Dr. Molly Cooke, the ACP’s immediate past president and a member of the group’s Clinical Practice Guidelines Committee, said that for years she performed pelvic exams in asymptomatic patients mainly out of "habit," rather than evidence. But with the ACP’s new guidelines, she plans to change her approach.
Going forward, Dr. Cooke said she will discuss the utility of the pelvic exam with patients and explain that the evidence indicates that the bimanual exam does not produce meaningful information and could lead them astray. She said she expects that most patients will agree to forgo the pelvic exam when presented with the evidence.
As for ob.gyns. who may continue to perform pelvic exams routinely in asymptomatic patients, Dr. Cooke said that they are essentially making a "faith-based" assertion about the usefulness of the exam.
Dr. Cooke said the ACP recommendations are meant to apply to all clinicians who provide well-woman care. "We don’t see any reason why the guideline isn’t as useful and applicable to a nurse practitioner, a gynecologist, a family physician, and an internist," she said.
The new ACP guidelines are being well received by some internists and family physicians who are feeling the pressure to cram more and more preventive care into a short visit.
"You really have to think about the opportunity cost here," said Dr. Giang Nguyen of the Hospital of the University of Pennsylvania, Philadelphia.
"When we take those extra minutes out of a visit, which might only be 15 minutes long, you’re preventing the patient and the provider from using that time for things that we have strong evidence for, like counseling about weight management, talking about smoking cessation, reviewing other parts of their sexual history that maybe would be useful to talk about in order to prevent future illness," he added.
Given the shortage of primary care physicians, Dr. Nguyen said spending visit time on screenings that aren’t evidence based essentially reduces access to care.
The American Academy of Family Physicians doesn’t have a recommendation for or against performing screening pelvic exams. As part of the Choosing Wisely campaign, the AAFP issued a clinical recommendation against requiring a pelvic exam or other physical exam to prescribe oral contraceptives.
mschneider@frontlinemedcom.com
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