A Doctor Points a Finger at Himself

It is time that we had a frank discussion about rectal exams. Just so there is no confusion here, I am referring to the act where a physician inserts his or her index finger into a patient’s anus and rectum and gleans a piece of clinical data that will be used in the care of said patient. This tidbit of information may be the palpation of the prostate, a search for a rectal tumor, a test of anal neurologic function or to test for bleeding. In my practice a rectal exam is as essential to the care of my patients as listening to the heart. As a patient myself, however, with a looming physical exam by a new primary care doctor, I am apprehensive about its role in my care. But can I put my trust in a doctor who is so cursory as to omit the rectal exam? Suddenly this disconnect between my role as a doctor and my role as a patient is headed for an existential collision!

Having performed this exam hundreds of times, I learned long ago to dissociate any personally embarrassing feelings or language that would inevitably crop up in a normal societal interaction where a stranger asks to insert his or her finger into your rectum. In medical school we are trained to be thorough, but often encounter an internal reluctance to perform this test or even to suggest it to a patient. This reluctance is good and healthy and reaffirms that physicians are not just sadists and voyeurs. My students need to be frequently reminded of this awkward privilege where the social boundaries we are taught as children are amended as clinicians.

Now here I am, a giver of hundreds, on the verge of receiving my own rectal exam, and I am newly skeptical of the utility of a finger in my rectum. What a hypocrite!  There is a saying in medicine that a minor procedure is one performed on someone else. On the other hand, I am painfully aware that doctors make the worst patients. I have practiced for years to become a good doctor; I have very little practice being a good patient.

Surely I do not need a rectal exam. My rectum feels fine. But we medical folks have a way relating any complaint to the rectum. Through a couple of steps of medical logic and imagination we are able to argue that a rash, a car accident, a fever, or a cough mandates a rectal exam. In medical school we are congratulated for this abstract thinking. As my practice has matured I recognize these indications for a rectal exam but have come to the realization that I also perform a rectal exam to show the patient that I am thorough and have not left any stone unturned in their care. In my practice the rectal exam has less to do with diagnostics but strangely more to do with establishing the doctor-patient relationship. Business people have the firm handshake; we have the rectal exam.

As I approach my own appointment I am running possible scenarios of my exam through my mind. On one hand I imagine having an intellectual, peer to peer discussion with my unfortunate doctor about why this test is unnecessary for me. The other half of me knows how difficult it is to care for patient who is also a physician (particularly one like myself). I hope my desire to be a good patient will win out against the anxious, anticipating side of myself, armed with medical literature. The pathetic irony is that an adult male patient like myself is approaching his doctor’s visit with a similar apprehension that women must confront as a teenagers during gynecologic exams. Here I am, a grown man dealing with anxieties that I have dismissed as juvenile from my younger patients. I suddenly feel immature and self-conscious.

Maybe there is more to the rectal exam than a simple test for disease? Much has been written about the therapeutic role of “laying on of hands,” but does the same apply when the those hands are in the rectum? A rectal exam performed by a caring physician indicates to the patient that his or her clinician is thorough, thoughtful and is focused on his or her care. In some circumstances it can add to the clinical evaluation of the patient. Time slows down when a doctor’s finger is in a patient’s rectum. Armed with this realization, I can rationalize why my doctor must perform a rectal exam: He cares about me. I hope my new doctor has put as much thought into my rectal exam as I have- the poor guy.

 

By Otis Warren

Otis Warren is Assistant Professor (Clinical) of Emergency Medicine at The Alpert Medical School of Brown University. His areas of academic focus include traumatic brain injury and alcohol intoxication.

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