Dissertations and Theses
Date of Degree
6-5-2025
Document Type
Dissertation
Degree Name
Doctor of Philosophy (Ph.D.)
Department
Community Health and Social Sciences
Advisor(s)
Meredith Manze
Committee Members
Heidi Jones
Spring Cooper
Margaux Genoff Garzon
Subject Categories
Health Services Research | Public Health | Women's Health
Keywords
patient-provider interactions, electronic medical record, clinical bias
Abstract
Background
This dissertation explored the complex dynamics of pelvic exams (PEs) for cancer screening through a multifaceted approach, focusing on documentation of the examination in the medical record, as well as patients' and providers' perceptions of the experience. The studies together consider biased documentation practices in the written description of the encounter (provider encounter notes), how patients describe positive and negative PEs, the possible impact of negative PE experiences on their willingness to engage in subsequent clinical care, and provider reactions to patient descriptions and results of record analysis.
Methods
This research employs a mixed-methods design spanning three distinct but interrelated studies.The first study utilized free text from the medical encounter note written by providers at a Federally Qualified Health Center Network during PEs between 2019-2022, while studies two and three relied on data from IDIs completed in 2024 and 2025 with both patient/community members and family medicine providers respectively.
Results
Analysis of encounter note free text from the medical record (n=2,167) found the majority of providers’ notes (88%) were coded as neutral, or not containing emotion-based or biased language. Among the notes categorized as including some emotion (positive or negative), most excerpts fit a priori definitions for type described by previous work, with one notable difference—a distinct positive language category for encounter notes with language expressing empathy and reassurance. Factors in a final adjusted multinomial multivariate model exploring both patient and provider sociodemographics with higher odds of being coded with emotion-based language include location, insurance status, and patient BMI category. Analysis of transcripts from the IDIs with patients/community members (n=21) highlighted the significance of narration, warmth, and empowerment during exams, while also revealing discrepancies between patient and provider perceptions of these clinical interactions. The data from the analysis of IDIs with primary care providers (n=18) included two themes, one expressing the clear attempts (albeit with challenges) of providing trauma-informed and patient-centered care, and the juxtaposition of idealized versus actual use of medical record notes.
Conclusions
Together, these findings contribute to a better understanding of patient needs and possible barriers and facilitators to effective patient-centered communication about PE, with implications for interventions to reduce the expression of bias towards patients and support their engagement in care. Findings from all three studies suggest that patients and providers consider a ‘good’ PE as one that draws on patient-centered care and trauma-informed communication practices, emphasizing clinicians’ use of empowering and empathetic language. While empathy and reassurance are more often explored through verbal communication in the clinical encounter, these findings suggest that this is also present in encounter notes. These data also highlight the importance of understanding how various factors—such as geographic location, patient characteristics, and provider types—might influence clinical communication through encounter notes.
Implications for Practice
These findings underscore the need for improved communication strategies, continued unbiased documentation, and a deeper understanding of factors influencing PE experiences across diverse patient populations. Future research should also explore the impact of positive, empathy-focused language in clinical documentation on patient outcomes, interventions to reduce discrepancies between patient and provider perceptions of communication during PEs, and developing targeted strategies to improve PE experiences for marginalized and underserved populations.
Recommended Citation
Shuman, Saskia Z., "THE PATIENT AND PROVIDER EXPERIENCE OF THE PELVIC EXAM: EXPLORING COMMUNICATION AND IMPLICATIONS FOR PRACTICE" (2025). CUNY Academic Works.
https://academicworks.cuny.edu/sph_etds/110
