1. ©2012 MFMER | slide-1 Differences in Pelvic Exam Performance by Less Versus More Experienced Primary Care Providers: Implications for Medical Education and Future Practice Jennifer B. Manning & Jani R. Jensen, MD Mayo Clinic College of Medicine April 27 th, 2015

2. ©2012 MFMER | slide-2 None Disclosures

3. ©2012 MFMER | slide-3 Aim: Better tailor pelvic exam education for undifferentiated medical students Image from: Undergraduate Medical Education Committee Faculty. Association of Professors of Gynecology and Obstetrics. Clinical Skills Curriculum: Pelvic Exam. 2011. Available at: https://www.apgo.org/education/clinical/pelvic-exam.html. Accessed January 20, 2014.

4. ©2012 MFMER | slide-4 www.APGO.org

5. ©2012 MFMER | slide-5

6. ©2012 MFMER | slide-6 What to teach?

7. ©2012 MFMER | slide-7 Methods Developed web-based survey of pelvic exam practices N =801 FM and IM physicians All Mayo Clinic sites (MN, FL, AZ) Rural and urban

8. ©2012 MFMER | slide-8 Survey Questions 1) Do you perform pelvic exams in practice?  Yes  No 2) On average, how many pelvic exams do you perform monthly?  1 to 10 Pelvic exams  11 to 20 Pelvic exams  21 to 30 Pelvic exams  31 or more Pelvic exams

9. ©2012 MFMER | slide-9 Survey Questions 3) How often do you think pelvic exams should be performed for low-risk reproductive age women?  Yearly  Every 1 to 2 years  Every 3 years  More than every 3 years  Never

10. ©2012 MFMER | slide-10 Survey Questions 4) How often do you perform the following when doing a pelvic exam? 5) Please rate how comfortable or uncomfortable you are with your level of skill in performing the following: 6) Please rate the importance or unimportance of the following elements of a pelvic exam:  Examine external genitalia  Insert speculum  Identify cervix  Examine vaginal walls with speculum  Bimanual exam - palpation of cervix  Bimanual exam - palpation of uterine fundus  Bimanual exam - palpation of adnexae  Rectovaginal exam  Examine external genitalia  Insert speculum  Identify cervix  Examine vaginal walls with speculum  Bimanual exam - palpation of cervix  Bimanual exam - palpation of uterine fundus  Bimanual exam - palpation of adnexae  Rectovaginal exam

11. ©2012 MFMER | slide-11 Survey Questions 7) How often do you refer patients to OBGYN for routine pelvic exams (instead of performing the exam yourself)?  Always  Almost always  Sometimes  Rarely  Never

12. ©2012 MFMER | slide-12 Survey Questions 8) Why do you refer patients to OB/GYN for routine pelvic exams? (Mark all that apply.)  Patient preference to see OB/GYN for pelvic exam instead of primary provider  Lack of equipment or supplies  Lack of time during scheduled clinical encounters  No chaperones available  Uncomfortable with exam technique  Personal modesty or beliefs against performing pelvic examinations  Medicolegal concerns about missing pertinent findings  Uncertain about guidelines of when to perform  Do not feel they are helpful/necessary  Ready availability of OB/GYN consult to perform the pelvic exam  Technically difficult exams, ie. Patient obesity  Other, please specify below: ____________________

13. ©2012 MFMER | slide-13 Methods <5 years experience = “less experienced” (LE) >5 years = “more experienced” (ME) Scaled items combined for analysis: Frequency: “always” + “most of the time” Comfort: “Very comfortable” + “somewhat comfortable” Importance: “Very important” + “somewhat important” LE vs. ME providers compared with Wilcoxon rank-sum tests P <0.05 considered significant

14. ©2012 MFMER | slide-14 Results 284 responses (36% response rate) FM = 154 vs. IM = 130 38% LE vs. 62% ME 97% routinely perform pelvic exams 10% refer to Ob/Gyn solely for routine exams Most common reasons for referral: patient preference (N=81) technically difficult exams (N=66) lack of time (N=20)

15. ©2012 MFMER | slide-15 Number of Pelvic Exams per Month by FM

16. ©2012 MFMER | slide-16 Suggested Frequency of Pelvic Exam

17. ©2012 MFMER | slide-17 Frequency in LE vs. ME Providers: Exam ComponentLEMEP Value Examine external genitalia98.0%98.8%NS Insert speculum94.1%89.6%NS Identify cervix94.1%90.2%NS Examine vaginal walls77.2%85.4%NS Palpate cervix80.2%90.4%0.0021 Palpate fundus75.0%93.3%0.0001 Palpate adnexae77.2%95.1%<0.0001 Rectovaginal exam12.0%27.4%0.0002

18. ©2012 MFMER | slide-18 Comfort in LE vs. ME Providers: Exam ComponentLEMEP Value Examine external genitalia95%99.4%<0.0001 Insert speculum93%100%<0.0001 Identify cervix90%99.4%<0.0001 Examine vaginal walls85%98.2%<0.0001 Palpate cervix84.1%100%<0.0001 Palpate fundus68%93.2%<0.0001 Palpate adnexae59.4%92.7%<0.0001 Rectovaginal exam42%82.6%<0.0001

19. ©2012 MFMER | slide-19 Importance in LE vs. ME Providers: Exam ComponentLEMEP Value Examine external genitalia97.0%98.8%NS Insert speculum96.3%96.4%NS Identify cervix95.1%97.6%NS Examine vaginal walls92.0%86%NS Palpate cervix74%77.9%NS Palpate fundus72%82.1%<0.02 Palpate adnexae69.4%82.8%<0.003 Rectovaginal exam42.6%46.2%NS

20. ©2012 MFMER | slide-20 Conclusions Most PCPs perform pelvic exams Experience matters Better exam education  more quality exams Training should familiarize learner with all components Training should focus on increasing comfort with high-yield pelvic exam components Evolving guidelines may decrease learning opportunities for LE providers

21. ©2012 MFMER | slide-21 Rectovaginal exam Overall performance is low Possible reasons: fear of causing discomfort concern over accuracy of exam findings Low sensitivity of rectovaginal examination?

22. ©2012 MFMER | slide-22 Discussion Which components are truly high yield? Less bimanual and rectovaginal exam by LE providers: good or bad? When to train? How to train?

23. ©2012 MFMER | slide-23 Teaching Modalities Videos NEJM Pelvic Examination 1 https://www.youtube.com/watch?v=CCHPclA9Vmk https://www.youtube.com/watch?v=CCHPclA9Vmk ACP “Patient Centered Pelvic Exam” ($49.95) Plastic Models Standardized patients Trained laywomen educators (“Gynecologic teaching associate”) Combination 1. Edelman A, Anderson J, Lai S, Braner DAV, Tegtmeyer K. Pelvic Examination. NEJM 2007;356:e26

24. ©2012 MFMER | slide-24 Acknowledgements Co-authors: Dr. Emily P. Barnard, Sarah M. Jenkins, Dr. Doug J. Creedon Grant from Mayo Clinic Department of Obstetrics & Gynecology Image from: Undergraduate Medical Education Committee Faculty. Association of Professors of Gynecology and Obstetrics. Clinical Skills Curriculum: Pelvic Exam. 2011. Available at: https://www.apgo.org/education/clinical/pelvic-exam.html. Accessed January 20, 2014.