In his commentary on 2 studies of Pap testing practices, Dr. Neal M. Lonky chides the authors of those studies for failing to ask respondents why they cling to the outmoded ritual of the yearly Pap smear (“How many ObGyns follow the new rules on Pap testing?” [April]). Dr. Lonky suggests the question is essential to explain why most ObGyns have not yet adopted the every -2-to-3-years rule now being promulgated by the “experts.” I’ll give you my non-expert answer: People are not cattle.
Consider this patient: A.B., age 59 (the case is real, the initials are not), had had 1 husband, 1 gynecologist, and 18 consecutive negative Pap smears (the last 4 liquid-based) when she came to see me in 2001 for her annual exam. Her Pap that year: a high-grade squamous intraepithelial lesion. Her cone results: carcinoma in situ with gland involvement.
No doubt your experts would dismiss such cases as “anecdotal,” which translates: “Evidence is what we say it is; believe what we tell you, not what you see.” When pressed, the experts will admit to exceptions and failures, but these few unfortunate women must be sacrificed for the sake of avoiding all those costly colposcopies—ie, for the greater good of the herd.
When we say “once a year,” we are hoping for every other. Start saying “every 3,” and what you will get is never.
If a young man or woman starting medical school asked me today what specialty to enter, I would say gynecologic oncology. There will be a greater need for their services 5 to 10 years from now, thanks to today’s experts.
Geoffrey C. Kincaid, MD
Dr. Lonky Responds:
These studies explored the opinions of patients and physicians. Since we seldom ask the “why” question to determine what drives behavior, I chided the authors for omitting it. I am very pleased that Dr. Kincaid chose to answer the challenge!
Sometimes it is fear of losing the patient’s trust, not scientific probabilities, that drives our practice. Dr. Kincaid certainly describes the challenges and potential conflicts behind managing and making decisions for large patient populations, as well as the decisions we make during 1-on-1 encounters. That is the relationship that makes the practice of medicine special. Thanks to Dr. Kincaid for his insights.