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Pap smears: frustrating for everyoneFrom: Ed Uthman (uthman@neosoft.com)Sun Sep 29 12:07:54 1996
Hi, folks, I am a general pathologist with a group in Houston, TX. I was turned on to this list by Rick Chudacoff and have been lurking here for the past few weeks. While I work primarily in a 100-bed community hospital in Richmond, TX, I also have major responsibilities through my group's contract with a large reference lab, which does 300,000 Pap smears a year, plus 45,000 surgical pathology cases, probably about half of which are gynecological material. Although I have done Paps for most of my entire fifteen-year career in pathology, I have found that this part of my practice has become more and more frustrating. I understand from talking with colleagues and reading that general gynecologists are experiencing similar frustrations in this area. The thing that immediately comes to mind is the ASCUS problem. The legal establishment has recently identified that the area of false-negative Pap smears is potentially very lucrative for them, since the smear is always there to be second-guessed by hired gun "expert witnesses," and the volume of Paps is so huge that the absolute number of false negatives at the national scale is very, very large. Each one of those can potentially be converted into a multimillion-dollar judgement or settlement. This tends to make us extremely wary about letting go as negative cases that look just a bit atypical. When most of us in the mid-career generation trained in pathology, we were taught that one tries to make all smears fall into a dysplasia category or a negative category, with only a few cases in between. It was understood that the Pap was not infallible, and that a certain number of false-negatives are inevitable. The legal climate has since made us change this whole philosophy, so that we feel we are now held to a standard of 100% accuracy. Anything less than that, and we may find ourselves bankrupt after the juries of our "peers" get through with us. The natural outcome of this paranoia is a large number of Paps that get classed as ASCUS, even though we realize that only a small proportion of those will ever come to anything clinically significant. On the other hand, the high ASCUS rate is a problem for gynecologists and their patients, as most readers of this list can attest. Not only that, but managed care executives are starting to balk at all the follow-up required of an ASCUS Pap and are putting pressure on the big labs to cut the ASCUS rate. Since these labs are run by bottom-line-oriented executives with little personal risk for Pap errors, they demand that we decrease the ASCUS rate accordingly. Rather than curse the darkness, I have decided to do what I can to decrease the ASCUS rate. I believe that the only controllable factor that can cut this figure is to increase the quality of the Pap smear specimen. I have found that I am much less reluctant to send out a negative if I can get a good appreciation for what the cells look like. If I have a lousy specimen, I am much more prone to check the "ASCUS" box on the form, simply because I cannot be sure of what I'm seeing. Accordingly, I have put together a list of brief suggestions for improving the Pap smear specimen and posted it on my Web site: <http://www.neosoft.com/~uthman/pap_tips.html> For anyone who is interested, I have several other pathology-oriented pieces (including a couple of opinion pieces on Paps) on my home page: <http://www.neosoft.com/~uthman/> I would certainly appreciate any feedback on any of this material. Ed _________________________________________________________ Ed Uthman, MD -- _________________________________________________________ <uthman@neosoft.com> "Nemo liber est qui <http://www.neosoft.com/~uthman/> corpore servit." Pathologist -Seneca Houston/Richmond, TX, USA
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