Department of Health Library Services ePublications - Historical Collection
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Northern Territory Department of Health Library Services Historical Collection
DL HIST 614.599
94 JOH 1996
HISTORICAL COLLECTION
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3 0820 00034943 6CERVICAL SCREENING
&DARWIN GENERAL PRACTITI
REPORT BY DR JESSIE JOHNSON PROJECT OBJECTIVES:
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1. To visit the General Practitioners currently working in private practice in the Darwm urban area (including Palmerston, Howard Springs and Humpty Doo) and encourage a good working relationship between GPs and the Women's Cancer Prevention Program.
2. To allow GPs to give feedback to the WCPP regarding the NT Pap Smear Register and to raise any questions or concerns that they may have concerning the Register.
3. To find out what strategies GPs would consider useful to increase the rate of cervical cancer screening in General Practice in Darwin.
4. To determine current attitudes and practice of GPs relating to cervical cancer screenmg.
5. To encourage GPs to think about overscreening and underscreening in relation to the National Cervix Screening Program.
6. To find out whether GPs are satisfied with the service provided by NT Breast Screen.
INTRODUCTION:
During the period from 8/4/96 to 24/6/96 I contacted 60 GPs as described above. The 1996 NT Yellow Pages was used to compile a list of GPs currently working in private practice in the Darwin area. Other lists supplied by the Top End Division of General Practice and the WCPP were not found to be as useful as they included numerous names of doctors that were not in the target group.
3 8 GPs were interviewed at their practices. 1 7 GPs were interviewed over the phone, either at the request of the GP, or towards the completion of this study as time did not permit all practices to be visited. 5 GPs responded through the mail as time restraints prevented a practice visit or a telephone discussion. In all 36 practices were involved in this study. No GP declined to participate. To the best of my knowledge only 2 GPs in the targetted group were not interviewed, one being on maternity leave and the other being on holiday. A questionnaire was used to record individual responses.
Where possible questions relating to the Register were dealt with at the time of discussion.
If this was not possible, letters were subsequently sent to the GPs to address their queries.
The recommendations from this GP activity are on page 9-10 of this report. An article about Cervical Screening and a synopsis of the report's findings was published in the July 1996 edition of the Top End GP Division newsletter, "The Echo".
"
GP RESPONSES:
Q.1. What do you think about the NT Pap Smear Register?
• There was widespread support amongst GPs for having a Pap Smear Register. It was frequently commented on that it was a good idea in principle. A smaller group of GPs seemed to be indifferent to the Register and very few were opposed to it.
• The majority of GPs commented that the Register was well accepted by women and that few if any of their clients had chosen to 'opt off the Register. There was one notable exception to this where the GP stated that only a few of his patients chose to go onto the Register.
• Several GPs expressed concern that due to the itinerant nature of the population in Darwin and the relatively frequent changes of address of patients, the Register may not be cost-efficient. One GP commented that for this reason he believes that the Register will in time become unmanageable.
• Another common response was that it was difficult to remember to tell patients about the Register in a consistent manner. One GP was concerned that failure to give the 'opt off option may lead to the GP having legal action brought against him or her for breach of confidentiality. Some GPs said that they would prefer an 'opt on' rather than an 'opt off process.
• Another GP said that all Pap smear results should go onto the Register and that women should be given a 'no mail' option. She anticipates that there may be a problem of breach of confidentiality when young, sexually active women living at home receive mail from the Register when their parents did not previously know that they were sexually active.
• It was pointed out that the Register would be particularly useful in enabling adequate follow-up of patients that attend two or more practices for their medical care.
• Several GPs commented on the extra time it takes to explain the Register to patients and there was a complaint about the extra paper work involved.
• There was a common misconception that the Register would function as a primary recall system replacing existing practice-based and laboratory-based systems.
• There was generally poor understanding of the functions of a Pap Smear Register beyond functioning simply as a reminder-recall system for women. A number of GPs expressed concern regarding perceived duplication of services.
• One GP believes the Register should take on the role of being the primary recall system sending letters when follow-up is due rather than overdue, seeing this as a way of avoiding duplication of services and ensuring efficient follow-up of patients.
• An argument brought up against the Register was that patients should be able to take responsibility for their own health.
• Another GP expressed concern about the Government having access to the confidential medical information of.clients. - - - - -
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Q.2. How comfortable are you with taking Pap smears? Results:
Very comfortable
1-51 2-5 3-2 4-1
Uncomfortable 5 - 1 Comment:
•
•
Very few doctors indicated that they were not comfortable with taking Pap smears. All the doctors that indicated that they were uncomfortable taking Pap smears were male.
4 GPs indicated that they either did very few Pap smears or no Pap smears at all.
Several male GPs commented that they were comfortable taking Pap smears if their female clients suggested it, but they were reluctant to raise the issue themselves. One reason given for this reluctance on the part of the GP was having done their medical training in a country where it was not considered acceptable for a male doctor other than a gynaecologist to perform a gynaecological examination on a female patient.
Another reason given was shyness related to cultural taboos in the country of origin of the GP.
Some other male doctors commented that they were comfortable taking Pap smears but that some of their female patients preferred to go to a female GP or to a Family Planning clinic for their Pap smears. Several male doctors mentioned the names of female GPs that they refer some or all of their patients to for Pap smears, and again several to the Family Planning clinic. One doctor said that it was disappointing to find that when he referred a female patient to a female GP or to the FP A for their Pap smear at that client's request, he frequently did not receive any feedback as to the result of the Pap smear. He suggested that female GPs and the FP A be encouraged to remember to request on the Pap smear pathology form that a copy of the pathology report be sent to the patient's usual GP.
Q.3 The WCPP would like to offer support to GPs to assist with improving the rates of cervical screening in the NT. Would you consider any of the following to be
useful?
3a. A project officer spending time in your practice to assist in developing an age- sex register, auditing medical records and identifying women eligible for screening. Invitations for screening could then be offered to these women, either by mail or when they next attend the practice:
Very useful
1 - 9 2-8 3-4 4-9
Not useful 5 - 30 Comments:
Several GPs commented that this would be very costly and time-consuming to implement.
It was questioned whether this would be an efficient way to increase screening rates as;
a) some practices have large numbers of files which are no longer current, and it would be an enormous task to go through them all, and
b) practices may have numerous files for patients that regularly attend more than one practice. Some GPs did not want a person from outside the practice coming in and going through the files. Others mentioned a confidentiality issue: how would patients respond to knowing that someone from outside the practice had access to their medical history?
In contrast several GPs were very much in favour of this option and some said that they - -were-cui:rentl-Y-in the-w~ss-of ©Stablishing-an age-sex-register--for--:their_p11;1· ·- - - - _
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3b. Assistance to set up a practice-based reminder-recall system, either manual or computer.
Very useful
1 - 16 2-7 3-2 4-5
Not useful 5- 30
26 GPs stated that they do not have a practice-based reminder/ recall system in place (see Q.6). In this sub-group the results for section 3. b. were as follows:
1- 8 2-6 3-1 4-1 5-10
Comments:
•
•
•
•
3c.
Some GPs who do not have a practice-based reminder / recall system said that they use a laboratory-based computerised reminder/ recall system run by a local laboratory.
One GP said that the laboratory sends him a reminder letter when a patient is due for a repeat smear as well as a reminder letter for him to send on to the patient. He said that this is very cost efficient for him as he does not duplicate the service being offered by the laboratory. He pointed out that the laboratory has a sophisticated computer system and that as far as he is aware it does not cost the pathology service any more to offer this service to GPs.
Other GPs make use of the pathology laboratory printouts summarising normal and abnormal smears taken for organising follow-up of patients (see Q. 7).
One GP said that he had no practice-based or laboratory-based reminder/ recall system in place, and for this reason knowing that the Register is in place makes him feel more comfortable as it is less likely that there will be mistakes made in the appropriate follow-up of his patients.
Some GPs who already have a reminder / recall system in place ( either manual or computer) expressed interest in having assistance to 'set up a r/r system' because they thought that there was room for improvement with their current system.
Printed appointment cards to encourage women to attend for a Pap smear at a later date (these could be handed out at the end of a consultation if there had been insufficient time to do a Pap smear ).
Very useful
1 - 15 2-7 3 - 10 4-7
Not useful 5 - 21 Comments:
22 GPs thought that this would be very useful or useful. Of the GPs that did not think this would be useful, reasons included:
• If a woman needs a Pap smear they do it there and then and do not tell her to come back on another day. If the smear is put off to another day she may either decide not to come back or she may forget.
• If she needs to come back on another day an appointment is made for her in the usual manner of the practice.
• The card may get lost in her handbag.
3d. Is there a female practitioner in your practice?
Yes-40 No-20 Ifno:
Would it be useful to have a female nurse practitioner visit your practice to do Pap smears?
Very useful 1 - 2 Comments:
2-0 3 - 1
Reasons given for not considering this to be useful included:
4 - 1
Not useful 5 - 16
• The nurse practitioner would have to come in on a certain day every so often and it would be difficult to arrange for all women needing a smear to attend on that particular day. It may be inconvenient for a woman to have to attend at a certain date or time.
• There may not be a room where the nurse practitioner could work alongside the GP(s).
• Some GPs did not like the idea of another practitioner coming into their practice.
• One GP objected to the idea of nurse practitioners doing Pap smears as he believes that a bimanual examination should be done at the same time as a smear, and as far as he is aware nurse practitioners are not taught to do this.
3e. Educational sessions reviewing the latest technical, clinical and public health aspects of cervical cancer screening.
Very useful 1 - 15
(No Response - 4) Comments:
2 - 11 3 - 10 4-9
Not useful 5 - 11
• This was considered very useful or useful by 26 GPs, however several commented that educational sessions need not be held too frequently. One GP said that as the last sessions of this nature were held in Darwin in 1994, it may be appropriate to hold similar sessions in 1999 after a 5 year interval. Another GP said that further sessions could be held if there were any changes that GPs should be brought up-to-date with.
• Other GPs felt that they knew all that they needed to know about cervix screening and did not consider further educational sessions to be of value.
3f. Have you considered the RACGP "Preventive Care in Women" self audit program for your practice assessment points for the current triennium?
Yes - 17 No - 40 No Response - 3
If the WCPP were to offer a subsidy to GPs conducting the "Preventive Care in women" audit, would you be more likely to choose this practice assessment program?
Yes - 24 No - 33 No Response - 3
Some GPs commented that it should not be necessary to have a financial incentive to carry out practice assessment programs. Others had no hesitation in saying that they would find a financial incentive attractive.
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3g. Do you have any suggestions? Comments included:
• Public Education:
• Many GPs said that they favoured money being spent on public education campaigns, and in particular media and television advertising. Campaigns should be targetted to reach the underscreened groups. One GP said that it is important to dispel the fear in women's minds regarding cervix screening. Another said that women frequently confuse what a Pap smear is and what an STD check is, and that a public education campaign should address this confusion, (this could pose a significant problem in a woman who has symptoms of an STD and goes along to her GP asking for a Pap smear to be done to check that 'everything is OK'). One GP said that women should be made aware that a 'well woman's check' involves a Pap smear, and also a blood
pressure check, a breast and a pelvic examination, and that a woman should be given the opportunity to refuse any of these if she so chooses. Not all women are aware that the recommended interval between routine smears is 2 years rather than I year.
• It was suggested that talks could be organised for consumer groups, such as Senior Citizens. It was also suggested that access to an underscreened minority group may be enhanced with the assistance of an educated liaison person from the group in question.
A trusted person from within that particular culture could talk to members of the group.
• There were requests for information pamphlets about Pap smears, and booklets for women with an abnormal smear result to be available in the following languages:
Chinese, Vietnamese, Laotian, Cambodian, Indian and Greek.
• Remuneration for GPs:
It was suggested that GPs should be paid more for doing Pap smears.
One GP commented that there should be a separate item for Pap smears on the Schedule of Medicare Benefits.
• Computerisation of Practices:
Some GPs said that the WCPP could subsidise the computerisation of practices, thus enabling practices to establish age-sex registers and to use a computerised reminder/
recall system.
It was pointed out that this would be much more cost-efficient than the option in Q.3a.
• Other comments made by individual GPs:
• Patients should have to register with one particular practice for all preventive health care, including Pap smears. This would encourage a rational, systematic approach to preventive care and would also eliminate unnecessary repetition of tests by different practitioners.
• It would be helpful if there was a forum for peer review amongst GPs, including discussion about cervix screening.
• It would be helpful if the WCPP produced a comprehensive preventive health care questionnaire that could be given to women on presentation at a practice. This would include questions about that particular woman's breast screening status, cervix screening status, alcohol consumption, tobacco use and so on, and could be used as a starting point for discussion of preventive health issues between the woman and the GP.
• GPs should ensure that vaginal speculums are sterile and that sterile gloves are used when taking smears. Attention should be paid to having adequate lighting as smear quality decreases with inadequate lighting. Lighted, disposable speculums are ideal.
There could be financial assistance from the governmJillUQ prmd.de this_equipment. _
• Resources should be directed to Aboriginal communities where death rates from cancer of the cervix are disproportionately high.
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• It would be useful to have a standard leaflet to give out to women with a particular Pap smear result explaining what the result means and indicating when her repeat smear is due.
• It would be helpful to have a simple leaflet to give to women with information about an abnormal smear result. The current booklet is too technical and involved for some women.
• Having a doctor from the WCPP doing practice visits to discuss cervix and breast screening may be a way of increasing rates of screening by GPs.
Q.4. Do you have a convenient place for recording Pap smear status on your patients' files?
Yes - 26 No - 34 Comment:
GPs who did not have a particular place for recording Pap smear status on their patients' files generally said that they made a note of the Pap smear status in the progress notes.
Many said that they would underline this or mark it in another colour.
Q. 5. Are you in the habit of routinely checking the Pap smear status of your female patients?
Yes - 56 No - 4
Q. 6. Do you have a practice-based reminder I recall system in place?
Yes-35 No-25
If yes, is it manual or computer?
Manual - 20 Computer - 15
Q. 7. Do you make use of the pathology laboratory printouts summarising normal and abnormal smears taken for organising follow-up of your patients?
Yes - 5 0 No - 10
Q.8. Can you estimate the percentage of women in the target age group in your practice who are up to date with cervix screening?
<20%-1, 20%-3, 30%-1, 40%-1, 50%-1, 60%-8,
70%- 13, 80%- 17, 90% - 8, 100%- 0 No idea - 6.
Q. 9. Are you aware of any problems arising from Pap smears being taken more often than the recommended interval?
Comment:
• This question was designed to encourage GPs to think about the issues of verscreeni-ng, and in particular to think-of the e-xtra cost to the-National Cervix
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•
Screening Program when Pap smears are taken more often than the recommended interval. In addition there is the extra cost involved when minor abnormalities are detected as a result of frequent smear taking and patients are referred for colposcopy.
A proportion of these abnormalities would have regressed spontaneously and hence would not have required further treatment.
• Some GPs were aware of the issues of health economics.
• Several GPs said they have some patients who insist on having a yearly Pap smear .
Q.J 0. The following groups of women are currently underscreened in Australia. Do you have significant numbers of women from these groups in your practice?
Over 50 years of age Non-English speaking background Not currently married Aboriginal and Torres Strait Islander Lower socio-economic status Rural and remote living
Comment:
This question was designed to encourage GPs to think about underscreened groups in relation to their own particular practice. Very few GPs said that they did not have significant numbers of women from any of these groups in their practice.
Q.11. Do you have any questions or problems regarding NT Breast Screen?
• Most GPs consider NT Breast Screen to be a very good service that is well accepted by patients. It was frequently commented on that the service is efficient and that GPs receive adequate feedback about patients. One GP stated that there are less
indeterminate results with NT Breast Screen than with a private service.
• It was commented on that women very much appreciate there being a largely female staff, including the radiographer and medical officer, and that they like the atmosphere of NT Breast Screen.
• There were several comments pertaining to the time taken for patients' results to come through, which is apparently as long as a number of weeks in some cases. One GP said that she has patients who request that their mammogram be done through the private radiology service as a result will be available the next day.
• A concern was expressed that Aboriginal women should be adequately screened.
• One GP said that some patients come back from screening mammography not knowing how to do Breast Self-Examination. He suggested that all women prior to mammography be shown a video on how to do BSE. He said that if women are given the choice of seeing the video, they may refuse due to shyness or embarrassment, or they may think that it would take too long, hence he does not think it is appropriate that they be given a choice.
• One GP suggested women should keep their own films so they are easily accessible if needed for comparison at a later date or if the woman is leaving for interstate.
• One GP commented on how difficult it was to convince Asian women to have Screening Mammography done.
• One GP said that she keeps on running out of brochures about NT Breast Screen. She suggested that order forms for brochures relating to both breast screening and cervix screening be sent out to GPs on a regular basis, perhaps every 6 months, to serve as a reminder to the GPs to keep well stocked and also to keep GPs thinking about the service provided by the WCPP.
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. - - ~ - .RECOMMENDATIONS:
1. Write to the GPs visited during the course of the study to thank them and provide brief feedback about the information obtained.
2. Attempt to further assist GPs in informing their patients about the Register:
The poster for GPs to put up on a waiting room pin-up board is a good idea. Perhaps in addition a box could be designed to sit on the receptionist's desk with a sign saying something along the lines of : 'Important information for all women, please read this pamphlet'. Information could be provided about both what a Pap smear involves ( e.g. the THINK TWICE brochure), and also about the Register ( NT Pap Smear Register,
Information for Women ). This information could be available for all women to pick up and read, either as one or two brochures. My concern about the current information sheet is that it may stay inside the folder on the GPs bookshelf or desk rather than being given to the woman.
3. Options discussed for assisting GPs to improve screening rates:
• The first (Q.3a) was generally poorly received (project officer spending time in a practice).
• Assistance to set up a reminder/ recall system, either manual or computer (Q.3b) would be useful for the GPs that expressed interest in this.
• Printed appointment cards (Q.3c) could be useful for the minority group that indicated that they would use them.
• The issue of accessibility of a female smear taker (Q.3d) could perhaps be addressed further. One third of GPs interviewed work in a practice where there is no female practitioner. The option of a nurse practitioner visiting the practice was very poorly received. Conversely several GPs mentioned referring their patients to a female GP or to FPNT for their Pap smear. I wonder if this could be taken a step further and perhaps formalised somewhat, by means of a printed referral sheet. This may be a useful way of assisting the GPs who put smear taking 'in the too hard basket' for whatever reason (some of these have been outlined in my report), and also facilitating feedback from the female smear taker to the usual male GP. It may also provide a positive message to women that they should and can go to get their smear taken by a female, if that is their preference and their usual doctor is a male, and may assist them by spelling out the name and address of a clinic that they can attend. It may make it easier for the male GP to bring the issue up in the first place, if he otherwise would find it too awkward. My only reservation about this idea is a certain reluctance to 'legitimise' the male GP who does not offer women's health services, which is of course unacceptable, however against this is the well documented preference of some women for a female smear taker.
• Educational sessions for GPs (Q.3e) obviously have their place, but there is no significant perceived need at this particular point in time.
• Financial assistance to do the RACGP "Preventive Care in Women" self audit program (Q.3f) was again well received by less than half of the GPs interviewed, but as a significant number expressed enthusiasm for this idea it could be considered further.
• Further suggestions and comments (Q.3g); a number of very interesting and
worthwhile comments have been listed in my report, which all deserve consideration. I liked the suggestion that the WCPP could produce a comprehensive preventive health care questionnaire that could be given to women on presentation at the practice. This could perhaps be devised in conjunction with the Division.
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4. If the WCPP is interested in having educational material printed up in other
languages, the doctors who requested various languages are documented in the completed questionnaires. This could then be followed up to find out, for example, which Chinese or Indian language would be considered appropriate.
5. It may be worthwhile spelling out for GPs exactly what is on offer from the different laboratories in the way of reminder / recall services.
6. I would support the GP who suggested that all women waiting for their screening mammogram should be shown a video on how to do BSE.
7. The suggestion that a mail-out of order forms be done every 6 months seems to me to be a good one, and perhaps the opportunity could be used to keep GPs up to date with any other relevant issues regarding the WCPP at the same time.
