Check your approach to the well-woman exam
When it comes to the periodic well-woman visit, how do you and your staff balance time management and patient care?
Many clinical experts now agree that:
- Pelvic exams may not be required annually.
- Pelvic exams are not required for initiating hormonal contraception.
- Not all women 30 years of age and older require annual cervical cytology screening.
- Women should be encouraged to pay attention to symptoms or changes in their breasts rather than being taught breast self-exam.1
One thing that should be included is counseling on contraceptive options and emergency contraception. Current guidelines from the American College of Obstetricians and Gynecologists (ACOG) recommend that adolescents and older reproductive-age women receive counseling on both topics at each periodic assessment.2
With today's ever-growing array of birth control methods, how can clinicians maximize their counseling time and still perform necessary screenings? Efficient use of ancillary staff can conserve the clinician's time, increasing the time available for counseling, according to a new review of the well-woman exam.3
For example, ask staff members to provide self-administered history forms to patients to fill out in the waiting room. Use the results to comment on positive findings and inquire on any incomplete responses. Also, allow staff members to record height, weight, and blood pressure readings; review allergies and medications; and confirm the reason for the patient's visit.
Also, use handouts to explain current guidelines for Pap smear screening. Take-home reading materials can reinforce topics of discussion, and refer to Internet resources to provide more information following the exam. If issues are not resolved during the counseling session, schedule another visit or a telephone appointment.3
Making adequate time for the contraceptive counseling segment of a well-woman exam is important. Research shows that women report greater satisfaction with reproductive counseling, have better understanding and recall of the information provided, and are more likely to use their chosen method successfully if there is a two-way dialogue with their provider.4,5
Take a look at what birth control method is currently in place. Even if a woman has found success with using an older oral contraceptive formulation, she may find that one of the newer hormonal options may be better suited to her current reproductive needs and lifestyle and may be better tolerated.3
"For a woman who has never used an effective method, I find it useful to use a contraceptive wall chart to 'walk' the patient down the different methods," says Andrew Kaunitz, MD, professor and assistant chair in the obstetrics and gynecology department at the University of Florida Health Science Center/Jacksonville. "This helps to present the cafeteria of options and allows her to narrow in about which options she was hoping to find out more about or what direction she'd like to go."
He keeps a box in the exam room with samples of the contraceptive patch, vaginal ring, and intrauterine devices so that patients can directly examine the devices. If the patient selects an intrauterine device, Kaunitz schedules a second visit for the actual insertion. By keeping the counseling and insertion functions in separate visits, the patient is able to fully absorb the information given in the counseling session and confirm in her own mind about use of a long-acting contraceptive, explains Kaunitz. The separate visits also allow office staff to check insurance coverage and work with the patient on payment options, he notes.
- Association of Reproductive Health Professionals. Periodic well-woman visit: Individualized contraceptive care. ARHP Clinical Proceedings; 2004.
- American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 292. Primary and preventive care: Periodic assessments. Obstet Gynecol 2003; 102:1,117-1,124.
- Shulman LP. New recommendations for the periodic well-woman visit: Impact on counseling. Contraception 2006; 73:319-324.
- DiMatteo MR. The physician-patient relationship: Effects on the quality of health care. Clin Obstet Gynecol 1994; 37:149-161.
- Donabedian A. The quality of care. How can it be assessed? JAMA 1988; 260:1,743-1,748.
The Association of Reproductive Health Professionals (ARHP) has produced a set of computerized graphic slides, "New Dynamics in Health Care: Contraception and the Periodic Well Woman Visit" that can be used as a free teaching tool. Visit the organization's web site, www.arhp.org. Click on "resources," "slide show library," and the slide show title.
Also check out a companion issue of ARHP's Clinical Proceedings. At www.arhp.org, highlight "healthcare providers" and "online publications," then click on "Clinical Proceedings" and "Periodic Well Woman Visit: Individualized Contraceptive Care."