Poll: These ObGyn “practice enhancers”shone brightly in 2010

Dr. Deschner practices as an OB hospitalist in Seattle, Wash.

7. Pap recommendations simplify care of young patients

Takeko Takeshige, DO

In February 2010, the New York State Medicaid program fully endorsed ACOG’s new recommendations on Pap testing, which call for no screening at all among adolescents and longer intervals between screenings among the rest of the population. Since then, we have modified our policy for cervical cytology to comply with the ACOG recommendations.

We are stringent about compliance. For low-risk patients, we perform no screening until 21 years of age. We then screen every other year in patients 21 to 29 years old and every 3 years in patients 30 years and older, provided there have been three consecutive negative Pap tests.

Not only does the new protocol reduce the financial burden of screening uninsured patients, it also alleviates anxiety among physicians as well as patients. We now know that, when a Pap test is found to be abnormal in the younger age group, watchful waiting is usually appropriate because human papillomavirus (HPV) regresses in a majority of patients.

For the same reason, we are less likely than before to perform an invasive procedure in a young woman who has an abnormal result. By abstaining from invasive interventions such as curettage, we preserve the integrity of her endocervical mucus and protect her reproductive capacity until such time as she is ready to conceive.

Dr. Takeshige practices ObGyn at Lincoln Hospital in Bronx, NY.

8. Documentation a problem? Redesign the form!

Raksha Joshi, MD

Monmouth Family Health Center, an outpatient facility, is a teaching institution for residents from the Monmouth Medical Center ObGyn program. Because the annual well-woman examination is an integral part of the care we provide, comprehensive documentation of it is vital. The exam covers all aspects of the patient’s gynecologic and obstetric history, including menses, contraception, Pap testing, sexually transmitted infection, sexual practices and partners, allergies, medications, and a review of systems. Also crucial is the patient’s medical, surgical, and family history.

In most cases at our center, although the examination was thorough, documentation was markedly deficient, especially among junior residents, despite regular review and feedback. To overcome this deficiency, I redesigned the documentation sheet so that all essential elements of the history and physical examination are printed on the form and documentation is achieved by circling the applicable element. For example, in regard to the uterus, the form lists the following:

• Parity: Nulliparous / Parous
• Size: 6 / 8 / 10 / 12 / >12 wks
• Position: Axial / Anteverted / Retroverted / Anteflexed / Retroflexed
• Consistency: Firm / Soft
• Contour: Regular / Irregular
• Mobility: Yes / No
• Tenderness: Yes / No
• Anterior fornix:
  • Mass: Yes / No
  • Tenderness: Yes / No
  • Thickening: Yes / No
  • Fullness: Yes / No
• Left fornix:
  • Mass: Yes / No
  • Tenderness: Yes / No
  • Thickening: Yes / No
  • Fullness: Yes / No
• Right fornix:
  • Mass: Yes / No
  • Tenderness: Yes / No
  • Thickening: Yes / No
  • Fullness: Yes / No
• Posterior fornix (cul de sac):
  • Mass: Yes / No
  • Tenderness: Yes / No
  • Thickening: Yes / No
  • Fullness: Yes / No

After implementation of this form, documentation and completeness improved markedly.

Other advantages of the form: It can be completed quickly, and it is legible!

We also use the form to teach essential elements of the comprehensive examination to new residents and students.

Dr. Joshi is Chief Medical Officer and Medical Director of Monmouth Family Health Center in Long Branch, NJ.

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