What influences the performance of pelvic examination in primary care: a qualitative investigation

Objective: Omission of pelvic examination (PE) has been associated with diagnostic delay in women diagnosed with gynaecological cancer. However, it is often not carried out in by general practitioners. The study aimed to determine the perceptions GPs on the role of pelvic examination and the barriers and facilitators, and their experience in practice. Design: Qualitative semi-structured interviews. Setting: One health board in Scotland (mixed urban and rural) with an approximate population of 500,000. Participants: 15 GPs (11 female) with differing levels of experience. Methods: Interviews were conducted face-to-face or by telephone. Framework analysis used the COM-B behaviour change model concepts of capability, opportunity, and motivation. Results: Data was compatible with all three domains of the COM-B framework. Capability related to training in and maintenance of skills. These went beyond carrying out examination to interpreting it reliably. Opportunity related to the clinical environment and the provision of chaperones for intimate examination. Interviewees described a range of motivations towards or against PE which were unrelated to either capability or opportunity. These all related to providing high quality care, but this was defined in different ways: “doing what is best for the individual”, “doctors examine” and “GPs as pragmatists”. Conclusions: GPs’ reasons for carrying out, or not carrying out, pelvic examination in women with symptoms potentially indicating cancer are complex. The Capability, Opportunity, Motivation framework provides a way of understanding this complexity. Interventions to increase the use of pelvic examination, and critics of its non-use, need to consider these multiple factors.