http://www.acog.org/from_home/publications/press_releases/nr11-20-09.cfm

particularly this excerpt, “A significant increase in premature births has recently been documented among women who have been treated with excisional procedures for dysplasia. “Adolescents have most of their childbearing years ahead of them, so it’s important to avoid unnecessary procedures that negatively affect the cervix,” says Dr. Waxman. “Screening for cervical cancer in adolescents only serves to increase their anxiety and has led to overuse of follow-up procedures for something that usually resolves on its own.” Naturally I haven’t read the original report or looked at the research data, but it’s noteworthy that the [insert unfavored press body of the minute] lobby is asking for something even the treatment-hungry Americans are finding of dubious benefit at best, harmful at worst.

Um, that’d be pretty much worthless.

The point of a pap smear is to find cervical cancer caused by a sexually transmitted virus. It takes years for this virus to cause cancer, not days or weeks — “years”, as in “median latency is generally believed to be 15 to 30 years”. Pretty much nobody has ever seen any sort of clinically detectable change in less than one year, which makes “as soon as you become sexually active” kind of silly.

Have you perhaps confused a pap smear with a pelvic exam? (That is very widely recommended “as soon as you become sexually active,” or even before then.)

Or do you think that your country’s health service thinks all the women lie to their physicians about their sexual lives? I suppose that if the regulator thought that most women were having sex at age 15, but lying to their docs until they were married at age 25, then you might suggest “as soon as you are willing to admit that you’re sexually active, because we believe that’s several years after you really started”.

There is no such thing as a “screening programme”. Screening does not give true positives and false positives. It just gives positives. These have to be found true or false by a follow-up test. It is a “screening and follow up programme” or useless.

In assessing risks of a potential programme, the follow-up is critical. It is usually (more) invasive. It may involve ionising radiation. Will this small intervention danger to a larger number of false positive patients cause more suffering than would the greater disease danger to the smaller number of true positives if left undiagnosed?

In assessing resource usage also, the resource-demanding follow-up is usually critical. How much suffering will the diversion of medical skills, facilities and equipment away from other treatments cause? Added to the suffering of false positives if the programme goes ahead, will this exceed the suffering of true positives left unscreened until they present later? This is the case whether health treatment is a cost to a national service such as the NHS or to a health insurance fund, or some fancy mixture of the two.

Perhaps the Scottish NHS policy was a “best guess” but more recent consideration could show the English programme to be wiser. The Scots are likely to carry on regardless because it is so difficult to withdraw an unwise service once it is established.
Then again, as both screening and follow-up procedures are improved, the time to extend screening in England to a further age cohort may already have arrived, but not yet be statistically demonstrable.
We know only that it is unsound to ground criticism of one nation on the past judgements of another, not which is better.

That said, distrust any overseas system which relies even in part on private insurance companies (or medics) who may vie to show they are “better” by offering medically unjustifiable screenings and treatments. And now our papers, and some politicians, are trying to do the same.

http://www.dh.gov.uk/en/AboutUs/MinistersAndDepartmentLeaders/NationalClinicalDirectors/NationalDirectorsBiography/DH_4105307

http://www.newstatesman.com/health/2009/11/health-care-system-change-nhs

Mike Richards: “Undoubtedly, our cancer survival rates have been poorer than many other countries. The question is, why? The more we look into that, the more apparent it is that late diagnosis is the problem and, therefore, failure to get the patient to the curative treatment. The curative treatments for cancer are very often not that expensive. The best treatment for cancer in many cases is surgery, and well-done surgery is not that expensive, whether it is for breast cancer, lung cancer or colorectal cancer. We are simply not picking up patients early enough.

This comes back to the previous discussion about primary care, of which I am a very strong supporter; I am from a family of general practitioners. We have tied the hands of our general practitioners to a certain extent because we have asked them to be overzealous gatekeepers, but we have not given them access to diagnostic tests. This is why I so strongly welcome the recent announcements that we will improve access to diagnostics for GPs. For cancer patients, for example, this will mean that people who have a low risk of having cancer based on their symptoms – but not no risk – will be investigated, and investigated quickly. The vast majority will then be reassured, but the small number who are found to have cancer will go into the system at a curable stage. That is a very important point. We need to put more emphasis on diagnosis and take more money out of the hospital system in terms of people being in beds when they do not need to be.”

2. urine test – again I can do a basic “dipstick” test – this will help to identify the presence of white cells (suggestive of infection), nitrites (suggestive of infection), protein (suggestive of infection but also found with kidney disease), blood/red cells (suggestive of infection but can also be caused by bleeding anywhere along the urinary tract), ketones (found with fasting or in poorly controlled diabetes) and glucose (found in diabetes of course). All these things can be tested for by a single dipstick with all results in maximum of 2 minutes. Sadly dipsticks are not conclusive and, although I may make a clinical decision on them (e.g. start antibioticsfor possible urinary tract) this decision would be made in conjunction with the history and physical examination and I would usually send the sample to the lab for full analysis – microscopy (to look for significant levels of white and red blood cells), culture for infection and, if significant dipstick protein, urine protein levels.

3. blood tests – these do have to be sent away but basic results (e.g. full blood count, kidney function liver function, etc.) are usually available online in about 2 working days. I can access them directly from the lab’s results system from my consulting room computer if necessary and in a case of real urgency I can ask the lab to do the tests when they receive them so they may be available the same day if I time the pick up lab van right! In the near future we are hoping to have a machine in our adjoining community hospital that can do these basic blood tests which of course will speed things up considerably.

4. vaginal swabs – again these go to the lab and do take a few days for results for the simple reason it takes that long to culture up bacteria. Some GPs will look at “wet smear” in their consulting room to look for trachoma which can be seen under a microscope but I don’t do that myself.

5. ESR – yes I do this in my room with result in an hour.

Oh, and in my practice, 15 minute appointments are standard which definitely helps. But there’s nothing above that couldn’t be done in any average GP surgery – I’m certainly no super-doc.

No.
But you will find that there are other countries in the developed world apart from the US and the UK.

Why is it that everybody who critices the NHS is always immediately told about healthcare in the US?
Why don’t you look at the French, German or Finnish system?

In France (in general), you pay for one third of your healthcare costs. Normally you take out insurance or you can pay as you go. If you can’t afford insurance, the state will pay for the missing third.
In Germany, you pay 11-13% of your income to a healthcare company, the state pays for the rest. If you are not employed, you get the service free.

Both systems are a bit more complicated than that, but the basics are true: everybody gets the service and if you earn enough, you pay for a part of it. For that contribution you get a MUCH BETTER service than the NHS. Yes, it is possible to do a hernia operation one week after the diagnosis, and not have to go on a nine-month waiting list.
Yes, a doctor CAN sit in the room while you are having your MRI scan and dictate the findings into a dictaphone as the images are being made, so afterwards the secretary types it up, gives it to you and you go away KNOWING the results (compare in the NHS, where even if you have a suspected cancerous tumour, and you have been in the specialist system for months, the doctor can allow himself – clinical guidelines will allow him – two weeks before looking at the images, and then comes the multidisciplinary team meeting, where they will all decide that they have no idea, and give themselves another week to think about what to do to find out.)

Somebody said on this blog a few months ago, that you now have access to psychotherapy on the NHS within 2 months or sooner. I decided to investigate: I asked a friend of mine who is a psychiatrist, and the answer was: oh, no, of course not, not in the area where she works. The waiting list is 2-3 years, or it WAS, before they were told they can’t refer anybody for psychotherapy for the time being. They need to sort out this waiting list first, nobody can even GET ON IT.

Swine flu vaccine? Free, sure. But only if you are in the risk group. If you are not in the risk group, you will not get it. In other EU countries you might contribute TOWARDS the cost if you are not in the risk group, but at least you can decide whether you want it or not.

I don’t think I am far from the truth when I say that people who have lived in another Western European country and have ever experienced better, will NOT say that the NHS is a fantastic system. It is free (at the point of receiving the service!), but you pay a huge price for it being free: you simply don’t get the quality of the healthcare that should be possible in the 21st century.
(The NHS generally has quite a bad reputation in Western Europe, if you are interested.)

And what choices have you got in Britain? You can go private, take out insurance or pay from your savings when you need it. In private healthcare, the service is completely market-oriented, where your membership fee goes up as you get older, if you have had a complicated disease etc., it might not cover what you need. Just like in the US.

And where did we start? Oh, cervical cancer screening. Ben criticising the MP who introduces a bill to lower the screening age. And people from other countries commented how younger women are included in other countries and benefit from it.

It seems to me that it is a taboo to criticise and suggest reforming the healthcare system in Britain. Like you are immediately a bad person or something.
But we will never have a better healthcare system here if we keep repeating that it is better to provide bad quality healthcare than no healthcare at all, and that the only alternative would be the US model.

OK, let’s see.

“I would do a pregnancy test there and then (…), I would also check her urine for white cells, red cells, protein and nitrites (…), I would also do chlamydia and high vaginal swabs and take blood for a full blood count (to look for high white cells which would suggest infection) and an ESR (erythrocyte sedimentation rate which increases in presence of infection or inflammation) – I can also do the ESR in my consulting room with result in an hour”

So you could (would if necessary) do a
1. pregnancy test
2. urine test
3. blood test
4. vaginal swabs
5. ESR

there and then, in your surgery, within the 10-minute appointment, with the results available immediately or on the same day?

Because if yes, I will have to move to Scotland (from England), because I have never heard of anything like that happen in a GP surgery here. My GP can’t do any of these tests, the nurse (with whom you would have to make another appointment) can do the urine and can take the vag. swabs, but she needs to send them off somewhere to get analysed (takes about a week). No bloods taken by the nurse, you have to go somewhere else, make an appointment first etc.

Wow again.

Also, I agree with adamk that

“When a GP says ‘come back if its not better in 2 weeks’ you can think of that as a test – a ‘if its not better in 2 weeks we may need to investigate further’ test. This is a very useful and valid tool.”

but in practice, this often means going back again and again, the GP trying out different tablets or increasing doses without doing any test or referring you anywhere, in fact treating something he doesn’t know what it is for weeks or months.

Exactly!

http://brighamandwomens.staywellsolutionsonline.com/RelatedItems/6,616350

The precise figures don’t really matter. I think we can both agree that the issue is that the wealthiest nation on Earth denies a substantial minority of its citizens the right to modern high-quality health care and its politicians would rather slag off the NHS (which, for all its faults, is a fab service) rather than get their own house in order. I think it’s called free market economics or something like that…

Oh, and figures suggest 71% of working adults in the US have difficulty paying medical bills (including 41% with insurance – in otherwords they are under-insured i.e. they don’t have FULL coverage).

This seems very plausible – indeed, I’m not quite sure what “full” insurance would mean. Most health insurance in the US requires “copayment”, so the patient pays a proportion of the cost of each procedure.

There’s no doubt in my mind that the NHS is a massively better system than the US model, both in terms of cost and coverage. (Indeed, I don’t really understand how the Glenn Becks of this world can persist in asserting the contrary.) I merely wanted to correct that one factual point.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC516134/

In the UK this is just not an issue.

Ooops. Of course I meant “status”! Ben, any chance of a preview button for comments?

Now remember this lady is one of the lucky 40% of US citizens who actually has insurance coverage.

Thanks for another very interesting and informative post. But I can’t let this go unmentioned – the real stats are shocking enough without this sort of exaggeration. I believe census information indicates that about 45 million Americans don’t have health insurance. The population is roughly 300 million, so about 15% of people are uninsured at any one time.

Many people drift in and out of insured statues (depending on their employment status etc) so the number of people uninsured at some point during any one year is somewhat larger, but nowhere near 60%.

1. appendicitis – yes I know that you exclude that but the key here may be the history and examination(sorry to keep harking back to that) – fever, nausea/vomiting, tachycardia (sorry, fast heart rate), perhaps some looseness of stool; pain that starts initially in central abdomen and is “colicky” in nature (i.e. gripping quality that comes and goes) but then becomes more severe, constant and shifts to the right lower abdomen (right liliac fossa – RIF) would be strongly suggestive of appendicitis; examination may reveal tenderness in the RIF associated with guarding (where the muscles tense up in repsonse to peritoneal irritation) and rebound (an extra spasm of pain when the hand is removed from the abdomen suddenly). This person has appendicitis till proved otherwise (although if their period was also late then you would have to consdier ectopic) and I would admit her as an emergency.

2. PID – again fever would possibly be present and there may be some abdominal tenderness and guarding/rebound; pelvic examination might reveal tenderness to either side of the cervix in the upper vaginal vault together with discomfort when the cervix itself is moved (so-called cervical excitation); if her period was late then again an ectopic would need to be considered in which case I would do a pregnancy test there and then (modern pregnancy tests are very sensitive); I would also check her urine for white cells, red cells, protein and nitrites (which are produced in the presence of bacteria); I would also do chlamydia and high vaginal swabs and take blood for a full blood count (to look for high white cells which would suggest infection) and an ESR (erythrocyte sedimentation rate which increases in presence of infection or inflammation) – I can also do the ESR in my consulting room with result in an hour.
Thereafter how I proceed would depend on how well or otherwise the patient was (and you have to take into consideration my 20 years of experience here) – if she was not too unwell and PID seemed likely I would commence antibiotics (whilst awaiting test results) and probably review her in 24 to 48 hrs depending on my level of concern; if she was unwell I would have no hesitation in admitting her as an emergency to Gynaecology.

3. vaginal infection – these tend to be superficial (although vaginal abscesses can occur) and there would possibly be vaginal discharge (in which case I would take swabs and possibly commence treatment based on likely diagnosis). Straightforward vaginal infections tend not to make someone unwell per se. If they were unwell I would proceed as per PID above.

4. ectopic pregnancy – you are right to mention this; it must always be considered in women of fertile age who are sexually active and, as said, may present like PID or appendicitis, although there is often some vaginal bleeding too together with a history of late period and positive home pregnancy test ( or symptoms of early pregnancy). If I had even the smallest suspicion of ectopic pregnancy this lady would be admitted as an emergency to gynaecology.

5. Don’t forget the possibility of sexually transmitted infection, though again with this I would proceed as per PID.

In the end of the day it comes down to how unwell the person is (and possible diagnoses) as to whether I admit them or arrange to review them. It’s not unusual if I am concerned sufficiently about someone (but I’m not sure whether they need admitting) for me to review and reassess someone that same day.
You right, most GP surgeries don’t have in-house ultrasound scanning (though some do). This is because to be good at anything like that you need to do it regularly. Most GPs would not be able to keep up their skills and this would then risk things being missed. There are sound reasons why specialist services are centralised as they are.
Hope this is helpful and, perhaps, reassuring. Please remember most GPs (and, indeed, most doctors in general)have the interests and needs of their patients at the forefront of their decision making process.
In the UK we get a fantastic deal – nobody pays “up front” and GPs don’t have to worry about the costs when making clinical decisions.
Contrast this with the USA where I did some primary care research. Here’s one anecdote that I saw (and couldn’t believe) with my own eyes – lady has a definite pathology requiring a specific drug which her doctor wants to prescribe but before he can he has to phone her insurance company there and then in the consultation to ask (a) can he prescribe this drug type for the lady (remember clinically there is NO doubt she needs it) and (2) if so which brand should he prescribe (he tells me the insurance company keeps changing brands every few weeks in attempt to cut costs by ensuring the cheapest brand is used). Now remember this lady is one of the lucky 40% of US citizens who actually has insurance coverage. Can anyone really say that’s a better system than the NHS?
P.S. Who are the coolest people in hospitals? The ultra-sound people…

“Certain treatments are not covered by the NHS, and if you want one of these you have to “go private” and pay for yourself, just as you would in many other countries. You can take out health insurance, if you choose to.”

That’s exactly what I often think.

But the NHS should also be honest and not feel embarrassed to “mention health care and money in the same breath, when it is the reality of the NHS.”

Cervical smear testing only once in 3 years, and only if you are over 25, because we can’t afford to waste resources on investigating false positive results. A small number of cancer cases will be missed, but only a small number. You can have it done as often as you want, privately.

But really, they should stop mumbling things like “we have evidence-based medicine here” = everybody else in the world is a bunch of idiots if they screen more often and we are cleverer than anybody else.