The Pelvic Exam

I am not exaggerating when I say that for some of my colleagues, yesterday was the most terrifying day of their medical school careers (or perhaps lives).  For most of us men, this was the first time we experienced the female anatomy in a 100% medical and professional manner, firsthand; and for others, it was an unforgettable inital foray and first discovery of the female reproductive system.  I will not speak for the women of my class; I am sure there were many mixed emotions involved in this teaching experience.  As noted by our instructors, many women may consider this yearly exam as a mild annoyance, others with trepidation, and still others with fear.  In practice, we as physicians will meet women for whom it is their first time, their fortieth, or some who have never had an exam performed.  Some women who have been victims of sexual assault, abuse, or rape (or even those who have not) may have difficulty with this experience.  It is our job as physicians to 1) never make assumptions, and 2) empower women during the exam to be advocates for their own health.

This, however, has proven difficult for many practitioners.  In the hum-drum of today's New York minute medicine, patience and sensitivity are often thrown out the window.  The simple gesture of knocking and waiting for your patient to answer before entering the room is often overlooked.  Allowing the patient to maintain a modicum of privacy and control over the exam can go a long way.  Offering to help her up after completion of the exam is a reminder to both parties that she's human, not a diagnostic specimen.  With this in mind, I will recreate last night's pelvic exam as we learned it, intertwining my own experiences and emotions with the process.  I will ask Perry, Olivia, and Kenton to correct me later concerning any omissions.  I hope to reflect on this experience after having done this exam for many years, recalling the care, attention to detail, and sensitivity of our first time.  And, more importantly, I hope that years from now my attention to the patient has not changed, and that I am still waiting for my patient's voice after knocking...

I was the first one to volunteer, so of course I made all the mistakes.  Now to be quite honest I wasn't nervous; I was more concerned that I would forget the steps our instructors taught us, and look like a fool in front of my fellow sophomores.  So the exam began as I knocked on the door.

"(Knock, knock, knock) Come in!  Hi, my name is Robby.  Karen, right?  Is it okay if I call you that?  Sure.  Okay, Karen.  Today I'm going to be performing your pelvic exam.  This is my assistant, and these are a couple medical students who are here to watch the exam.  They are here to learn, not to observe you specifically.  This is part of their medical training.  Is it okay if they watch?  Umm, I guess so.  Okay, Karen, you can let me know if they make you uncomfortable, and I can have them leave.  Now, you've had one pelvic exam before, correct?  Yes.  Okay, well, just as a refresher, the pelvic exam has three parts to it.  The first is external.  I will palpate your external genitalia and mons pubis, seeing if I feel any bumps or anything abnormal.  The second part is internal.  Here we will use the speculum to look at your cervix, and do a pap smear and STD test.  Would you like to take a look at it?  No.  Okay, then the third part is "bi-manual."  This means that I will use both of my hands, one externally and one inside your vagina to feel your uterus and ovaries.  Do you have any questions, Karen, before we started?  Umm, we're going to do that STD test, right?  Yes, that will be done during the internal exam.  Do you have any other questions?"

Pause.

"Would you like to hold a mirror and flashlight to follow along?  Sure.  Okay, also this exam is not supposed to be painful.  If you feel any discomfort, please let me know.  That may be easily fixed by simply adjusting my hand or the instrument.  Also, let me know if you would like a blanket, or for me to change the temperature of the room.  Okay."

Now is when the practitioner adjusts the table to 45 degrees.  The patient's feet are put in the footstools (NB: the word "stirrups" is now taboo), and the patient moves her buttocks to the end of the table where my hand rests.  Standing in front of the patient, I can then place my hands where I would like the patient's knees and say, "you can let you knees fall to my hands."  Words to avoid: "spread your legs" or "open up."

Here is a time for silence.  While washing my hands and putting on gloves, our instructors told us to allow some time for reflection and questions before the exam.  Eye contact is key when answering all questions.  (If only I could have been as matter of fact and confident as this reads).  The gown/sheet is then rolled from the bottom up, maintaining as much privacy and autonomy as possible.

"Okay, first I'm going to perform the external exam.  You can feel me touching you here."

The back of your non-dominant hand is placed on the patient's inner thigh so the first time you touch her is not on her genitalia.  This is for comfort, and so you don't scare your patient.  Twice during the exam I forgot this important gesture.

"Now I'm am palpating your external genitalia to feel for any bumps or lesions.  I will palpate down to your labia majora, and then inspect your labia minor.  You will feel me push up your clitoral hood and see your clitoris.  This is where many nerve endings are located, and these can be stimulated during sex.  With your mirror you can see your urethra here; that is where you pee from.  Here is your vagina, and here is your anus.  Any questions?"

"Now I'm going to perform the internal exam."  (Reach for speculum that has been resting in warm water).  "You can feel me touching you here.  Now I am going to insert one finger to find your cervix.  Okay.  Now I'm going to ask you to clench like you are stopping yourself from peeing.  And relax."   (Curling my fingers so they don't rest on my patient's perineum, I remove my finger until the first knuckle and press down).    Okay you will now feel me insert the speculum."

You insert the speculum at a 45 degree angle, open it slowly, and remove your finger simultaneously to visualize the cervix.  I did not observe the cervix on my first attempt.  I did not observe the cervix on my second try.  Nor the third.  Not until the fourth attempt did the cervix come into partial view.  Embarrassed, I apologized to my instructor.  Pap smear was feigned, and I continued, frustrated.

"The third part of the exam is bi-manual.  You will feel two fingers and my right hand will be on your abdomen feeling for you uterus and then your ovaries.  You can feel me touching you here..."

No uterus or ovaries were felt, although not feeling the latter is normal.  I convinced myself that I felt the uterus "rocking" back 'n forth, but this most likely was a figment of my imagination.

"Okay we're all done.  Do you have any questions..."

It was a rocky first attempt.  Had I been able to read from this dialogue, it would have gone a helluva lot smoother.  Instead I was concentrating intently on remembering the order for the exam, and what to say.  More importantly, I was thinking about what not to say.  You "insert," not "put in" or "penetrate."  You "remove," not "pull out."  You don't "scrape the cervix," "stick" anything in it, or use "stirrups.".  I was terrible about maintaining eye contact, and it felt like a year putting on my gloves.  Of course I didn't dry my hands well enough, and so it took me an hour to coax the gloves all the way onto each finger.  I maintained that silence awkwardly; being able to hear a pin drop was eerie.

The exams got better and better as the group took turns.  Perry was absolutely fantastic, not only with the physical aspects (insert, open, and boom: there's the cervix), but also with his patient care.  He asked all the right questions, knew all the right answers, and even knew how to make a dental dam out of a condom (cut it in half on one side... who knew?!).  Simply his manner and demeanor though; it is a style worth emulating.

Experiences like these prove to me over and over again that I learn more from my peers than from any class or textbook.