“It’s time to retool the annual exam: Here’s how” by Barbara S. Levy, MD (June)
Although Dr. Levy’s article contained many thoughtful points, I felt she inappropriately de-emphasized screening for domestic violence. In her outline, domestic violence screening is listed as “optional,” along with screening for bladder health and thyroid disease. In the subsequent discussion of these optional items, she ignored domestic violence entirely but took time to point out that there is money to be made from screening for bladder health.
Universal screening for domestic violence with new patients, and annual re-screening of those with a positive history or suggestive signs and symptoms, are standard of care for all primary care specialties, especially obstetrics and gynecology. Let us not turn back the clock to the days when we ignored this major health problem.
John P. Stewart, MD
Dr. Levy responds: Focus was on the evidence
Dr. Coppin is certainly correct: An astute clinician can uncover significant conditions in asymptomatic patients at the time of routine screening. However, studies looking at outcomes in a population of screened versus unscreened patients for most of the interventions he discusses have not demonstrated any statistically significant improvement in health outcome in the screened population. For these large-scale studies to prove effectiveness, a condition would need to be prevalent in the population studied and easily discovered with the screening intervention. As Dr. Coppin points out, the conditions he mentions may be quite challenging to diagnose with physical examination alone, and most are uncommon in the population we routinely see.
Nevertheless, the point of my article is that, indeed, there is value in an annual encounter with the patient. What each of us chooses to include in that encounter will vary, but Dr. Coppin and I are in agreement that screening should certainly encompass those evidence-based interventions discussed in the article. The addition of a careful and well-informed history and physical examination will at times add value to the standard protocols I described.
Dr. Stewart raises an important issue, which certainly deserves attention at every encounter with our patients—not just the annual well-woman examination—along with screening for substance abuse (especially alcohol), depression, and sexual dysfunction. These are areas in which ObGyns have excelled.