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.
• 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.
• 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.
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.
Variables that Affect Patient Status
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.
Table 1.1 Variables that Influence the Status of the Patient
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Patient |
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Age |
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History of illness |
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Attitudes and perceptions |
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Sexual orientation |
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Habits (e.g., use of alcohol, tobacco, and other drugs) |
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Family |
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Patient’s status (e.g., married, separated, living with a partner, divorced) |
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Caregiving (e.g., young children, children with disabilities, aging parents) |
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Siblings (e.g., number, ages, closeness of relationship) |
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History (e.g., disease) |
|
Environment |
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Social environment (e.g., community, social connectedness) |
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Economic status (e.g., poverty, insuredness) |
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Religion (e.g., religiosity, spirituality) |
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Culture and ethnic background (e.g., first language, community) |
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Career (e.g., work environment, satisfaction, responsibilities, stress) |
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). 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).
Communication
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.
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).
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 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).
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).
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 successful health care delivery (18).
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 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).
Physician–Patient Interaction
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.
Table 1.2 Important Components of Communication between the Patient and Physician: The Physician's Role
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The Physician Is: |
The Physician Is Not: |
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A good listener |
Confrontational |
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Empathetic |
Combative |
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Compassionate |
Argumentative |
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Honest |
Condescending |
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Genuine |
Overbearing |
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Respectful |
Dogmatic |
|
Fair |
Judgmental |
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Facilitative |
Paternalistic |
|
The Physician Uses: |
|
|
Understandable language |
|
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Appropriate body language |
|
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A collaborative approach |
|
|
Open dialogue |
|
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Appropriate emotional content |
|
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Humor and warmth |
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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 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). The physician’s challenge is to be able to personalize the interaction and communication.
Table 1.3 Behaviors Associated with the 14 Structural Elements of the Interviewa
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Preparing the Environment |
Negotiating a Priority Problem |
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Create privacy |
Ask patient for priorities |
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Eliminate noise and distractions |
State own priorities |
|
Provide comfortable seating at equal eye level |
Establish mutual interests |
|
Provide access |
Reach agreement on order of addressing issues |
|
Preparing Oneself |
Developing a Narrative Thread |
|
Eliminate distractions and interruptions |
Develop personal ways of asking patient to tell her story |
|
Focus |
Ask when last felt healthy |
|
Self-hypnosis |
Ask about entire course of illness |
|
Meditation |
Ask about recent episode or typical episode |
|
Constructive imaging |
Establishing the Life Context of the Patient |
|
Let intrusive thoughts pass through |
Use first opportunity to inquire about personal and social details |
|
Observation |
Flesh out developmental history |
|
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 |
|
Notice physical signs |
Establishing a Safety Net |
|
Presentation |
Memorize complete review of systems |
|
Affect |
Review issues as appropriate to specific problem |
|
What is said and not said |
Presenting Findings and Options |
|
Greeting |
Be succinct |
|
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 |
|
Introduction |
Ask patient’s perspectives |
|
Explain one’s role and purpose |
Negotiating Plans |
|
Check patient’s expectation |
Activate 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 |
|
Include cultural barriers |
Say goodbye |
|
Recognize patient’s psychological barriers, such as shame, fear, and paranoia |
|
|
Surveying Problems |
|
|
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. |
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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. |
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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.
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. 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).
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 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).
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. Ask rephrased questions.
4. Give complete responses to the patient’s questions.
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 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).
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).
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.
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.
Strategies for Improving Communication
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).
Table 1.4 Importance Attached to the Patient–Physician Relationshipa
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.
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.
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.
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.
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).
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).
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).
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).
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.
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).
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
Through joyous and free reflection
know the other side of the flesh’s frame.
JSB
History and Physical Examination
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).
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.
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.
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 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 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.
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 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.'”
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.
Table 1.5 Technique of Taking the History of the Present Illness
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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. 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. 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. 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. 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. 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. |
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Modified from Hochstein E, Rubin AL. Physical diagnosis. New York: McGraw-Hill, 1964:9–11, with permission. |
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.
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. Labia minora
b. Clitoris
c. Urethral orifice
d. Vaginal outlet (introitus)
e. Hymen
f. Perineal body
g. Anus
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
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. 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. Neoplastic
3. Vascular
4. Pigmented—bluish discoloration of pregnancy (Chadwick’s sign)
5. Miscellaneous (e.g., endometriosis, traumatic lesions, and cysts)
d. Structural abnormalities (congenital and acquired)
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. 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. Bimanual palpation
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.
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. Position
b. Architecture, size, shape, symmetry, tumor
c. Consistency
d. Tenderness
e. Mobility
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. 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.
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.
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. Lesions
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. 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. 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. Uterine or adnexal masses
3. Rectouterine fossa for tenderness or implants
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.
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.
Figure 1.1 The lithotomy position for the pelvic examination.
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.
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 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.
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 1.3 The bimanual examination.
The smallest width speculum necessary to produce adequate visualization should be used. 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 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.
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.
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 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.
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).
Figure 1.4 The rectovaginal examination.
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. 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.
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.
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.
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 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).
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.
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.
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.
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 for the frequency of any follow-up or ongoing care visits.
Summary
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).
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.
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