Gynecology_Novak

Gynecology_Novak. Jonathan S. Berek Paula J. Adams Hillard We are all products of our environment, our background, and our culture. The importance of ascertaining the patient’s general, social, and familial situation cannot be overemphasized. The physician should avoid being judgmental, particularly with respect to questions about sexual practices and sexual orientation. Good communication is essential to patient assessment and treatment. The foundation of communication is based on key skills: empathy, attentive listening, expert knowledge, and rapport. These skills can be learned and refined. The Hippocratic Oath demands that physicians be circumspect with all patient-related information. For physician–patient communication to be effective, the patient must feel that she is able to discuss her problems in depth and in confidence.


Gynecology_Novak

Gynecology_Novak. Different styles of communication may affect the physician’s ability to perceive the patient’s status and to achieve the goal of optimal assessment and successful treatment. The intimate and highly personal nature of many gynecologic conditions requires particular sensitivity to evoke an honest response. Some patients lack accurate information about their illnesses. Incomplete or inadequate understanding of an illness can produce dissatisfaction with medical care, increased anxiety, distress, coping difficulties, unsuccessful treatment, and poor treatment response. After a dialogue is established, the patient assessment proceeds with obtaining a complete history and performing a physical examination. Both of these aspects of the assessment rely on good patient–physician interchange and attention to details.


Gynecology_Novak

Gynecology_Novak. At the completion of the physical examination, the patient should be informed of the findings. When the results of the examination are normal, the patient can be reassured accordingly. When there is a possible abnormality, the patient should be informed immediately; this discussion should take place after the examination, with the patient clothed.


Gynecology_Novak

Gynecology_Novak. The practice of gynecology requires many skills. In addition to medical knowledge, the gynecologist should develop interpersonal and communication skills that promote patient–physician interaction and trust. The assessment must be of the “whole patient,” not only of her general medical status. It should include any apparent medical condition as well as the psychological, social, and family aspects of her situation. To view the patient in the appropriate context, environmental and cultural issues that affect the patient must be taken into account. This approach is valuable in routine assessments, and in the assessment of specific medical conditions, providing opportunities for preventive care and counseling on an ongoing basis.


Gynecology_Novak

Gynecology_Novak. Many external variables exert an inﬂuence on the patient and on the care she receives. Some of these factors include the patient’s “significant others”—her family, friends, and personal and intimate relationships (Table 1.1). These external variables include psychological, genetic, biologic, social, and economic issues. Factors that affect a patient’s perception of disease and pain and the means by which she has been taught to cope with illness include her education, attitudes, understanding of human reproduction and sexuality, and family history of disease (1–3). Cultural factors, socioeconomic status, religion, ethnicity, language, age, and sexual orientation are important considerations in understanding the patient’s response to her care.


Gynecology_Novak

Gynecology_Novak. We are all products of our environment, our background, and our culture. The importance of ascertaining the patient’s general, social, and familial situation cannot be overemphasized (4). Cultural sensitivity may be particularly important in providing reproductive health care (5). The context of the patient’s family can and should be ascertained directly. The family history should include a careful analysis of those who had significant illnesses, such as cancer or an illness that the patient perceives to be a potential explanation for her own symptoms. The patient’s perspective of her illness can provide important information that informs the physician’s judgment; specific questioning to elicit this perspective can improve satisfaction with the interaction (6). Table 1.1 Variables that Inﬂuence the Status of the Patient History of illness Habits (e.g., use of alcohol, tobacco, and other drugs) Patient’s status (e.g., married, separated, living with a partner, divorced)


Gynecology_Novak

Gynecology_Novak. History of illness Habits (e.g., use of alcohol, tobacco, and other drugs) Patient’s status (e.g., married, separated, living with a partner, divorced) Caregiving (e.g., young children, children with disabilities, aging parents) Siblings (e.g., number, ages, closeness of relationship) History (e.g., disease) Social environment (e.g., community, social connectedness) Economic status (e.g., poverty, insuredness) Religion (e.g., religiosity, spirituality) Culture and ethnic background (e.g., first language, community) Career (e.g., work environment, satisfaction, responsibilities, stress)


Gynecology_Novak

Gynecology_Novak. Religion (e.g., religiosity, spirituality) Culture and ethnic background (e.g., first language, community) Career (e.g., work environment, satisfaction, responsibilities, stress) The patient’s understanding of key events in the family medical history and how they relate to her is important. The patient’s sexual history, relationships, and practices should be understood, and her functional level of satisfaction in these areas should be determined. The physician should avoid being judgmental, particularly with respect to questions about sexual practices and sexual orientation (see Chapter 11).


Gynecology_Novak

Gynecology_Novak. Good communication is essential to patient assessment and treatment. The patient–physician relationship is based on communication conducted in an open, honest, and careful manner that allows the patient’s situation and problems to be accurately understood and effective solutions developed collaboratively. Good communication requires patience, dedication, and practice and involves careful listening and both verbal and nonverbal communication.


Gynecology_Novak

Gynecology_Novak. The foundation of communication is based on four key skills: empathy, attentive listening, expert knowledge, and the ability to establish rapport. These skills can be learned and refined (4,7,8). When the initial relationship with the patient is established, the physician must vigilantly pursue interviewing techniques that continue to create opportunities to foster an understanding of the patient’s concerns (9). Trust is the fundamental element that encourages open communication of the patient’s feelings, concerns, and thoughts, rather than withholding information (10).


Gynecology_Novak

Gynecology_Novak. One very basic element of communication—sharing a common language and culture—may be missing when a clinician interacts with a patient of limited or no English proficiency. Language concordance between physician and patient is assumed in many discussions of communication. More than 18% of Americans speak a language other than English at home, and over 8% have limited English proficiency (11). Language barriers are associated with limited health education, compromised interpersonal care, and lower patient satisfaction in health care encounters (11,12). Medical interpreters can mitigate these effects. The State of California recognized the importance of communication in patient–physician interactions through a provision in the Health and Safety Code that states “where language or communication barriers exist between patients and the staff of any general acute care hospital, arrangements shall be made for interpreters or bilingual professional staff to ensure adequate and speedy


Gynecology_Novak

Gynecology_Novak. barriers exist between patients and the staff of any general acute care hospital, arrangements shall be made for interpreters or bilingual professional staff to ensure adequate and speedy communication between patients and staff” (13). Training future physicians to work with interpreters is receiving increasing attention in United States medical schools and will contribute to improved clinical practice and reduce health care disparities (14).


Gynecology_Novak

Gynecology_Novak. Although there are many styles of interacting with patients, and each physician must determine and develop the best way that she or he can relate to patients, physicians must convey that they are able and willing to listen and that they receive the information with utmost confidentiality (1). The Hippocratic Oath demands that physicians be circumspect with all patient-related information. The Health Insurance Portability and Accountability Act (HIPAA), which took effect in 2003, established national standards intended to protect the privacy of personal health information. Initial fears expressed about the impact of HIPAA regulations and the potential for legal liability led to discussions of appropriate communication and physicians’ judgments based on the ethical principles of confidentiality in providing good medical care (15,16) (see Chapter 2).


Gynecology_Novak

Gynecology_Novak. Communication Skills It is essential for the physician to communicate with a patient in a manner that allows her to continue to seek appropriate medical attention. The words used, the patterns of speech, the manner in which words are delivered, even body language and eye contact, are all important aspects of the patient–physician interaction. The traditional role of the physician was paternalistic, with the physician expected to deliver direct commands or “orders” and specific guidance on all matters (4). Now patients appropriately demand and expect more balanced communication with their physicians. Although they may not have equivalent medical expertise, they do expect to be treated with appropriate deference, respect, and a manner that acknowledges their personhood as equal to that of the physician (17). Doctor–patient communication is receiving more attention in current medical education and is being recognized as a major task of lifelong professional learning and a key element of


Gynecology_Novak

Gynecology_Novak. physician (17). Doctor–patient communication is receiving more attention in current medical education and is being recognized as a major task of lifelong professional learning and a key element of successful health care delivery (18).


Gynecology_Novak

Gynecology_Novak. As a result of electronic access to medical information, patients sometimes have more specific medical knowledge of a given medical problem than the physician does. When this is the case, the physician must avoid feeling defensive. The patient often lacks broader knowledge of the context of the problem, awareness of the variable reliability of electronic sources of information, the ability to assess a given study or journal report within an historical context or in comparison with other studies on the topic, knowledge of drug interactions, an ability to maintain objective intellectual distance from the topic, or essential experience in the art and science of medicine. The physician possesses these skills and extensive knowledge, whereas the patient has an intensely focused personal interest in her specific medical condition. Surveys of physicians’ perceptions of the impact of Internet-based health information on the doctor–patient relationship found both positive and negative


Gynecology_Novak

Gynecology_Novak. interest in her specific medical condition. Surveys of physicians’ perceptions of the impact of Internet-based health information on the doctor–patient relationship found both positive and negative perceptions; physicians express concerns about a hindrance to efficient time management during an office visit, but a positive perception of the potential effects on the quality of care and patient outcomes (19). A collaborative relationship that allows patients greater interactive involvement in the doctor–patient relationship can lead to better health outcomes (1,20,21).


Gynecology_Novak

Gynecology_Novak. The pattern of the physician’s speech can inﬂuence interactions with the patient. Some important components of effective communication between patients and physicians are presented in Table 1.2. There is evidence that scientifically derived and empirically validated interview skills can be taught and learned, and conscientious use of these skills can result in improved outcomes (8). A list of such skills is found in Table 1.3.


Gynecology_Novak

Gynecology_Novak. For physician–patient communication to be effective, the patient must feel that she is able to discuss her problems in depth and in confidence. Time constraints imposed by the pressures of office scheduling to meet economic realities make this difficult; both the physician and the patient frequently need to reevaluate their priorities. If the patient perceives that she participates in decision making and that she is given as much information as possible, she will respond to the mutually derived treatment plan with lower levels of anxiety and depression, embracing it as a collaborative plan of action. She should be able to propose alternatives or modifications to the physician’s recommendations that reﬂect her own beliefs and attitudes. There is ample evidence that patient communication, understanding, and treatment outcomes are improved when Table 1.2 Important Components of Communication between the Patient and Physician: The Physician’s Role


Gynecology_Novak

Gynecology_Novak. Table 1.2 Important Components of Communication between the Patient and Physician: The Physician’s Role Table 1.3 Behaviors Associated with the 14 Structural Elements of the Interviewa Preparing the Environment Negotiating a Priority Problem Provide access Reach agreement on order of addressing issues Eliminate distractions and interruptions Develop personal ways of asking patient to tell her story Self-hypnosis Ask about entire course of illness Constructive imaging Establishing the Life Context of the Patient Let intrusive thoughts pass through Use first opportunity to inquire about personal and social details Create a personal list of categories of observation Learn about patient’s support system Practice in a variety of settings Learn about home, work, neighborhood, safety Presentation Memorize complete review of systems Affect Review issues as appropriate to specific problem What is said and not said Presenting Findings and Options


Gynecology_Novak

Gynecology_Novak. Presentation Memorize complete review of systems Affect Review issues as appropriate to specific problem What is said and not said Presenting Findings and Options Create a personal stereotypical beginning Ascertain patient’s level of understanding, cognitive style Introduce oneself Ask patient to review and state understanding Check the patient’s name and how it is said Summarize and check Create a positive social setting Tape record and give tape to patient Negotiate about differences in perspective Agree on what is feasible Be sure expectations are congruent with patient’s Respect patient’s choices whenever possible Detecting and Overcoming Barriers to Communication Closing Develop personal list of barriers to look for Ask patient to review plans and arrangements Include appropriate language Clarify what to do in the interim Physical impediments such as deafness, delirium Schedule next encounter


Gynecology_Novak

Gynecology_Novak. Include appropriate language Clarify what to do in the interim Physical impediments such as deafness, delirium Schedule next encounter Recognize patient’s psychological barriers, such as shame, fear, and paranoia Develop personal methods of initiation of problem listing Ask “What else?” until problems are elicited aLipkin M Jr. Physician–patient interaction in reproductive counseling. Obstet Gynecol 1996;88:31S–40S. Derived from Lipkin M, Frankel RM, Beckman HB, et al. Performing the interview. In: Lipkin M, Putnam SM, Lazare A, eds. The medical interview: clinical care, education, and research. New York: Springer-Verlag, 1995:65–82.


Gynecology_Novak

Gynecology_Novak. discussions with physicians are more dialogue than lecture. In addition, when patients feel they have some room for negotiation, they tend to retain more information regarding health care recommendations. The concept of collaborative planning between patients and physicians is embraced as a more effective alliance than the previous model in which physicians issued orders (22). The patient thus becomes more vested in the process of determining health care choices. For example, decisions about the risks and benefits of menopausal hormone therapy must be discussed in the context of an individual’s health and family history as well as her personal beliefs and goals. The woman decides whether the potential benefits outweigh the potential risks, and she is the one to determine whether or not to use such therapy. Whereas most women prefer shared decision making in the face of uncertainty, with an evidence-based discussion of her risks and benefits, others want a more directive approach (23).


Gynecology_Novak

Gynecology_Novak. use such therapy. Whereas most women prefer shared decision making in the face of uncertainty, with an evidence-based discussion of her risks and benefits, others want a more directive approach (23). The physician’s challenge is to be able to personalize the interaction and communication.


Gynecology_Novak

Gynecology_Novak. There is evidence that when patients are heard and understood, they become more vocal and inquisitive and their health improves (9). Participation facilitates investment and empowerment. Good communication is essential to the maintenance of a relationship between the patient and physician that will foster ongoing care. Health maintenance, therefore, can be linked directly to the inﬂuence of positive interactions between the physician and patient. Women who are comfortable with their physician may be more likely to raise issues or concerns and convey information about potential health risks and be more receptive to the physician’s recommendations. This degree of rapport may promote the effectiveness of health interventions, including behavior modification. It helps ensure that patients return for regular care because they feel the physician is genuinely interested in their welfare and they have confidence in the quality of the treatment and guidance they receive.


Gynecology_Novak

Gynecology_Novak. When patients are ill, they feel vulnerable, physically and psychologically exposed, and powerless. The physician, by virtue of his or her knowledge and status, has power that can be intimidating. It is essential that the physician be aware of this disparity so the “balance of power” does not shift too far away from the patient. Shifting it back from the physician to the patient may help improve outcomes (1,20,21). Physicians’ behaviors can suggest that they are not respectful of the patient. Such actions as failing to maintain scheduled appointment times, routinely holding substantive discussions when the patient is undressed, or speaking to her from a standing position while she is lying down or in the lithotomy position can emphasize the imbalance of power in the relationship. In assessing the effects of the patient–physician interaction on the outcome of chronic illness, three characteristics associated with better health care outcomes were identified (21): 1.


Gynecology_Novak

Gynecology_Novak. In assessing the effects of the patient–physician interaction on the outcome of chronic illness, three characteristics associated with better health care outcomes were identified (21): 1. An empathetic physician and a high level of patient involvement in the interview. 2. Expression of emotion by both patient and physician. 3. Provision of information by the physician in response to the patient’s inquiries. Among patients with diabetes, these characteristics resulted in improved diastolic blood pressure and reduction of hemoglobin A1c. The best responses were achieved when an empathetic physician provided as much information and clarification as possible, responded to the patients’ questions openly and honestly, and expressed a full range of emotions, including humor. Responses improved when the relationship was not dominated by the physician (21).


Gynecology_Novak

Gynecology_Novak. In studies of gender and language, men tend to talk more than women, successfully interrupt women, and control the topics of the conversation (24). As a result, male physicians may tend to take control, and this imbalance of power may be magnified in the field of obstetrics and gynecology, in which all the patients are women. Male physicians may be more assertive than female physicians. Men’s speech tends to be characterized by interruptions, command, and lectures, and women’s speech is characterized by silence, questions, and proposals (25,26). Some patients may feel more reticent in the presence of a male physician, whereas others may be more forthcoming with a male than a female physician (27). Women’s preference for a male or female physician may be based on gender as well as experience, competency, communication styles, and other skills (28,29). Although these generalizations clearly do not apply to all physicians, they can raise awareness about the various styles of


Gynecology_Novak

Gynecology_Novak. as experience, competency, communication styles, and other skills (28,29). Although these generalizations clearly do not apply to all physicians, they can raise awareness about the various styles of communication and how they shape the physician–patient relationship (30,31). These patterns indicate that all physicians, regardless of their gender, need to be attentive to their style of speech because it may affect their ability to elicit open and candid responses from their patients (32–34). Women tend to express their feelings in order to validate, share, and establish an understanding of their concerns or establish a shared understanding of their concerns (22,24,25).


Gynecology_Novak

Gynecology_Novak. Different styles of communication may affect the physician’s ability to perceive the patient’s status and to achieve the goal of optimal assessment and successful treatment. The intimate and highly personal nature of many gynecologic conditions requires particular sensitivity to evoke an honest patient response. Style The art of communication and persuasion is based on mutual respect and fosters the development of the patient’s understanding of the circumstances of her health. Insight is best achieved when the patient is encouraged to question her physician and when she is not pressured to make decisions. Patients who feel “backed into a corner” have the lowest compliance with recommended treatments (20). Following are techniques to help achieve rapport with patients: 1. Use positive language (e.g., agreement, approval, and humor). 2. Build a partnership (e.g., acknowledgment of understanding, asking for opinions, paraphrasing, and interpreting the patient’s words). 3.


Gynecology_Novak

Gynecology_Novak. 2. Build a partnership (e.g., acknowledgment of understanding, asking for opinions, paraphrasing, and interpreting the patient’s words). 3. Ask rephrased questions. 4. Give complete responses to the patient’s questions.


Gynecology_Novak

Gynecology_Novak. The manner in which a physician guides a discussion with a patient will determine the patient’s level of understanding and her ability to successfully complete therapy. The term compliance has long been used in medicine; it suggests that the patient will follow the physician’s recommendations or “orders.” The term is criticized as being overly paternalistic; an alternative term, adherence to therapy, was proposed (35–37). This term still implies that the physician will dictate the therapy. A more collaborative approach is suggested by the phrase successful use of therapy, which can be credited mutually to the physician and the patient. With this phrase, the ultimate success of the therapy appropriately accrues to the patient (38). If a directive is given to take a prescribed medication without a discussion of the rationale for its use, patients may not comply, particularly if the instructions are confusing or difficult to follow. Barriers to compliance may result from practical


Gynecology_Novak

Gynecology_Novak. without a discussion of the rationale for its use, patients may not comply, particularly if the instructions are confusing or difficult to follow. Barriers to compliance may result from practical considerations: Nearly everyone finds a four times daily (qid) regimen more difficult than daily use. A major factor in successful compliance is the simplicity of the regimen (39,40). Practical factors that affect successful use include financial considerations, insurance coverage, and literacy (41). A discussion and comprehension of the rationale for therapy, along with the potential benefits and risks, are necessary components of successful use; but they may not be sufficient in the face of practical barriers. The specifics of when and how to take medication, including what to do when medication is missed, have an impact on successful use. Positive physician–patient communication is correlated with patient adherence to medical advice (42).


Gynecology_Novak

Gynecology_Novak. The style of the presentation of information is key to its effectiveness. As noted, the physician should establish a balance of power in the relationship, including conducting serious discussions about diagnosis and management strategies when the patient is fully clothed and face-to-face with the physician in a private room. Body language is important during interactions with patients. The physician should avoid an overly casual manner, which can communicate a lack of respect or compassion. The patient should be viewed directly and spoken to with eye contact so that the physician is not perceived as “looking off into the distance” (9).


Gynecology_Novak

Gynecology_Novak. Laughter and Humor Humor is an essential component that promotes open communication. It can be either appropriate or inappropriate. Appropriate humor allows the patient to diffuse anxiety and understand that (even in difficult situations) laughter can be healthy (43,44). Inappropriate humor would horrify, disgust, offend, or generally make a patient feel uncomfortable or insulted. Laughter can be used as an appropriate means of relaxing the patient and making her feel better.


Gynecology_Novak

Gynecology_Novak. Laughter is a “metaphor for the full range of the positive emotions.” It is the response of human beings to incongruities and one of the highest manifestations of the cerebral process. It helps to facilitate the full range of positive emotions—love, hope, faith, the will to live, festivity, purpose, and determination (43). Laughter is a physiologic response, a release that helps us feel better and allows us to accommodate the collision of logic and absurdity. Illness, or the prospect of illness, heightens our awareness of the incongruity between our existence and our ability to control the events that shape our lives and our outcomes. We use laughter to combat stress, and stress reduction is an essential mechanism used to cope with illness.


Gynecology_Novak

Gynecology_Novak. All physicians should appreciate the importance of the art of communication during the medical interview. It is essential that interactions with patients are professional, honorable, and honest. Issues that were reported to be important to physicians regarding patient–physician interactions are presented in Table 1.4. Similarly, patients suggested the importance of many of these same issues in facilitating participatory decision making (45). Following are some general guidelines that can help to improve communication: 1. Listen more and talk less. 2. Encourage the pursuit of topics introduced by and important to patients. 3. Minimize controlling speech habits such as interrupting, issuing commands, and lecturing. 4. Seek out questions and provide full and understandable answers. 5. Become aware of any discomfort that arises in an interview, recognize when it originates in an attempt by the physician to take control, and redirect that attempt.


Gynecology_Novak

Gynecology_Novak. 5. Become aware of any discomfort that arises in an interview, recognize when it originates in an attempt by the physician to take control, and redirect that attempt. Table 1.4 Importance Attached to the Patient–Physician Relationshipa a Results of a physician survey of 649 oncologists in regard to patient–physician communication. Modified from Cousins N. Head first: the biology of hope and the healing power of the human spirit. New York: Penguin Books, 1989:220, with permission. 6. Assure patients that they have the opportunity to discuss their problem fully. 7. Recognize when patients may be seeking empathy and validation of their feelings rather than a solution. Sometimes all that is necessary is to be there as a compassionate human being.


Gynecology_Novak

Gynecology_Novak. 7. Recognize when patients may be seeking empathy and validation of their feelings rather than a solution. Sometimes all that is necessary is to be there as a compassionate human being. In conducting interviews, it is important for the physician to understand the patient’s concerns. Given the realities of today’s busy office schedules, an additional visit may be required to discuss some issues in sufficient depth. In studies of interviewing techniques it was shown that although clinicians employ many divergent styles, the successful ones tend to look for “windows of opportunity” (i.e., careful, attentive listening with replies or questions at opportune times). This communication skill is particularly effective for exploring psychological and social issues during brief interviews. The chief skill essential to allow the physician to perceive problems is the ability to listen attentively.


Gynecology_Novak

Gynecology_Novak. An interview that permits maximum transmission of information to the physician is best achieved by the following approach (10): 1. Begin the interview with an open-ended question. 2. As the patient begins to speak, pay attention to her answers, to her emotions, and to her general body language. 3. Extend a second question or comment, encouraging the patient to talk. 4. Allow the patient to respond without interrupting, perhaps by employing silence, nods, or small facilitative comments, encouraging the patient to talk while the physician is listening. 5. The physician should periodically summarize his or her understanding of the history to confirm accuracy. 6. Expressions of empathy and understanding at the completion of the interview along with a summary of the planned assessments and recommendations will facilitate the closure of the interview.


Gynecology_Novak

Gynecology_Novak. 6. Expressions of empathy and understanding at the completion of the interview along with a summary of the planned assessments and recommendations will facilitate the closure of the interview. Attentiveness, rapport, and collaboration characterize good medical interviewing techniques. Open-ended questions (“How are you doing?” “How are things at home?” “How does that make you feel?”) are generally desirable, particularly when they are coupled with good listening skills (46).


Gynecology_Novak

Gynecology_Novak. Premature closure of an interview and an inability to get complete information from the patient may occur for several reasons. They may result from failure to recognize the patient’s particular concern, from not providing appropriate opportunity for discussion, from the physician’s discomfort with sharing the patient’s emotion, or perhaps from the physician’s lack of confidence that he or she can deal with the patient’s concern. One of the principal factors undermining the success of the interview is lack of time. This is a realistic concern perceived by physicians, but skilled physicians can facilitate considerable interaction even in a short time by encouraging open communication (47).


Gynecology_Novak

Gynecology_Novak. Some patients lack accurate information about their illnesses. Incomplete or inadequate understanding of an illness can produce dissatisfaction with medical care and increased anxiety, distress, and coping difficulties, resulting in unsuccessful treatment and poor treatment response. As patients increasingly request more information about their illnesses and more involvement in decisions about their treatment, and as physicians attempt to provide more open interactive discussions, there is an even greater need to provide clear and effective communication. Although patients vary in their levels of intellectual finesse, medical sophistication, anxiety, denial, and ability to communicate, the unfortunate occurrence of impaired patient comprehension can be the product of poor physician communication techniques, lack of consultation time, and in some cases, the withholding of information considered detrimental to patient welfare (48).


Gynecology_Novak

Gynecology_Novak. If clinical findings or confirmatory testing strongly suggest a serious condition (e.g., malignancy), the gravity and urgency of this situation must be conveyed in a manner that does not unduly alarm or frighten the individual. Honest answers should be provided to any specific questions the patient may want to discuss (49,50).


Gynecology_Novak

Gynecology_Novak. Allowing time for questions is important, and scheduling a follow-up visit to discuss treatment options after the patient has an opportunity to consider the options and recommendations is often valuable. The patient should be encouraged to bring a partner or family member with her to provide moral support, to serve as another listener to absorb and digest the discussion, and to assist with questions. The patient should be encouraged to write down any questions or concerns she may have and bring them with her to a subsequent visit; important issues may not come to mind easily during an office visit. If the patient desires a second opinion, it should always be facilitated. Physicians should not feel threatened by patient attempts to gain information and knowledge.


Gynecology_Novak

Gynecology_Novak. Valuable information can be provided by interviews with ancillary support staff and by providing pamphlets and other materials produced for patient education. Some studies demonstrated that the use of pamphlets is highly effective in promoting an understanding of the condition and treatment options. Others showed that the use of audiotapes, videotapes, or information on an Internet site has a positive impact on knowledge and can decrease anxiety (51–53). There are numerous medical Web sites that can be accessed, although the accuracy of the information is variable and must be carefully reviewed by physicians before recommending sites to patients. Physicians should be familiar with Internet sources offering accurate information and be prepared to provide the addresses of these sites if the patient expresses interest (54).


Gynecology_Novak

Gynecology_Novak. The relationship between the patient and her physician, as with all aspects of social interaction, is subject to constant change. The state of our health is dynamic and it affects our ability to communicate with others, including conversations between patients and physicians. Open communication between patient and physician can help achieve maximum effectiveness in diagnosis, treatment, and compliance for all patients. Talk to the heart, speak to the soul. Look to the being and embrace the figure’s form. Reach deeply, with hands outstretched. Talk intently, to the seat of wisdom, as life resembles grace. Achieve peace within a fragile countenance. Seek the comfort of the placid hour know the other side of the ﬂesh’s frame.


Gynecology_Novak

Gynecology_Novak. Talk intently, to the seat of wisdom, as life resembles grace. Achieve peace within a fragile countenance. Seek the comfort of the placid hour know the other side of the ﬂesh’s frame. After a dialogue is established, the patient assessment proceeds with obtaining a complete history and performing a physical examination. Both of these aspects of the assessment rely on good patient–physician interchange and attention to details. During the history and physical examination, risk factors that may require special attention should be identified. These factors should be reviewed with the patient in developing a plan for her future care (see Chapter 8).


Gynecology_Novak

Gynecology_Novak. These factors should be reviewed with the patient in developing a plan for her future care (see Chapter 8). Depending on the setting—ambulatory office, inpatient hospitalization, or outpatient surgical center—record keeping is typically facilitated by forms or templates (either written or electronic), which provide prompts for important elements of the medical, family, and social history. Increasingly, electronic medical records are used in the office and hospital setting. One challenge is that paper and electronic records do not always “mesh,” and both paper and electronic records may be periodically unavailable. Efforts to develop patient-held medical records are not yet widely adopted.


Gynecology_Novak

Gynecology_Novak. History After the chief complaint and characteristics of the present illness are ascertained, the medical history of the patient should be obtained. It should include her complete medical and surgical history, her reproductive history (including menstrual and obstetric history), her current use of medications (including over-the-counter and complementary and alternative medications), and a thorough family and social history.


Gynecology_Novak

Gynecology_Novak. A technique for obtaining information about the present illness is presented in Table 1.5. The physician should consider which other members of the health care team might be helpful in completing the evaluation and providing care. Individuals who interact with the patient in the office—from the receptionists to medical assistants, nurses, advance practice nurses (nurse practitioners or nurse-midwives)—can contribute to the patient’s care and may provide additional information or insight or be appropriate clinicians for providing follow-up. In some teaching hospitals, residents or medical students may provide care and participate in an office setting. The role that each of these individuals plays in a given office or health care setting may not be apparent to the patient; care should be taken that each individual introduces her-or himself at the opening of the interaction and explains his or her role on the team. It may be necessary to discuss the roles and functions of each individual


Gynecology_Novak

Gynecology_Novak. that each individual introduces her-or himself at the opening of the interaction and explains his or her role on the team. It may be necessary to discuss the roles and functions of each individual member of the team. In some cases, referral to a nutritionist, physical or occupational therapist, social worker, psychologist, psychiatrist, or sex counselor would be helpful. Referral to or consultations with these clinicians and with physicians in other specialty areas should be addressed as needed. The nature of the relationship between the obstetrician/gynecologist and the patient should be clarified. Some women have a primary clinician whom they rely on for primary care. Other women, particularly healthy women of reproductive age, consider their obstetrician/gynecologist their primary clinician. The individual physician’s comfort with this role should be discussed and clarified at the initial visit and revisited periodically as required in the course of care. These issues are covered


Gynecology_Novak

Gynecology_Novak. The individual physician’s comfort with this role should be discussed and clarified at the initial visit and revisited periodically as required in the course of care. These issues are covered in Section III, Preventative and Primary Care (see Chapters 8–13). Laboratory testing for routine care and high-risk factors is presented in Chapter 8.


Gynecology_Novak

Gynecology_Novak. Physical Examination A thorough gynecologic physical examination is typically performed at the time of the initial visit, on a yearly basis, and as needed throughout the course of treatment (Table 1.6). The extent of the physical examination during the gynecologic visit is often dictated by the patient’s primary concerns and symptoms. For example, for healthy teens without symptoms who are requesting oral contraceptives before the initiation of intercourse, a gynecologic examination is not necessarily required. Some aspects of the examination—such as assessment of vital signs and measurement of height, weight, blood pressure, and calculation of a body mass index— should be performed routinely during most office visits. Typically, examination of the breasts and abdomen and a complete examination of the pelvis are considered to be essential parts of the gynecologic examination. It is often helpful to ask the patient if the gynecologic examination was difficult for her in the past; this


Gynecology_Novak

Gynecology_Novak. of the pelvis are considered to be essential parts of the gynecologic examination. It is often helpful to ask the patient if the gynecologic examination was difficult for her in the past; this may be true for women with a history of sexual abuse. For women who are undergoing their first gynecologic examination, it may be useful to ask what they have heard about the gynecologic examination or to state: “Most women are nervous before their first exam, but afterward, most describe it as ‘uncomfortable.’”


Gynecology_Novak

Gynecology_Novak. Abdominal Examination With the patient in the supine position, an attempt should be made to have her relax as much as possible. Her head should be leaned back and supported gently by a pillow so that she does not tense her abdominal muscles. Flexion of the knees may facilitate relaxation. The abdomen should be inspected for signs of an intra-abdominal mass, organomegaly, or distention that would, for example, suggest ascites or intestinal obstruction. Auscultation of bowel sounds, if deemed necessary to ascertain the nature of the bowel sounds, should precede palpation. The frequency of intestinal sounds and their quality should be noted. In a patient with intestinal obstruction, “rushes,” as well as the occasional high-pitched sound, can be heard. Bowel sounds associated with an ileus may occur less frequently but at the same pitch as normal bowel sounds.


Gynecology_Novak

Gynecology_Novak. The abdomen is palpated to evaluate the size and configuration of the liver, spleen, and other abdominal contents. Evidence of fullness or mass effect should be noted. This is particularly important in evaluating patients who may have a pelvic mass and in determining the extent of omental involvement, for example, with metastatic ovarian cancer. A fullness in the upper abdomen could be consistent with an “omental cake.” All four quadrants should be carefully palpated for any evidence of mass, firmness, irregularity, or distention. A systematic approach should be used (e.g., clockwise, starting in the right upper quadrant). Percussion should be used to measure the dimensions of the liver. The patient should be asked to inhale and exhale during palpation of the edge of the liver. Areas of tenderness should be evaluated after the examination of the rest of the abdomen.


Gynecology_Novak

Gynecology_Novak. Table 1.5 Technique of Taking the History of the Present Illness 1. The technique used in taking the history of the present illness varies with the patient, the patient’s problem, and the physician. Allow the patient to talk about her chief symptom. Although this symptom may or may not represent the real problem (depending on subsequent evaluation), it is usually uppermost in the patient’s mind and most often constitutes the basis for the visit to the physician. During the phase of the interview, establish the temporal relation of the chief symptom to the total duration of the illness. Questions such as, “Then up to the time of this symptom, you felt perfectly well?” may elicit other symptoms that may antedate the chief one by days, months, or years. In this manner, the patient may recall the date of the first appearance of illness. Encourage the patient to talk freely and spontaneously about her illness from the established date of onset. Do not interrupt the patient’s account,


Gynecology_Novak

Gynecology_Novak. the date of the first appearance of illness. Encourage the patient to talk freely and spontaneously about her illness from the established date of onset. Do not interrupt the patient’s account, except for minor promptings such as, “When did it begin?” and “How did it begin?,” which will help in developing chronologic order in the patient’s story. After the patient has furnished her spontaneous account (and before the next phase of the interview), it is useful to employ questions such as, “What other problems have you noticed since you became ill?” The response to this question may reveal other symptoms not yet brought forth in the interview.


Gynecology_Novak

Gynecology_Novak. Thus, in the first phase of the interview, the physician obtains an account of the symptoms as the patient experiences them, without any bias being introduced by the examiner’s direct questions. Information about the importance of the symptoms to the patient and the patient’s emotional reaction to her symptoms are also revealed.


Gynecology_Novak

Gynecology_Novak. 2. Because all available data regarding the symptoms are usually not elicited by the aforementioned techniques, the initial phase of the interview should be followed by a series of direct and detailed questions concerning the symptoms described by the patient. Place each symptom in its proper chronologic order and then evaluate each in accordance with the directions for analyzing a symptom. In asking direct questions about the details of a symptom, take care not to suggest the nature of the answer. This particularly refers to questions that may be answered “yes” or “no.” If a leading question should be submitted to the patient, the answer must be assessed with great care. Subject the patient to repeated cross-examination until you are completely satisfied that the answer is not given just to oblige you.


Gynecology_Novak

Gynecology_Novak. Finally, before dismissing the symptom under study, inquire about other symptoms that might reasonably be expected under the clinical circumstances of the case. Symptoms specifically sought but denied are known as negative symptoms. These negative symptoms may confirm or rule out diagnostic possibilities suggested by the positive symptoms. 3. The data secured by the techniques described in the first two phases of the interview should now suggest several diagnostic possibilities. Test these possibilities further by inquiring about other symptoms or events that may form part of the natural history of the suspected disease or group of diseases. 4.


Gynecology_Novak

Gynecology_Novak. 4. These techniques may still fail to reveal all symptoms of importance to the present illness, especially if they are remote in time and seemingly unrelated to the present problem. The review of systems may then be of considerable help in bringing forth these data. A positive response from the patient on any item in any of the systems should lead immediately to further detailed questioning. 5. Throughout that part of the interview concerning the present illness, consider the following factors: a.


Gynecology_Novak

Gynecology_Novak. 5. Throughout that part of the interview concerning the present illness, consider the following factors: a. The probable cause of each symptom or illness, such as emotional stress, infection, neoplasm. Do not disregard the patient’s statements of causative factors. Consider each statement carefully, and use it as a basis for further investigation. When the symptoms point to a specific infection, direct inquiry to water, milk, and foods eaten; exposure to communicable diseases, animals, or pets; sources of sexually transmitted disease; or residence or travel in the tropics or other regions where infections are known to exist. In each of the above instances, ascertain, if possible, the date of exposure, incubation period, and symptoms of invasion (prodromal symptoms). b.


Gynecology_Novak

Gynecology_Novak. b. The severity of the patient’s illness, as judged either by the presence of systemic symptoms, such as weakness, fatigue, loss of weight, or by a change in personal habits. The latter includes changes in sleep, eating, ﬂuid intake, bowel movements, social activities, exercise, or work. Note the dates the patient discontinued her work or took to bed. Is she continuously confined to bed? c. Determine the patient’s psychological reaction to her illness (anxiety, depression, irritability, fear) by observing how she relates her story as well as her nonverbal behavior. The response to a question such as, “Have you any particular theories about or fear of what may be the matter with you?” may yield important clues relative to the patient’s understanding and feeling about her illness. The reply may help in the management of the patient’s problem and allow the physician to give advice according to the patient’s understanding of her ailment.


Gynecology_Novak

Gynecology_Novak. Modified from Hochstein E, Rubin AL. Physical diagnosis. New York: McGraw-Hill, 1964:9–11, with permission. Table 1.6 Method of the Female Pelvic Examination The patient is instructed to empty her bladder. She is placed in the lithotomy position (Fig. 1.1) and draped properly. The examiner’s right or left hand, depending on his or her preference, is gloved. The pelvic area is illuminated well, and the examiner faces the patient. The following order of procedure is suggested for the pelvic examination: A. External genitalia 1. Inspect the mons pubis, labia majora, labia minora, perineal body, and anal region for characteristics of the skin, distribution of the hair, contour, and swelling. Palpate any abnormality. 2. Separate the labia majora with the index and middle fingers of the gloved hand and inspect the epidermal and mucosal characteristics and anatomic configuration of the following structures in the order indicated below: a. b. c. d. e. f. g. 3.


Gynecology_Novak

Gynecology_Novak. b. c. d. e. f. g. 3. If disease of the Skene glands is suspected, palpate the gland for abnormal excretions by milking the undersurface of the urethra through the anterior vaginal wall. Examine the expressed excretions by microscopy and cultures. If there is a history of labial swelling, palpate for a diseased Bartholin gland with the thumb on the posterior part of the labia majora and the index finger in the vaginal orifice. In addition, sebaceous cysts, if present, can be felt in the labia minora. B. Introitus With the labia still separated by the middle and index fingers, instruct the patient to bear down. Note the presence of the anterior wall of the vagina when a cystocele is present or bulging of the posterior wall when a rectocele or enterocele is present. Bulging of both may accompany a complete prolapse of the uterus. The supporting structure of the pelvic outlet is evaluated further when the bimanual pelvic examination is done. C. Vagina and cervix


Gynecology_Novak

Gynecology_Novak. The supporting structure of the pelvic outlet is evaluated further when the bimanual pelvic examination is done. C. Vagina and cervix Inspection of the vagina and cervix using a speculum should always precede palpation. The instrument should be warmed with tap water—not lubricated—if vaginal or cervical smears are to be obtained for the test or if cultures are to be performed. Select the proper size of speculum (Fig. 1.2), warmed and lubricated (unless contraindicated). Introduce the instrument into the vaginal orifice with the blades oblique, closed, and pressed against the perineum. Carry the speculum along the posterior vaginal wall, and after it is fully inserted, rotate the blades into a horizontal position and open them. Maneuver the speculum until the cervix is exposed between the blades. Gently rotate the speculum around its long axis until all surfaces of the vagina and cervix are visualized. 1. Inspect the vagina for the following: a. The presence of blood b.


Gynecology_Novak

Gynecology_Novak. 1. Inspect the vagina for the following: a. The presence of blood b. Discharge. This should be studied to detect trichomoniasis, monilia, and clue cells and to obtain cultures, primarily for gonococci and chlamydia. c. Mucosal characteristics (i.e., color, lesions, superficial vascularity, and edema) The lesion may be: 1. Inﬂammatory—redness, swelling, exudates, ulcers, vesicles 2. 3. 4. Pigmented—bluish discoloration of pregnancy (Chadwick’s sign) 5. Miscellaneous (e.g., endometriosis, traumatic lesions, and cysts) d. Table 1.6 (Continued ) 2. Inspect the cervix for the same factors listed above for the vagina. Note the following comments relative to the inspection of the cervix: a. Unusual bleeding from the cervical canal, except during menstruation, merits an evaluation for cervical or uterine neoplasia. b. Inﬂammatory lesions are characterized by a mucopurulent discharge from the os and redness, swelling, and superficial ulcerations of the surface. c.


Gynecology_Novak

Gynecology_Novak. b. Inﬂammatory lesions are characterized by a mucopurulent discharge from the os and redness, swelling, and superficial ulcerations of the surface. c. Polyps may arise either from the surface of the cervix projecting into the vagina or from the cervical canal. Polyps may be inﬂammatory or neoplastic. d. Carcinoma of the cervix may not dramatically change the appearance of the cervix or may appear as lesions similar in appearance to an inﬂammation. Therefore, a biopsy should be performed if there is suspicion of neoplasia. D.


Gynecology_Novak

Gynecology_Novak. D. The pelvic organs can be outlined by bimanual palpation; the examiner places one hand on the lower abdominal wall and the finger(s) (one or two) (see Fig. 1.3) of the other hand in the vagina (or vagina and rectum in the rectovaginal examination) (see Fig. 1.4). Either the right or left hand may be used for vaginal palpation. The number of fingers inserted into the vagina should be based on what can comfortably be accommodated, the size and pliability of the vagina, and the weight of the patient. For example, adolescent, slender, and older patients might be best examined with a single finger technique. 1. Introduce the well-lubricated index finger and, in some patients, both the index and the middle finger into the vagina at its posterior aspect near the perineum. Test the strength of the perineum by pressing downward on the perineum and asking the patient to bear down. This procedure may disclose a previously concealed cystocele or rectocele and descensus of the uterus.


Gynecology_Novak

Gynecology_Novak. Advance the fingers along the posterior wall until the cervix is encountered. Note any abnormalities of structure or tenderness in the vagina or cervix. 2. Press the abdominal hand, which is resting on the infraumbilical area, very gently downward, sweeping the pelvic structures toward the palpating vaginal fingers. Coordinate the activity of the two hands to evaluate the body of the uterus for: a. b. Architecture, size, shape, symmetry, tumor c. d. e. Tumors, if found, are evaluated for location, architecture, consistency, tenderness, mobility, and number. 3. Continue the bimanual palpation, and evaluate the cervix for position, architecture, consistency, and tenderness, especially on mobility of the cervix. Rebound tenderness should be noted at this time. The intravaginal fingers should then explore the anterior, posterior, and lateral fornices. 4.


Gynecology_Novak

Gynecology_Novak. 4. Place the “vaginal” finger(s) in the right lateral fornix and the “abdominal” hand on the right lower quadrant. Manipulate the abdominal hand gently downward toward the vaginal fingers to outline the adnexa. A normal tube is not palpable. A normal ovary (about 4 × 2 × 3 cm in size, sensitive, firm, and freely movable) is often not palpable. If an adnexal mass is found, evaluate its location relative to the uterus and cervix, architecture, consistency, tenderness, and mobility. 5. Palpate the left adnexal region, repeating the technique described previously, but place the vaginal fingers in the left fornix and the abdominal hand on the left lower quadrant. 6. Follow the bimanual examination with a rectovaginal–abdominal examination.


Gynecology_Novak

Gynecology_Novak. 6. Follow the bimanual examination with a rectovaginal–abdominal examination. Insert the index finger into the vagina and the middle finger into the rectum very gently. Place the other hand on the infraumbilical region. The use of this technique makes possible higher exploration of the pelvis because the cul-de-sac does not limit the depth of the examining finger. 7. In patients who have an intact hymen, examine the pelvic organs by the rectal–abdominal technique. Table 1.6 (Continued ) E. Rectal examination 1. Inspect the perianal and anal area, the pilonidal (sacrococcygeal) region, and the perineum for the following aspects: a. Color of the region (note that the perianal skin is more pigmented than the surrounding skin of the buttocks and is frequently thrown into radiating folds) b. 1. The perianal and perineal regions are common sites for itching. Pruritus ani is usually indicated by thickening, excoriations, and eczema of the perianal region and adjacent areas. 2.


Gynecology_Novak

Gynecology_Novak. 1. The perianal and perineal regions are common sites for itching. Pruritus ani is usually indicated by thickening, excoriations, and eczema of the perianal region and adjacent areas. 2. The anal opening often is the site of fissures, fistulae, and external hemorrhoids. 3. The pilonidal area may present a dimple, a sinus, or an inﬂamed pilonidal cyst. 2. Instruct the patient to “strain down” and note whether this technique brings into view previously concealed internal hemorrhoids, polyps, or a prolapsed rectal mucosa. 3. Palpate the pilonidal area, the ischiorectal fossa, the perineum, and the perianal region before inserting the gloved finger into the anal canal. Note the presence of any concealed induration or tenderness in any of these areas. 4.


Gynecology_Novak

Gynecology_Novak. 4. Palpate the anal canal and rectum with a well-lubricated, gloved index finger. Lay the pulp of the index finger against the anal orifice and instruct the subject to strain downward. Concomitant with the patient’s downward straining (which tends to relax the external sphincter muscle), exert upward pressure until the sphincter is felt to yield. Then, with a slight rotary movement, insinuate the finger past the anal canal into the rectum. Examine the anal canal systematically before exploring the rectum. 5. Evaluate the anal canal for: a. Tonus of the external sphincter muscle and the anorectal ring at the anorectal junction b. Tenderness (usually caused by a tight sphincter, anal fissure, or painful hemorrhoids) c. Tumor or irregularities, especially at the pectinate line d. Superior aspect: Reach as far as you can. Mild straining by the patient may cause some lesions, which are out of reach of the finger, to descend sufficiently low to be detected by palpation. e.


Gynecology_Novak

Gynecology_Novak. Superior aspect: Reach as far as you can. Mild straining by the patient may cause some lesions, which are out of reach of the finger, to descend sufficiently low to be detected by palpation. e. Test for occult blood: Examine the finger after it is withdrawn for evidence of gross blood, pus, or other alterations in color or consistency. Smear the stool to test for occult blood (guaiac). 6. Evaluate the rectum: a. Anterior wall 1. Cervix: size, shape, symmetry, consistency, and tenderness, especially on manipulation 2. 3. In patients with an intact hymen, the examination of the anterior wall of the rectum is the usual method of examining the pelvic organs. b. Right lateral wall, left lateral wall, posterior wall, superior aspect; test for occult blood Modified from Hochstein E, Rubin AL. Physical diagnosis. New York: McGraw-Hill, 1964:342–353, with permission.


Gynecology_Novak

Gynecology_Novak. Modified from Hochstein E, Rubin AL. Physical diagnosis. New York: McGraw-Hill, 1964:342–353, with permission. Pelvic Examination The pelvic examination is usually performed with the patient in the dorsal lithotomy position (Fig. 1.1). The patient’s feet should rest comfortably in stirrups with the edge of the buttocks at the lower end of the table so that the vulva can be readily inspected and the speculum can be inserted in the vagina without obstruction from the table. Raising the head of the examination table, if possible, may facilitate relaxation. Drapes should be placed to provide a measure of cover for the patient’s legs but should be depressed over the abdomen to allow observation of the patient’s expression and to facilitate communication. Before each step of the examination, the patient should be informed of what she will feel next: “First you’ll feel me touch your inner thighs; next I’ll touch the area around the outside of your


Gynecology_Novak

Gynecology_Novak. Before each step of the examination, the patient should be informed of what she will feel next: “First you’ll feel me touch your inner thighs; next I’ll touch the area around the outside of your Figure 1.1 The lithotomy position for the pelvic examination.


Gynecology_Novak

Gynecology_Novak. vagina.” The vulva and perineal area should be carefully inspected. Evidence of any lesions, erythema, pigmentation, masses, or irregularity should be noted. The skin quality should be noted as well as any signs of trauma, such as excoriations or ecchymosis. Areas of erythema or tenderness are noted, particularly in women with vulvar burning or pain, as might be seen with vulvar vestibulitis or localized provoked vulvodynia. The presence of any visible lesions should be quantitated and carefully described with regard to their full appearance and characteristics on palpation (i.e., mobility, tenderness, consistency). A drawing of the location of skin lesions is helpful. Ulcerative or purulent lesions of the vulva should be evaluated and cultured as outlined in subsequent chapters, and biopsy should be performed on any lesions. It may be helpful to ask the patient if she is aware of any vulvar lesions and to offer a mirror to demonstrate any lesions.


Gynecology_Novak

Gynecology_Novak. After thorough visualization and palpation of the external genitalia, including the mons pubis and the perianal area, a speculum is inserted into the vagina. In a healthy adult who is sexually active, a Pederson speculum typically is used. The types of specula that are used in gynecology are presented in Figure 1.2. Figure 1.2 Vaginal specula: 1, Graves extra long; 2, Graves regular; 3, Pederson extra long; 4, Pederson regular; 5, Huffman “virginal”; 6, pediatric regular; and 7, pediatric narrow. The smallest width speculum necessary to produce adequate visualization should be used.


Gynecology_Novak

Gynecology_Novak. The larger Graves speculum may be required in women who have lax vaginal walls, are pregnant, or will be undergoing cervical or endometrial biopsies or procedures. In some women, a longer speculum (either Pederson or Graves) may facilitate visualization of the cervix in a manner that is less uncomfortable to the patient. If any speculum other than the typically sized specula is used, the patient should be informed and encouraged to remind the clinician before her next examination. The speculum should be warmed before it is inserted into the vagina; a heating pad or speculum warmer should be placed under the supply of specula. If lubrication is required, warm water generally is sufficient or a small amount of lubricant can be used without interfering with cervical cytology testing. The patient should be asked to relax the muscles of her distal vagina before the insertion of the speculum to facilitate the placement and to avoid startling her by this portion of the examination. After


Gynecology_Novak

Gynecology_Novak. patient should be asked to relax the muscles of her distal vagina before the insertion of the speculum to facilitate the placement and to avoid startling her by this portion of the examination. After insertion, the cervix and all aspects of the vagina should be carefully inspected. Particular attention should be paid to the vaginal fornices, because lesions (e.g., warts) may be present in those areas and may not be readily visualized.


Gynecology_Novak

Gynecology_Novak. The appropriate technique and frequency for cervical cytology testing is presented in Chapter 19. Biopsy should be performed on any obvious lesions on the cervix or in the vagina. An endometrial biopsy usually is performed with a ﬂexible cannula or a Novak curette (see Chapter 14). Any purulence in the vagina or cervix should be cultured (see Chapter 18). Testing for sexually transmitted diseases should be performed routinely in adolescents and young adults as recommended by the Centers for Disease Control and Prevention.


Gynecology_Novak

Gynecology_Novak. After the speculum is removed and the pelvis palpated, lubrication is applied to the examination glove, and one or two (the index or index and middle) fingers are inserted gently into the vagina. In general, in right-handed physicians, the fingers from the right hand are inserted into the vagina and the left hand is placed on the abdomen to provide counter-pressure as the pelvic viscera are moved (Fig. 1.3). In patients with pelvic pain, a stepwise “functional pelvic examination” involves the sequential palpation of anatomic structures, including the pelvic ﬂoor muscles, bladder, rectum, cervix, and cul-de-sac. These areas are assessed for tenderness and a specific source of pain. Pelvic ﬂoor muscle spasm is a common concomitant of pelvic pain. The vagina, its fornices, and the cervix are palpated carefully for any masses or irregularities. One or two fingers are placed gently into the posterior fornix so the uterus can be moved. With the abdominal hand in place, the uterus usually


Gynecology_Novak

Gynecology_Novak. palpated carefully for any masses or irregularities. One or two fingers are placed gently into the posterior fornix so the uterus can be moved. With the abdominal hand in place, the uterus usually can be palpated just above the surface pubis. In this manner, the size, shape, mobility, contour, consistency, and position of the uterus are determined. The patient is asked to provide feedback about any areas of tenderness, and her facial expressions are observed during the examination.


Gynecology_Novak

Gynecology_Novak. Figure 1.3 The bimanual examination. The adnexa are palpated gently on both sides, paying particular attention to any enlargements. Again, the size, shape, mobility, and consistency of any adnexal structures should be carefully noted. When indicated, a rectovaginal examination should be performed to evaluate the rectovaginal septum, the posterior uterine surface, the adnexal structures, the uterosacral ligaments, and the posterior cul-de-sac. Uterosacral nodularity or posterior uterine tenderness associated with pelvic endometriosis or cul-de-sac implants of ovarian cancer can be assessed in this manner. Hemorrhoids, anal fissures, sphincter tone, rectal polyps, or carcinoma may be detected. A single stool sample for fecal occult blood testing obtained in this manner is not adequate for the detection of colorectal cancer and is not recommended (55) (Fig. 1.4).


Gynecology_Novak

Gynecology_Novak. At the completion of the physical examination, the patient should be informed of the findings. When the results of the examination are normal, the patient can be reassured accordingly. When there is a possible abnormality, the patient should be informed immediately; this discussion should take place after the examination with the patient clothed. A plan to evaluate the findings should be outlined brieﬂy and in clear, understandable language. Figure 1.4 The rectovaginal examination. The implications and timing of any proposed procedure (e.g., biopsy) should be discussed, and the patient should be informed when the results of any tests will be available.


Gynecology_Novak

Gynecology_Novak. The implications and timing of any proposed procedure (e.g., biopsy) should be discussed, and the patient should be informed when the results of any tests will be available. Pediatric Patients A careful examination is indicated when a child presents with genital symptoms such as itching, discharge, burning with urination, or bleeding. The examiner should be familiar with the normal appearance of the prepubertal genitalia. The normal unestrogenized hymenal ring and vestibule can appear mildly erythematous. The technique of examination is different from that used for examining an adult and may need to be tailored to the individual child based on her age, size, and comfort with the examiner.


Gynecology_Novak

Gynecology_Novak. A speculum examination should not be performed in a prepubertal child in the office. A young child usually can be examined best in a “frog leg” or “butterﬂy leg” position on the examining table. Some very young girls (toddlers or infants) do best when held in their mother’s arms. Sometimes, the mother can be positioned, clothed, on the examination table (feet in stirrups, head of table elevated) with the child on her lap, the child’s legs straddling her mother’s legs. The knee-chest position may be helpful for the examination (56). The child who is relaxed and warned about touching will usually tolerate the examination satisfactorily. An otoscope can be used to examine the distal vagina if indicated. Two percent lidocaine jelly may be used as a topical anesthetic to facilitate the examination if needed.


Gynecology_Novak

Gynecology_Novak. Some children who were abused, who had particularly traumatic previous examinations, or who are unable to allow an examination may need to be examined under anesthesia, although a gentle office examination should almost always be attempted first. If the child had bleeding and no obvious cause of bleeding is visible externally or within the distal vagina, an examination under anesthesia is indicated to visualize the vagina and cervix completely. A hysteroscope, cytoscope, or other endoscopic instrument can be used to provide magnification and as a light source for vaginoscopy, which should be performed under anesthesia.


Gynecology_Novak

Gynecology_Novak. Adolescent Patients A pelvic examination may be less revealing in an adolescent than in an older woman, particularly if it is the patient’s first examination or if it takes place on an emergency basis. An adolescent who presents with excessive bleeding should have a pelvic examination if she had intercourse, if the results of a pregnancy test are positive, if she has abdominal pain, if she is markedly anemic, or if she is bleeding heavily enough to compromise hemodynamic stability. The pelvic examination occasionally may be deferred in young teenagers who have a classic history of irregular cycles soon after menarche, who have normal hematocrit levels, who deny sexual activity, and who will reliably return for follow-up. A pelvic examination may be deferred in adolescents who present to the office requesting oral contraceptives before the initiation of intercourse or at the patient’s request, even if she has had intercourse. Newer testing methods using DNA amplification techniques


Gynecology_Novak

Gynecology_Novak. the office requesting oral contraceptives before the initiation of intercourse or at the patient’s request, even if she has had intercourse. Newer testing methods using DNA amplification techniques allow noninvasive urine testing for gonorrhea and chlamydia (57). Current guidelines recommend that cervical cytology testing in most adolescents be initiated at age 21 (58).


Gynecology_Novak

Gynecology_Novak. Other diagnostic techniques (such as pelvic ultrasound) can substitute for or supplement an inadequate examination. An examination usually is required when there is a question of pelvic pain, genital anomaly, pregnancy-related condition, or possibility of pelvic infection. The keys to a successful examination in an adolescent lie in earning the patient’s trust, explaining the components of her examination, performing only the essential components, and using a very careful and gentle technique. It is helpful to ascertain whether the patient had a previous pelvic examination, how she perceived the experience, and what she heard about a pelvic examination from her mother or friends.


Gynecology_Novak

Gynecology_Novak. Before a first pelvic examination is performed, a brief explanation of the planned examination (which may or may not need to include a speculum), instruction in relaxation techniques, and the use of lidocaine jelly as a lubricant can be helpful. The patient should be encouraged to participate in the examination by voluntary relaxation of the introital muscles or by using a mirror if she wishes. If significant trauma is suspected or the patient finds the examination too painful and is truly unable to cooperate, an examination under anesthesia may be necessary. The risks of general anesthesia must be weighed against the value of information that would be obtained by the examination.


Gynecology_Novak

Gynecology_Novak. Confidentiality is an important issue in adolescent health care. A number of medical organizations, including the American Medical Association, the American Academy of Pediatrics, and the American College of Obstetrics and Gynecologists, endorsed adolescents’ rights to confidential medical care. Particularly with regard to issues as sensitive as sexual activity, it is critical that the adolescent be interviewed alone, without a parent in the room. The patient should be asked whether she engaged in sexual intercourse, whether she used any method of contraception, used condoms to minimize the risks of sexually transmitted diseases, or she feels there is any possibility of pregnancy.


Gynecology_Novak

Gynecology_Novak. Follow-Up Arrangements should be made for the ongoing care of patients, regardless of their health status. Patients with no evidence of disease should be counseled regarding health behaviors and the need for routine care. For those with signs and symptoms of a medical disorder, further assessments and a treatment plan should be discussed. The physician must determine whether she or he is equipped to treat a particular problem or whether the patient should be directed to another health professional, either in obstetrics and gynecology or another specialty, and how that care should be coordinated. If the physician believes it is necessary to refer the patient elsewhere for care, the patient should be reassured that this measure is being undertaken in her best interests and that continuity of care will be ensured. Patients deserve a summary of the findings of the visit, recommendations for preventive care and screening, an opportunity to ask any additional questions, and a recommendation


Gynecology_Novak

Gynecology_Novak. care will be ensured. Patients deserve a summary of the findings of the visit, recommendations for preventive care and screening, an opportunity to ask any additional questions, and a recommendation for the frequency of any follow-up or ongoing care visits.


Gynecology_Novak

Gynecology_Novak. The management of patients’ gynecologic symptoms, and abnormal findings and signs detected during examination, requires the full use of a physician’s skills and knowledge. Physicians are challenged to practice the art of medicine in a manner that leads to effective alliances with their patients. The value of skilled medical history taking cannot be overemphasized. Physicians should listen carefully to what patients are saying about the nature and severity of their symptoms. They should listen to what patients may not be expressing: their fears, anxieties, and personal experiences that lead them to react in a certain manner when faced with what is often, to them, a crisis (such as the diagnosis of an abnormality on examination, laboratory testing, or pelvic imaging).


Gynecology_Novak

Gynecology_Novak. Physicians should supplement their formal education and clinical experience by constantly seeking valid new information and honing their communication skills. To meet the challenges posed by the complexities of patient care, physicians must learn to practice evidence-based medicine, derived from the very latest data of highest quality. Computers make the world of information management accessible to both physicians and patients. Physicians need to search the medical literature to acquire knowledge that can be applied, using the art of medicine, to patient care that maintains health, prevents disease, alleviates suffering, and manages and cures illness. 1. Simpson M, Buckman R, Stewart M, et al. Doctor-patient communication: the Toronto consensus statement. BMJ 1991:303:1385–1387. 2. Ley P. Communicating with patients. London: Croom Helm, 1988. 3. Butt HR. A method for better physician-patient communication. Ann Intern Med 1977;86:478–480. 4.


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Gynecology_Novak. 2. Ley P. Communicating with patients. London: Croom Helm, 1988. 3. Butt HR. A method for better physician-patient communication. Ann Intern Med 1977;86:478–480. 4. Lipkin M. The medical interview and related skills. In: Branch W, ed. Office practice of medicine. Philadelphia: Saunders, 1987:1287– 1306. 5. Omar H, Richard J. Cultural sensitivity in providing reproductive care to adolescents. Curr Opin Obstet Gynecol 2004;16:367–370. 6. Lang F, Floyd MR, Beine KL, et al. Sequenced questioning to elicit the patient’s perspective on illness: effects on information disclosure, patient satisfaction, and time expenditure. Fam Med 2002;34:325. 7. Beck RS, Daughtridge R, Sloane PD. Physician-patient communication in the primary care office: a systematic review. J Am Board Fam Pract 2002;15:25–38. 8. Lipkin M Jr. Physician-patient interaction in reproductive counseling. Obstet Gynecol 1996;88:31S–40S. 9.


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Gynecology_Novak. 8. Lipkin M Jr. Physician-patient interaction in reproductive counseling. Obstet Gynecol 1996;88:31S–40S. 9. Branch WT, Malik TK. Using “windows of opportunities” in brief interviews to understand patients’ concerns. JAMA 1993;269:1667– 1668. 10. Shenolikar RA, Balkrishnan R, Hall MA. How patient-physician encounters in critical medical situations affect trust: results of a national survey. BMC Health Serv Res 2004;4:24. 11. Flores G. Language barriers to health care in the United States. N Engl J Med 2006;355:229–231. 12. Ngo-Metzger Q, Sorkin DH, Phillips RS, et al. Providing high-quality care for limited English proficient patients: the importance of language concordance and interpreter use. J Gen Intern Med 2007;22(Suppl 2):324–330. 13. California State Legislature. California Health and Safety Code, in Section 1259. Available at ONECLE: http://law.onecle.com/ california/health/1259.html 14.


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Gynecology_Novak. 13. California State Legislature. California Health and Safety Code, in Section 1259. Available at ONECLE: http://law.onecle.com/ california/health/1259.html 14. Lie D, Bereknyei S, Braddock CH 3rd, et al. Assessing medical students’ skills in working with interpreters during patient encounters: a validation study of the Interpreter Scale. Acad Med 2009;84:643–650. 15. Lo B, Dornbrand L, Dubler NN. HIPAA and patient care: the role for professional judgment. JAMA 2005;293:1766–1771. 16. Angelos P. Compliance with HIPAA regulations: ethics and excesses. Thorac Surg Clin 2005;15:513–518. 17. Mishler EG, Clark JA, Ingelfinger J, et al. The language of attentive patient care: a comparison of two medical interviews. J Gen Intern Med 1989;4:325–335. 18. Conti AA, Gensini GF. Doctor-patient communication: a historical overview. Minerva Med 2008;99:411–415. 19.


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Gynecology_Novak. 18. Conti AA, Gensini GF. Doctor-patient communication: a historical overview. Minerva Med 2008;99:411–415. 19. Kim J, Kim S. Physicians’ perception of the effects of Internet health information on the doctor-patient relationship. Inform Health Soc Care 2009;34:136–148. 20. The Headache Study Group of The University of Western Ontario. Predictors of outcome in headache patients presenting to family physicians—a one year prospective study. Headache 1986;26:285– 294. 21. Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989;27(Suppl):S110–127. 22. Fallowfield L, Hall A, Maguire GP, et al. Psychological outcomes in women with early breast cancer. BMJ 1990;301:1394. 23.


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Gynecology_Novak. 22. Fallowfield L, Hall A, Maguire GP, et al. Psychological outcomes in women with early breast cancer. BMJ 1990;301:1394. 23. Walter FM, Emery JD, Rogers M, et al. Women’s views of optimal risk communication and decision making in general practice consultations about the menopause and hormone replacement therapy. Patient Educ Couns 2004;53:121–128. 24. Spender D. Man made language. New York: Routledge & Kegan Paul, 1985. 25. Tannen D. You just don’t understand: women and men in conversation. New York: Ballantine, 1990. 26. West C. Reconceptualizing gender in physician-patient relationships. Soc Sci Med 1993;36:57–66. 27. Todd A, Fisher S. The social organization of doctor-patient communication, 2nd ed. Norwood, NJ: Ablex, 1993. 28. Adams KE. Patient choice of provider gender. J Am Med Womens Assoc 2003;58:117–119. 29.


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Gynecology_Novak. 28. Adams KE. Patient choice of provider gender. J Am Med Womens Assoc 2003;58:117–119. 29. Plunkett BA, Kohli P, Milad MP. The importance of physician gender in the selection of an obstetrician or a gynecologist. Am J Obstet Gynecol 2002;186:926–928. 30. Roter D, Lipkin M, Korsgaard A. Sex differences in patients’ and physicians’ communication during primary care medical visits. Med Care 1991;29:1083–1093. 31. Roter DL, Hall JA. Why physician gender matters in shaping the physician-patient relationship. J Womens Health 1998;7:1093– 1097. 32. Lurie N, Slater J, McGovern P, et al. Preventive care for women. Does the sex of the physician matter? N Engl J Med 1993;329:478– 482. 33. Sandhu H, Adams A, Singleton L, et al. The impact of gender dyads on doctor-patient communication: a systematic review. Patient Educ Couns 2009;76:348–355. 34. Bertakis KD. The inﬂuence of gender on the doctor-patient interaction. Patient Educ Couns 2009;76:356–360. 35.


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Gynecology_Novak. 34. Bertakis KD. The inﬂuence of gender on the doctor-patient interaction. Patient Educ Couns 2009;76:356–360. 35. Donovan JL. Patient decision making. The missing ingredient in compliance research. Int J Technol Assess Health Care 1995;11: 443–455. 36. Haynes RB, Taylor DW, Sackett DL. Compliance in health care. Baltimore: Johns Hopkins University Press, 1979. 37. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353:487–497. 38. Association of Reproductive Health Professionals. Helping women make choices that facilitate successful contraceptive use. Clinical proceedings: periodic well-woman visit 2004 April. Available online at: http://www.arhp.org/healthcareproviders/cme/onlinecme/wellwoman/ helpingwomen.cfm 39. Erhardt LR. The essence of effective treatment and compliance is simplicity. Am J Hypertens 1999;12(Pt 2):105S–110S. 40.


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Gynecology_Novak. Erhardt LR. The essence of effective treatment and compliance is simplicity. Am J Hypertens 1999;12(Pt 2):105S–110S. 40. Krueger KP, Felkey BG, Berger BA. Improving adherence and persistence: a review and assessment of interventions and description of steps toward a national adherence initiative. J Am Pharm Assoc 2003;43:668–678; quiz 678–679. 41. Parker RM, Williams MV, Baker DW, et al. Literacy and contraception: exploring the link. Obstet Gynecol 1996;88:72S–77S. 42. Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care 2009;47:826–834. 43. Cousins N. The laughter connection. In: Cousins N, ed. Head first: the biology of hope and the healing power of the human spirit.New York: Penguin, 1989:125–153. 44. Wender RC. Humor in medicine. Prim Care 1996;23:141–154. 45. Epstein RM, Alper BS, Quill TE. Communicating evidence for participatory decision making. JAMA 2004;291:2359–2366. 46.


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Gynecology_Novak. 44. Wender RC. Humor in medicine. Prim Care 1996;23:141–154. 45. Epstein RM, Alper BS, Quill TE. Communicating evidence for participatory decision making. JAMA 2004;291:2359–2366. 46. Good RS. The third ear. Interviewing techniques in obstetrics and gynecology. Obstet Gynecol 1972;40:760–762. 47. Levinson W, Chaumeton N. Communication between surgeons and patients in routine office visits. Surgery 1999;125:127–134. 48. Dunn SM, Butow PN, Tattersall MH, et al. General information tapes inhibit recall of the cancer consultation. J Clin Oncol 1993;11:2279–2285. 49. Baile WF, Kudelka AP, Beale EA, et al. Communication skills training in oncology. Description and preliminary outcomes of workshops on breaking bad news and managing patient reactions to illness. Cancer 1999;86:887–897. 50. Maguire P, Faulkner A. Improve the counselling skills of doctors and nurses in cancer care. BMJ 1988;297:847–849. 51.


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Gynecology_Novak. 50. Maguire P, Faulkner A. Improve the counselling skills of doctors and nurses in cancer care. BMJ 1988;297:847–849. 51. Dunn RA, Webster LA, Nakashima AK, et al. Surveillance for geographic and secular trends in congenital syphilis—United States, 1983–1991. MMWR CDC Surveill Summ 1993;42:59–71. 52. Elkjaer M, Burisch J, Avnstrøm S, et al. Development of a web-based concept for patients with ulcerative colitis and 5-aminosalicylic acid treatment. Eur J Gastroenterol Hepatol 2010;22:695–704. 53. O’Conner-Von S. Preparation of adolescents for outpatient surgery: using an Internet program. AORN J 2008;87:374–398. 54. Ilic D. The role of the internet on patient knowledge management, education, and decision-making. Telemed J E Health 2010;16:664– 669. 55. ACOG Editorial Committee for Guidelines for Women’s Health Care, ed. Guidelines for women’s health care: a resource manual, 3rd ed. ACOG: Washington, DC: ACOG, 2007:573. 56.


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Gynecology_Novak. 55. ACOG Editorial Committee for Guidelines for Women’s Health Care, ed. Guidelines for women’s health care: a resource manual, 3rd ed. ACOG: Washington, DC: ACOG, 2007:573. 56. Emans SJ, Laufer MR, Goldstein DP. Pediatric and adolescent gynecology, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2005:1076. 57. Spigarelli MG. Urine gonococcal/Chlamydia testing in adolescents. Curr Opin Obstet Gynecol 2006;18:498–502. 58. ACOG Committee. Opinion No. 431: routine pelvic examination and cervical cytology screening. Obstet Gynecol 2009;113:1190–1193. Principles of Patient Care Joanna M. Cain Professionalism is the foundation of patient care and is as much an ongoing educational endeavor as learning new procedures or techniques. The right to privacy prohibits a physician from revealing information regarding the patient unless the patient waives that privilege.


Gynecology_Novak

Gynecology_Novak. The right to privacy prohibits a physician from revealing information regarding the patient unless the patient waives that privilege. Informed consent is a process whereby the physician educates the patient about the medical condition, explores her values, and informs her about the risks and benefits of treatment and reasonable medical alternatives. The concept of autonomy does not allow a patient’s wishes to take precedence over good medical judgment. For children, parents are the surrogate decision makers, except in circumstances in which the decision is life threatening and might not be the choice a child would make later, when adult beliefs and values are formed. Creating a highly professional environment of safe culture, lack of harassment, high professional behavior standards, and disclosure of unexpected outcomes benefits both patients and health professionals.


Gynecology_Novak

Gynecology_Novak. The practice of gynecology, as with all branches of medicine, is based on ethical principles that guide patient care. These principles and concepts create a framework for ethical decision making that applies to all aspects of practice: Autonomy: a person’s right to self-rule, to establish personal norms of conduct, and to choose a course of action based on a set of personal values and principles derived from them Confidentiality: a person’s right to decide how and to whom personal medical information will be communicated is part of autonomy Beneficence: the obligation to promote the well-being of others or, in medicine, to benefit the patient through meeting a goal of medicine by the care offered Covenant: a binding agreement between two or more parties for the performance of some action Fiduciary Relationship: a relationship founded on faith and trust and the obligation to act in a trustworthy manner


Gynecology_Novak

Gynecology_Novak. Fiduciary Relationship: a relationship founded on faith and trust and the obligation to act in a trustworthy manner Informed Consent: the patient’s acceptance of a medical intervention after adequate discussion and consideration of the nature of the procedure, its risks and benefits, and alternatives Justice: the right of individuals or groups to claim what is due to them based on certain personal properties or characteristics Maleficence: the act of committing harm (Nonmaleficence obliges one to avoid doing harm) Patient and Physician: Professionalism


Gynecology_Novak

Gynecology_Novak. Health care providers fulfill a basic need—to preserve and advance the health of human beings. Despite the challenges imposed by the commercial aspects of the current medical environment, for most physicians, the practice of medicine remains very much a “calling,” a giving of oneself to the greater good. The behavior of health professionals is judged against this list of ethical principles and concepts by other professionals and the public who share the belief in the “calling” of medicine. There are examples of unprofessional behaviors that mar this professional image. They are demonstrably easier to see in others than ourselves, including unprofessionalism in relation to drug companies, shouting at or mistreating others, or inappropriate behaviors with students, patients or colleagues, that abuse professional standing such as boundary violations or learner abuse (1). Lapses do not always represent inherent ﬂaws in professionals, “most lapses represent deficiencies in judgment and


Gynecology_Novak

Gynecology_Novak. that abuse professional standing such as boundary violations or learner abuse (1). Lapses do not always represent inherent ﬂaws in professionals, “most lapses represent deficiencies in judgment and skill. They occur when the physician in question fails to recognize the presence of a challenge to professionalism or lacks the skill to handle a challenge at the time it occurs” (2). As Lucey and Souba note, the solution to unprofessional behavior is not recrimination but development of a set of skills that allow professionals to recognize and address these professional challenges—and those skills need to be developed and reinforced not just by individuals but by the whole community of practicing physicians throughout their professional careers (2). Professionalism is as much an ongoing educational endeavor as is learning new procedures or techniques, and “we should assume that our peers want to be professional and that they will welcome interventions from a trusted colleague when


Gynecology_Novak

Gynecology_Novak. educational endeavor as is learning new procedures or techniques, and “we should assume that our peers want to be professional and that they will welcome interventions from a trusted colleague when circumstances suggest that a lapse is imminent” (2). Creating an environment where we can help one another in this way improves the quality and safety of the care for our patients by preventing unprofessional behavior. An environment without fear of recrimination, harassment, or unprofessional behavior promotes speaking up for patients’ interests and promotes safer environments for everyone. It is a fundamental principle of excellence in patient care.


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Gynecology_Novak. Professionalism has to balance the differences of fiduciary and contractual relationships between physician and patient:“The kind of minimalism that a contractualist understanding of the professional relationship encourages produces a professional too grudging, too calculating, too lacking in spontaneity, too quickly exhausted to go the second mile with his patients along the road of their distress” (3). There is a relationship between physician and patient that extends beyond a contract and assumes the elements of a fiduciary relationship—a covenant between parties. The physician, having knowledge about the elements of health care, assumes a trust relationship with the patient where her interests are held paramount. Both the patient and the physician have rights and responsibilities in this relationship, and both are rewarded when those rights and responsibilities are upheld. Honesty, disclosure, confidentiality, and informed consent are expressions of that trust or covenantal


Gynecology_Novak

Gynecology_Novak. in this relationship, and both are rewarded when those rights and responsibilities are upheld. Honesty, disclosure, confidentiality, and informed consent are expressions of that trust or covenantal relationship.


Gynecology_Novak

Gynecology_Novak. In creating a trustworthy and safe environment, disclosure of unanticipated outcomes can add to the trust patients have in their health care team and ensure that all medical errors or near misses are used to improve the environment of care. If we are obligated as professionals by our trust relationship with our patients, then patients should expect truthfulness, including being made aware of individual or systemic errors, which, as Kohn et al. noted in To Err Is Human, are inevitable in the delivery of health care (4). The climate of no-fault discussion of errors creates an environment conducive to restructuring the systems or procedures that make it possible for errors to occur and is critical in development of a safety culture.


Gynecology_Novak

Gynecology_Novak. Medical errors can create a keen sense of shame, humiliation, and failed responsibility in health professionals, and efforts have begun to identify and develop the skills and methods for disclosing and learning from them (5). Support for individuals facing these feelings and wanting to disclose is critical in this development. Skills that seem common to disclosure are: telling the medical facts, honesty and truthfulness (responsibility and answering questions), empathy (and apology), stating how future errors will be prevented, and using good communication skills (6). These are skills that require training and development and should not be taken for granted. Many institutions have risk management groups or other support groups that can be helpful in development of skills and can accompany or lead such a discussion in the absence of those skills. Disclosure and apology cause apprehension for physicians—particularly in the discipline of obstetrics and gynecology where litigation


Gynecology_Novak

Gynecology_Novak. or lead such a discussion in the absence of those skills. Disclosure and apology cause apprehension for physicians—particularly in the discipline of obstetrics and gynecology where litigation adversely affected practice patterns (defensive medicine) and heightened a reluctance to disclose medical errors for fear of litigation (7). It is interesting to note that open disclosure overall generated less litigation than failing to disclose, and the growth of compensation with disclosure seems to add to this decrease (8– 12). Apology raises particular anxiety about implying culpability and inciting litigation, so help with framing an apology is always appropriate. The obligation of trust (fiduciary relationship) that we have with our patients is part of the healing aspects of medicine—and we owe it to our patients and to ourselves to develop the robust curricula and support at all levels of medicine to make disclosure the step toward solution and healing that it can be for both physician


Gynecology_Novak

Gynecology_Novak. owe it to our patients and to ourselves to develop the robust curricula and support at all levels of medicine to make disclosure the step toward solution and healing that it can be for both physician and patient.


Gynecology_Novak

Gynecology_Novak. Confidentiality The patient seeking assistance from a health professional has the right to assurance that the information exchanged during that interaction is kept private. Privacy is essential to the trust relationship between doctor and patient. Discussions are privileged information. The right to privacy prohibits a physician from revealing information regarding the patient unless the patient waives that privilege. Privileged information belongs to the patient except when it impinges on the legal and ethical rights of institutions and society at large, regardless of the setting. In a court situation, for example, physicians cannot reveal information about their patients unless the patient waives that privilege. If privilege is waived, the physician may not withhold such testimony.