Tuesday, April 07, 2009

Just Say No to "Just Scoot up": The End of the Pap Smear


Here is in an insight into everything that's wrong with American Medicine. The New York Times report that a newly discovered dna test is so much more accurate than the traditional Pap smear as to make that humiliating and sometimes painful test (not to overshare, but that's my truth) obsolete. What might be an obstacle to this miracle? American Medicine's Paternalism.

According to Debbie Saslow, executive director of the American Cancer, her greatest problem in getting the Pap smear replaced by DNA testing is that
" [W]e haven’t been able to get doctors to go along,” Why not? Are doctors concerned about the cost or accuracy of the new test? Not at all. They are concerned about the ability of American Women to manage their own health. Dr. Saslow reports that “The average gynecologist, especially the older ones, says, ‘Women come in for their Pap smear, and that’s how we get them in here to get other care.’ We’re totally overscreening, but when you’ve been telling everyone for 40 years to get an annual Pap smear, it’s hard to change.”

I'd like to suggest that if there were a DNA test for prostate cancer that would replace the current hands-on method of diagnosis, it would be adopted faster than you could snap on a latex glove.

I have a student currently writing a paper on the gender inequalities of Health Insurance (why is Viagra covered but not birth control?), but I wonder if our bigger problem isn't that it's hard to focus on the goals of quality and cost effectiveness when you're blinded by paternalism. And lest anyone think this is a criticism of male doctors, it is not. The values of the medical profession in the United States are transmitted equally to men and women. While this quote by Dr. Saslow is directed signficiantly at older doctors (more of whom are probably male)I would be surprised if they are the only ones to endorse this view.


Kelly Hills said...

I'm going to repeat myself, but I think this is a really fascinating conversation to be having right now, so I like the idea of pulling in more bright minds. :-)

The really fascinating thing, for me, is the apparent fear factor of the doctors involved. I've heard doctors say before that if women didn't come in for paps, they wouldn't have *any* access to well-health checkups for adults; kids generally see peds, and aside from that? People see the doctor when sick.

So in a way, if a woman going in for a yearly pap guarantees access to a well health visit for her (and very likely her spouse), I can see why doctors are hesitant to give it up.

I think the real question becomes: how do we re-educate Americans to think about health and their bodies like they think about their cars and oil changes? Most Americans know that you take your car in for an oil change every 3,000 miles or so many months. Most Americans know that the car needs antifreeze and water, wiper fluid, the brakes need peeking at just in case, and so forth. We accept the idea of preventative maintenance in our automobiles - so why not our bodies?

How do we change that perception, so the idea of seeing a doctor on a maintenance schedule is appealing and seems like common sense? Aren't our bodies worth as much attention and care as our cars? (And on that note, would people be more motivated if, say, you had well health checkups with FNPs that ran about the same as the cost of an oil change?)

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The Social Commentator said...

Interesting discussion.

I'm of two minds with this:
1. I live in NY, and when I was in graduate school did not have health insurance or stable income. As a result, I qualified for free well visits and birth control, which included pap smears, at the local Planned Parenthood. It was funded by the State's Medicaid program, and primarily utilized by women in their 20s who were in school, underemployed, or both. If I hadn't had this coverage, I would not have had ANY coverage.

2. Women SHOULD be going for these checkups, regardless of a DNA screening, especially if they're sexually active. A DNA screening isn't going to catch an STD, or a UTI, for example.

3. The two above points dovetail into Kelly's comment. It isn't just women who don't go in for wellness visits each year - it's EVERYONE. And, this has little to do with this country's poor health coverage - people who have health coverage skip these visits, too. If this DNA test is going to allow for early detection and overall better health, it should be allowed. Doctors shouldn't be blocking it solely because they feel that women should come and get checked out - that's not their choice to make.

Andrea said...

Thank you for picking up on this story. I wonder if the hesitation to switch to DNA tests comes from paternalism or more from the medical-industrial complex that profits from annual visits, tests, drugs, etc. Doctors have a fear that their practices will diminish, and pharmaceutical and testing companies are worried about profit margins. Paternalism is just a lubricant.

Kelly Hills said...

Andrea, do you suppose doctors would end up with a more profitable model if they could convince more people to come in for annual or semi-annual visits by dropping some of the hassle and cost?

Unfortunately, there's not an easy solution for the pharma and test companies, who are driven by a capitalist market that insists on constantly increasing revenue, rather than being happy at a consistent middle ground of revenue.

Andrea said...

Kelly, I agree--there's no easy solution to the ill effects of a health care delivery system driven by a capitalist market. As a society we should try to change our attitudes towards medicine to be more routine and preventive. However, few stand to profit from such a model and thus it likely will not have the driving force behind it to become the norm. Unwarranted or unnecessary tests, prescriptions, and procedures will likely dominate our medical landscape if it continues to be driven by the private sector.

Anonymous said...

This blog takes the wrong tack, if I may say so. The NYT article clearly indicates that a cervical swipe has to be taken to facilitate the DNA test, just as it does to facilitate the pap smear. It is the form of testing to which the cells are later subjected which is the difference in the two tests, not the procedure. So it looks like there will continue to be 'scooting up' with or without the Gates-funded genetic test. Speaking of paternalism...