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Shared Decision-Making Framework for Pelvic Examinations in Asymptomatic, Nonpregnant Patients

Chor, Julie, MD, MPH; Stulberg, Debra B., MD, MA; Tillman, Stephanie, CNM, MSN

doi: 10.1097/AOG.0000000000003166
Contents: Office Practice: Current Commentary
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Controversy exists regarding whether to perform pelvic examinations for asymptomatic, nonpregnant patients. However, several professional organizations support the notion that health care providers should no longer recommend that asymptomatic patients receive a yearly pelvic examination. At minimum, health care providers must respect patients' autonomy in decision making around this examination and initiate a joint discussion about whether to proceed with a pelvic examination. Shared decision making is a model used in other aspects of medicine that can aid such discussions. This model recognizes two experts in these clinical encounters—the health care provider is the expert regarding medical information and the patient is the expert regarding their values, preferences, and lived experiences. When shared decision making is used, not only is each expert valued for their knowledge, but the power differential shifts to a shared power model. This commentary aims to educate about shared decision making, explain why shared decision making is appropriate to use when discussing whether to perform a pelvic examination, and provide a framework for using shared decision making in discussing whether to proceed with a pelvic examination with asymptomatic, nonpregnant patients.

Shared decision making provides a framework to discuss whether to proceed with pelvic examinations in asymptomatic, nonpregnant patients that engages patients' values, preferences, and experiences.

Department of Obstetrics and Gynecology, the MacLean Center for Clinical Medical Ethics, and the Department of Family Medicine, the University of Chicago, and the Department of Obstetrics and Gynecology, the University of Illinois at Chicago, Chicago, Illinois.

Corresponding author: Julie Chor, MD, MPH, Department of Obstetrics and Gynecology, The University of Chicago, 5841 South Maryland Avenue, MC 2050, Chicago, IL 60637; email: jchormd@gmail.com.

Financial Disclosure The authors did not report any potential conflicts of interest.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews and author correspondence are available at http://links.lww.com/AOG/B307.

Received November 14, 2018

Received in revised form December 19, 2018

Accepted January 10, 2019

More than 50 million patients undergo pelvic examinations yearly.1 A large number of these examinations are performed as part of routine, preventive gynecologic care in asymptomatic patients. Controversy exists regarding whether asymptomatic, nonpregnant individuals should receive pelvic examinations. The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) recommend against performing “screening pelvic examinations,” which they view as lacking supporting evidence and potentially harmful owing to risks of emotional distress and unnecessary additional procedures for benign findings.2,3 In contrast, the Society of Gynecologic Oncology (SGO) recommends discussing risks and benefits of the pelvic examination and that every patient presenting for an annual visit should be offered a pelvic examination.4

The American College of Obstetricians and Gynecologists (ACOG) published a Committee Opinion in 2018 consistent with recommendations by the U.S. Preventive Services Task Force.5,6 Both organizations determined that data on risks and benefits of performing pelvic examinations for asymptomatic, nonpregnant patients are limited. The American College of Obstetricians and Gynecologists concluded that whether or not to perform this examination is a matter of clinical equipoise—there is no clear right or wrong decision. They recommended that whether to proceed with this examination should be determined through discussions between patient and health care provider about the pros and cons of performing the examination.

Research demonstrates that most obstetrician–gynecologists routinely perform pelvic examinations for asymptomatic patients and believe that performing annual pelvic examinations is integral to caring for reproductive-age patients.7 Although professional organizations (ACP, AAFP, SGO, the U.S. Preventive Services Task Force, and ACOG) differ in their conclusions about whether to offer a pelvic examination to asymptomatic patients, their statements support the position that health care providers should no longer automatically perform this examination with asymptomatic patients. Contemporary guidelines underscore that, at minimum, health care providers must recognize the role of patient autonomy in decision making, have an a priori discussion about potential advantages and disadvantages, and come to a joint decision about whether to proceed with the examination. When educated about recommendations for or against screening examinations, women overwhelmingly believe that discussions of benefits and harms should precede screening pelvic examinations.8 Knowing how to have these discussions, and incorporating them into a busy practice, is not always easy. We propose that shared decision making is the most patient-centered approach and a concrete tool that clinicians can incorporate with little to no extra training, because it incorporates key facets of patient–provider communication already familiar to many health care providers.

The American College of Obstetricians and Gynecologists endorses shared decision making to guide discussions around whether to proceed with a screening pelvic examination. This model validates the roles patients and health care providers play in deciding how to proceed with medical management, especially when facing decisions involving clinical equipoise. This commentary aims to educate readers about shared decision making, explain why this is an appropriate model to use when discussing whether to perform a pelvic examination, and provide a user-friendly framework for applying shared decision making when discussing with asymptomatic, nonpregnant patients whether to proceed with a pelvic examination.

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HISTORY AND BACKGROUND OF SHARED DECISION MAKING

Shared decision making was conceptualized in the 1970s and 1980s.9,10 Reflecting the changing nature of the patient–provider relationship, shared decision making developed as an alternative to prevailing models of decision making at that time—primarily the paternalistic and consumerist models. Paternalism places knowledge and decision making in the hands of health care providers. Conversely, in consumerism, health care providers provide patients with large amounts of medical information and defer decision making entirely to patients. Both of these models are unidirectional, either the patient or the health care provider is left to make decisions alone. In contrast, shared decision making is bidirectional, recognizing two experts within the clinical encounter—the health care provider is the expert regarding medical information, and the patient is the expert regarding their values, preferences, and lived experiences. Shared decision making is both a process, whereby patient and health care provider enter into a voluntary and mutually agreed on relationship, and an outcome, whereby both agree on a plan reflecting the moral, medical, and personal factors shaping the relationship.9

Shared decision making is advocated as an ideal model to address discussions around preventive health and treatment decisions and is associated with improved patient satisfaction and decreased decisional conflict. Within the field of sexual and reproductive health, shared decision making has been explored as a way to approach contraceptive counseling.11 This work recognizes contraceptive selection as a preference-sensitive decision, where several methods would be medically appropriate. Contraceptive counseling is posited as ideal for shared decision making, whereby health care providers contribute medical knowledge of contraception and patients contribute knowledge of their values and preferences. Individuals who experience shared decision making in contraceptive counseling are more satisfied with counseling and method selection compared with individuals who experience health care provider–driven or patient-driven decision making, respectively.11

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ARGUMENTS FOR USING SHARED DECISION MAKING ABOUT PELVIC EXAMINATIONS

Several arguments support integrating shared decision making into discussions about routine pelvic examinations. First, the pelvic examination experiences can be influenced by patient's values, preferences, and lived experiences. For some, the uncertain likelihood to detect a treatable gynecologic condition before developing symptoms may not outweigh potential discomfort. Some may have personal or family cultural beliefs that go against the idea of undergoing an invasive pelvic examination. Patients identifying as lesbian, gay, bisexual, transgender, or queer often have had negative gynecologic experiences and may decline a pelvic examination if offered. Proceeding with the pelvic examination without eliciting values, preferences, and lived experiences fails to acknowledge how they may affect a patient's experience and ultimately undermines attempts to develop positive rapport. Shared decision making ensures that health care providers explore these factors to jointly determine whether and how to conduct the examination in a way that addresses patients' preferences, needs, and concerns in a patient-centered manner.

Second, medical ethics requires clinicians to weigh the principles of beneficence, doing what is in the best interest of the patient, and nonmaleficence, not causing harm to the patient. As explained in ACOG's Committee Opinion, data are limited on potential medical benefits and harms of performing this examination.6 Potential benefits include educating patients about their anatomy and fostering patient–provider communication. Potential harms include fear, anxiety, pain, and discomfort.6 Although performing this examination may be an act of beneficence, proceeding without first discussing the examination with patients may cause harm and violate the principle of nonmaleficence. Shared decision making facilitates joint discussions between patients and health care providers to consider potential benefits and harms and come to mutually agreed on conclusions that uphold these two principles.

Finally, the pelvic examination encounter can be conducted in such a way as to foster patients' bodily autonomy in health care provision and in developing empowering and positive patient–provider relationships. Historically and in contemporary practice, a great power differential has existed within the patient–provider relationship. Integrating shared decision making into discussions of whether or not to conduct the pelvic examination empowers patients to express their preferences and opinions during clinical encounters. This can be especially important for patients with prior sexual or other trauma who may want to avoid an invasive examination. Patients with a history of sexual assault may be at risk of experiencing distress, pain, or retraumatization during the examination. Shared decision making incorporates key principles of trauma-informed care that further empower patients and foster human agency and bodily autonomy in health care decisions, including trustworthiness, transparency, and collaboration.

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FRAMEWORK FOR USING SHARED DECISION MAKING FOR PELVIC EXAMINATIONS

Several frameworks exist for integrating shared decision making into the clinical encounter. The proposed 5-step framework adapts a framework by Stiggelbout et al12 to discussions about whether to proceed with a routine pelvic examination (Fig. 1).

  1. Identify that a decision needs to be made. Rather than simply stating to patients, “Ok, it is now time for your pelvic exam,” the first step in shared decision making is to instead inform that a decision is to be made by stating something to the effect of, “Ok, it is now time to discuss whether we should proceed with a pelvic exam.” This signals a move away from the presumption that the examination will automatically take place. Essential in this step is to acknowledge the equipoise around this decision—according to ACOG, there is no clear right or wrong choice in this scenario.6 This shift helps to level the power dynamic and underscores the important role of patient autonomy in deciding whether or not to proceed with this examination. This shift may be surprising to patients who are used to the expectation that this examination will take place and uncomfortable to health care providers who are used to performing the examination as routine practice.
  2. Explain medical options and the potential benefits and harms of these options. It is not uncommon for a patient to state that they “had a Pap smear in the emergency department” when asked whether they ever had a pelvic examination. Although it is unlikely that a patient actually had a Pap test in the emergency department and instead likely had a speculum or bimanual examination, this example illustrates a general lack of clarity about terminology. For the patient to determine how they would like to proceed, the health care provider must ensure both are using the same, medically accurate terminology and explain components of the pelvic examination: external visual examination, internal speculum examination, and bimanual examination. It is important to recognize and ensure that patients know that they may elect to have none, some, or all components of the examination and to fully respect the patient's decision. When discussing potential benefits and harms of performing or not performing the examination, attention must be paid to both potential medical benefits and harms (for example, identifying asymptomatic pathology and obtaining unnecessary further testing, respectively) and psychosocial benefits and harms (for example, providing reassurance about anatomy and creating anxiety before the examination, respectively). Providing patients the opportunity to ask questions is integral to ensuring a solid understanding of the medical considerations that are required to make an informed and autonomous choice.
  3. Elicit values, preferences, and experiences and engage in how these may inform the decision. As previously stated, numerous factors may inform an individual's decision as to whether to proceed with a pelvic examination. This step can be prompted with open-ended questions such as, “What are your thoughts about this decision?” and “What considerations may be factoring into whether or not you would like to proceed with this examination?” Exploring possible fears or concerns about the examination is essential to addressing potential concerns or uncovering prior negative experiences that may affect an individual's care. Intake forms that ask about prior history of sexual or other trauma or using normalizing language such as “Some patients who have had past negative experiences may prefer to avoid such an examination if not urgently needed” are some strategies to allow patients to report such experiences in a less intimidating manner.
  4. Agree on a decision or to defer the decision. This step can again reiterate that there is no clear best choice from a medical perspective. This is an opportunity for the health care provider to summarize and verify their understanding of what the patient has said regarding preferences about the examination. As opposed to the consumerist model in which the health care provider plays no role in making a medical decision, in shared decision making, the health care provider can reflect back what the patient has stated regarding their values, preferences, and lived experiences and make a suggestion about how to proceed based on that shared knowledge. Additionally, deferring this decision to another visit and proceeding with other aspects of the clinical encounter is also appropriate.
  5. Educate regarding pelvic health and warning signs. Regardless of whether a health care provider opts to follow the recommendations of the ACP and AAFP to not offer the pelvic examinations for asymptomatic patients or if a health care provider offers the examination and a patient declines the examination, educating patients on pelvic health and warning signs is critical. Consistent with the ethos of partnership inherent in the shared decision-making model, the health care provider should also ensure that the patient feels welcome for future follow-up, regardless of whether the patient has opted for or against proceeding with the pelvic examination. Furthermore, because an individual's values, preferences, and life experiences may change over time, patients and health care providers can continue to use shared decision making to periodically reexplore this decision. Anticipatory guidance can be provided for future examinations.
Fig. 1

Fig. 1

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CONCLUSIONS

This commentary responds to recommendations to use shared decision making to engage patients before potentially performing pelvic examinations in asymptomatic, nonpregnant individuals. The proposed framework is one approach to using shared decision making during these encounters. This framework also can be used to engage patients in decisions around whether to perform a pelvic examination under additional circumstances and additional examination components, including the rectal examination. For example, even when indicated, some individuals may strongly prefer to defer a pelvic examination owing to a number of reasons or circumstances. Especially in nonemergent situations, engaging in shared decision making can foster bidirectional dialogue that allows health care providers to elicit important factors that may affect patient care. Frequently under such circumstances, patients and health care providers can identify alternative evaluation strategies.

Although a full discussion of counseling adolescent patients is beyond the scope of this commentary, the shared decision-making framework described here can be applied with many adolescents. Most state laws allow adolescents to receive confidential reproductive care such as contraception and sexually transmitted infection management without involving their parents or guardians. When clinically and legally appropriate, this shared decision-making model is also applicable to teens.

Some health care providers may be concerned that integrating shared decision making into this encounter may be time consuming. Shared decision making advocates suggest that this approach can lead to greater patient satisfaction, improved patient–provider communication, and potentially greater treatment adherence and outcomes.12 Although shared decision making around routine pelvic examinations is appropriate for many patients, we acknowledge that, in busy gynecology practices, this time may be prioritized to counsel patients on a variety of primary medical needs. Research is needed to determine how to optimally integrate this counseling into clinical encounters and to potentially develop decision aids to help busy clinicians in this endeavor. Others may have concerns that making the pelvic examination optional may render the annual gynecologic visit obsolete. However, ACOG continues to underscore the value of the annual visit to provide important preventive reproductive health care, including contraception, health screening, and vaccinations, and to educate patients about sexual and reproductive health.6

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REFERENCES

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3. American Academy of Family Physicians. Screening pelvic exam. Clinical preventive service recommendation. Available at: https://www.aafp.org/patient-care/clinical-recommendations/all/screening-pelvic-exam.html. Retrieved November 1, 2018.
4. Society of Gynecologic Oncology. Pelvic examinations. SGO position statement. Available at: https://www.sgo.org/newsroom/position-statements-2/pelvic-examinations/. Retrieved November 1, 2018.
5. US Preventive Services Task Force; Bibbins-Domingo K, Grossman DC, Curry SJ, Barry MJ, Davidson KW, et al. Screening for gynecologic conditions with pelvic examination: US Preventive Services Task Force recommendation statement. JAMA 2017;317:947–53.
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