Not enough time?
Problems identified during the exam can sometimes be dealt with immediately. Otherwise, schedule a follow-up visit; a coding modifier may be appropriate if done at the time of the annual visit.
Benefits to practice
If the Pap interval increases for a woman, she is more likely to see the benefit of an annual visit if she understands that you are providing comprehensive care. You as a clinician will be even more valuable to insurers if you provide more comprehensive care and this may help you drive better fee schedules. And for the patients who haven't been motivated to get an exam every year, even under the perception that an annual Pap was a must, perhaps annual comprehensive health status monitoring will give them a reason to make an appointment.
Obviously we don't want to bypass the rest of the medical system either, and we should refer as appropriate.
How we added USPSTF screening in our practice
The following pages discuss how we implement USPSTF guidelines, in addition to the ACOG guidelines for cervical cancer screening.
CHLAMYDIA SCREENING
What to tell patients
Physicians often assume that we won't find chlamydia in our patients, especially among people who are monogamous, in their mid20s, or married for several years, so why test? But many times we're also concerned that the patient may be embarrassed or feel we are judging them if we suggest an STD test. An easy solution is to talk in terms of guidelines. Simply say that chlamydia infection is a serious, common disease that can be longstanding but silent, and that the test is recommended as routine for everybody under 25.
I probably find 1 case a month, and I have a middle- to upper-middle class patient population. When you look for it more, you find it more.
In states with chlamydia programs, infection among women has been reduced by as much as 67%. As a nation, we are screening only about 25% to 35% of patients who should undergo chlamydia screening. All sexually active women 25 and younger and all women who may otherwise be at risk—whether or not they are pregnant—should be tested.
Young women are the most important group to screen: 1 in 10 teenage girls tested for chlamydia is infected; 15- to 19-year-old girls account for almost half of all reported cases among females; 20- to 24-year-old women account for another 33%.
Women with new or multiple partners, who live where chlamydia is common, and who have had an STD are among important targets for screening women over 25.
BREAST SELF-EXAMINATION
I recommend that all patients do self-examination. The Task Force concludes there is insufficient evidence to recommend for or against teaching or performing routine self-examination. Still, many women are the first to discover breast cancer.
LIPID SCREENING
I finally got away from fasting blood work because many patients just never go, whereas popping into the lab on the way out of the office and having their blood drawn is more convenient. If the numbers come back poorly then we can assess the next step.
There is virtually no age cutoff—young or old. All women aged 45 and older should be screened routinely for lipid disorders—a change from the previous limit of 65. Younger women should be screened if they have diabetes, high blood pressure, or family history of heart disease or high cholesterol, or use tobacco.
COLORECTAL CANCER
I've had at least 3 patients in the last 5 years who had early colon cancer discovered because I insisted they go for colonoscopy. They were just over 50 with no symptoms whatsoever, and I kept bugging them to go. It really made me a believer that colonoscopy is the right thing to be doing.
Colon cancer is the second leading cause of death in the United States, and 80% of cases are in "normal-risk" patients; only 20% occur in "high-risk" patients. A person who dies from colorectal cancer loses an average of 13 years of life. Screening is "strongly" recommended, and should start at age 50.
DIABETES
Although widespread routine screening was not endorsed by the current or the previous USPSTF, the current recommendation is that patients with hypertension or hyperlipidemia be screened, as they are more likely to have diabetes and be in greater need of treatment, as it is a serious comorbidity.
OBESITY
The most effective interventions combine nutrition education and diet and exercise counseling with behavioral strategies. Screen for and treat or refer obese (30 or higher body mass index) patients for intensive counseling and behavioral interventions; consider pharmacological treatment only as part of intensive interventions.