Although the Papanicolaou (PaF) smear is one of the most effective scr
eening tests ever invented for a common cancer, it remains an imperfec
t test. The technical shortcomings of the Pap smear have been compound
ed by the general public's unrealistically high expectations of the te
st's accuracy, underestimations of the importance of regular smears, a
nd the actions within the medico-legal system. To remedy some of the t
echnical shortcomings, the Bethesda System, which better reflects our
current knowledge about cervical neoplasia, has been proposed to repla
ce the old Papanicolaou classification system. Although standardized c
ytologic criteria may reduce interobserver variability, the false-nega
tive rate of Pap smears is at least 5%, even in the best laboratories.
No amount of training or experience with human observers can reduce t
he error rate to zero. Automated Pap screening holds the promise of hi
gher sensitivity, but no instruments to date have been approved as a s
ole means of primary screening. The family physician can play a unique
role in overcoming the limitations of the Pap smear by educating pati
ents about the value and limitations of the test, instituting patient-
specific treatment or follow-up of abnormal smears based on clinical a
nd cytologic findings, and encouraging patients to get regular smears
at intervals based on risk.