Family Medicine Recommendation #4: Don’t screen women with Pap smears if under 21 years of age or over 69 years of age. Also appears in the following lists: Nurse Practitioner, Pathology, and Obstetrics and Gynaecology.
Choosing Wisely Canada: What shared decision making strategies or tools have you implemented in your practice around this recommendation?
Dr. Christa Mindrum: In a busy family practice, it can be a challenge to keep track of all screening tests due. Working as a locum means that I do not have control over individual practice tools to prompt discussion around cervical cancer screening. Some clinics use an electronic medical record reminder tool to indicate when various screening tests are due, and others have a simple reminder at the top of patient charts. Some clinics run a report of which screening tests are due for the day’s patient list, and others post a sign to remind people to book a Pap test. I have made it a habit to bring up cervical cancer screening nearly every time I see an eligible patient. I am particularly prompted to review cervical cancer screening during visits when there are gynecologic or sexual health issues, when there is extra time, when the patient has questions about health maintenance, or when someone has had multiple visits for complex medical issues that might have distracted them and the practitioner from routine screening. I also review screening with patients who rarely seek medical care.
It often only takes a minute to review the need for and timing of cervical cancer screening. A patient’s response to the question “When was your last Pap test?” offers important information. Some patients will share that they get one at a particular time interval and their reasons for doing so, that they are overdue, that they do not need them anymore, or that they have been avoiding one. The responses to the question are a jumping-off point to explore their understanding of the recommendations, values, preferences, and experiences (positive or negative) around cervical cancer screening.
The resources that are most in line with conversations I have with patients are the guidelines for cervical cancer screening in Nova Scotia1 and the Canadian Task Force on Preventive Health Care guidelines and patient tools.2
CWC: What makes shared decision making around this topic challenging or rewarding?
CM: The main challenge is helping patients “unlearn” advice they have been given. Working as a locum means I see various practice styles and frequently navigate shared decision making with patients who are new to me. Some clinicians have taught patients they need a Pap test every year even if they have no history of abnormalities, do not have a cervix (hysterectomy for benign causes), or fall outside of the age range. Many people feel empowered by ensuring they have an annual Pap test. It is rewarding to explore a patient’s philosophy and values around his or her health. Many people feel validated when their reason for avoiding the test is acknowledged and feel supported when a shared decision is made about how to proceed. I find patients very accepting of cervical cancer screening guidelines when they understand the rationale for the age range and intervals between testing. Frequently patients are relieved when they agree that they no longer need annual Pap tests or any at all!
CWC: Why is shared decision making around this specific Choosing Wisely recommendation or clinical topic essential to you?
CM: Sharing knowledge of the risks and benefits of screening while accounting for patient preferences and values builds therapeutic alliance, empowers patients, and increases adherence. Making shared decisions around preventive care is an opportunity to focus on wellness rather than illness. Cervical cancer screening requires an intimate examination that can be distressing—particularly for transgender people, postmenopausal women, and those who have experienced trauma. Finding common ground and sharing the decision to screen fortifies trust, which is essential to practising good medicine and helps a patient feel educated, valued, and empowered.
This article first appeared in Canadian Family Physician. The interview was prepared by Dr Kimberly Wintemute, Primary Care Co-Lead, and Hayley Thompson, Project Manager, for Choosing Wisely Canada.
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