The dreaded “annual exam” that women must endure on a yearly basis involves a complete physical exam, pelvic exam and Pap smear. It is unique to women as there is nothing quite equivalent for men. While there are many jokes about the exam, it is extremely important for women to undergo this check-up on a regular basis. Many women joke to their male counterparts about having to endure taking off all your clothes and having your private parts probed and prodded. Young women especially can feel like their body is being violated. It begins for most women as a teenager, often seeking contraception, and continues yearly until well into their later years of life. It is the prime example of preventive medicine for women. Regular annual exams have resulted in decreased death rates from many diseases which occur in this area of the body. The exam can produce quite a bit of anxiety, however, and I have been told by several patients that they have not slept for days prior to it. While it is an extremely personal examination, I want everyone to know what is involved, why it is so important, and relate some of the interesting and even amusing statements I have heard over the almost 40 years I have been performing the exam. Most, if not all, Gynecologists understand the anxiety it creates and do their best especially with a patient undergoing the exam for the first time to allay their fears and debunk the myths surrounding it. I was taught this by one of my professors, Dr. Humbert Riva. He taught me many ways to put the patient at ease and to understand their fears. How fortunate I was to be taught early in my career by this wonderful teacher and physician. The exam that I do is modeled after the teachings that I learned from this giant of a man whom I could never thank enough for all he has taught me. My career has been shaped by him in so many ways. May he rest in peace knowing his teachings have remained with me and so many others for all these years.
To understand this important recurring event in a woman's life, I would first like to explain in detail what is involved in this examination. When I think of it, I am often reminded of the skit that the comedienne Joan Rivers used to do about it. In it she describes the anxiety that it creates beforehand. The fact that all your clothes must be removed and replaced with thin paper garments, the positioning on the exam table in stirrups and the “coup de grace” of the doctor inserting the notorious cold metal "clamp" into the patient's vagina. You can imagine the laughter the skit elicits and the many memories it stirs in women while they relive their own experiences with it. The fact that Ms. Rivers was the daughter of a Gynecologist I am sure made her privy to many jokes about the examination. The levity that can be created by the thought of the exam should in no way detract or lessen the importance of it. So many diseases in women are silent during their early stages and frequently do not lead to any symptoms until late in the course of the disease. It is heartbreaking for me to see a woman who has not had an exam in many years who finally comes in and, unfortunately, it is too late to cure her. So it is my goal to make sure you understand that, although it may be an unpleasant experience, it is extremely necessary because it can, and does, save lives.
Some of my older patients are quite nervous and, I am sure, embarrassed to have a male physician do their annual exams. One day I was talking to one of my elderly patients in the hallway before she went into the exam room. I could tell she was very nervous as we chatted. Many of these women, I know, must think about going through the exam for days or even weeks before they come in. I do my best to appreciate their anxiety and, over the years, I have tried my best to allay their fears and apprehension as much is possible. Despite their nervousness I am always amused at some of the comments they have. That lady was no exception but her comment as she headed for the exam room was priceless. "Doctor, can't we just do lunch instead today?" I almost fell on the floor laughing, but I understood her underlying apprehension. I replied “maybe next year, Mrs. B”. I’ve also heard many times the expression brought on by nerves “usually doctor a man buys me dinner before this”. I think you're beginning to understand how this exam affects women in so many ways.
There is a very nice elderly lady that I take care of who was a former patient of one of my senior partners. She had been his patient for many years and, like most patients, was used to how he cared for her. Well, one day she came in and was told that he had retired and the nurses asked her if she would mind seeing the new young doctor, me. She said “it’s okay I’m sure I have nothing he hasn’t seen before.” My wife happened to be filling in for another nurse that day. She went into the exam room with the patient to help her get ready. The patient was there for a pessary check, which involves removing, cleaning and reinserting a rubber ring in the vagina to support a dropped bladder or uterus. My wife could tell the patient was very nervous about seeing the new young doctor. The patient, however, is quite a character and she began questioning my wife about me. “ So tell me honey, what's this new guy like, is he nice?" “Is he cute?” My wife said " yes he is nice and I think you will like him." “How do you know" she asked? My wife proceeded to explain to her that I was her husband and I know you will find him kind and gentle. The patient later on told me she wanted to crawl under the table after she found out that the nurse was my wife. She also was very embarrassed at the questions she had asked her about me. We have had many laughs over the years about her first visit with me and I have subsequently cared for that lovely lady for many years. She always asks how my lovely wife is doing with a slight grin on her face.
Now let’s talk about what is actually involved with the examination in detail and explain what is done and why it is so important. The history and basic physical exam is pretty straightforward. Most women consider their Gynecologist to be their primary care physician. As such, we have a very important role in their access to the health care system. While most common medical problems are easily related to physicians, many women find it embarrassing to discuss some of their problems like sexual dysfunction, period problems and even abusive relationships. It is there where a good physician must be able to communicate with the patient and give them a sense of security and trust to allow them to freely discuss their problems. But it is the pelvic exam that women really picture in their minds about the annual exam. It is at that point that I frequently hear patients say "and now for the fun part." Rest assured, there is no fun involved for the patient or physician. It is a very personal exam and deserves as Dr. Riva taught me the utmost respect. It is these comments that frequently help the patient allay their anxiety. The exam begins with taking or updating the patient’s history. A general physical exam follows including a breast exam. Finally a pelvic exam begins with an examination of the area around the vaginal opening, known as the vulva. This area can be involved with various conditions from sexually transmitted diseases to cancer. The physician then carefully inserts a metal instrument, known as a speculum, into the vagina. Contrary to a common myth, the instrument is not kept in a refrigerator but on a heating pad. It enables the physician to directly examine the vagina and cervix, which is the part of the uterus that is in the vagina. It is also where the pap smear is taken from. The vagina is a frequent site of disease, the most common one being yeast infections. The cervix is the site of many premalignant conditions, known as dysplasia, and also cancer. After removing the instrument, the physician inserts their fingers into the vagina to do a manual examination palpating the uterus and ovaries. This is simultaneously done by pushing on the lower abdomen with the opposite hand. Then depending on the patient's age and symptoms, the exam may be concluded by doing a rectal exam also. So as you can imagine, it takes a lot of confidence by a woman in her physician to allow him or her to do that type of exam. It also explains why once a woman finds a Gynecologist that she likes and trusts, many times it becomes a lifelong relationship. I even have several patients who travel from out-of-state to see me for their annual exams. I also have two patients who come to see me regularly from England. They are both very displeased with the care they receive under the national health insurance system there. It also explains why I frequently see women who have not had an exam for many years because of a change in their insurance where their physician is no longer in their current plan or because of the retirement of their prior Gynecologist. I think you can see that it is a very unique relationship between patient and physician.
Lastly, I would like to explain in detail about the Pap smear test. The name is the short version of the Papanicolaou Test named for its inventor, Dr. George Papanicolaou. It is a screening test for detecting abnormal cells, both premalignant and malignant, in the cervix and vagina. His famous paper called “Diagnosis of Uterine Cancer by the vaginal smear" was first published in 1943 and the procedure was subsequently named the Pap Test in his honor. He was a true giant in the annals of medicine and the test named after him has literally saved millions of lives. He is responsible for one of the major advances in medical care for women in the last century. While it is a valuable test, it is not infallible and false negatives do occur. Recently, the virus that causes cervical cancer has been identified. Human Papillomavirus, or HPV, can now be detected from the same specimen that the Pap smear is done from. The combination greatly enhances the detection of premalignant and malignant changes in the cervix. Young women can now be protected against acquiring this sexually transmitted virus by a vaccination called Gardasil or Cervarix. It is highly recommended that young women have this vaccination prior to becoming sexually active.
Over the years I have found that the annual exam has enabled me to establish a close personal relationship with my patients. Seeing women year after year and caring for them as teenagers, managing their pregnancies, delivering their children, providing emotional support during divorces and the deaths of children or spouses and finally assisting them through their menopausal changes brings about a special bond between patient and physician. I have grown to know their children, husbands and the most personal details of their lives. In a single day, I may be called on to console a patient who has just lost a spouse, counsel a patient whose husband has been unfaithful, deliver a child, share the successes of children I have delivered or console a patient with a terminal disease. At this stage in my career, I have cared for many women for over 30 years. When I look at my schedule in the morning, I look forward to updating both their medical condition and hearing important details about their lives. It is a pleasure and a privilege that I value very much. Many of them I have laughed and cried with over the years I have cared for them. Many times patients will bring in pictures of the children I have delivered and I enjoy knowing that I was the one who assisted in bringing them into the world. I am very proud when I am introduced to children as the doctor who delivered them. Also because it is such an intimate exam and discussion of problems several times a patient of mine who becomes a good friend of mine outside of the office declines to have me continue as their Gynecologist. I understand this totally and never question the fact that they may switch physicians.
One of my patients recently wrote me a letter which I would like to share with you and let you see how special it made me feel when I read it. "Dear Doctor Ketelaar, this note of gratitude to you may be late in expression, but it is nonetheless heartfelt in its entirety. Thank you for all your kindnesses always, but most especially for discovering that I needed surgery for a large ovarian tumor. Without your knowledge and concern, I would certainly not be feeling as well as I currently do and my gratitude is total. Very often we take our physicians for granted and as part of life service. I have found that your concern and caring for detail is a wonderful part of your service and who you are. I was fortunate in choosing you when I moved into this area. Once again, thanks for being such a special doctor. I certainly appreciate it and I appreciate you."
Whether it is receiving such a letter or receiving a heartfelt thanks from a patient, that is what makes my job so special and rewarding. Such is the nature of the job that I have been blessed to have. How much more personal could a relationship be? It gives me great satisfaction to continue to care for my patients as we both age together over the years. Many of them I consider to be good friends in addition to patients. That is what being a physician is all about and why I consider myself so lucky to be in this profession. Where else could I have so much personal satisfaction? So it is the annual exam that really brings it all together on a personal and professional level.
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