Original Publication
Open Access

Challenging Pelvic Exam

Published: November 4, 2015 | 10.15766/mep_2374-8265.10256

Included in this publication:

  • Challenging Pelvic Exam Instructor's Guide.docx
  • Challenging Pelvic Exam Complete Case.docx
  • Challenging Pelvic Exam Faculty Examiner Checklist.docx
  • Challenging Pelvic Exam SP Checklist.docx

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Editor's Note: This publication predates our implementation of the Educational Summary Report in 2016 and thus displays a different format than newer publications.

Abstract

Introduction: The pelvic exam is by nature a challenging procedure to perform well, as it requires a provider to establish with a patient a level of trust high enough to permit inspection and palpation of one of the most private and intimate parts of the body. Unfortunately, data suggest that providers have not mastered the art of performing a sensitive and tolerable pelvic exam. Levels of distress have been shown to be especially high among certain groups, including patients with sexual and gender minority status, disabilities, obesity, and a history of trauma. Individuals who experience exam-related pain or discomfort are less likely to return for future care; accordingly, disparities in cervical cancer screening have been documented in each of the aforementioned populations. This resource includes all of the materials needed to run an OSCE station focused on providing formative feedback to primary care residents regarding their ability to perform a sensitive and technically proficient pelvic exam/Pap test for a standardized patient who identifies as lesbian and has a history of trauma. Methods: For the past 3 years we have implemented (and continue to use) this OSCE as an integral component of a multistation OSCE designed to provide formative feedback to residents enrolled in the HIV Primary Care Track of the 3-year BIDMC internal medicine residency program. After completion of each year of training, residents rotate through four sequential OSCE stations; this OSCE is one of these stations administered at the end of the PGY2 year. Results: To date, 12 PGY2 residents (four per year) enrolled in the HIV Primary Care Track have participated in this OSCE station. Total performance, encompassing history, exam, and counseling skills, as rated by faculty checklists was 23.5 out of 30. Communication performance (i.e., patient centered communication, interpersonal skills, and global rating), available for eight of the residents, as rated by standardized patients, was 78.3/90. Discussion: The pelvic exam is by nature a challenging procedure to perform well. Unfortunately, data suggest that providers have not mastered the art of performing a sensitive and tolerable pelvic exam. This OSCE includes all the materials to run a station focused on providing formative feedback to residents regarding their ability to perform a sensitive and technically proficient pelvic exam. With minor adaptations, the case can be adapted to feature a patient on the female-to-male transgender spectrum. Use of the case may also be appropriate for other health professions trainees.


Educational Objectives

By the end of this OSCE, learners will be able to:

  1. Address a patient’s questions or concerns about having a pelvic exam/Pap test.
  2. Review options to optimize the patient’s comfort during the pelvic exam, including determining the patient's preference for a specific support person or chaperone.
  3. Obtain the patient’s verbal consent prior to proceeding with the pelvic exam.
  4. Conduct the pelvic exam/Pap test in a respectful and supportive manner that maximizes the patient’s sense of safety, comfort, and control.
  5. Perform pelvic exam maneuvers and cervical sampling in a technically proficient manner.
  6. Provide support and reorientation to the present and use grounding techniques when the patient dissociates during the exam or otherwise signals emotional distress.
  7. Conclude the encounter by providing clear information about next steps and discussing an immediate self-care plan to help the patient cope if the patient continues to experience distress after leaving the office. 

Author Information

  • Jennifer Potter, MD: Beth Israel Deaconess Medical Center
  • David Fessler, MD, MPH: Beth Israel Deaconess Medical Center
  • Grace Huang, MD: Beth Israel Deaconess Medical Center
  • Joseph Baker, MD, MPH: Fenway Health
  • Hillary Dearborn: Fenway Health
  • Howard Libman, MD: Beth Israel Deaconess Medical Center

Disclosures
None to report.

Funding/Support
This OSCE was developed in the context of the Beth Israel Deaconess Medical Center Internal Medicine Residency Program's HIV Primary Care Track. This track was funded by American Recovery and Reinvestment Act - Residency Training in Primary Care Health Resources and Service Administration Training Grant #1D5FHP20672-01-00.


References

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  2. Bloomfield HE, Olson A, Greer N, et al. Screening pelvic examinations in asymptomatic, average-risk adult women: an evidence report for a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161(1):46-53. http://dx.doi.org/10.7326/M13-2881
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  5. Hollenbach A, Eckstrand KL, Dreger AD, eds. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born With DSD: A Resource for Medical Educators. Washington, DC: Association of American Medical Colleges; 2014.
  6. Peitzmeier SM. Promoting cervical cancer screening among lesbians and bisexual women. http://fenwayhealth.org/documents/the-fenway-institute/policy-briefs/PolicyFocus_cervicalcancer_web.pdf. Published 2013. Accessed July 7, 2015.
  7. Peitzmeier SM, Khullar K, Reisner SL, Potter J. Pap test use lower among female-to-male patients than non-transgender women. Am J Prev Med. 2014;47(6):808-812. http://dx.doi.org/10.1016/j.amepre.2014.07.031
  8. Potter J, Peitzmeier SM, Bernstein I, et al. Cervical cancer screening for patients on the female-to-male spectrum: a narrative review and guide for clinicians [published online ahead of print July 10, 2015]. doi:10.1007/s11606-015-3462-8
  9. Yudkowsky R, Downing SM, Sandlow LJ. Developing an institution-based assessment of resident communication and interpersonal skills. Acad Med. 2006:81(12):1115-1122. http://dx.doi.org/10.1097/01.ACM.0000246752.00689.bf


Citation

Potter J, Fessler D, Huang G, Baker J, Dearborn H, Libman H. Challenging pelvic exam. MedEdPORTAL. 2015;11:10256. https://doi.org/10.15766/mep_2374-8265.10256