If you don’t put your finger it..

…you put your foot in it. So goes the old surgical adage.

There is a piece of kit available to every doctor that is unbelievably sensitive, flexible, reusable and cheap and is woefully underused, the index finger.

I have strong views on pr examinations, this is because I think that if it is indicated it should be done at the time of the initial examination as part of the physical assessment and clerk in. What I hate, and sadly all too often happens, is that I come and do a ward round and find someone who should have been examined per rectum and has not been.

Picture the scene, there are 10 of us at the end of a bed, some junior is presenting their findings to the team and the error of omission is revealed; all of us look to the presenting doctor and then the patient. The spotty wee junior doctor gulps “the thing is. I didn’t think a rectal was indicated in this person who has presented with rectal bleeding”.

The patient now looks to me, like I am some deranged anal pervert who thinks that he does need a finger shoved up his bum when the nice young doctor has said it “wasn’t indicated”. Not one to be upstaged or undermined by some little shit bag 6 weeks out of medical school with little or no understanding of anything, I deal with this swiftly by asking the nice young doctor what he would consider an indication for a pr, this baffles them.

The junior doctor is excused from the round and they are sent back to the patient to do the examination.

It’s SO aggravating, it makes a big deal of something that isn’t a big deal. They should do it at the time of initial examination and spare the patient this awkward interaction on the ward round. It’s even worse because the rest of the bay knows exactly what is happening because they have overheard it all and then see curtains drawn and a flying visit for a pr. It’s humiliating for the patient.

Some patients decline to be examined pr and I probably would too. It is now standard practice to have a chaperone for this examination and this is always documented in the notes. As a screening tool for colorectal cancer the finger is not much use and the old school mandatory pr for the whole ward has been dropped.

It is still useful in assessing a patient, especially in cases of constipation and faecal impaction, change in bowel habit, assessing the prostate, in all cases of pr bleeding and for neurological problems but I have never diagnosed appendicitis based on pr alone and it often doesn’t alter my management much as it is usually normal.

That aside, it is still indicated a lot of the time and as it is an intimate and sometimes uncomfortable procedure it should be done with care and consideration.

The medical school spend a lot of time teaching them how to do it on a big fake dummy bottom that they talk to like it’s real, it is painful to be involved in. I had the bad luck of being the examiner for this in a recent exam. The only amusing part was when one student referred to the KY Jelly as “lube” which suggested a degree of pre-existing familiarity with the procedure.

I think the part the medical school miss out, which is unlike them in the current touchy feely curriculum climate, is that the timing of this examination makes all the difference.

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7 thoughts on “If you don’t put your finger it..

  1. We had paid fake patients that had nervous med students perform rectal, prostate and vaginal checks on them, one after another, until they could stand no more…. Way nicer, in a weird way, than talking to the dummies!

    • There is no substitute for the real thing when it comes to PV and PR examination. Not sure that you could pay me enough to go through that though. Some of the students asked me if they were to talk to me like they were going to examine my rectum. They were swiftly told just to talk to the dummy!

      • They made us say and do all sorts of ridiculous crap to pass that test. Like sliding our hand down a woman’s thigh until we got to the vagina. Who comes up with that crap? If my physician did that to me in reality, I would never, ever be back. Creepy. But yes, the real thing can never be adequately replicated by a dummy.

  2. I remember staying back till 10pm to “tie up loose ends” which included PR exams on all the patients which I admitted earlier. Only to leave out one who had her pr done by the gp. The following day said patient was septic from a big ischiorectal abscess….

    • That’s easily done. Especially if you know and trust the GP and the patient often influences you by saying “by GP already did it and said it was normal”. Hence you seem unreasonable for wanting to do it. Don’t beat yourself up for these things!

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