Inconsistent guidelines lead to wide variation in chaperone use during Pap smears, U-M study finds

November 25, 2003

ANN ARBOR, Mich. - When doctors were first encouraged to have a nurse or medical assistant in the room while collecting a Pap smear, it was so the patient would feel comfortable. In time, hospital lawyers began to advocate chaperones for legal protection.

Today, few guidelines and little consistency exists, leaving patients at the mercy of their doctor's training, gender or geographic location.

A study by doctors at the University of Michigan Health System found three-quarters of family physicians surveyed said they routinely use a nurse or medical assistant as chaperone during Pap smears. But a woman living in the South is more likely to have a chaperone in the exam room while her doctor performs a Pap smear than is a woman living in the Midwest. At the same time, women who have male doctors will see an extra face in the room more often than women with female doctors.

"Before I did the research for this study, I always used a chaperone," says lead researcher Pamela Rockwell, D.O., clinical assistant professor of family medicine at U-M Medical School. "I was trained that you always had someone else in the room for legal reasons, and I always insisted on having a chaperone. Then I started reading that some women didn't like them. I had never thought to ask."

Now, for routine Pap smears, Rockwell forgoes the chaperone. She says most of the women she sees prefer it that way, especially if they are long-time patients who know her and her staff well.

The study, which will be published in the Annals of Family Medicine, surveyed 5,000 members of the American Academy of Family Physicians, a trade group for that specialty. The questionnaire was designed to follow the steps a doctor takes during a Pap smear; chaperone use was a secondary item.

The study found that gender was the biggest predictor of whether a doctor used a chaperone, with 84 percent of male doctors and only 31 percent of female doctors having someone else in the room. In addition, doctors who performed fewer than 20 Pap smears a month were more likely to use a chaperone than doctors who did the screenings more frequently, 81 percent vs. 69 percent.

"It's probably an efficiency issue," Rockwell says. "If you're doing a lot of Pap smears, you're good at it, you're efficient at it and you probably don't need someone to look over your shoulder."

The researchers also found significant variation by region. Doctors in the South used a chaperone 89 percent of the time while doctors in the Midwest brought in a chaperone only 66 percent of the time. Doctors in the Northeast and the West used chaperones 72 percent of the time. Southern female physicians were as likely to report chaperone use as Midwestern male doctors.

The regional differences seem to reflect the training in that area, and in many cases when a doctor trains in a certain region, he or she develops a practice in that same region.

"I was trained in Virginia and North Carolina where the accepted norm was a chaperone at every pelvic exam regardless of the gender of the provider," says senior study author Mack T. Ruffin IV, associate professor of family medicine at U-M Medical School. "After training, my first practice location was in Minnesota. The norm in many training programs in that region was not to use a chaperone unless the patient requested one. I continued to use a chaperone, much to the concern of the medical directors and office business managers."

To this day, Ruffin insists on a chaperone during all pelvic exams, even turning down patient requests that the nurse not be present. Ruffin explains to his patients that the nurse is there to make the procedure faster and more comfortable for the patient.

No formal legal mandates or guidelines exist regarding chaperones during pelvic exams. The U-M Health System does recommend its doctors perform Pap smears with a nurse or assistant in the room, but it is not required.
In addition to Rockwell and Ruffin, Terrence Steyer, M.D., of the University of South Carolina, was an author. The study was supported by grants form the Research Council of the Department of Family Practice and Community Health at the University of Minnesota, the Bureau of Health Professions HRSA Grant for Faculty Development in Family Medicine, the Minnesota Medical Foundation, the American Academy of Family Physicians Foundation, the American Cancer Society, and the Research Committee of the U-M Department of Family Medicine. Steyer is supported by the Robert Woods Johnson Foundation Clinical Scholars program, and Ruffin by the National Cancer Institute.

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