Accommodating Patients

New patients often do not inform providers of their disability when making an appointment. However, if a patient does disclose that she has a disability which requires accommodation, practitioners and/or reception staff should ask the patient about:

• The amount of time needed for the appointment
• Accommodations for completing forms and the exam itself
• The need for assistants to aid in transferring and positioning
• The need to arrange for a sign language interpreter
• Any assistive technology that the patient uses and how it will affect the exam process. Assistive technology can include communication devices as well as wheelchairs, canes, etc.

A good introductory question is, "is there anything we can do to help this visit/examination easier for you?" Generally, it is more respectful to inquire about accommodations than the nature of the disability itself.

Accessible Equipment

Accessible equipment includes exam tables that are wider and/or can be lowered and offer side, foot, leg and knee support, and mammogram machines that enable women to have a mammogram without standing or leaning (this issue is of particular concern for women who use wheelchairs or who have other mobility impairments). Assessing patient experiences and the views of other medical professionals who have used accessible equipment may be helpful if you are considering such a purchase.

Consider the layout of the exam room when preparing for a patient with disabilities. Additional space may be necessary to accommodate a wheelchair, interpreter, or assistant. Additionally the use of padded stirrups and related equipment may increase the comfort of the patient.

Alternative Positions for the Exam

The following descriptions are provided in order to promote the notion of flexibility in positioning. This list is by no means exhaustive; there are a variety of ways to modify positioning in order to maximize the comfort of the patient and accommodate mobility impairments. Patients may often be able to describe positioning accommodations that have worked well in the past. It is worthwhile to query the patient about her experiences in this regard.

This position does not require the use of stirrups. It is particularly good for a woman who feels most comfortable and balanced lying on her side.

Because the woman is lying on her side, the practitioner should be sure to angle the speculum towards the small of the patient's back and not straight up towards her head. The woman should not roll onto her back until the speculum has been removed.

As with many of these positions, an assistant may be necessary to provide support for the patient while she is on the exam table, help the woman straighten her bottom leg if necessary, or support the patient in rolling onto her back for the bimanual exam. If the patient cannot spread her legs, the assistant may help her elevate one leg. The woman may have a personal assistant accompanying her, but it is necessary to ask the patient if she would prefer to have a medical staff assist with this portion of the exam. The assistant who arrived with her may not, in fact, be qualified to assist with such a procedure.

The woman lies on her back with her knees bent so that both legs are spread flat and her heels meet at the foot of the table. The speculum must be inserted with the handle up. The bimanual exam can be easily performed from the side or foot of the table.

The assistant may help the patient support herself on the table and hold her feet together in alignment with her spine to maintain this position. A woman may be more comfortable using pillows or an assistant to elevate her thighs and/or use a pillow under the small of the back.

Obstetrical stirrups provide much more support than the traditionally used stirrups. This position allows a woman who has difficulty using the foot stirrups to assume the traditional pelvic exam position.

The woman lies on her back near the foot of the table with her legs supported under the knee by obstetrical stirrups. The speculum can be inserted with the handle down. The bimanual exam can be performed from the foot of the table.

The patient may want assistance in putting her legs into the stirrups. The stirrups can be padded to increase comfort and reduce irritation. A strap can be attached to each stirrup to hold a woman's legs securely in place if the woman prefers this increased support.

NOTE: This material was adapted in part from the "Table Manners and Beyond" guide to accessible sexuality and reproductive health services, developed by Kathleen Lankasky. The full manual may be accessed at http://www.bhawd.org/sitefiles/TblMrs/cover.html and is public domain.