Sensitive Exam Research Articles

CMS Revises Guidelines on Informed Consent for Invasive Procedures and Sensitive Exams

CMS Revises Guidelines on Informed Consent for Invasive Procedures and Sensitive Exams

Patient and Provider Opinions Regarding Chaperones for Sensitive Exams.

Recommendations for chaperone use during sensitive exams have been left mostly to individual institutions, despite a paucity of data providing guidance. The purpose of this study was to survey patients and medical providers on their attitudes toward chaperone use and explore factors that may influence these attitudes. A survey was administered at a single tertiary military medical center to providers and patients across multiple specialties, and further sub-analysis of the data were completed. For patients, sub-analysis was done for gender, age, history of sexual abuse, and clinic seen. For providers, sub-analysis was done for provider gender and training status. Before data collection, this study was deemed exempt from institutional review board approval by the Eisenhower Army Medical Center Human Research and Protections Office. A total of 319 patient surveys and 61 provider surveys were collected. Fifty seven percent of patients have no preference regarding chaperone use, 19% prefer having a chaperone, and 24% prefer to not have a chaperone. Female patients and patients with a history of sexual abuse are more likely to prefer a chaperone. Forty two percent of providers always use a chaperone, 79% are more likely to use a chaperone if a patient is of the opposite gender, and 43% select a chaperone based on the gender of the patient. Male providers and providers still in training are more likely to use a chaperone. The majority of patients do not have a preference regarding chaperone presence during sensitive exams; however, female gender and history of sexual abuse increase the likelihood of a patient preferring to have a chaperone present. These factors should be considered when creating an institutional policy regarding chaperone use. Future research should focus on homosexual and transgender patient preferences as this has yet to be explored.

Consent and Educational Sensitive Exams on Anesthetized Patients: Experiences of Medical Students Across Canada

ObjectivesThis study investigates experiences of medical students across Canada related to consent for educational sensitive (i.e., pelvic, rectal) exams under anesthesia (EUAs). MethodsA bilingual online questionnaire was developed and distributed to medical students across Canada. ResultsOf 134 respondents, 63% had performed a pelvic EUA, 35% a rectal EUA, and 11% another sensitive EUA during their training. For those who had performed pelvic EUA, 28% were unsure if consent had taken place, 26% reported no specific consent, 20% reported specific consent, and 25% had mixed experiences of consent. For rectal EUAs, 48% reported no specific consent, 37% were unsure if consent had taken place, 13% reported that there had been specific consent, and 2% reported mixed experiences. Most respondents were uncomfortable (36%) or not sure if they were comfortable (32%) with how the consent process was handled for student pelvic EUAs; 31% were comfortable. In open-ended responses, respondents described experiences related to variability, discomfort, and authority. ConclusionsNon-consensual educational sensitive EUAs continue to take place in medical training across Canada, although practices of consent are highly variable. The majority of respondents reported being uncomfortable or unsure if they were comfortable with how consent for educational sensitive EUAs was practised during their training, and some respondents struggled to express their discomfort given the power dynamics at play.

Assessing Patient Experiences With Patient-Centered and Inclusive Care in Academic Obstetrics and Gynecology Outpatient Clinics [ID 2683581

INTRODUCTION: Ensuring patient satisfaction remains an important objective for obstetrics and gynecology care. To address a research gap in this field, we aimed to assess patient satisfaction with culturally competent and respectful care in our obstetrics and gynecology clinics after initiation of diversity, equity, and inclusion programming. METHODS: From September 2021 to February 2022, we surveyed outpatient ob-gyn visitors about their experiences, using a 21-item survey that assessed cultural competency, treatment discussions, clinic accommodations, and comfort during sensitive exams, using a Likert scale. Participants also self-reported demographic information. RESULTS: Out of 246 returned surveys, participants generally reported positive interactions with clinic staff and health care providers, feeling heard (91%), respected (95%), and having their cultural/spiritual beliefs considered in treatment (95%). Most felt respected and comfortable during sensitive exams (96%) and were satisfied with treatment discussions (84%). However, those with a high-school education (79%) were less likely than college or graduate degree holders (93%) to feel administrative staff listened to them and their families (P<.05). Experiences with culturally competent care varied by race/ethnicity. Black/African American participants were less likely to feel staff understood their cultural experiences (55% versus 67–88%; P<.05) and that they recognized differences within their racial/ethnic group (50% versus 82–88%; P<.01). Black/African American individuals reported the highest incidence of race-based unfair treatment (20% versus 0–2%; P<.01). CONCLUSION: Lower satisfaction among Black/African American participants indicates care can be improved. Enhanced education for clinical teams can foster respectful, inclusive, and culturally competent care. Future qualitative research can offer further insights into inclusive practices in obstetrics and gynecology care.

Evaluating Patient Experiences with Patient-Centered and Inclusive Care in Academic Obstetrics and Gynecology Outpatient Clinics.

Ensuring patient satisfaction is crucial in obstetrics and gynecology (OB/GYN) care. This study aimed to assess patient satisfaction and experiences with respectful and culturally competent care in an institution's OB/GYN clinics following the initiation of diversity, equity, and inclusion programming. A survey was conducted from September 2021 to February 2022 among patients who had completed outpatient OB/GYN visits, focusing on staff and provider cultural competency, treatment discussion, clinic accommodations, and comfort during sensitive exams. Results from 246 participants indicated that most had positive interactions with clinic staff and healthcare providers. However, disparities emerged, with black or African American participants reporting lower satisfaction and a higher incidence of unfair treatment due to race. These findings highlight the need for additional educational endeavors to equip clinical care teams with skills for providing respectful, inclusive, and culturally competent care. Future qualitative research can further explore patient experiences with inclusive practices in OB/GYN care.

Not Just Non-Consensual Pelvic Exams

Not Just Non-Consensual Pelvic Exams

PRESUMPTIVE DIAGNOSIS OF SPINA BIFIDA IN CANINE PATIENT

The aim of this report is to describe a presumptive diagnosis of spina bifida in a mixed breed dog, due to previous diagnostic inconsistencies. Spina bifida is an uncommon congenital anomaly characterized by poor bone formation due to incomplete closure or the absence of the dorsal arch of the vertebral structure during the process of embryogenesis. Animals with this condition may have difficulties in the locomotion process, which constantly threatens the quality and survival of those affected. Spina bifida can present itself in four different forms and to varying degrees. A 5-month-old mixed breed dog was seen at a veterinary clinic in Conselheiro Lafaiete/MG with difficulties in the locomotion process and previous diagnostic inconsistencies in other veterinary services. On physical examination, he had kyphosis in the thoracic region and decreased proprioceptive capacity in the hind limbs. After radiographs were taken, morphological thoracic alterations were observed in the segment between the T5 to T9 vertebrae, with duplicated spinous processes and a decrease in the dimensions of the intervertebral space. The radiographic examination suggested presumptive evidence of thoracic spina bifida due to the unavailability of the tutor to perform more sensitive exams such as tomography and magnetic resonance. Therefore, drugs for pain and neuropathic control such as gabapentin and pregabalin were prescribed, at different times, until new recommendations, which have shown therapeutic efficacy to the patient. Currently, the patient uses a wheelchair adapted for locomotion due to the loss of movement of the hind limbs, in addition to weekly physical therapy follow-up and acupuncture sessions.

134 Diagnostic Accuracy of the Physical Exam in Patients With Vertigo or Dizziness Presenting to the Emergency Department: A Systematic Review and Meta Analysis Supporting the Guidelines for Reasonable and Appropriate Care in Emergency Medicine

134 Diagnostic Accuracy of the Physical Exam in Patients With Vertigo or Dizziness Presenting to the Emergency Department: A Systematic Review and Meta Analysis Supporting the Guidelines for Reasonable and Appropriate Care in Emergency Medicine

Medical Student Attitudes on Explicit Informed Consent for Pelvic Exams Under Anesthesia

To obtain an overview of medical student attitudes on the need for explicit consent for pelvic exams under anesthesia performed for educational purposes DESIGN: From February to October 2020, 201 medical students at a single medical school in the United States participated in a cross-sectional survey after completion of the obstetrics and gynecology clerkship. Outcome measures included endorsement of need for explicit informed consent for educational pelvic exams under anesthesia, and knowledge of informed consent processes for such exams. University of Pittsburgh School of Medicine PARTICIPANTS: Third- and fourth-year medical students RESULTS: Overall, 75% of medical students endorsed a need for explicit informed consent for educational pelvic exams under anesthesia, which extended to prostate, rectal, and breast exams under anesthesia. Additionally, 45% and 77% of these participants indicated that consent for educational pelvic exams under anesthesia should take the form of a separate signature line on the surgical consent form and/or a verbal form, respectively. Only 40% of students correctly identified institutional policy for obtaining informed consent for educational pelvic exams under anesthesia. Rotation with the oncologic surgical service (p = 0.02) and correct identification of institutional informed consent policies (p = 0.002) were associated with decreased perceptions of the importance of explicit informed consent for educational pelvic exams under anesthesia. Medical students at the institution studied largely support explicit informed consent for educational pelvic and other sensitive exams under anesthesia, but a knowledge gap on institutional informed consent policy exists. Medical students support increased transparency and bodily autonomy. Due to the agreement of patients and medical students and the ethical rationale for this position, it may be appropriate for physicians and institutions to consider new processes of obtaining explicit informed consent for pelvic exams under anesthesia by medical students.

Current and Future Directions of Breast MRI.

Magnetic resonance imaging (MRI) is the most sensitive exam for detecting breast cancer. The American College of Radiology recommends women with 20% or greater lifetime risk of developing breast cancer be screened annually with MRI. However, other high-risk populations would also benefit. Hartmann et al. reported women with atypical hyperplasia have nearly a 30% incidence of breast cancer at 25-year follow-up. Women with dense breast tissue have up to a 4-fold increased risk of breast cancer when compared to average-risk women; their cancers are more likely to be mammographically occult. Because multiple cohorts of women are at high risk for developing breast cancer, there has been a movement to develop an abbreviated MRI (abMRI) protocol to expand the availability of MRI screening. Studies on abMRI effectiveness have been promising, with Weinstein et al. demonstrating a cancer detection rate of 27.4/1000 in women with dense breasts after a negative digital breast tomosynthesis. Breast MRI is also used to evaluate the extent of disease as part of preoperative assessment in women with newly diagnosed breast cancer, and to assess a patient’s response to neoadjuvant chemotherapy. This paper aims to explore the current uses of MRI and propose future indications and directions.

Addressing learner anxiety via reflective practice.

Medical students experience anxiety when learning the pelvic, breast and male genitourinary exam (also known as sensitive physical exams). Reflection can help students process emotionally challenging learning experiences and help give those experiences meaning. We describe the development of a reflection module to enhance reflection during sensitive exam instruction. We developed this module following Kern's Six Step Method for curriculum development, including a targeted needs assessment. Informed by educational reflection theory, the module addressed all elements of reflection. The module was optional, asynchronous and administered online, requiring minimal administrative support. Prior to sensitive exam instruction, participants identified goals and values and named emotions. Following exam instruction, participants again named their emotions and then self-evaluated whether they had met their goals and upheld their values. Participants found the module to be a useful modality to reflect. Most notably, they identified the naming of emotions, goals and values clarification and the opportunity to reflect both prior to and after an educational experience as helpful. Younger students found the module particularly helpful. An online, low-resource, asynchronous reflection module is feasible and can be a way for students to reflect on challenging learning experiences. In addition to using with sensitive exam instruction, the module can be applied to activities such as anatomic dissection, ethics workshops or clinical learning.

Combining Simulation and Male Urogenital Teaching Associates to Increase NP Student's Clinical Knowledge and Confidence

BackgroundNurse practitioner (NP) programs use skills-based activities such as structured simulations and instructional sessions to prepare students for clinical practice. NP students often have limited opportunities to perform sensitive exams during their clinical experiences. This study combined simulation and Male Urogenital Teaching Associate (MUTA) instruction to evaluate student's preparedness, knowledge, perceived learning, and confidence in diagnosing/managing urogenital complaints. SampleTwenty-six NP students entering their first clinical course completed a simulation/MUTA clinical encounter. MethodsThe encounter included a pre-brief, simulation, urogenital examination instructional session, learning activities, and debrief. Descriptive and inferential statistics were analyzed on pre-test/post-test and post-evaluation questionnaires. ResultsData revealed a statistically significant difference in student's confidence postintervention. Students reported an increase in knowledge and preparedness. ConclusionsThere is a paucity of evidence on the use of simulation with MUTA instruction in NP curriculum. Findings suggests that a combined simulation/MUTA instruction can meet student needs and increase preparedness, knowledge, and confidence.

Amyloid Goiter in Familial Mediterranean Fever: Description of 42 Cases from a French Cohort and from Literature Review.

Our aim was to describe the main features of amyloid goiter in adults with amyloidosis secondary to familial Mediterranean fever. Therefore, we analyzed cases from a French cohort of familial Mediterranean fever patients with amyloidosis and from literature review. Forty-two cases were identified: 9 from the French cohort and 33 from literature review. Ninety percent of patients were on hemodialysis for renal amyloidosis before the development of goiter. The goiter grew up rapidly in 88% of cases; 75.6% of patients were euthyroid, 58% displayed dyspnea, and 44.8% dysphagia. Various features were seen on ultrasound, from diffuse to multinodular goiter. When it was performed, fine-needle aspiration biopsy almost always revealed amyloidosis. Thirty-one patients underwent thyroidectomy: to manage compressive symptoms (72%) or rule out malignancy (27%). Histology showed mature adipose tissue in 64% of cases and lymphocytic infiltration in 21.4%. In conclusion, amyloid goiter in familial Mediterranean fever preferentially occurs in patients with end stage renal failure. Fine-needle aspiration biopsy seems to be a sensitive exam for diagnosis, but thyroidectomy remains sometimes necessary to rule out malignancy or release compressive symptoms.

Consent in the Exam Room

IntroductionExplicitly obtaining consent from a patient prior to starting a sensitive physical exam is essential to improve their experience with intimate examinations such as the genitourinary exam. AimThe purpose of this article is to raise awareness among providers about how and why to obtain consent for intimate examinations. MethodsThe current literature on consent was reviewed and the opinion piece was created using current events and literature. ResultsProviders have a responsibility to consent patients for a sensitive exam. ConclusionExplicitly obtaining consent from a patient priro to starting a sensitive physical exam such as a genitourinary exam is essential to improve the patient experience with such exams.Keller JM. Consent in the Exam Room. J Sex Med 2019;16:618–620.

Perceptions of caregivers and adolescents of the use of telemedicine for the child sexual abuse examination.

Childhood sexual abuse is a common cause of morbidity and mortality. All victims should receive a timely comprehensive medical exam. Currently there is a critical shortage of child abuse pediatricians who can complete the comprehensive child sexual abuse examination. Telemedicine has emerged as an innovative way to provide subspecialty care to this population. Despite the growing popularity of telemedicine, no literature exists describing patient and caregiver perceptions of telemedicine for this sensitive exam. To explore caregiver and adolescent perspectives of the use of telemedicine for the child sexual abuse examination and discover factors that drive satisfaction with the technology. Caregivers and adolescents who presented for a child sexual abuse medical evaluation at our county's child advocacy center. We completed semi structured interviews of 17 caregivers and 10 adolescents. Guided by the Technology Acceptance Model interviews assessed perceptions about: general feelings with the exam, prior use of technology, feelings about telemedicine, and role of the medical team. Interviews were audio-recorded, transcribed, coded and analyzed using content analysis with constant comparative coding. Recruitment ended when thematic saturation was reached. There was an overwhelming positive response to telemedicine. Participants reported having a good experience with telemedicine regardless of severity of sexual abuse or prior experience with technology. Behaviors that helped patients and caregivers feel comfortable included a clear explanation from the medical team and professionalism demonstrated by those using the telemedicine system. Telemedicine was widely accepted by adolescents and caregivers when used for the child sexual abuse examination.

Obstruction of aortic prosthesis caused by valvular pannus: Characteristics and diagnostic strategy

Valvular pannus is a rare cause of obstructive prosthesis, about which few data exist in the literature. Its diagnostic may therefore be difficult. Analyze the characteristics of patients who underwent reoperation for obstructive aortic, reintervention delay, types of prosthesis involved, current diagnostic strategies and their evolution over the last decade. Retrospective multicentric French study, which included all the patients reoperated for obstructive aortic pannus. Between 2006 and 2016, 71 consecutive patients were included in 3 surgical French centers. Mean age was 62 years, and 2/3 were women. Most of pannus appeared on mechanical prosthesis (82%) with mean intervention delay of 16 years. Mean reintervention delay was significantly shorter in patients with bioprosthesis (8.1 vs. 18.2 years, P < 0.0001). On the 4 tests available for the diagnostic of valvular pannus (transthoracic and trans-esophageal echocardiography, CT scan and fluoroscopy for mechanical prosthesis), CT scan was the most sensitive (50%) but also the less frequently practiced (25%). Over time, we see a clear increase in the use of CT scan for the diagnostic of pannus, this entity being more and more renown ( Fig. 1 ). Pannus occurs mostly on mechanical prosthesis, in a female population in majority. Reintervention delay is significantly shorter with bioprothesis. CT scan is the most sensitive exam to detect it, and should be practiced in all cases of obstructive prosthesis without evident diagnostic in stable patients.

Finger tapping impairments are highly sensitive for evaluating upper motor neuron lesions

BackgroundIdentifying highly sensitive and reliable neurological exam components are crucial in recognizing clinical deficiencies. This study aimed to investigate finger tapping performance differences between patients with CNS demyelinating lesions and healthy control subjects.MethodsTwenty-three patients with multiple sclerosis or clinically isolated syndrome with infratentorial and/or cervical cord lesions on MRI, and 12 healthy controls were videotaped while tapping the tip of the index finger against the tip and distal crease of the thumb using both the dominant and non-dominant hand. Videos were assessed independently by 10 evaluators (three MS neurologists, four neurology residents, three advanced practice providers). Sensitivity and inter-evaluator reliability of finger tapping interpretations were calculated.ResultsA total of 1400 evaluations (four videos per each of the 35 subjects evaluated by 10 independent providers) were obtained. Impairments in finger tapping against the distal thumb crease of the non-dominant hand, identified by neurologists, had the greatest sensitivity (84%, p < 0.001) for detecting impairment. Finger tapping against the thumb crease was more sensitive than the thumb tip across all categories of providers. The best inter-evaluator reliability was associated with neurologists’ evaluations for the thumb crease of the non-dominant hand (kappa = 0.83, p < 0.001).ConclusionsImpaired finger tapping against the distal thumb crease of the non-dominant hand was a more sensitive technique for detecting impairments related to CNS demyelinating lesions. Our findings highlight the importance of precise examinations of the non-dominant side where impaired fine motor control secondary to an upper motor injury might be detectable earlier than the dominant side.

688 - Blunt scrotal trauma in adults: A multi-institution experience evaluating the American Association for the Surgery of Trauma organ injury grading scale about 107 cases

The authors evaluated the usefulness of the American Association for the Surgery of Trauma (AAST) testis injury scale based on preoperative scrotal ultrasonography (US) and physical examination compared to peroperative findings. A retrospective review was performed on 107 patients (mean age=29,2±5.8 years) with a testis blunt trauma treated between January 2005 and August 2015. All patients underwent surgical scrotal exploration. Preoperative US was performed in all cases. Testis trauma was classified according to the AAST organ injury scale, preoperatively based on physical examination and scrotal US and then compared to peroperative definitif grading scale. Of the included patients, 14 were found to have abnormal testis contours on US, 25 had a rupture of the tunica albuginea, with a sensitivity of 70,8% and a specificity of 71,2%. Orchidectomy was performed in 12 cases, partial orchidectomy in 32 and tunica albuginea repair in 35 patients. Through this series, US was not a specific and sensitive exam to really precise the severity grade of testis trauma. Pre- and preoperative findings were significantly different. Thus, we continue to support history and clinical findings and we encourage surgical exploration when testis lesion is suspected.

Missing the mark: Current practices in teaching the male urogenital examination to Canadian undergraduate medical students.

The urogenital physical examination is an important aspect of patient encounters in various clinical settings. Introductory clinical skills sessions are intended to provide support and alleviate students' anxiety when learning this sensitive exam. The techniques each Canadian medical school uses to guide their students through the initial urogenital examination has not been previously reported. This study surveyed pre-clerkship clinical skills program directors at the main campus of English-speaking Canadian medical schools regarding the curriculum they use to teach the urogenital examination. A response rate of 100% was achieved, providing information on resources and faculty available to students, as well as the manner in which students were evaluated. Surprisingly, over one-third of the Canadian medical schools surveyed failed to provide a setting in which students perform a urogenital examination on a patient in their pre-clinical years. Additionally, there was no formal evaluation of this skill set reported by almost 50% of Canadian medical schools prior to clinical training years. To ensure medical students are confident and accurate in performing a urogenital examination, it is vital they be provided the proper resources, teaching, and training. As we progress towards a competency-based curriculum, it is essential that increased focus be placed on patient encounters in undergraduate training. Further research to quantify students' exposure to the urogenital examination during clinical years would be of interest. Without this commitment by Canadian medical schools, we are doing a disservice not only to the medical students, but also to our patient population.

Capsule Endoscopy for Differentiating Early Crohn's Disease from Behçet's Disease

Objective: Crohn's disease (CD) and Behcet's disease (BD) are two major causes of inflammatory lesions in the small bowel. For detecting such lesions, the most sensitive exam is small-bowel capsule endoscopy (CE), an imaging modality suitable for evaluating lesions of the small intestine, with a relatively low rate of capsule retention. However, few reports have employed CE to compare the small-bowel inflammation in early CD with that in early BD. Thus, the aim of our study was to obtain a systematic characterization of small-bowel lesions in early CD and BD by using CE. Methods: This retrospective single-center study included 22 patients with early CD and 16 patients with early BD. The patients underwent small-bowel CE for detection and characterization of small-bowel lesions. After reviewing the CE findings in each patient, we assessed the small-bowel mucosal inflammation using the Lewis score, an inflammatory biomarker (C-reactive protein), and the disease activity index. The CE findings (number, distribution, and shape of lesions), Lewis score, disease activity index, and C-reactive protein levels were compared between the groups of CD and BD patients. Results: Small-bowel lesions were observed in 90.9% of CD patients, and in 68.7% of BD patients. Regarding distribution, CD patients exhibited multiple concentrated ulcers, which were more severe distally, while BD patients mostly exhibited solitary ulcers. Regarding shape, linear and longitudinal ulcers were observed, respectively, in 68.2% and 50% of CD patients; however, no such ulcers were observed in BD patients. C-reactive protein levels and disease activity indices were poorly correlated with Lewis score for both diseases. Capsule retention during CE did not occur in any patient included in this study. Conclusion: CE is a valuable tool to assess the mucosal inflammation of the small bowel in early CD and BD. Greater mucosal inflammation in the distal small bowel, and presence of linear and longitudinal ulcers may be the key findings for the differential diagnosis of small-bowel inflammation between early CD and BD