An exam difficult for both
In August, the U.S. Preventive Services Task Force, a government-sponsored panel of medical experts, issued new recommendations regarding prostate cancer screening: Men ages 75 and over should no longer be screened for prostate cancer with the PSA blood test or digital rectal exam.
An unexpected benefit may be an improvement in the doctor-patient relationship. The rectal exam can be one of the odder moments between a patient and his doctor. Not long ago, for example, I saw a 75-year-old for his routine annual visit. Things were not going well for him.
His wife’s dementia was worsening daily. She would leave the stove on, accuse him of stealing her things, holler at him day and night. And yet he could not imagine putting her in a nursing home.
His eyes, usually sparkling with delight, were dull. As I examined his heart and lungs, neck and belly, ankles and feet, he heaved a long sigh. I felt gloomy about his wretched situation.
I must have been preoccupied, because when it was time for the rectal exam, I bumbled my words. I asked him to lower his pants, but instead of saying “Lie on the table,” I told him to lie on the floor. The patient and I burst out laughing.
Still chuckling, I stepped out of the room so he could get ready. To be sure, my bumble had brought levity to a traditionally awkward moment -- but why, I asked myself, did this encounter have to end with an examination of his anus?
I was drawn to primary-care medicine by the human connection that comes with the white coat and stethoscope, the prospect of people willing to share their everyday thoughts and deepest secrets, and their expectation that I would use this information to help them.
What I didn’t fully grasp was that this intimacy also had a critical physical component -- one that came gloved and lubed.
I’d never imagined that performing rectal exams would become a daily reality. Most of my patients are men over 50, which means that I ask them if they’d like to be screened for prostate cancer.
Some inquire whether the PSA (prostate-specific antigen) blood test alone will suffice. I explain that it’s most informative to have both the PSA and the digital exam: Some cancers hide in prostate nodules in men whose PSA readings are normal.
So for men under 75 and over 50 (earlier for higher-risk men) who wish to be screened, just as important as the PSA is the old-fashioned, low-tech way with a pair of rubber gloves, a foil packet of lubricating jelly and an index finger.
For years I didn’t feel confident in my ability to do a good rectal exam. In medical school, we spent about two months learning the heart exam, maybe one month on the lungs. The rectal exam was granted a single session.
Not surprising: It’s one thing for a parade of students to line up, stethoscopes ready, at the bedside of a chatty patient with a heart murmur; it’s quite another to find a patient willing to roll over and endure a series of rectal exams by unskilled, anonymous fingers. The result: a culture of squeamishness.
During residency, I did a lot of rectal exams and tried to get a sense of the prostate’s normal size and consistency. But often I wasn’t sure of myself. Was a slight asymmetry a normal variant or something worrisome?
I probably sent too many patients to urologists earlier in my career because of my self-doubt, but that was better, I suppose, than missing something.
And although plenty of men will hop onto the exam table without hesitation, there’s no shortage of reluctant and nay-saying patients, of awkward silences followed by excuses.
One patient I recall stole a glance at my hands, the muscles in his face relaxing ever-so-slightly when he looked at my fingers. “My old doctor,” he said, “had thick fingers, like sausages.”
Another said, “My other doctor did one a few months ago, I think.” And another, “Next time, I promise.” Many opt for the PSA without the rectal exam.
Back in my exam room, the patient lay on the exam table in a fetal position, pants down, buttocks exposed, testicles dangling.
I examined his rectal area for internal hemorrhoids, the subtle edge of an anal fissure, the flat cauliflower of an anal wart, and found none.
I touched the precise spot of the anal skin that elicits the mischievously named “anal wink reflex,” a test of nerve function. I dabbed my finger with the jelly and eased it in against the muscular resistance until I touched the prostate.
To feel the whole prostate and distinguish between its two lobes, I bent my knees, turned my arm upside down and swiveled my finger to reach the other side of the gland. It was the size of an apricot, smooth and rubbery.
As usual, I grimaced: The rectum has muscles that clench and unclench at the slightest sensation, and it always feels odd to have my finger locked in that tight embrace. It doesn’t get more intimate than this.
Then I closed my eyes and focused on all of the nerve endings packed closely in my fingertip. As my finger swept the prostate gland, I felt its normal consistency, its symmetry and, to my relief, not a single nodule.
It was almost a Zen moment: worlds of otherwise hidden information uncovered through careful probing -- earlier, via conversation; now, via a digit.
I wiped my finger on the stool-sample card and discarded my gloves. The old man looked over his shoulder from the table, the twinkle in his eyes returned. “Does this mean we’re friends?”
There’s nothing like an awkward joke to defuse an awkward moment. But thanks to the U.S. Preventive Services Task Force, there may now be fewer of both.
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