A viral tweet reveals what's wrong with gynecological exams

Earlier this month, urogynecologist Ryan Stewart tweeted that he was remodeling his office and asked women how they would “design/optimize a visit to the gynecologist’s office”, adding “no detail is too small.” To the surprise of probably no one who’s ever had to go to the gynecologist, Dr. Stewart was quickly inundated with replies - more than 3000 as of this writing. Requests and suggestions ran the gamut, from better representation, to office color choices, to exam procedure concerns. But one frequent type of comment gets to the heart of why a gynecologist appointment is something many women find unpleasant at best or even downright uncomfortable, frightening, or traumatic. In reply to Dr. Stewart’s tweet, one woman wrote, “I hate paper gowns for exams. It makes me feel so exposed.” Another requested, “Do not make the end of the exam table face the door….I worked at a clinic where every room was the opposite of what I’m suggesting and it was horrible and embarrassing!!!!!” A third woman made two suggestions: “A wide variety of speculum sizes, and introduction to the exam room including a play by play of how the visit will go. Most people never get this and the office staff never ask if it’s their first exam and most people wouldn’t disclose fear or stress if they have it.” If you’ve never been to a gynecologist, you may be especially surprised by that last response. For one thing, why would a gynecologist not be equipped with differently sized speculum options? Unfortunately, not all gynecologists use different sized specula, and many women, myself included, don’t even know this could be an option. How surprising the tweet’s second suggestion is depends on your own experience with doctors. While some doctors are very good at communicating, you may have felt like you’ve had to pry information out of others - or that you simply got no information at all, since you didn’t ask any questions. Unfortunately, gynecologists aren’t any more forthcoming, despite the fact that most of their patients are nervous even at routine exams and may have also experienced issues like pain, sexual assault, or trauma that’s affecting their experience. It would be extremely helpful to understand what to expect during an exam, or even for the gynecologist to explain what they’re doing as they go through the motions. Some gynecologists do. But many don’t take the time to communicate, and many patients feel too uncomfortable or intimidated to ask questions if they need to. The responses to Stewart’s questions show a disturbing fact about what going to the gynecologist means for most women. While it’s inherently embarrassing for most of us to have a relative stranger poking around in places we usually keep private, the experience itself can be dehumanizing. Why wouldn’t a gynecologist consider what their examination table is facing? Why wouldn’t procedures be explained? Another respondent remarked: “From my non-Twitter-using wife: offer painkillers. Don’t make people ask/have to know to ask. Anyone getting a cervical biopsy should be offered the same suite of painkillers and anxiety drugs I was for my vasectomy.” This suggests that the issues go deeper than the common problem of doctors lacking time and/or bedside manner. It implies that one of the reasons gynecologist appointments are dreaded by so many women is that at the foundation of gynecology, women were seen as “other”, not social and intellectual equals who should be informed about treatment and asked about their questions and concerns. In some cases, even when there are discussions, they aren’t done with respect for the patient. In another reply to Dr. Stewart’s tweet, a woman wrote: “Don’t discuss care or diagnoses when people are naked, I remember how much more respected and comfortable I felt when a new gynaecologist introduced himself to me while I was clothed, did the exam, then had me get dressed and meet him in his office to discuss care! Much better!” The fact that this basic courtesy isn’t standard practice in gynecology speaks volumes. Although it may be based on a doctor’s ignorance of how much it bothers the patient, or the fact that there are other patients to get to, it sends a message to patients that we are considered unimportant or not equals. Fortunately, not all gynecologists practice in this negative, outdated way. For instance, journalist Bailey Calfee shares one interviewee’s experience at her chosen gynecologist’s: Assurance, and other tactics such as asking your patients for consent before performing a procedure, can go a long way in making the experience of going to the gynecologist better for a patient. Hart tells me that she has visited an LGBTQ health clinic called Callen-Lorde for eight years, which she loves. "When they come into the room, they're asking for consent," Hart says. "They're telling you every step of the way—before they put the speculum in, before they take samples from your cervix, they're walking you through it. So you know exactly what's happening to your body, as you should." It's not only going to make for a more informed patient, but it could ease fears or triggers. While it requires little or no additional effort for staff, this sounds like some unattainable paradise to many of us. Dr. Stewart also seems to be on the right track. He followed up his initial tweet by telling respondents that he will be adding their replies to his employee handbook. It’s not a concrete promise that things will change, but it seems promising. And maybe it will help in the way many things that go viral do. A recent WebMD article opened with this phrase: “No woman looks forward to going to the gynecologist.” According to an important survey on gynecology, more than 2/3 of women are afraid of at least one aspect or implication of a visit to the gynecologist. But a majority said they didn’t share their concerns with their gynecologist because they found them “uncaring and patronizing”. Maybe the attention Stewart ‘s tweet will help change this by making other gynecologists reflect on how to make patients feel safe, respected, and understood.



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