Medicine From The Trenches

Experiences from medical school, residency and beyond.

The Rectal Exam- perhaps a microcosm of health care

Introduction

And there we were, sitting in orientation in medical school, contemplating our futures as physicians. Sure, there were the warnings, “Look to your left and look to your right…” but we were anxious to get on with the business of becoming physicians. We would change the world one patient at a time and we would have instant intimate relationships with our fellow human beings so that we can solve their health problems and get them on to healthy life styles. As we moved from orientation to our first courses in medical school: Cells and Tissues, Professionalism along with a healthy dose of “you can’t learn it all”, we were introduced to the science of learning how to study the diseases and structures that would make up our careers in the future. Nothing in those preclinical science courses prepared us for some of the intimate probings that we would have to learn to perform on our diverse patient population. For many of us, we lost the art of doing a complete and thorough physical exam largely because we say that we don’t have the time or we don’t want to embarrass the patient because we just met them.

My early experiences

Let’s look at how I learned to perform the rectal exam. My first experience with the rectum was in my studies of gross anatomy, microbiology, histology and pathology. If I even do a mind stretch, I can say that my first experiences were back when I was a child, recently toilet-trained, thanks to my older brother (age 8) who was a master at using the “porcelain convenience”- even at that age, he sat in there for hours reading comics and contemplating his life. I, on the other hand, was fascinated with how things would disappear in the swirl of blue water, never to be present in my life again. Some things, fecal matter, vomitus and urine, were great to get out of my life but my hair brush and toothbrush, things my brother and sister would lovingly flush when they were angry with me, were things that I wanted to keep around but would have to be replaced once they were flushed.

My earliest experiences with urine and feces, by smell, let me know that these were things that were not wanted as keepsakes. My parents were adamant, “Don’t let that dog poop in the house!” “This place smells like an out house, why didn’t you let the dog out when she was at the door?” What was in “dog poop” that was so awful and even more interesting, what was in my fecal material that encouraged me to flush as soon as I detected odor so that I wouldn’t be teased by my siblings? Being a budding scientist, I obtained a sample of my feces (very small sample) and my dog’s feces so that I could examine them closely. I even had a microscope where I examined these items very carefully and made notes. Yes, I grew up in a household with three physicians (my uncle, my aunt and my father) who encouraged me to explore all parts of my environment and log what I saw. I could ask questions or even better, go to the library (we had one in our house) and look up the answers. So, I asked what was in feces and looked for the answer. The encyclopedia and a couple of medical books stated bacteria (accounted for the smell), sloughed intestinal cells and indigestible materials from food that was eaten earlier.

Later experiences

As I moved through my undergraduate coursework (chemistry and math major), I learned about chemical compositions of biologic materials and bacterial physiology. These courses came in handy for my graduate study in biochemistry and molecular biology. There was nothing about the human body that I couldn’t break down into elements and macromolecules; the bacteria, the indigestible materials, the bilirubin and sloughed enterocytes. In short, the process of digestion and peristalsis (loads of study of neurotransmitters), vomiting, formation of urine and feces could be studied scientifically and eventually broken down into biochemistry. Yes, I have found the keys to all things in life and they are chemical elements with chemical characteristics. All things in life could be studied, characterized and explained by their chemical characteristics and properties. This was heady material for a budding biochemistry and molecular biology researcher. I would go on to design my experiments with these elements in mind and a healthy dose of skepticism that all scientists must cultivate. In short, there is likely alternative explanations for what I am observing and I should make sure that I look for them.

Medical School

As I moved into my first year of medical school, we were required to rotate in a clinical area. I chose Emergency Medicine and the Emergency Department because I was pretty sure that I would not be entering Emergency Medicine but I wanted the experience of working in this area without doing a 4th-year elective.  My clinical preceptor wanted us to get the most didactic learning out of our experience but knew that we had only been in medical school for one week (orientation week). He knew that we didn’t have much basic science background, outside of what we had brought into medical school with us. Trust me on this, for the vast majority of us, the pre-med courses in science are a good basis but not enough to understand complex pathology.  He opted to teach us how to elicit a solid history from a patient which is an exercise that anyone can learn without much clinical background. “You want to know why they are here and what convinced them at this point in time, they should head to the Emergency Room”, he told us in the beginning. “Besides, anyone can ask questions and those who don’t have preconceived notions are the best questioners so I want you to dive in and try to figure out what is going on with your patient”.

He taught us the proper form to write up a patient history and most importantly, he taught he to relay clinical historical information to an attending physician in a form that is useful. This was a fabulous experience for me because our medical school was located in an inner city with a very diverse patient population. We had a diversity of ages, sexes and ethnicities with a dose of religious diversity thrown in. Everyone, regardless of age, socioeconomic status, ethnicity, sex or religion gets sick and all human beings want their clinical problems solved, especially those that are in the emergency room. As novice history takers, we started out with the patients that had been triaged to the “non-critical” areas which gave them something to do and provided valuable experience for us.

What I learned right away

Patients interact with their gastrointestinal tract on a daily basis and under many different occasions during that daily interaction. When we are frightened, we may have an urge to run but also an urge to defecate. We feel disappointment “in the pit of our stomachs”. We may eat something new that causes the experience of nausea or we may experience nausea and vomiting by eating something that is contaminated or cooked improperly. We can have an allergic reaction to a food or we may have an adverse reaction to a medication that is gastrointestinal from difficulty swallowing a tablet to stomach upset to diarrhea along with rash and swelling. In short, the GI tract can give important information as to the systemic condition of a patient or can give clues that the GI system itself is the source of pathology.

It is up to the physician to ask the patient about gastrointestinal symptoms if they don’t volunteer this information. A patient may tell you that they have a stomach “ache” which may mean that they have nausea, intestinal cramping or heartburn (may be reported as chest pain too). Patients need to be asked about fever, chills, vomiting, diarrhea in addition to difficulty swallowing, eructation, changes in the color of their urine/feces (darker colored to lighter colored) with or without mucus or blood streaking.  Are they experiencing bloating, vomiting blood or blood streaks on the bathroom tissue. Is there rectal itching present or increased passage of intestinal gas or a feeling that they are not emptying their bowels completely? Do they have pain with defecation or does defecation relieve their pain? Have they noted a change in the size or odor of their stool? Have they developed problems with certain or all foods that were usually a part of their diet? All of these symptoms especially those that deal with defecation may not be volunteered by the patient.

Cultural Barriers

Some patients, especially young and older men are not going to want to discuss their bowel habits with a female physician. Perhaps their religion will not allow them to speak with a female or they feel embarrassed and will reluctantly give any information at all. I have encountered male patients that would not consent to an examination by me, a female surgeon even though they were in pain from an incarcerated hernia. I make every effort to safely accommodate their wishes but sometimes, especially if I am the only surgeon on call, I have to explain the situation and the danger of delaying the examination.

Some of my physician colleagues will not perform rectal exams on patients. I vividly remember my physical diagnosis professor from medical school saying that the only reason not to perform an indicated rectal exam is that the patient doesn’t have a rectum and you don’t have a finger. Indications for a rectal exam are any suspected acute abdominal pathology or as part of a screening physical examination. I can’t relay the sadness of finding a rectal tumor that has metastasized through the rectal wall that is within the reach of a finger in a patient that hasn’t had a rectal exam in several years. This situation is commonly encountered in elderly nursing home residents especially those who with poor mobility and limited ability to communicate. Often these patients have pages and pages of physical exam findings but “deferred” when it comes to the rectal exam.

Medical Care

Your patients entrust their health in your hands. When it comes to their health, language and cultural barriers on the part of the patient or the physician must not delay or defer good medical practice. It is incumbent upon the physician, who is the professional to present sound clinical reasons for any exam and alleviate any embarrassment on the part of the patient. No, rectal exams are not fun but they are necessary and in some cases, they are life saving. A physician is not performing a rectal exam to make the patient more uncomfortable but to make sure that the patient gets the most complete care possible. To defer a necessary test because one does not want to “bother” the patient is not sound medicine. In today’s world of pushing patients through offices and emergency departments as quickly as possible, to skip something that is warranted is equivalent to not giving care at all. We as physician are entrusted with the care of our patients and in many cases, we have to explain that our care may be uncomfortable or embarrassing but it will be complete and necessary.

The Rectal Exam

As with any aspect of a patient’s examination, we perform what is necessary for the alleviation of a patient’s clinical problem. If a patient stated that they had a sore throat, would you allow them to leave your care without ever looking at their throat? If a patient has gastrointestinal symptoms that warrant a rectal exam, will you allow them to leave your care without performing a rectal exam because they talked you out or it? Will you allow your patient to talk you out of doing what you know is sound medical care?

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18 April, 2015 - Posted by | medical school, physiology, surgery | ,

1 Comment »

  1. I really enjoy your writing. You’ve got this great technical/analytical approach, but then a line like “I can’t relay the sadness…” catches me off guard and reminds me of the human, compassionate side of what you do. Thanks for keeping the blog going 🙂

    Comment by K & T | 22 April, 2015 | Reply


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