An OB/GYN perspective on Choosing Wisely

From ACOG comes five new cautions, part of the American Board of Internal Medicine Foundation’s Choosing Wisely campaign, to eliminate wasteful and unnecessary medical interventions that can actually cause harm. All the recommendations are evidence-based and have broad consensus.

1. Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age. Delivery prior to 39 weeks 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.

I agree. However, while,”medically necessary” is generally agreed upon, there will always be cases that fall outside the agreed upon parameters, and we need to respect physician judgement, patent autonomy and informed consent.  But when the parameters are exceeded, there should be documentation as to what the medical reasoning is and that the patient is well informed.

2. Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.  Ideally, labor should start on its own initiative whenever possible. Higher cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care practitioners should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.

I agree.  Again, there needs to be room for physician judgement and informed choice. Not every pregnancy can be as accurately dated as we’d like, even though it may seem obvious using the retrospectoscope, so we need to be reasonable with this and the first recommendation to allow for a realistic range of error.

3. Don’t perform routine annual cervical cytology screening (Pap tests) in women 30–65 years of age. In average-risk women, annual cervical cytology screening has been shown to offer no advantage over screening performed at 3-year intervals. However, a well-woman visit should occur annually for patients with their health care practitioner to discuss concerns and problems, and have appropriate screening with consideration of a pelvic examination.

I sort of agree. I have to admit that I am still having a little trouble with this one. I once diagnosed a very very tiny, early invasive cancer in a woman who had no history of abnormal paps and whose last pap was just a year prior. Not that anecdotes make for good healthcare.  I am using HPV testing to assist in the decision to back off on annual screens (If the test is negative, you can go 3-5 years between paps.) The recommendation has made me much more comfortable in reassuring patients, many of whom express guilt at being “late for my annual”, that they have not done themselves any harm. (Currently writing an upcoming post on the demise of the annual exam…)

4. Don’t treat patients who have mild dysplasia of less than two years in duration.  Mild dysplasia (Cervical Intraepithelial Neoplasia [CIN 1]) is associated with the presence of the human papillomavirus (HPV), which does not require treatment in average-risk women. Most women with CIN 1 on biopsy have a transient HPV infection that will usually clear in less than 12 months and, therefore, does not require treatment.

I agree. I have already been doing this for some time now in almost all patients, the exception being the occasional women with no recent new partners who is past childbearing, has visible lesions on colposcopy and would prefer treatment to follow up.

5. Don’t screen for ovarian cancer in asymptomatic women at average risk. In population studies, there is only fair evidence that screening of asymptomatic women with serum CA-125 level and/or transvaginal ultrasound can detect ovarian cancer at an earlier stage than it can be detected in the absence of screening. Because of the low prevalence of ovarian cancer and the invasive nature of the interventions required after a positive screening test, the potential harms of screening outweigh the potential benefits.

I strongly agree. I’ve been trying to do this for a long time, and fighting my patients all the way on this one. I hope that the publicity around it will lead to less requests for routine ovarian cancer screening.

The Choosing Wisely campaign is joined by nine medical societies, each of whom has identified 5 areas where wiser choices can lead to better health outcomes – and probably significant cost savings.  It’s a reasoned approach to the spiraling costs of healthcare.

Unfortunately, in some cases, not performing a test requires more time on the doctor’s part in educating the patient as to why that test is unnecessary. Trust me on this – it takes 5 times as long to talk a patient out of a CA125 screening test for ovarian cancer than it does to order one.

Margaret Polaneczky is an obstetrician-gynecologist who blogs at The Blog That Ate Manhattan.

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  • http://twitter.com/BenGreenMD Ben Green

    Thanks for your perspective. Always nice to see providers agreeing with these positions. As a family physician, I too agree with the FP recommendations suggested. I love the Choosing Wisely campaign as a consumer friendly (and evidence based!) tool for patients to become more informed about their care. No longer should decisions be unilaterally made.

  • ninguem

    I’m a little leery of the “every three year” PAP as well.

    I say “every year” and consider myself lucky if the patients show up every two years.

    If I say “every three years”, I’m afraid they’ll show up every five years.

    • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

      It may lengthen their follow-up…yes. I encourage a yearly exam, but do the pap every 3 years. The studies are pretty good on this though. People almost never go from ASCUS to cancer in a year. I have seen women sit at LGSIL for years…

    • Mandy

      “I say ‘every year’ and consider myself lucky if the patients show up every two years.”

      Maybe your patients are not stupid, and they KNOW they don’t need one every year. They may then be too polite to tell you to your face that they disagree with your advice and that it is in fact wrong, so they just smile and nod with no intention of following your orders.

  • doc99

    You’ve left out an important elephant in the room – the annual mammogram.

    • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

      To which I say, what do you do? I have been encouraging yearly to every other year from 40-50 and then yearly until 75 or later depending on health. thoughts…

  • Jean Oliver

    I am a healthy 59 year old and I have not been to a gyno in over 20 years and, frankly, don’t see the need to. Why are women treated like they are a disease waiting to happen? First of all, most cervical cancer is caused by the HPV virus, which is sexually transmitted. Do all doctors assume that all women have multiple partners or are sexually active by age 21? In other words, if one has been in a mutually monogamous relationship for over 30 years why would they even need regular PAP smears? Like myself, I had to have one every year for the first 15 years of my marriage just to get birth control (which is questionable in itself as cancer screening should be by choice and not used to withhold BC pills) and never had an abnormal result. I am still married to the same man and therefore I see no need whatsoever to have PAP smears. I have no worry at all of cervical cancer. I would not have been exposed to the HPV virus in all those years. And there are also women who are still virgins at 21. Why would they possibly need a PAP smear??? There is also ample research currently that shows a pelvic exam in asymptomatic women is not indicated and useless. It is overdone here in the US. It is not recommended in other countries unless symptoms warrant it. It just baffles me as to why women feel the need to have their reproductive organs under constant surveillence and why some doctors focus all women’s care on this area.

    • minti cakes

      I agree with your comment. I have never understood the medical community’s obsession with female reproductive organs. Is it because women are a lifelong source of income?

    • elizabeth52

      Jean, you’re wise to protect your asymptomatic body from this harmful excess. 1 in 3 American women will have a hysterectomy by age 60, a huge 600,000 are performed every year, more than double the number of countries that do not perform well-woman exams. That says a lot to me…also, read through the forums and see the misery, fear and damage caused by this exam and medical coercion…it should be a scandal.
      This may be great business, but it’s bad medicine. I’m very pleased I was protected from medical excess when i was a teenager and was left to decide for myself whether I wanted pap tests and later, mammograms. As a low risk woman it was an easy decision to reject pap tests, I was content with my near zero risk of cervix cancer. The lifetime risk of referral for colposcopy/biopsies Is a huge 77% for a cancer with a 0.65% lifetime risk.

      Now I understand the only women who can benefit from pap testing are the roughly 5% who are HPV+ and aged 30 or older. Women can even test themselves for HPV, so there is no need at all for most women to have any invasive screening tests. Using both the pap and HPV test on all women aged 30+ creates the most over-investigation, it’s unnecessary. The Dutch are the ones to watch for those who want evidence based cervical screening. I also, rejected mammograms…few benefit with a significant risk of over-diagnosis. The Nordic Cochrane Institute have a great summary of the evidence at their website. The rest of the well-woman nonsense is not recommended here for good reason. I’d have rejected it anyway…things like routine breast and bimanual pelvic exams, recto-vaginal and visual inspections of the genitals. Never had them and never will… The greatest threat to our health and lives is iMO, medical excess and coercion. There are great doctors out there who’ll put you first, you just have to search for them.

  • elizabeth52

    “In the U.S., women received three to four times the number of
    Pap smears over a period of three decades as women in the Netherlands,
    yet the two countries’ cervical cancer mortality rates were similar.

    The Netherlands follows a model of screening based on governmental
    guidelines; the U.S. has traditionally followed a model based on
    decisions by individual physicians, insurance plans and guidelines from
    medical organizations.”
    Talking of excess…
    http://www.cfah.org/hbns/2012/doctors-in-us-overuse-pap-smears#.UW7LRIKn8rc
    Referral rates for colposcopy/biopsy would also, be much higher than the Netherlands, over-screening increases the likelihood of a false positive. The lifetime risk of referral is a huge 77% in Australia and I think the States would be as high, if not higher with some women still having annual pap testing. The lifetime risk of cervical cancer is 0.65%…

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