The Schmear Job

 interior of a green Caboose 
“You have never had an abnormal PAP before and your PAP and HPV screens last year were normal so you don’t have to do a PAP this year!”

I expected to hear a celebratory, “Woohoo!” Instead, she scrunched up her face and regarded me suspiciously. “No. Really?” She sounded doubtful.

“Really!” I smile back at her. 

“Yeah…. I don’t know about that. I am used to doing them every year. That’s what my OB always did.”

“These evidence based guidelines have been around for years. I cannot speak as to why your OB was not following them. I reviewed those records. You had no history of anything abnormal. You just told me that you have not had any funky discharges or abnormal bleeding. No new sexual partners….”

“I still want to do a PAP.”


“I just do.” She sighed. “Look, my friend just had a PAP with her doctor. She gets one every year. Why did she have to do one and you are telling me I don’t have to?”

I have had countless conversations like this. Variations are: Accusations that I am lazy. Or stupid. Or I am trying to kill them. Or that this is a vast democratic male governmental scheme to save money and kill women.

Sometimes we do such a good job educating patients that to reverse that ingrained notion is a major uphill battle…


124 thoughts on “The Schmear Job

    • Sorry to burst your bubble, Elyse, but the docs still like to do an annual pelvic. It’s the Pap and HPV testing that can be done every three years if a women meets certain criteria. I think that’s correct, isn’t it Victo? It’s obviously a different issue in peds. So get that gown on, Elyse! πŸ˜‰

      Liked by 2 people

      • Actually, a recent study showed that a pelvic exam for the sake of a pelvic exam without symptoms was not helpful, so you don’t really need to spread your legs every year! Now, sometimes STD screening needs to happen routinely, though. And certainly if you have abnormal bleeding, vaginal discharges, pelvic pain, etc. you need to be seen pronto. You should have a yearly physical with your PCP and discuss at that visit if you need the hoohah check or not. Prior history of abnormal PAPs and hysterectomy status will affect recommendations so you want to have that discussion with someone who knows you and your history instead of taking the advice of some person with VD as a pen name…

        Liked by 5 people

  1. Oh no. Don’t even start on that one. In my Cervical Screening Quality Assurance Group, we wanted to be able to move women out of the system who were low (nil) risk but we had to wait for national guidelines. And, if you don’t know, years back in the UK we had three year and five year recall programmes. One year?!!!

    With no abnormals? Unsatisfactory? No new partners?

    Truly, people even in America, are still sucked into Doctor Knows Best. And in the case of cervical, people still probably see it as preventive, or a definite test for cancer cells.

    Are you still doing actual smears by the way?

    Liked by 1 person

    • We use the thin prep PAPs at my clinic. I find that there is a subset of patients here who believe that the more that gets done the better their care is. Anyone denying them of the opportunity for a test is the enemy. That is less and less the case as patients bear the burden of cost more and more but PAPs fall under preventive care and are covered 100%.

      Liked by 1 person

      • Wow. You know, your practices are well different to UK. Anyway, some many years back, one of my hospitals, ie one of the ones I had jurisdiction over for cervical screening, agreed to put in for a pilot for LBC. And we got it, which was good for the lab as motivation among lab staff is well low. Since I left the UK, afaik, the UK has introduced LBC, means easier on lab staff. So, no longer, technically a smear, nor is it called it any more.

        In terms of care, and cost, I would view that 100% as ridiculous. It isn’t preventive and it isn’t cost effective either. But I worked in a public sector health care system. Very different.

        Liked by 1 person

  2. Clearly she’s a whacky girl.
    I will just be glad to EVER EVER EVER have a normal PAP again EVER EVER EVER.

    I’ve put mine off for too long. Long enough to get a notice in the mail. It won’t be a good schmear. Painful procedures and anxiety will take over.
    But I am going. After this anniversary weekend, I will go. *sigh*

    Liked by 1 person

  3. I guess there are people who are reassured by extra tests.
    I know those guidelines about Paps have been around for several years, and I remember reading about it in the newspaper when they were first changed. I’m perfectly OK with not getting a pap or other unnecessary test. πŸ™‚

    Liked by 1 person

  4. Please don’t confuse us with facts. As studies show, introducing facts in an attempt to correct mistaken beliefs tends to make things worse. Apparently contradictory facts simply harden us in the beliefs we already had.

    Liked by 1 person

  5. It must be horrible to live with that kind of fear. I know several people like that. I myself am not worried about when I dye, I worry more about getting so feeble that I need diapers. Hopefully I sill pass in my sleep or a the very least a quick death.
    I think you are a good doctor. A very informative one that keeps up with all the new medical news.
    You know Doc, “you can bring a horse to water, but you can’t make him drink it.” :o)

    Liked by 2 people

  6. Yeah, I get that too. In South Africa’s public sector PAPs will actually be rejected if it’s not according to the recommended schedule (unless accompanied by a motivation), and in private health care our medical insurances won’t pay for Paps outside of the schedule. People are scared, and they’d rather trust the media than their doctors.

    Liked by 1 person

      • that was what I was going to ask… it covered yearly? So if it is, then the insurance companies need to change….like eye glasses…. they say only every two years…. which is great if nothing changes, but it does, and then they do not cover hearing aides at all… snatch, dick and boobs,…yearly ears? forgedaboudit.

        Liked by 1 person

  7. I got it, no one told me. I didn’t get it, no one told me. I figured “This is life”, and went back to my meatballs.

    10 points to whoever can tell me who I just quoted! πŸ™‚

    Liked by 1 person

  8. Trying to change habits after years of reinforcement is not an easy task. I don’t feel qualified to comment on the conversation content of the testing but the habits are interesting. Remember Smokey the Bear? When I was young there was rarely a day went by that I didn’t see Smokey in one form or another. Then he disappeared – ever wonder why? It seems that as much as we hate them, forest fires actually act to clear out flammable material from the dead wood to the broken branches. Fire also is necessary for some trees to reproduce. and to encourage diversity in the forest (clears out underbrush to allow new trees to compete with mature trees). Smokey the Bear was such an effective program (like the PAP every year program) that it virtually stopped small fires and accidental fires. The underbrush and deadwood built up so much in the forests that they became tinder boxes and when they eventually caught fire, they burnt so hot that they destroyed the whole forest instead of just the underbrush and became massive burns covering thousands of acres that were impossible to put out.

    The moral of the story is when we spend years reinforcing habits they become so ingrained as to take years to deprogram me. Humans are fascinating critters. πŸ˜€

    Liked by 2 people

  9. Oh, man.

    Different jobs, same problem.

    If I got to come in at ground zero and say, “This is how this product is licensed!” I would be elated. But, no. Everyone already knows how it’s licensed …

    … they just know wrong.

    I have to spend two hours disabusing people of weird notions to every five minutes I get to spend explaining the licensing itself.

    I wish I had a time machine so I could say, “Do not build a papier mache foundation and call it brick! It will not stand the test of time and it will suck to clean up!”

    Liked by 2 people

  10. I understand the patient’s hesitation, given how long yearly PAPs were done, but I also understand your educated advice not to do an unnecessary test. It’s tough because the media can be helpful in getting the word out about new guidelines, but also inflames issues, and resulting emotions, at times. The Big C is a terror most people think about daily.

    Liked by 1 person

  11. We’ve been so programmed! I’m happy to only have a PAP every other year, and my next colonoscopy will be my last! Still think mammograms should be yearly, although my OB/GYN (husband) says it’s not necessary.

    Liked by 1 person

  12. Though I usually try to avoid politics here, I don’t think it would be the democratic males who would want to kill women off. And on a lighter note, I like the color of the walls in your intriguing picture. Wondering what color pap smears are.

    Liked by 1 person

  13. I can’t speak from the perspective of a doctor; if you believe they’re unnecessary tests, then that’s fantastic. It probably saves a lot of time and money and worry.

    For me, I beat cancer because of an LPN who was aggressive on PAP smears. Without her and the OB/GYN who begged me to get a 2nd opinion after my first cold conization resulted in an ‘all clear’, I don’t know where I’d be.

    I get that anecdotal evidence isn’t much in the face of empirical studies — but even though I don’t even have a cervix anymore, I go to get poked and prodded, to make sure everything’s as it should be. It just isn’t that much pain or inconvenience to make sure I don’t die of something ridiculous.

    Liked by 1 person

      • I guess I don’t comprehend in what circumstance you wouldn’t need a yearly. In one full year, if you have any sex, otherwise stick anything up in there, get a UTI, have a period, get cramps, get a yeast infection… all of those things can result in or be symptoms of urogenital issues that can affect the results of a PAP. The fact that what, 75% of the population have strains of HPV and may not know it… that shit can go pear-shaped at any point. Why would you wait more than a full year to get things looked at? My car goes in every 3 months. Should my vagina really wait for 2 years or more?

        Liked by 1 person

      • Stats should that it takes at least three years to contract HPV and start to have abnormal cells that would show up on a PAP. Check out the online ACOG guidelines. There is really good data to support them. Abnormal cells history or positive HPV status takes you out of the low risk spread out exam pool. Any symptoms mean you need an exam.

        Liked by 1 person

  14. LOL! Try not to take it so personally… People are actually probably just thinking that their insurance company is trying to screw them over. It’s kind of like when the car powers-that-be recently said you can go 5,000 miles between oil changes now instead of 3,000…. It’ll just take a while to sink in. πŸ˜‰

    Liked by 1 person

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