The Rectal Is Dead…Long Live The Rectal

My R-1 presented a case this morning, describing a 58 year old woman with left lower abdominal pain. Tradition holds that, in these situations, you get the patient’s name, ask a few other inconsequential questions, and then immediately jam your finger into their rectum.

O.K., that’s hyperbole. But from the perspective of an intern, sometimes that’s exactly how it seems.

“We have a 58 year old lady with left lower quadrant pain wh-”

“Did you do a rectal?”

So, the rectal exam looms over the entire patient encounter, tapping impatiently on the back of your skull until you finally relent and just get it over with. Not to be crass (although I’m post-call and feeling a little punchy), but doing a rectal – especially the first few – is a little like I remember the first kisses of my high school girlfriends (all 2 of them). At some point, The Kiss becomes the elephant in the room. I know I’m about to drop her off at her house, and I know we’re at that point where I have to kiss her or walk away, and so I procrastinate and ask all kinds of stupid questions to delay the inevitable.

rectal.jpgBut unlike a kiss (which is more like a rectal exam than you might think…so don’t think about it), I have never wanted to do a rectal exam. As medical students and interns, however, the exam is not only expected…it’s DEMANDED. One sure way to get torn up by an attending is to skip the rectal exam. Here’s a few of the things you’re supposed to be able to learn from the simple “digital sweep”:

– if there’s feces in the “rectal vault” and whether it’s hard (suggesting constipation) or soft
-if there’s blood (have to smear your finger on a test-card after the rectal exam, which isn’t pretty looking or smelling.
-if there’s external hemorrhoids
-if there’s rectal sphincter tone (if not, worry about major neurological trauma or stroke)
-if there’s polyps
-theoretically you can identify a fissure which can be a major source of bleeding
-you can check the prostate on males and feel for nodules (has almost no statistical correlation to prostate cancer, but we do it anyway in this country)

So, that’s a lot of stuff you can figure out with a simple rectal exam. Today, my intern failed to do the exam. He failed to “remember” it the other day as well. The ire of our attending was impressive as a result, but still, I think my intern will “forget” to do the exam on his next patient as well. Here’s some reasons why:

-the exam is an outmoded test that isn’t necessary – only old-school docs still do it
-it often stinks
-it makes everyone uncomfortable – doc and patient
-I can’t think of many places I’d less like to be
-modern imaging and a good history give you just as much information
-it really, really stinks

sunfinger.jpgThere was a time when every patient who came to the ER got a rectal by a hapless med student or intern. It was like they just wandered around the unit with an extended finger, a box of gloves and some KY, looking into every exam room. These days, even many ER docs don’t do the exam. Same for the admitting internists. The truth is that many physical exam techniques are becoming extinct, much to the dismay of the Old Guard who believe that you can diagnose everything from a triple-A to a spinal abscess with a good stethoscope and a tongue depressor. Back in the day, the physical exam was just about all a doctor had to diagnose serious disease. These days, we have all kinds of nifty tools that, yes, cost bajillions of dollars but spare us the ignominy of coating our fingers with someone else’s feces. Frankly, to most of us, it’s worth it.

4 thoughts on “The Rectal Is Dead…Long Live The Rectal

  1. Kevin

    I read this post a few days late. Or you wrote it a few days late, because I, a relatively healthy 26 year old male, was just given my first rectalation examination. And BOY O BOY was it a grand ol time. “I’m gonna need you to get on your hands and knees on the table.”

    So many classic lines that will surely end up in a movie or a book or just my journal, or, as was the case saturday night, told to friends at a party, loudly, after enough beer was consumed to make the story seem appropriate.

    And you’re telling me this wasn’t necessary? He seemed to learn a lot from it. Nothing discharged onto the slide he held in front of my yoohoo afterwards. The lack-there-of seemed to say a lot to him. And to me in the end.

    But for the love of GODDDDDDDDDDDDDD, I never want another one.

    “Does it hurt?”

    “No more than I ever imagined it would,” is all I could say.

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  2. drtombibey

    In med school we had a urology professor who finished every lecture the same way. He’d put down his notes, stand to the side of the podium and say, “Please. Do a rectal. Make me proud. Do a rectal. My mother died because the doctor didn’t do a rectal. So please. Make me proud. Do a rectal.”

    We thought he was a bit nutty.

    Love your blog. Come visit me. As far as I know I am the first physician bluegrass fiction writer’s weblog. (The above story was true, though.)

    Dr. Tom Bibey

    drtombibey.wordpress.com

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  3. I once had a senior resident, out of spite, insist that I go and do a rectal on every patient on the inpatient service. It was a petty, pointless exercise in “cause-I-told-you-so” domineering, and all the more frustrating because it was not clinically necessary for the patients’ care.

    Having no choice, I did the rectals. Being a medical student at the time, I had to confess that I was not entirely sure what an abnormal prostate nodule actually felt like. So I documented on each and every patient “possible prostate nodule.” The senior resident then had to go repeat the exams to clear up the issue.

    Shit goes both ways.

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  4. drtombibey

    Cool. One has to learn early on to hedge their bets to stay out of trouble.

    Q: “You know what the national tree is for a radiologist?”

    A: “The hedge.”

    Dr. B

    Like

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