The View From the Other Side of the Glove

I have been out to discredit the routine use of the screening digital rectal exam (DRE) for years. My first experience was vivid and eye opening. The setting: England Air Force base in Louisiana. The circumstances: getting my pre-training Air Force physical. I was young (20), and I had no idea what I was about to go through. I was vigorous, healthy, and had absolutely no symptoms of anything, except perhaps too much cockiness.  A pre-flight physical before flight school – sure, no problem! I remember very few events about this exam other than one – after completing a myriad of forms, I was ushered into a room where a bored doctor asked me to drop pants and bend over. I was too shocked to not comply, and before I knew it I was in a world of hurt.

Fast forward to today. Now I know better – there is basically no screening value to performing DRE on healthy young men. Because I have some knowledge of military culture, I’m sure that traditional exam was a vestige of days gone by when “one size fits all”-medicine was the rule.

As a medical student learning the art of physical exam and the importance of being thorough, we were taught that everybody needed a DRE—well, almost everybody. The only clinic where this was not a required part of the medical database was the psychiatry ward. And that’s the way it should be, because it is critical to train young doctors to be diligent and complete in their evaluations.

In today’s medical world, doctors vary in their opinion as to when a patient needs a DRE. For instance, some still maintain that a pelvic examination is incomplete without a DRE in order to access the deeper structures of the female pelvis. The same goes with prostate cancer screening – DRE is always mentioned in conjunction with the PSA blood test. We are now advised to have a lengthy and detailed discussion of the relative merits of prostate cancer screening with men.  But if we’re realistic, we know that most men will choose to dodge the finger if given the choice! The number of additional cancers found because of an abnormal DRE in men with low PSA levels is estimated to be limited. 

Clearly there are times and circumstances when DRE is critical to an accurate diagnosis. Rectal bleeding or pain, for instance, or a change in bowel habits suggesting a rectal or colon cancer would necessitate an examination of the rectum. Also, an unexplained anemia can be a sign of bleeding in the intestinal tract, so checking the stool for traces of blood by DRE is quite important.

The question really is whether routine DRE for the purposes of screening is helpful or important. On the one hand, DRE is easy(for the doctor anyway), low risk,  and inexpensive to perform. While there may be a random surprise diagnosis made by routine DRE, those would be few and far between, especially if the systems review is honestly and completely negative. So if the patient has a trusting relationship with the physician and honestly reports no unusual symptoms, then DRE is very unlikely to be helpful. Furthermore, how many men and women demure from regular check ups for fear of DRE?  Humorous parodies of patients enduring DREs are widespread and influential. We’ve all been subjected to the juvenile quips from those whom we are approaching with index finger extended. I can’t prove it, but I suspect unspoken fear of DRE is the basis for declining routine physicals for a significant number of adults.

Given that the most common killer of Americans is cardiovascular disease, we would do much better to selectively perform DRE only on those patients who have a positive systems review, especially if both colon cancer and prostate cancer screening by colonoscopy and PSA is up to date. Wish I would have known this when I was 20!

Let's Work Together

After reading a recent Wall Street Journal article entitled “What If the Doctor Got It Wrong,” I began thinking about how both doctors and patients equally contribute to the undermining of good healthcare. The article’s critiques focused on specialists such as pathologists and radiologists who, by a single diagnostic pronouncement, may drastically affect a patient’s ultimate outcome. In these tense situations, it is very important that a correct pathologic diagnosis be made, and these specialists have only one chance to get it right. Hence, as the article says, second opinions are critical when there is any doubt. To their credit, many specialists are now consistently creating pathways to ensure accurate diagnoses in these critical cases by obtaining second opinions from other doctors.

For those of us in primary care, the potential for a disastrous and life-changing misdiagnosis is just as likely, but perhaps not as frequent. Faced with large volumes of daily interactions, we often see diseases and acute illnesses in their earliest stages. Vagueness of symptoms and a sparcity of specific revealing physical findings is the rule for primary care physicians, and we are often faced with making our best educated guess. It is rare that someone walks through our door with a clear and unequivocal diagnosis.

I like to think of an illness or chronic disease as an unwinding story with twists, turns, and occasional surprises, so that the final chapter cannot be known by one who has read only the first few pages. While most of what we see in the office ends “happily ever after,” sometimes that is not the case. Nobody like surprise bad endings. Physicians and patients must read along together, because as the plot ripens more of the ending can be predicted.

I believe that there needs to be an easy and collaborative process of ongoing reevaluation as events of an illness unfold—as more details are known, more can be anticipated. If an illness that looked benign in the beginning seems to be evolving into something more serious, more evaluative steps may be taken such as lab tests or various x-rays. And this can be accomplished at the appropriate pace.

So how do both physicians and patients undermine this process? 

Physicians and other primary providers often create barriers to access. In our desire not to be overwhelmed, we put processes and people between us and our patients. Phone trees, messaging machines, rapid-fire appointments, and poorly-trained office staff create inaccessibility that undermines our need to stay abreast of an evolving illness. In the harried frenicity of our daily professional lives, we often fail on our side of the unspoken agreement with our patients: in return for being given the status of a trusted guide, we pledge to walk with the patient until the illness is resolved or controlled. If they can’t access us, we can’t know what is happening.

What’s more, our current medical record system requires such high levels of security that it is often inaccessible and useless for the purposes of information exchange. Nobody knows where the story began or what turns it has already taken. We have also failed to create a seamless and timely backup system for when we simply can’t be available. This has led to increased dependence on the busy, expensive, and often inefficient emergency room system as the backup of choice. Because most physicians think much alike, it should be easy for us to pick up the illness storyline when another physician has stopped for a respite, as long as he/she is aware of what has transpired before.

Patients have some culpability, too. Hesitancy to tell us all of the facts, failure to explain specific worries or fears, or poor listening skills make that collaborative relationship difficult for physicians to maintain. Too often patients devalue that relationship by trading it off for the expedience of “quick clinics.” Trust is built on repetitive interaction, not from quick fixes and drive-through health care.

Often patients’ expectations are too high. After all, most acute illnesses and injuries are benign and self-limited, typically resolving on their own. Give your doctor permission to tell you that. Also, one of the inevitabilities of the human condition is aging, and the slow and inexorable decline that we all face can be slowed, but not stopped. Take this into account.

Another frequent complaint of physicians is that patients do not show respect for doctors’ schedules and timing. It is not uncommon for patients to deliberately (or through poor time management) choose to update their physician about their condition at odd hours, thus undermining the physician’s desire to maintain easy availability. Have you ever been treated grumpily by a physician on call? No excuses, but sometimes those late calls feel unnecessary and intrusive. Take time to think about the importance of your health issue before calling your doctor at 3:00 am. Of course sometimes it just can’t be helped.

Much of what has happened to complicate a close working relationship between patient and physician is systemic. Medical care is just too expensive (affecting patients), and disparate information systems and payment systems have made it much too complicated (affecting physicians). I hope that new forms of communication (email for instance) lead to a simpler, more effective and efficient way for us to walk through life together. In the meantime, for those of you who honor me by allowing me to be your physician, keep me posted, hopefully during working hours whenever possible!