Chaperone Use by Family Physicians During the Collection of a Pap Smear

INTRODUCTION

Historically, chaperone use during pelvic examinations was first encouraged for the comfort of the patient, and gradually chaperones were advocated for the purpose of legal protection.¹ Additional rationales for use of chaperones are convenience and time efficiency, although there are no supporting data. Little consistency and uniformity, however, are found in the use of chaperones during a pelvic examination.^2–,⁷

Relatively few studies have explored the issue of chaperone use based on physician variables. Published data suggest that physician specialty and physician sex might contribute to the variation in chaperone use, but these data are limited to small samples, one geographic location, or one medical society. No existing study has a sample population that is representative of practicing family physicians.

We proposed to test the hypothesis that family physicians’ use of a chaperone during a routine pelvic examination to collect a Papanicolaou (Pap) smear would vary by physician sex but not by age, other physician characteristics, number of Pap tests done, or geographic location of the practice.

To address this hypothesis, we used data previously collected with the primary intent to gather information on Pap smear collection and processing techniques. One aspect of the study queried physicians about their routine use of chaperones during the collection of a Pap smear.

METHODS

RESULTS

The responses to the mailed physicians’ survey were 3,551 (71% response rate) with 2,748 (55%) useable questionnaires. The reasons for excluding the 803 responses were that cervical cancer screening was not part of the physician’s clinical practice, 466 (58%); the physician was no longer involved in patient care, 249 (31%); or the physician was no longer alive, 88 (11%). Differences were not found between respondents (3,551) and nonrespondents (1,449) by age (mean age 44.8 years compared with 49.1 years) and sex (82.7% male compared with 85.2% female). Table 1⇓ highlights the demographics of the participants in this survey.

Of the 1,449 nonresponders, 800 were reached by telephone. Among these 800 physicians, 384 (48%) did not see women, 240 (30%) did not screen for cervical cancer in their practice, 96 (12%) had moved to another practice location, and 80 (10%) were no longer in clinical practice. No other information was available on the nonresponders for comparison.

Table 1⇑ shows the results of the unadjusted and adjusted logistic regression models for predicting use of a chaperone during the collection of a Pap smear. The most predictive variable for the use of a chaperone was physician sex, with men being significantly more likely (odds ratio [OR] = 15.4; 95% confidence interval [CI], 11.2–20.1) than women to use chaperones. The number of Pap smears performed per month was also important, in that those family physicians who performed 20 or more Pap smears per month were significantly less likely to use chaperones (OR = 0.76; 95% CI, 0.59–0.96). Finally, the geographic location of a practice was significantly associated with the use of a chaperone. Physicians in the South were significantly more likely to use chaperones than those in the Midwest (OR = 6.1; 95% CI, 4.5–8.3).

DISCUSSION

Among a random sample of active members of the AAFP, the hypothesis that male physicians would report use of a chaperone more often than female physicians was confirmed. Other physician characteristics were found to be associated with reported chaperone use, refuting our other hypothesis. Those family physicians who performed fewer than 20 Pap smears per month were significantly more likely to use chaperones than those who performed more than 20. Physicians in the South used chaperones more often than physicians did in the Northeast, the Midwest, and the West. It is interesting that Southern female physicians were as likely to report chaperone use as Midwestern male physicians.

Some limitations to this study can be noted. First, physician behavior was self-reported, which might not be valid. The primary focus of the survey, however, was on Pap smear collection and processing, not the use of chaperones, so the responses might be less biased than had the primary intent of the survey been to target the issue of chaperone use. Second, the study population was 5,000 randomly selected active members of the AAFP. This group might not reflect the practices of all family physicians; AAFP members might be more informed because of required continuing medical education. Third, although the response rate to the survey was 71%, which is quite good, variation in chaperone use might still be significantly different among the nonresponders.

The use of chaperones during gynecologic examinations remains a controversial issue with no formal guidelines or legal mandates. The topic is poorly addressed by the medical literature and by our current medical education system. No consensus is found among state medical and osteopathic boards on the use of a chaperone.⁹ From the legal perspective, the recommendations are nearly unanimous in strongly supporting the use of chaperones. Many questions related to this issue are unanswered. Does chaperone use decrease malpractice claims? Does chaperone use have an impact on clinical efficiency, as the inverse relationship with the volume of Pap smears performed suggests? What are the regional influences contributing to the geographic variation in reported use of a chaperone? We believe the question with highest priority is, What is the perspective of patients?