Skepticism

Quickies: Pelvic exams, Ruth Bader Ginsburg, and saving the world with cat videos

Amanda

Amanda is a science grad student in Boston whose favorite pastimes are having friendly debates and running amok.

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23 Comments

  1. The OitNB article guy is such a classic statistics fail. It’s like if I insisted that my mostly Midwestern American born-and-raised friends and co-workers failed to accurately represent the Earth’s population because 15% of them don’t speak some dialect of Chinese as a first language.

        1. I was saying that Mandarin and Cantonese aren’t dialects of the same language. (Strictly speaking, two dialects of the same language can be understood by speakers of either.) I’m of course only speaking of the spoken language, rather than the written language.

  2. I have to admit to being pretty torn about the pelvic exam (full disclosure: I’m and OB/GYN). On the one hand, there isn’t good evidence to do an annual pelvic to prevent death (FYI this is NOT the speculum exam but is instead the bimanual exam- two fingers in vagina, one external on the abdomen). But on the other hand, I don’t know that we have that kind of data for ANY routine physical exam. I know I have used the routine exam to diagnose ovarian masses in asymptomatic women and to make an informed decision about liklihood of some rare cancers (ex leiomyosarcoma). So it’s hard to say that it’s useless. Now, that said, I don’t do pelvic exams on non-pregnant asymptomatic young women (under 21).

    The tone of the slate piece irritated me. First of all, it references the speculum which is NOT what this is talking about. It also gets into the Pap smear guidelines- again taking the tone that those evil gynecologists just want to touch your lady parts and make a quick buck. The Pap smear guidelines may yet change back closer to what they once were. The guidelines are untested and we haven’t seen the effects yet. If the rate of cervical cancer increases after the implementation of the guidelines, I imagine we will be screening more frequently again.

    1. I’m super against unnecessary procedures. I’ve read what you said, and I sort of agree. I have a few thoughts here.

      Maybe the problem is invasiveness? That’s why they keep referencing the speculum. I’m sorry, but I also think it’s a tool of torture. (But that’s because I figured out I have a physical problem that no doctor wants to believe me about, but have no idea what to do, so I avoid the gyno.) For me, it’s terribly uncomfortable and painful. And that’s not even addressing sexual abuse survivors, which are numerous, as we’ve learned, at least 20% of women, probably more.

      They’re saying there’s not a lot of evidence of its benefit for how much the procedures get done. Why is there little evidence? You say the bimanual exam has helped you diagnose some cancers. Is there not another way, like ultrasound or something? Maybe some way that hasn’t been found yet, because doctors rely on what’s good enough. I still think it sounds really invasive.

      Maybe you’re a really good doctor, and your patients like coming to you. I’ve had some not so great doctors, paternalistic, bad bedside manner, impatient, unwilling to listen. Perhaps it’s these doctors the article talks about, the ones who don’t care, and just want to make money. I think the author has encountered those doctors, like I have, because I completely understand her tone. Maybe you don’t like it because it criticizes doctors, who’ve been put on a pedestal for so long. We’re skeptics, we question everything, right? Even doctors. Sorry if I sound defensive or even angry. I’m just so tired of people thinking doctors are god, and what they say is dogma. It’s nice for me to read something once in a while that actually agrees with my experiences.

      1. An ultrasound is WAY more pricey than a pelvic exam, for which doctors usually don’t even bill separately anyway. I’ve yet to encounter an insurance plan that covers screening ultrasounds. And the typical ultrasound to examine the ovaries is super invasive – it’s not the probe-on-the-belly like with pregnant women, but a transvaginal dealio with a probe way bigger than your doctor’s fingers.

        I don’t really think ultrasounds are a viable alternative.

          1. Maybe you should itemize next time, to which things people are allowed to respond and which things everyone is required to totally ignore.

  3. I was really surprised reading the pelvic exam article. As a Brit I’ve had my routine pap smear tests every 3 years but unless I had a specific problem I’ve never had a doctor do a pelvic exam, even when I’ve had to have medicals for visas or jobs. Why are US doctors so concerned (or, I suppose, why aren’t British doctors as concerned) about women’s reproductive parts? The cynical side of me says that doctors in the US can charge for this so it’s a nice little money earner whereas in the UK they don’t get anything so don’t waste their time with as many pointless check-ups.

    I know that there’s bound to be many confounding factors but it would be interesting to compare the US to other western countries where these exams are not so routine to see if there are any differences.

  4. With regards to being skeptics and questioning: I have no problem with questioning. In fact, I’m questioning the fact that internal medicine doctors are making recommendations on an exam they don’t perform. And I think questioning the utility of exams is useful- I’m just intrigued by the fact that they don’t question their heart and lung exams.
    As to the speculum exam- this recommendation does not address that at all. Speculum exams are not part of the pelvic exam. So when you say the speculum is a “tool of torture” it’s equivalent to saying, “MRIs are tools of torture”. Neither a speculum exam nor an MRI are part of the pelvic exam.
    Ultrasound is a very poor screening tool- increased cost, poor predictive value, an high rates of operation for benign findings. It is explicitly NOT meant to be a screening tool. Also, it’s invasive. To get a thorough scan of the pelvic organs you need a transvaginal ultrasound.
    You’re right: doctors aren’t gods, they aren’t infallible, and they need to be questioned. I don’t get paid any money for doing a bimanual exam. I do get paid for doing an ultrasound. I’m sorry you have had bad experiences with doctors but that doesn’t mean we are out to get the public.

      1. I’m sorry that I didn’t reply to all of your post. I was reading/responding from my phone while in line at the DMV so I don’t think I was at my best.

        I also apologize for coming off as defensive. Reading my post I can see how it would sound that way. I’ll try to include a more comprehensive reply here, but I am very open to a dialog about this.

        I think you’re right that the biggest issue with this particular exam is that it feels both deeply personal and invasive. Many women are uncomfortable with it. There is a more nuanced answer to your concern than what I have earlier and that is that doing a pelvic exam should be part of a dialog between the doctor and patient. Ultimately, the choice is the patient’s- it is only the doctor’s job to inform and make recommendations. Sexual abuse survivors often avoid a gyn out of fear of the exam. Not having a pelvic exam may make these women more likely to come to the doctor- so that’s a potential upside to these recommendations.

        Regarding why there is so little evidence: the outcomes that we would be looking at are extremely rare and so without good quality studies, it is very difficult to look at those outcomes. Additionally, it is very hard to test something like exam findings for a variety of reasons: it’s an established practice so finding a control group is very difficult; there are many confounding factors; variability between examiners and studies are vast.

        I think I addressed your other points in my last post. Ultimately, I suspect you and I agree on most things. I recognize that you and many women have had negative experiences with doctors in the past (I’ve had plenty myself). Not every doctor is a good doctor and even good doctors aren’t a good fit for every patient.

        I hope you’re able to find a good doctor who will fit your needs- whether a gynecologist or a generalist who is aware of important women’s health issues.

        1. I, too, am open to dialog. I have very strong feelings about doctors. I have been fortunate enough to find one (a GP) who listens to me, and respects me as a woman and as a person. That’s how I know how bad the bad ones are; finding a great doctor makes lesser doctors pathetic. He has recommended plastic surgery to me (blah) because my problem is beyond his expertise. Now how to I find a plastic surgeon who’ll believe me? Sigh.

          I totally agree with you about a dialog between the doctor and patient. But how many patients know that they can say no to the doctor?

          I’m sorry for saying that a speculum is an instrument of torture. For me, it has been. Doctors just shove it in without thought, then expand it, and wow, my pain factor goes to 10, but they don’t listen to me because “it’s always a little uncomfortable,” and “women always overreact, am I right?” So I guess some sexism goes into not believing women, too. So, you might guess, I have never had a pelvic exam; why force myself into that situation? Me and my GP aren’t terribly worried; I’m monogamous in a mono relationship. He still recommends I should get one though, but I shoot him down.

          I understand how fuzzy science and medicine and evidence can be sometimes. I don’t know what the truth is, but I truly appreciated an article that had my back for once. I’ve thought for a long time that many tests we do are unnecessary and hurt people. But I’m not anti-medicine or science, I just question them. If it comes out that pelvic exams are necessary every year, then I will believe it. Perhaps what I’m trying to say is that a blanket statement, “every woman must have a pelvic exam!” turns off the very women you’re trying to reach because of negative experiences without positive benefits in return. Perhaps there needs to be a different approach to reach women instead of saying, “just grin and bear it.” That attitude certainly does me no favors and makes me avoid the gynecologist. Also, you probably don’t do this, but I have heard stories of gynos who hold the promise of birth control over women’s heads if they get a pelvic exam. That is seriously sick and messed up. Sigh. I don’t know what the answer is though. I’m just giving you my perspective as a well-informed and analytical patient. It’s not for me to fix the problem, it’s for you docs.

          One last thing, I remember you complained that these were internists that were studying and analyzing the data. It’s ok to have outsiders look at something you do. It keeps your group from being a closed-off circle jerk. I know that’s really blunt, so I’m sorry for my blunt tone. But it’s still true.

    1. It’s more than that, though. I mean, I was molested when I was 7. (I always mention she was white, just because I can think of what goes on in people’s minds.) When puberty hit, being checked for testicular cancer made me more than a little uncomfortable.

      That’s what it’s like for survivors of sexual abuse. if you’re not completely comfortable with someone touching your genitalia, it just throws you right back there.

        1. I’m feeling better about it now. I mostly brought it up to mention that he didn’t answer your issue. (Namely, medical procedures and survivors of sexual abuse.)

          And that brings up an important point about transvaginal ultrasounds, which are only required before an abortion (in certain states) as a means of guilt tripping women. Because every patient is different. And if she was raped, she certainly doesn’t want you sticking anything more than absolutely necessary down there. Which is…probably the point, my more cynical side would say.

          1. Excellent point, I was noticing it myself. What do doctors do about survivors of sexual abuse? How do gynos bring it up with patients, or do they even bother?

            And yes, the cynic in me also thinks that transvaginal ultrasounds are a way of guilt-tripping, and even deterring women from having abortions.

  5. Interestingly, I was thinking just today that Orphan Black probably needs to undergo a reverse Bechdel test: is there a scene in which two dudes talk to each other about something other than a lady? It was kind of hilarious to wonder.

    It’s a symptom of just how insecure guys are when they complain that something exists that has nothing (or not much) to do with them. Guys who aren’t little nervous nellies don’t make those kinds of complaints.

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