 My talk is entitled Patient Provider Communication and Decision Making about the Pelvic Examination. Again, as Dr. Lindau had to go through the anatomy of the female breast, I'm going to define the term pelvic examination. This term gets used frequently, incorrectly, and is interchanged with other terms like pap smear, so I'm just going to put it out there. The components of the pelvic exam include external genital examination, the internal specular examination of the vagina and cervix, and a bimanual examination of the uterus, adnexa, and bladder. Over 50 million of these exams are performed annually, indications ranging from pelvic pain, abnormal bleeding, vaginal discharge, and of course to perform the pap smear, which is now every three to five years. Clinical controversy exists, however, as to whether or not we should be performing pelvic examinations on asymptomatic non-pregnant women, also referred to as the screening pelvic exam. A survey in 2013 of over 500 OBGYNs found that 80 to 90 percent of them felt that we should routinely perform these examinations on asymptomatic women, citing reasons as to adhere to standard practice, to reassure patients, to detect ovarian cancer, and to detect benign uterine and ovarian conditions. Number of professional organizations have weighed in as to whether or not we should be offering or performing these examinations. The American College of Physicians and the American Academy of Family Physicians both say that we should not be offering this examination based on their assessment that there is really no adequate evidence to demonstrate benefit of the exam. The Society for Gynecologic Oncology, however, recommends offering the exam to all women and having discussion with the patient as to whether or not to proceed with the examination. The U.S. Preventative Services Task Force and the American College of Obstetricians and Gynecologists both come to the conclusion that there is no conclusion. There's insufficient evidence to suggest whether we should or should not perform this examination, and so they recommend that it should be discussed with patients, and that's how we should determine whether or not to proceed with this exam. So in conclusion, whether or not to perform this examination on asymptomatic patients is a matter of clinical equipoise. So these five organizations vary as to whether or not to offer the exam or to perform the exam. However, they all support in reading the opinion pieces, there is a conclusion that we should no longer automatically perform public examinations on asymptomatic women. That should not be a knee-jerk, just presumed next step as a part of the gynecologic visit. At minimum, providers must recognize patient autonomy and decision making around this exam have an a priori discussion about whether to proceed and come to a joint decision with patients about whether or not to proceed with the examination. So this is an opportune encounter to incorporate shared decision making into the gynecologic visit. As most of us in this room know, shared decision making was conceptualized in the 1970s and 1980s, also referred to as patient accommodation by Mark Siegler in 1981. This reflected a changing nature of the patient provider relationship during this time period and was presented as an alternative to the prevailing unidirectional models of decision making of the time, including paternalism and consumerism. Importantly, this model recognizes that there are two experts in the room. While the healthcare provider is the expert with regard to medical information, the patient is the expert with regard to their values, preferences, and lived experiences. I'm going to present three arguments for integrating shared decision making into the discussion about whether or not to proceed with a screening pelvic exam. One based on the values, preferences, and lived experiences of patients. Second, based on weighing of beneficence and non-maleficence. And a third around the issue of patient agency. And looking at values, preferences, and lived experiences, the pelvic examination is influenced by several factors. This pictorial diagram stems from work that I conducted with a then medical student and now first year surgery resident, Ava Ferguson Bryant. Excuse me. Talking to women about their experiences with their first pelvic examinations, this looks at factors that impact the sense of preparedness for that exam. Looking at modifiable and non-modifiable factors. Non-modifiable factors include prior sexual experiences and sexual trauma, age at the examination, comfort with one's own body. Modifiable factors include pre-examination knowledge and education about the exam. Other factors influencing this experience include medical trust or mistrust and also the context of the examination. Shared decision making ensures that providers explore these factors. And then with patients can jointly determine whether or how to proceed with the exam based on the patient's preferences, needs, and concerns. Looking at beneficence and non-maleficence, there's really limited data as to the potential medical and psychosocial benefits and harms. Some potential benefits include educating patients about their anatomy, fostering patient provider communication. There's really limited data as to any actual medical benefits with regard to detecting ovarian cancer or other pathology and otherwise asymptomatic individuals. Potential harms include fear, anxiety, pain. So given this clinical equipoise, balancing benefits and harms really should be based on a discussion about the patient's preferences. In turning to agency, it's important to consider the historical context around this examination. Marion Sims, oftentimes referred to as the father of modern gynecology, has a dark history in the 19th century of conducting examinations and surgical experimentation on enslaved women without consent and without anesthesia. This picture is of current contemporary protests in front of a statue in New York City of Marion Sims. So this really continues to be a very heated, debated history. More recently, the American Plan in the 19th and 20th centuries was a public health campaign to round up sex workers and those who were concerned or at risk of being sex workers, sometimes institutionalizing them and forcing these individuals to public examinations and very untested treatments to attempt to cure and reduce the spread of sexually transmitted infections. Also important is to consider contemporary context. In the Me Too era, there's been a greater focus on abuses at the hands of physicians, most notably the Olympic gymnast scandals. And so these really inform how we discuss and think about the public examination. Now of course, these egregious abuses are rare, but they do call attention to important considerations, including the patient provider power differential in all encounters, but especially this encounter. The importance of empowering patients during clinical encounters. And I would say especially this procedure being quite intimate and intimidating and a need for stepwise consent. This is a discussion that comes up very much in our discussion on campuses around sexual assault. But also, this is a process that can be incorporated into clinical encounters and should be issues around power exchange and trauma informed care. Shared decision making helps achieve these goals as it is based on the principles of mutuality, voluntariness, and respect for autonomy. So I'm going to present a framework that's based on a four step framework by Stigl-Bauten colleagues. This being a five step framework for shared decision making around the public examination. First step is to call attention to the fact that a decision needs to be made. Secondly, to explain medical options, potential benefits, and harms. Thirdly, to elicit patients values, preferences, and experiences, and engage patients as to how these inform the decision as to whether or not to proceed with the exam. Fourthly, to arrive at a decision or agree to defer the decision to another day. And then fifthly, to educate patients about public awareness, pelvic health, and importantly, to keep the door open for individuals who may want to extend this discussion to another visit. So focusing on step one, calling attention to the fact that a decision needs to be made, this is critical to signal move away from the presumption that a pelvic examination will be performed. And shifts the level of power dynamic around this examination, giving a portion of this decision, of course, to the patient. This underscores the role of patient autonomy in decision making about whether or not to proceed with the exam. And it's important to recognize that this may actually be surprising to patients and uncomfortable to providers, both of whom are used to just going along and doing the public examination as a next step that would just be assumed to be part of this visit. Explaining medical options, potential benefits, and harms. As I said earlier, it's important to just define the terminology. Also to recognize and ensure awareness that patients can choose to have none, some, or all of the components of the exam. And to discuss the potential medical and psychosocial benefits and harms. And eliciting patients' values, preferences, and experiences. This can be accomplished through open-ended questions. Oftentimes using a form, as Dr. Lindow indicated, that patients can fill out, allows them to disclose information that may be uncomfortable to talk about, verbally, and also it's critical to use normalizing language around these issues. This is important to explore, especially to potentially uncover a history of trauma or other factors that may negatively impact the exam. In terms of arriving at a decision or deciding to defer this decision, it's important to reiterate that, based on the evidence, there's no clear best choice here. And summarizing and verifying the understanding of what patients have stated with regard to preferences about the examination. The bidirectionality of shared decision-making allows providers to reflect back on what they have heard their patient tell them. And actually to make a suggestion or recommendation. This isn't a consumerist model or a cafeteria-style model where we present the option and hands off, it's up to the patient. We can engage with our patients. And finally, deferring the decision to another visit is very appropriate in the setting. And finally, educating patients about pelvic self-awareness and warning signs. This is especially true for providers who choose to follow the guidelines of the ACP and the AFP and not offer the exam, but also important for individuals who choose not to receive this examination. It's also important to ensure that patients feel welcome for follow-up. This is, again, especially critical for those patients who decline the examination, as they may have a sense that they're not adhering to some expectation that has been there in the past. And recognizing that patients' values, preferences, and lived experiences can change over time, and that this is an issue that needs to be re-explored at future visits. While this is a model that's focused on the asymptomatic patient, this can also extend to patients who present for where there may be a call for an indicated though non-emergent procedure or examination. A patient come in for irregular abnormal vaginal bleeding, vaginal discharge. While those are certainly bothersome and warrant further evaluation, a pelvic examination on that specific visit may not be necessary. It's also important to recognize that even when indicated, this may be an exam that's not tolerated or that's something that a patient doesn't want to proceed with. Again, based on potential history or other factors. Engaging in shared decision-making under these circumstances allows providers to elicit these reasons, foster the therapeutic relationship, and create a safe space for patients. And it's essential under these circumstances to also offer alternatives. The pelvic examination is not the only way to explore many of these complaints, an ultrasound or sexually transmitted infection screening without a pelvic exam are available and wonderful options. Pelvic examination experiences can influence subsequent health care seeking behaviors, especially around reproductive health care seeking behaviors. Again, the work conducted that I've conducted with Dr. Bryant indicates that there are features of the encounter that can create a positive impact on future health care seeking behaviors, including establishing a relationship with a trusted provider, ensuring familiarity about the exam for subsequent encounters, and feeling empowered to take control of one's own reproductive health. In conclusion, there's a good amount of clinical equipoise around the benefits and harms of performing screening pelvic examinations. So this is a great opportunity to incorporate shared decision-making into this clinical encounter. The framework, while as proposed, focuses on asymptomatic patients, can also extend to indicated non-emergent situations. And shared decision-making in this circumstance fosters conditions favorable for positive patient-provider relationship and subsequent health care seeking behaviors. Thank you. Five minutes. And I welcome any questions around this. Yes. I would say that I think the discussion around this examination is critical in talking to women about their experiences with pelvic examinations, especially the first pelvic examination. It's an, for many women, it's not, you know, it's certainly not a traumatic experience or even an uncomfortable experience. But for many, it elicits a good amount of stress, anxiety, potentially pain. I do think that there is something important about this examination in particular that warns... I just want to be fair, I'm completely aware that if you were done at the way that it should happen to you, the question is, is there a set of women who shouldn't even have the discussion and could make a different discussion? Right. And so those are the recommendations of the ACP and the AFP. And I think that certainly the shift is in that direction. I think that to, as you noted, obstetrics and gynecology and medicine in general is a slow shifting field. And I think that this is, I think, the first step in moving towards that direction, absolutely. You know, I think that in the majority of cases, it's not an indicated examination and hopefully we're moving in that direction where absolutely more tension is focused on other things that can have greater impact on women's health care. And, you know, certainly part of this discussion and part of the pushback I think is going to be, and physicians have already expressed concerns about, so if we're not doing a past year every year, if we're not doing a public exam every year, why are they coming? There are a lot of good reasons to see a gynecologist every year. And so I think that, again, this is, it's a culture shift. And I think that that's why we have to have these discussions around this issue. Dr. Siegler. Thank you, Julie. Siegler, Chicago. First of all, I loved your application of shared decision making to a particular specific issue. I thought it was a superb analysis and an application of that concept. I also thought that your comment on how important this was to acknowledge some of the deep and essential ethical elements of voluntariness, deep respect for autonomy, ultimately a deep respect for the patients whom you're seeing, especially in the current hashtag MeToo era, who was extremely applicable. And so my question is really a straightforward one. What would you estimate to be the percent of OB gynecologists who use such an approach in contrast to the standard approach? I think the vast, vast majority of OBGYNs are still doing this reflex. Let's go ahead and, you know, get you position for your pelvic examination. That's based on, you know, the study that I cite is older and that was conducted before the five professional organizations made these recommendations. But I can say as a member of a listserv, there's a group of obstetricians and gynecologists who on Facebook, it's thousands of OBGYNs. This question has actually come up and the vast, vast majority of respondents on this listserv also say that, you know, we know what the recommendations are, but we still do it. So I think that there's a huge culture change that has to happen around this. Yes. Last question. Julie, awesome. Great talk. So as David was saying his comment, something came up and I want you to comment. Help me think about it when I talk to my residents for a moment. So I'm an emergency medicine physician, as you know, and oftentimes, you know, we do a lot of things because we feel it's in the best interest of the patient, particularly around this examination. There might be many different complaints, pain, right, lower quadrant. I got to do a public exam, right? Or I have, you know, maybe the person's UTI is not just UTI to PID, I got to do a public exam. Patient is pregnant, I got to do an ultrasound. So like this notion, I have to do all these other things to make sure someone's not going to die. And oftentimes I'm the one saying, well, do we need to do so? Yeah. Are you going to talk to the patient about it? So, so I was very, I enjoyed your presentation, but the challenge is this, and here's the pushback from others, perhaps more senior to me in the profession, that we have become a specialty that thinks about procedures and not the visit. That we want to write, there's a lot of ancillary secondary benefits of doing a lot of things when we see a patient. And the problem is, right, the pushback is sometimes we just think about this one procedure, and where does that stop, right? So do I have shared decision-making or conversations on every step? I'm going to do a speculum exam. Okay, what if I do an autoscopic exam? What if I do something else? And so this is a pushback sometimes from both those senior to me and the residents, right? But well, it's a whole visit, right? They came to the ED, it's a whole visit. I'm doing all these things because I think it's the best for the patient. So how do you help me counsel my patients, or my trainees to think about, well, it's not just a visit, right? There are different parts of the visit. I would say that these are not mutually exclusive. I think that having a discussion, for example, a 17-year-old coming in with pelvic pain, part of the discussion is going to be eliciting her history, any history of trauma. I think that this is part of the encounter and not just about this procedure, whether or not to proceed with the examination. I don't think that these are mutually exclusive. I think that the discussion is part of the whole encounter and informs the rest of the encounter as well. Right, so what I'm trying to say is that sometimes they say that we might not have an accurate history, right? There might be things we find out on the way between something that we think is in the best interest. Those secondary benefits can't be thought about prior or right until we do it. And so when a person is accepting our care for a potentially emergent life-threatening situation, I mean, you have a different context that you're talking about that we should be less about trying to deliberate over every single decision, but rather as a unit of care. So as I said, as David was speaking, I was thinking about that notion that there might be context where it's a unit of care, right? Not just a specific procedure that we're talking about. Now, there might be some procedures that have a threshold. We have to have a conversation. But as I said, am I going to do a conversation about an autoscopic exam for someone who might have mastoditis? I don't know if I do that in every single procedure that I do as part of my parcel of my care. So I was trying to give an illustration of an episodic notion, not just a procedure notion. Right, and I fully hear what you're saying, and I'm not talking about getting a blood pressure check. I'm talking about what for many, you know, again, seeing patients after their ER visit who tell me, Dr. Korr, I had a pelvic exam in the ER and it was incredibly traumatic. I wish that you had been the one to do it right. So I think there is something in particular around this examination that warrants further discussion. I'm not saying that for every single, you know, every single little component of the encounter, we need to break it down and extend every conversation. But I do think that there is something in particular around this actual experience that warrants that discussion. I agree. Thank you. Thank you.