Thursday, January 8, 2009

In Honor of Me (and the DRE)

My brother remarked over Christmas Break that I seemed overly obsessed with the gastrointestinal tract in my blogging.  I promised him that I would write about something different; kidneys, ovaries, maybe lungs.  Somehow, I ended up back in the gut.  Just like Dr. P, year after year, introducing his gastrointestinal (GI) physiology lecture series dancing and jerking wildly in the spotlight at the front of the lecture hall in one of those giant accordion-like plastic tubes we all used to crawl through when we were little, tossing Butterfinger bars to a surprised and entertained audience of second year medical students.  I can't escape it.  This week:  The Rectum.  Sorry bro - maybe next week.

When I was a third year med student, I learned how to perform a digital rectal examination (DRE).  It's not rocket science, really, just put a glove on and try to concentrate on normal vs. abnormal anatomy rather than being completely overwhelmed by the fact that you are sticking your finger into a stranger's anus.

Somehow, I always ended up on the rotation where the attending was obsessed with the DRE.  I might have thought they all were, if I hadn't discussed it with my friends.  Sure, when you are on internal medicine, or surgery, you are expected to perform a DRE with every history and physical (H&P), especially at the Veteran's Hospital (VA).  In fact, you cannot even open a patient's computerized chart at the VA without a bunch of flags popping up, alerting the onlooker to various check-ups and tests that are "overdue;" including colonoscopies, Tuberculosis skin tests, and often first and foremost:  the DRE.

When I got to my psych rotation, I was surprised to learn that with each new admission I was expected to perform a DRE during H&P.  I was working on a unit for men with combined psychiatric disorders and substance abuse issues.  Upon admission, they were often not only high or reeking of alcohol (or both), but also clearly devoid of much-needed antipsychotic medication.  Yet my attending still insisted upon my performing a DRE (couldn't they get that on their yearly check-up with their family practitioner?).  He also sent me to one of the nurses on the first day, who haughtily informed me I could not wear a skirt unless I was wearing pantyhose.  She stared accusingly at my modest floral calf-length skirt and closed-toed flats as if I was wearing a leather mini and peep-toe spiky heels.  I felt like I had stepped back into the 1950's. First of all, I did not own a pair of pantyhose.  Furthermore, it was sweltering mid-summer and I couldn't imagine even trying to put them on much less wear them in the less-than-air-conditioned facilities, sweating through smelly DRE's in tight, crowded rooms.  I wore pants for the rest of the month.

When I got to my family practice rotation in a small town, I was not surprised to be expected to perform DRE's in men of a certain age group.  Shockingly, my attending also wanted me to perform a rectal on every woman receiving a pap smear.  Was this old school or complete lunacy?  I mean, what did he expect me to find up there?  There was no prostate to palpate for firmness or abnormalities.  At the most, I guess I might feel a hyperplastic or prolapse polyp, or maybe some hemorrhoids, or a rectal tonsil -- but these are all benign entities!  Why subject the poor woman to pointless probing?

Needless to say, by the time I reached the end of my third year, I was getting pretty good at the DRE.  I was not yet certain of my future specialty, but I had a list of possibilities that would ensure I would not be performing any rectal exams for the rest of my life.  When I got to my last rotation, I ended up back at the VA.  One morning, I was doing a complete H&P on a 45 year-old male who was already admitted to a room.  Without even being asked, I performed a DRE; it was knee-jerk by now.  This time, I felt something unusual, and had no idea what it was.  It is extremely rare to find anything unusual on a DRE - most prostate cancer is found by elevated Prostate Specific Antigen levels (PSA), which is a blood test, and most colon cancer is discovered on colonoscopy.  All the more reason that the rectal is the bane of the med student's existence.  So when I finally felt something, after all of those previously normal rectal exams I had performed throughout the year, I wanted to ignore it -- the patient wasn't even being admitted for GI or prostate issues.  I was positive that whatever I was feeling was nothing, and I was going to be made the butt (no pun intended) of every rectal joke in the future if I followed up on it.  But I HAD to.  Always the schoolgirl.  

Luckily, I had a really nice attending, Dr. Baugh.  He was so tall that it made you look for tell-tale signs of Marfan's Syndrome (there weren't any).  He was thin and well-dressed, with short dark hair, a clean-shaven face, and an easy smile.  I hesitantly knocked on the door of his office.  

"Um, Dr. Baugh?"

"Yes, Dr. Shyder?"

I was distracted by a mound of papers on his desk, covered in what looked like equations.

"What are you doing?"

"Quantum physics, in my spare time.  Nice to have some, in a VA job."  He was so modest, I managed to feel even more inadequate than if he had bragged about it.  I looked around and noticed he had more physics than medical journals stacked on the floor of his cramped office.

"I was doing an H&P on Mr. W., and I think I felt something when I did the, um, I mean, on the DRE."

"On the WHAT, Dr. Shyder?"

"On the, um, rectal exam."  I turned away, blushing.

Dr. Baugh investigated Mr. W's rectum himself, and was concerned enough to order a CT scan.  Surprisingly, Mr. W. ended up with an early rectal cancer diagnosis.  Dr. Baugh was ecstatic.  "Dr. Shyder!  We have never had anyone diagnose rectal cancer on a DRE in my history here at the VA!  This calls for a celebration!  7:00 a.m. Saturday morning!  We'll invite the entire staff!  I'm buying!"

So Dr. Baugh brought orange juice, donuts, and coffee to Saturday morning rounds.  And made sure that everyone knew exactly why we were celebrating, to my extreme mortification.  I remember calling my dad to tell him Dr. Baugh (whom he knew) was throwing a party for me, because of a diagnosis I had made.  My dad asked me to tell him about it.  When I did, I could tell he was shocked, and it took him a second to muster the appropriate response.

"You did what?"

I repeated myself.

"Oh.  That's what I thought you said.  I hadn't ever heard of anyone doing that before.  Well.  That's really great.  I'm proud of you."

Have you ever had a party convened in your honor?  Aside from birthdays and graduations, I mean.  I really hadn't, until then.  Not complaining -- there is nothing I detest more than being the center of attention.  Even worse that the cause for celebration was my proficiency in performing a rectal examination.  Thank goodness, that was my last DRE.  I got to go out with a bang.  Too bad I don't like donuts.


John Hornor said...

Elizabeth, forgive me for what I'm about to type, please, but I can't help myself.

Becoming a doctor, enjoying a high salary and having the respect of almost everyone you meet...sorry...I'm laughing and it's hard to've had your digits up half a thousand assholes.

I can handle that.

LOL. Goddamn, that's funny.

Sorry. I know you're gonna be mad.

You know the three rules of plumbing?

You get paid on Thursday.

Shit rolls downhill.

And don't bite your fingernails.

Gizabeth Shyder said...

That's why the smart health care professional keeps short, tidy fingernails. The consequences of glove perforation can be quite hazardous.

Thankfully, hand washing was already in vogue when I went through med school. A seventy-plus year old attending, who is still working part time - still doesn't use gloves religiously for autopsies or examining specimens in the gross room. I wonder what rectals were like in his training.

Anonymous said...

omigod! that is the funniest story. i, somehow, did not perform very many rectals. sort of the same way i got out of delivering babies. i faded into the background and let the fellows do it!

Gizabeth Shyder said...

Leave it to you, Trishie, to get out of the DRE. You suck.

Don't forget to send me the autoerotic asphyxiation powerpoint. Good luck at Grand Rounds. Wish I could be there!


Anonymous said...

Finally catching up with the blog-that was so hilarious! Now I remember why I didn't seriously consider med school- well that, and the fact that I suck at chemistry, physics, and biology.

Gizabeth Shyder said...

I suck at weather, law, and economics. So we complement each other well, Scientist of Seasons!

Solitary Diner (Also Known as The Frugalish Physician) said...

Hilarious post. I guess you take the celebrations wherever you can find them.

medaholic said...

Oh the DRE, the medical student's job. But as bad as it sounds, it's stories like this that help you realize how important being vigilant and thorough is, and I'm surprised by how many things medical students pick up because they end up being the only ones that check.

Gizabeth Shyder said...

Thanks SD!

Nice point, medaholic. Makes my rectal experiences worth it, I guess.

Wick E. Scratch said...

So, did you pick up the donuts by putting your finger in the hole? :-D

Gizabeth Shyder said...

Ha ha. Remember, I don't like donuts.