Is pelvic examination a key part of a patient’s gynaecological cancer diagnostic journey? A qualitative study of GPs and specialists.


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Pauline Williams1,Maggie Cruickshank1,Christine Bond1,Christ Burton2,Peter Murchie1
1University of Aberdeen,2University of Sheffield

Abstract

Background

Despite urgent suspected cancer guidelines recommending that pelvic examination should be an integral part of the diagnostic journey of patients diagnosed with a gynaecological cancer, there is evidence that it is underperformed (1, 2); it is not known why. This study aimed to examine the reasons which influence pre-referral examination rates in primary care.

Method

Qualitative semi-structured interviews were conducted face-to-face with gynaecological specialists and GPs within NHS Grampian. Five specialists and 123 GPs from 14 practices (recruited for an earlier phase of the research), were invited to participate. Data were audio-recorded, transcribed verbatim and analysed using thematic analysis based on COM-B constructs of capability, opportunity and motivation (3).

Results

Three consultants and one specialist registrar (two female/two male) and ten GPs (nine female/one male; two rural and eight urban) participated. Experience, related to exposure in speciality training and clinical practice, was a key theme of capability, influencing technical and interpretive competencies and misattribution of symptoms. Self-selection of female GPs by patients influenced exposure. Several barriers to opportunity emerged, including time, equipment and use of chaperones. Longer appointments and increased exposure were important facilitators. Positive motivators were: professional identity and need for best practice. The intimate nature of pelvic examination was identified as a barrier. The perceived value of examination was both a positive and negative influencer.

Conclusion

Results indicate a complex interplay of influences on whether pelvic examination was performed. Some cross cutting subthemes such as changes in service provision and misattribution of symptoms influenced all constructs. Competency was strongly determined by experience during training and exposure in subsequent clinical practice. However, barriers to examination were more likely to be seen as insurmountable if motivation was poor. Further research is required to fully evaluate potential organisational and educational interventions which could lead to improved rates of pre-referral pelvic examination.