this years ago when my health insurance would cover only a set amount for annual physical. My doctor said, well, you don’t need the pelvic exam every year if you havent had any problems. THIS despite having given me one every year until the (insurance) money ran out. So, I guess I know what the motivation was there. I have a different doctor now. And ask a lot more questions.

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Annie posted on July 1, 2014 at 11:20 am

Looks as if the person who wrote this post is a man.

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    Gary Schwitzer posted on July 1, 2014 at 12:20 pm

    Yep. No hiding that. And no reason to.

    And your point is……? That my lack of a vagina means I don’t know a journalism conflict of interest when I see one?

    Reply

Finley Austin posted on July 1, 2014 at 11:28 am

Kudos for calling this out on two points. First, this is a clear example (one of many) that shows why we have a bloated, inefficient, overly costly health system in the US. A practice started as well meaning has no health value but it makes money for the practitioner and the patient thinks they are doing the best for their health. It gets entrenched without study to support its validity. Over time – this took 60 years – the utility is called into question and the data clearly shows the practice has no value. However, for those earning a living off of it and for those who have internalized the routine there is great reluctance to change, but change we must if we want better healthcare.

Second, shame on ABC for allowing an “expert” with a financial conflict of interest to editorialize. Next time ABC wants to do a piece on the high cost of healthcare instead of going after the pharmaceutical companies they should take a look at physicians who continue to advise patients to undergo proven useless procedures. They have an in-house expert.

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Tazia K. Stagg posted on July 1, 2014 at 6:41 pm

CBS This Morning did about the same. (Invited the wrong guest, then didn’t ask the right questions.)
NPR’s Shots blog presented the recommendation as controversial; some commenters caught on.

I don’t think the average journalist, the general public, or medical specialists themselves understand how professional bias works. It’s not only about character…

Ashton is a joke. In one of her appearances on The Dr. Oz Show, she stated that abstinence doesn’t prevent HPV infection, and that women need a pelvic exam every year. I asked her for an explanation last year; still waiting for a response. She deserves more scrutiny and less attention.

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Ranit Mishori posted on July 3, 2014 at 3:03 pm

In response to Dr. Streicher….expert opinion (EBM 101) is the lowest grade and level of evidence. Here’s a quick reminder:
http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/
Unfortunately, this is very confusing to the public..as the word ‘expert’ has a certain cache.

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Mark F posted on July 4, 2014 at 5:10 pm

Lauren Streicher and that ABC “journalist” are both wrong, and I don’t care if they’re gynecologists. Neither is a scientist or a clinical epidemiologist or a health services researcher. Screening exams mean exams done on people without symptoms. Streicher basically implies that if a woman has complaints she doesn’t want to share, you should stick a couple fingers up her vagina and into her rectum so she’ll talk. Gimme a break. There are other ways to get people to open up (if you will) and reveal their symptoms. And you can’t argue for mass, population-based screening, involving millions and millions of people, on the basis of anecdotes, e.g. “I once did a pelvic exam and felt something the woman didn’t know was there…”. First, if you felt cancer, this doesn’t mean that you’ve found it in time to improve the final outcome. If you happened to find ovarian cancer, it’s almost always too late (any ovarian tumor you’d feel would be large enough that, by definition, it would not be early stage). But, more importantly, what about all those women for whom you THINK you found something and now you have to expose them to radiation and exploratory surgery and pain and anxiety and expense when, in fact, they have absolutely nothing wrong with them. False positives done on pelvic exam are WAY, WAY more common than true positives. The harms of the pelvic exam simply outweigh the benefits for asymptomatic women on a mass population basis. So, do me a favor Dr. Streicher: accept change. What we need for ovarian cancer is a real screening test, not worthless, tradition-bound smoke and mirrors that give women and doctors nothing more than an illusion of control. Btw, some of the most respected gynecologist in the US endorse this new recommendation (e.g. Dr. George Sawaya at UCSF).

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Mark F posted on July 5, 2014 at 8:39 pm

As an addendum. Lauren Streicher thinks that there is benefit in doing pelvic exams and discovering fibroids or other non-cancerous lesions even if these are asymptomatic. But there is no evidence that making these discoveries does any good if the woman isn’t bothered by these things. Once a woman IS bothered by something, then it might make sense to do a pelvic exam. But then, we’re no longer talking about a screening exam. Streicher displays the same cultural bias that is rampant in American medicine, which is to discover and intervene on anything and everything that’s not “normal”. But this is terribly misguided. Meanwhile, the ABC “journalist” OB/Gyn got her facts wrong on another count. She confuses Pap smears (cervical cancer screening) with pelvic exams when she says the recommendation is to get “it” done every three years instead of every year. In fact, although Pap smears are often done at the same time as pelvic exams, the two are different: the former involves scraping cells from the cervix, the latter involves putting a couple fingers into the vagina and feeling the ovaries and other structures to detect abnormalities. She is right that cervical cancer screening is recommended every three years or, in some cases, five years (her own gynecology society recommends this). On the other hand, the new internal medicine guideline recommends no screening pelvic exam in women WITHOUT symptoms exactly this often: never. People like Streicher and Ashton are lamentable representatives of careful thinking, nuance, and accuracy.

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A Woodward posted on July 7, 2014 at 1:53 pm

What does one do when you do not have another primary care phasiscian but your OBGYN refuses to see you even though your issues you are experiencing a related to female things. My doctors nurse told me to go to the emergency room even though I am not in need of emergent attention. Going the emergency room would cost me a great deal of money which I do not have where as going to my OB would cost a small amount for an initial check up. I called back to ask for a referral to a doctor who would be willing to treat me and have not received a call back.

Is there a number for nurses or someone with a medical background that someone could call to get direction and help?

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