AJCM--Section on Office Management
It is not a legal standard, and it is not policy that all Paps smears, pelvic exams, or transvaginal ultrasounds require a female chaperone. Chaperones should be used selectively for procedures which require an extra set of hands, and/or for women with psychiatric/chronic pain issues. Male doctors have the right to request a chaperone, but it is not required.
Some have requested a chaperone to do an abdominal ultrasound on a female patient. This is an inappropriate use of resources, and delays care for other patients who are waiting.
Colposcopies, endometrial biopsies, D&C, Bartholin cyst,--These are examples of gyn procedures which require an extra set of hands. Doing them without an assistant is ill advised and may lead to a low quality result.
At Medicos it is usual, customary, and reasonable to have routine Paps smears and Group B strep cultures performed by female medical assistants/nurses. Rectovaginal exams and culdocentesis are obsolete. Suspected pelvic pathology requires ultrasound. Transvaginal ultrasound can and should replace the bimanual pelvic examination when such an examination is indicated. Medicos is designed to offer transvaginal ultrasound without prior appointment.
If the physician does not have time to review the chart and update the problem list prior to a pelvic exam, transvaginal ultrasound, or office surgery, STOP. GET THIS INFORMATION BEFORE YOU START. Every year someone who has a post-op complication fueled by previously unknown mental issues. Patients with mental disabilities cannot legally sign a surgical consent.
As part of the ultrasound curriculum and normal QA-QI, all physicians are required to complete 30 before and after comparisons using the bimanual pelvic exam followed by transvaginal ultrasound. These documents will be filed for part of a QA-QI study. Otherwise, a bimanual pelvic examination is NOT required for the well woman examination.
Male physicians may be anxious about being alone in a room with a female patient, but in 40 years we have seen no risk develop from this situation. The big exception is the patient with mental illness.
Family physicians should have skills in the recognition and management of mental illness. But fragmented care and out of date problem lists are persistent problems. It is Medicos policy that physicians review problem lists, current medications, and previous notes prior to a pelvic exam or office surgery. OB patients have similar requirements.
Female physicians should feel comfortable with a male assistant for pelvic exams and gyn surgeries. The main issue is to have a second pair of hands for equipment and specimens. Some have delayed pelvic exams pending the availability of a female chaperone. Some staff feel that the doctors have "always" required a female assistant for a pelvic exam. This is not true, and we have clarified this policy every year during the summer orientation..
Assistants are not legally required for Paps smears and transvaginal ultrasound exams. Physicians with concerns about lurking psychosexual risk, may request a chaperone for protection of a witness, but the gender of the assistant is not the major issue(my opinion).
When female assistants are mandated for every pelvic and transvaginal ultrasound, it unnecessarily delays care and adds no benefit. Some Muslim women may prefer women only, and we try to work with these requests on a case by case basis. Medicos does not guarantee that "female-only" service is always available. Those who require it, will be referred to a female only medical practice.
Physicians should develop the clinical judgment to maintain quality while adapting to the realities of pelvic exam "chaperones" in a heath care system with limited resources.
Wm. MacMillan Rodney MD, FAAFP, FACEP
Cliniical professor and Chair
Medicos para la Familia
Nashville, Memphis and International
Index--Policy-- Paps smear chaperones, medical assistants, gyn surgery, pre operative clearance in the office. May 8, 2010; update July 2011
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