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Comment and Controversy

Most women don’t need annual visits

November 2005 · Vol. 17, No. 11

In his September 2005 article, “How to keep the annual visit annual,” Dr. Mark S. DeFrancesco cites the US Preventive Services Task Force (USPSTF) guidelines for preventive care and concludes that the annual exam is still advised even if Pap smears are done every 3 years. I applaud him for using the USPSTF guidelines, but I draw a very different conclusion from them: Annual preventive visits for most patients cannot be recommended.

Many low-risk women still undergo annual exams and tests such as a complete blood count and glucose and cholesterol measurement; periodic thyroid testing; periodic bone densitometry starting at age 50; and in-office fecal occult blood testing. The USPSTF does recommend cholesterol testing starting at age 45 and bone densitometry starting at 65 for low-risk patients, but not these other tests.

Gynecologists often assert that—even without annual Pap smears—the office visit is important for the pelvic bimanual exam and clinical breast exam. However, the USPSTF has found no evidence to recommend either of these in asymptomatic patients. There is no proof that colonoscopy decreases mortality from colon cancer, and currently recommended USPSTF testing regimens include the much more convenient, less risky, and cheaper home fecal occult blood testing.

In fact, many of the USPSTF recommendations can be performed by a patient independently—without an annual physician exam. In-office preventive care also is less expensive (for the health care system) if provided by a nongynecologist; that is why most insurance companies assign every patient a primary care provider, who can also provide global preventive services.

I am not affiliated with any insurance company and have no financial disclosures. I am citing these guidelines and facts to convince my colleagues that annual visits and many other “preventive services” are wasteful. Double-digit medical inflation is slowing our country’s economy and depleting resources that might better be utilized reaching the underserved both at home and abroad. Perhaps it’s time we educate patients realistically rather than acquiesce to what they or subspecialty organizations want.

Joe Walsh, MD
Farmington, Conn

Dr. DeFrancesco responds:

It was not my intention to imply that USPSTF guidelines recommend annual preventive visits, but to recognize that, for many women, the ObGyn is the only regular interface with the health care system. Given that observation, ObGyns would serve their patients well if they stayed up-to-date on preventive service guidelines and use that knowledge to provide comprehensive patient care. This should not become a “turf war” between specialties.

So many patients do not visit a primary care provider unless they have an acute problem. Thus, there is a danger that some preventive screenings (with proven value) may not be done if the ObGyn doesn’t do them.

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