Read on Twitter
Ok, we're going to do my first real Tweetorial. It's crazy long, but doing paps right is worth the time. Here's hoping I built this thread right...
My first pap experience sucked, it was done by a woman and I expected her to tell me what would happen. Instead, I was rushed back, felt scared, didn't know what they were doing, and it HURT. I felt like she judged me for asking why it hurt.
Later paps were hit and miss, sometimes being warned before the cytobrush scrape and cramp, but most times not. Even my last one, during residency by an OB attending, was done in a half-assed, rushed way. No explanation for residents who know the "drill" I guess.
I've had them done by RNs at PP, OBs in several states, and by FM docs, too. Many uncomfortable. As a physician, it's my goal to make paps suck less for my patients. And if you're reading this, it's my goal to make you EXCELLENT at communication during a pap.
First, I always see patients in their clothes. Sure, it saves YOU time if they're in a gown. It also makes the patient feel exposed, cold and want to get through the talking as fast as possible so they can put their darn clothes back on, thank you very much.
During this time, I ask if they know why we do pap smears. Most people do not (thank you, terrible US sex-ed). Many still say yes, and I ask them to tell me what they know. I listen and wait for their pause, then say "Good, mostly right, but here's my spiel!" :D
I then explain "the exam is done to collect cells from the cervix (see my quick drawing below) to analyze in a lab and look for abnormal or cancerous cells, and for the HPV virus. Since it's slow growing checking every (3-5) lets us find cancer early enough to intervene.
"Have you had bad experiences or pain with a pap before?" Most of the time get a yes and sometimes an awful story of the past. I listen. Then I acknowledge the past and apologize - "I'm sorry you had that experience, I'm going to do my best to make this one less terrible.
"I'll tell you everything BEFORE I do it, and walk you through breathing so it's not so uncomfortable." I use this time to make sure all my pap supplies are present, that the pap vial is not expired (check expiration date!) and the light works.
"Most people cramp when we collect cells" - show them the cytobrush and broom/spatula. FYI don't say your pap doesn't hurt. You have no idea what this person will experience. Some folks feel nothing, some have intense cramps, some people get nauseated the cramps are so bad.
"Everyone is different, some people have more discomfort than others. It's normal to cramp during cell collection, and normal to spot after. We'll talk as we go, so if something is uncomfortable you can tell me and we can stop." And you better STOP if they say so!
One last thing - you will have some attendings tell you to always perform a bimanual exam first, and others tell you only to do it if you can't find the cervix. I find this personally uncomfortable and invasive, and that's with a mild history of painful paps. :\\
So, I discuss with the patient, using my drawing+modify it... "Everyone's different, sometimes the cervix if off to the left or right, sometimes tilted toward the front or back" (don't say ceiling or floor) "& sometimes I can't find it immediately and have to do a manual exam.
"If you've had difficult paps before I can do the manual exam first, but if you haven't I can try with the speculum first." A LOT of people know if they have a hard to find cervix and will tell you. Some don't. But give the patient the choice.
Quick aside - word choice matters in the exam room! It's not a bed, it's a TABLE. It's not a sheet, it's a DRAPE. They absolutely are NOT stirrups, they're FOOT RESTS. Do not say "I'm going to touch you" instead use clinical language "I'm going to examine you now."
Not everyone will tell you if sexual trauma in their past, so you need to use neutral, safe language ALWAYS. It's especially important when you are doing the actual exam to say neutrally "I'm going to place the speculum, let me know if you have any discomfort."
Now, they can change. I explain "It's easiest if you have your bottoms off entirely, including underwear, but you can keep your top on. You can keep socks and shoes on, too, I know it's cold in here." Because it's always freezing in clinics. Ugh.
"This drape (sheet) is to put over your lap, but I will be moving it when I return, so please don't tuck it under you" (last part is important because it's cold, they're uncomfortable, and wrapping up tight in a sheet feels better, but gets awkward when you return)
When I come back I knock, crack the door and ask "Are you ready for me to return?" and WAIT for their answer. Remind them I'll explain as I go. They are seated on the table, a drape on their lap, wishing for this to be over ASAP. They may say so. But a rushed pap is not good!
I tell them "Ok, I'm going to get the foot rests out, and have you move your bottom close to the end of the table, and put your feet in the foot rests." I move out of the way (ie: off to the side of the table) while they do this, because sometimes you get kicked. ¯\\_(ツ)_/¯
Then I sit on the stool at the foot of the table. "I'm going to adjust the drape and make sure you're close to the edge" - they won't be, and I'll say "There's still some room at the end of the table, can you move further?" Don't say scoot, don't say butt.
I often will say "If you feel like your bottom is about to fall off you're in the right place," but not if the patient seems anxious or has expressed concern about falling off already.
Regardless of age I ask "Any discomfort in your knees or hips? Do you want me to adjust the foots rests?" Pap's already suck, no need for them to have knee, hip or back pain, too. You can adjust table back so it's not entirely flat, for comfort.
"Today I'm using a plastic speculum, and the bad thing about it is this noise it makes" (I press the speculum so it makes the awful noise) "and I will try to keep it from making that noise. Now I'm going to move the drape again so it won't fall on me while I do the exam"
Now set drape back so that doesn't happen, but attempt to keep it covering the patient as much as possible. "Ok, I'm going to place the speculum now. Everyone tends to lift up off the table, so it helps to take a deep breath, breathe out on 3, and keep your bottom on the table"
They do 2-3 deep breaths, I make sure the speculum has enough lubricant gel on it to make the placement comfortable. ProTip, yes, it's a lot of gel, on top and bottom of the speculum, it will not ruin the pap collection. And for patients I refer to it as speculum gel.
"Ok, take another deep breath, I'm going to set the speculum near you, it'll feel cold, breathe out... ok, good job, are you ok? Great." "Now is when the speculum may make that clicking noise, and there may be some discomfort while I make sure I can visualize your cervix"
Do not root around with an open speculum, that HURTS. If you see the cervix drop into the speculum, close it, readjust and open. If you try this twice without locating then you need to do a manual exam & find the cervix rather than torturing the person on the table.
"Ok, I can see the cervix, it looks normal." Normal or healthy are good choices here. Do NOT say weird crap like "good" or "beautiful" etc. Medical terms only, avoid anything that may be sexualized or trigger past trauma.
"I'm going to use the brush and broom I showed you earlier, this is the part that can cause cramping. I will count to three. Take a deep breath and out on three" - your tools are within the speculum, and on three you should place the tool at the os of the cervix & gather cells.
"Ok, now for the seconnd one, we're nearly done with the pap." I work without an MA now, so I set both broom and brush into the pap vial and set it aside on the counter, but when I had an MA I handed both to them and they did the rest.
"I'll remove the speculum" (CLOSE IT FIRST OMG; remove and set it aside, pull drape down to give privacy to patient, then pull ptable extender out. Tell patient "You can put both your feet in the middle & move back on the table, & then I'll move the footrests out of your way"
(I do all that to prevent a topple from table, and to prevent them getting a gnarly bruise banging their leg into one of those foot rests moving away from the table). "Ok, I'll let you get dressed" and step out.
This seems like a lot of steps, and may seem like a lot of talking, but for an invasive cancer screening that happens every 3-5 years this is appropriate and should be expected. And you know what?
I have had a LOT of patients tell me the pap I performed was "the least horrible version of this" and as someone who knows EXACTLY what that means it makes me feel like a great doctor to hear it.
I've had a few patients thank me for making the exam less scary for them, and some have cried because it was such a relief to be treated properly after past shitty experiences. It's worth the time, for them. So be awesome for them!
I've tried to use inclusive language in this post, but if I missed some I apologize. Also, following are some links for basic pap info and trauma informed care. Educate yourself on all the details!
Sexual Assault in the Exam Room https://www.reproductiveaccess.org/2019/04/a-reflection-on-sexual-assault-in-the-exam-room-from-patient-stories-to-provider-lessons/
Providing Trauma Informed Care https://www.aafp.org/afp/2017/0515/p655.html
What is Trauma Informed Care? http://socialwork.buffalo.edu/social-research/institutes-centers/institute-on-trauma-and-trauma-informed-care/what-is-trauma-informed-care.html
When a Pelvic Exam is Traumatic https://www.health.harvard.edu/blog/when-a-pelvic-exam-is-traumatic-2019012915863
AAFP Choosing Wisely: Pap Smears
https://www.aafp.org/patient-care/clinical-recommendations/all/cw-pap-smears.html#:~:text=The%20USPSTF%20recommends%20screening%20for,5%20years%20(A%20recommendation).
https://www.aafp.org/patient-care/clinical-recommendations/all/cw-pap-smears.html#:~:text=The%20USPSTF%20recommends%20screening%20for,5%20years%20(A%20recommendation).
AAFP Cervical Cancer Screening https://www.aafp.org/afp/2018/0401/p441.html
The End!
PS: Trans-specific care link https://twitter.com/heykatbutler/status/1277198465945210880?s=20
PS2: Forgot to mention if there are body jewelry or tattoos in the genital region it is NOT a topic of conversation unless you see signs of infection. Just because you can see it is not an invite to comment.
