A Med School Memoir

Don't worry, we'll be in and out real quick.

Since the day I got my acceptance to medical school, I had been dreading one thing. Every time I thought about it, I felt my anxiety level bubble up like a two-liter of diet coke with a pack of mentos dropped in it. It wasn’t the thought of cutting up a dead body. No, that didn’t bother me too much. It wasn’t the promise of never-ending studying and a constant onslaught of tests. No, weirdly enough, I was actually excited about the prospect of getting to spend some time studying. (Weird as it may sound.) It wasn’t even the thought of spending hundreds of thousands of dollars for my education. No, I actually managed to get over that shock pretty fast.

No, without fail, the one thing that had been stressing me the fuck out since even before the first day of school was the dreaded pelvic exam. As part of the Intro to Clinical Medicine (ICM) curriculum here at my school, all first year students are expected to learn how to perform several different clinical exams, like the routine abdominal exam, lung exam, heart exam, yadda yadda yadda.

Even these normally routine and innocuous exams tend be anxiety-inducing on their own. I’ll never forget how nervous I was before the very first one–the upper limb exam. My palms were all sweaty and I felt incredibly self-conscious as I approached the standardized patient to feel his shoulder. See, it’s all about the anticipation of awkwardness to come; the thought that you’ll have to put your hands on some stranger’s body and pretend to feel something that you either can’t feel, or isn’t even actually there. Even though it’s an educational activity, it’s also an act–a ruse–pretending to be knowledgeable about something you’re not. It can at times seem so entirely disingenuous and outright phony as to induce some serious cognitive dissonance.

In the end, these ICM clinics are never a big deal at all. But going into it, you have to understand, can be just as stressful as going into a test. I mean, I even managed to make it though the breast exam a couple months ago with little lasting psychological damage. But the pelvic exam, that’s a different story.

It should almost go without saying that along with the general nervousness that I always feel before any of these ICM clinics, there was a unique layer of nervousness involved with the pelvic exam. I mean, touching on other people’s junk and stuff? You have to admit that when you’re used to spending most of your day with your head in a book, it’s a pretty jarring change to suddenly find your head quite literally between a strange woman’s knees. But adding to my anxiety was the fact that at my school, the pelvic exam is bundled together in one fun-filled afternoon with the male genitourinary exam, and a heaping helping of digital rectal exam thrown in for good measure. Yippee! It’s like getting to go to Disney World AND Six Flags in the same day. Except, at this Disney Land, there is no Mickey Mouse–instead there is just some old guy who teaches you how to palpate his testicles. And at Six Flags, there’s a roller coaster where you wind up in a cervix at the bottom of the first hill.

So, anyway, eventually the dreaded genitourinary exam day arrives. On clinic days, we are required to wear “professional attire,” which means I wear my nice shoes, I get a dimple in my tie, and I wear my stupid short white coat that makes me look like a hunchback. On the outside, I am the image of a self-confident medical-professional-in-training. My outward appearance is deceptive, however, because under my spiffy collared shirt, I’m sweating buckets.

I go to the ICM clinic where I see several of my classmates milling around in anticipation of our afternoon’s task. Stories are floating around that the male students are going to have to get up in the stirrups–excuse me “heel rests”–to “see how it feels.” My level of anxiety immediately doubles. Now, don’t get me wrong–I’m sympathetic to how vulnerable it must feel to have your feet up in those “heel rests,” but really? Is now really the best time to do this? Don’t they realize that we’re being traumatized enough as it is? Do they really need to add insult to injury? At this point I’m sweating like a fat guy eating a turkey leg in a sauna. I can feel my undershirt sticking to my back, like I’ve run a few miles–and I’m not even in the exam room yet. Eventually we get instructed on what we’ll be doing that afternoon, and soon we’re all separated into small groups to begin the clinic.

A few minutes later, I’ve been lumped into a group of four, and we stand outside the door to the exam room. No one wants to knock. We dare each other with our eyes until eventually I muster up the courage and knock on the door. I hear a voice invite me in from the other side, and I step in and introduce myself to an older gentleman who, for purposes of anonymity, I’ll call Mr. T. (Who didn’t look anything like the real Mr. T, despite how much cooler that would make my story.) He’s sitting on the edge of the exam table in his hospital gown, and to break the ice he asks if we’re nervous. The four of us all chuckle and admit to our collective nervousness, and he tells us to relax, because we’re not the ones who will be getting 10 rectal exams a day for the next week. I laugh. He makes an excellent point.

Mr. T is about 50, has long hair, and he carries himself with the kind of carefree nonchalance and un-selfawareness that makes me think he might be a little bit stoned. I mean, afterall, this guy’s about to get felt up, and poked, and prodded by a bunch of bumbling idiots for the next three hours. His genitals are literally at risk here, but he’s not sweating it. If I were in his shoes (which were Birkenstocks, by the way) I’d be pleading with my examiners to go gently on the balls. Instead, he waxes philosophical about how much more relaxing it is to exhale than inhale. After a short introduction to the exam, he looks around the room and asks who wants to go first.

I don’t volunteer.

Eventually one of my classmates–we’ll call him “Steve”– bravely volunteers. Steve is one of my Gross Anatomy partners, and he’s an easy-going, modest guy who takes medical school very seriously. I’ve been partnered with him a few times during these ICM clinics, and he always impresses me with his professionalism. But even Steve is a little flustered today. He hides it well, but you can tell by the unusual redness in his cheeks that he’s not 100% comfortable. Nonetheless, he makes it through the first half of the exam without any incident. He is calm, courteous, and he seems to know what he’s doing. He’s seems like a natural.

Until the rectal exam, that is. As he inserts his finger in the standardized patient’s rectum, the look on his face suddenly and unexpectedly melts into a look of terror. Somehow he keeps his voice calm and explains what he’s doing to Mr. T, but the whole time, his face is the visage of fright and disgust. (Kinda like this guy.)

I can’t help but kinda laugh at him.

The standardized patients (SPs) at my school have a dual role. They are instructors in the exam, meaning that they teach us how to properly palpate the pertinent anatomy and build a rapport with the patient, etc. At the same time, however, they’re actors who pretend to be patients. This can be confusing at times when you don’t know if you’re talking to your teacher or your patient. Mr. T seems to have some confusion on this point as well. At the end of the exam, my classmate forgets to instruct Mr. T to regown. Even though the exam has ended, Mr. T is still playing the role of a patient, I guess, and his pants are still down around his ankles. At the same time, however, he’s giving helpful pointers about how to properly dispose of soiled latex gloves. It’s more than a little weird.

When it’s my turn to go, I try to mask my nervousness by acting calm and chatting up Mr. T a little bit. We’re normally given a bit of a script to work with, and this time is no different. I introduce myself, tell the patient why I’m here, and what he can expect from the upcoming exam. Trying to keep the tone casual and easygoing to offset the emotionally charged nature of the whole thing, I tell him, “don’t worry–this will only take about four minutes. We’ll be in and out in real quick.”

Whoops.

God, I’m stupid.

“In and out real quick?” Before I’ve even finished my sentence I realize what a stupid thing I’ve just said. My verbal diarrhea immediately elicits a row of laughter from my classmates, and I know I won’t live this one down any time soon. I back up, apologize to the standardized patient, and try to explain what I meant. It’s no use. He reprimands me for using such unprofessional language and warns me to choose my words more carefully in the future.

No duh.

For a minute, I try to shake it off. Maybe instead of beating myself up for my poor choice of words, I should just roll with it. Maybe this can be my trademark. Maybe I’ll open up a chain of clinics called “In And Out Clinics” where you come in for a genitourinary exam, and if it takes longer than four minutes, your exam is on the house.

But it’s no use. I’m flustered. My face is burning. I fumble my way through the remaining formalities before we move on to the meat of the exam. When I ask Mr. T to disrobe, and begin the inspection phase of the exam, he reminds me to explain what I’m doing. I tell him I’m inspecting his genitals for “redness, swelling, or other abnormalities.”

He adds to that, “and parasites. Don’t forget to tell the patient that you’re inspecting for parasites.”

Parasites? Really? I mean, yes, I’m examining for parasites. If you’ve got a leach on your balls, I don’t think I’m going to miss it. But I’m sure as hell not going to tell a patient point-blank: “I’m examining your genitals for parasites.” That just sounds bad. (Not that I’m an expert at sounding good, but I’m trying.)

The next phase of the exam is the palpation, which means I have to stretch the guy’s penis out and feel it for lumps, and then feel his scrotum and testicles for any masses or other abnormalities. This goes without incident until I work my way over to his left testicle. “Did you feel my varicocele?” He then proceeds to maneuver his left testicle into position so that I might feel his enlarged veins.

I palpate his left testicle and the the knotty tangle of veins running around his spermatic cord. Mr. T instructs me to feel for something that has the consistency of a wad of limp noodles. “Yeah, I guess I feel it,” I say, and add, “but I wouldn’t have pegged that as abnormal.” Again, my classmates all snicker at me. I add, “but maybe that says more about me than you care to know.” That makes everyone laugh a little more and somehow I feel like that awkwardness bomb has been momentarily defused.

Up next is the prostate exam. Before I lube up my finger, Mr. T addresses me and my classmates with a helpful tip. “I think it’s worth pointing out that I can feel it when you palpate my prostate. Because the prostate and the penis share some common nerves, stimulation of the prostate makes a tingling sensation in my penis. So I will know if you palpate the prostate or not.”

Oh, okay. Great. Thanks for sharing?

I ask Mr. T to rest his elbows on the table. (We were instructed before the exam to watch out for language like “bend over and spread your legs.”) I inspect his rectum. Hemorrhoids. I tell him that I’m about to insert my finger into his rectum. “Take a deep breath… and exhale.” I slide my finger in. I can’t tell what I’m feeling. It’s a dark slippery mess, and honestly, I could just as easily have my finger in a hot pocket, and I wouldn’t know the difference. I slide my finger in a bit more and eventually I come on something that feels different. That must be it. It seems abnormally large and firm to me. But what do I know?

“That’s it,” he says.

Thank god.

Trying not to seem too overzealous, I swirl my finger up the lateral walls of his anus to feel for masses, and I’m done. I pretend to test his stool for blood on a prop guiac card, and I make a bee-line for the sink so I can deglove and wash my hands.

I tell him that everything’s normal. Keep in mind that I have no idea if this is true or not. But it lets me conclude the exam and begin the long process of recovery.

The point of these clinics is not to teach us about pathology. The point isn’t even really to teach us about what a normal anatomy looks like. Of course, those are bonuses if they occur, but we’ll see enough normal and enough abnormal in the coming years to learn what a normal prostate is and what an abnormal prostate is.

The purpose of today’s exercise, really, was just to get us used to the idea that for the rest of our professional lives, possibly, we will be sticking our fingers up people’s butts. We need to know how to do this, how to be comfortable with it, and how to make the patient comfortable with the exam. After the male genitourinary clinic, I can actually say that whatever fears and anxiety I felt about performing a digital rectal exam are significantly diminished, thanks largely to the excellent instruction of Mr. T. Am I totally comfortable? No. But I’m not sure if you ever get totally comfortable with these things. I suppose only time will tell. The one thing I can say for sure is that I won’t sweat a gallon of nervousness into my clothes the next time I have to do this. And that’s a good thing, because the next time I perform one of these exams, it will probably be on a real patient. And to me, that makes all the anxiety of today worth it in the long run.

So, with one GU exam under my belt, I return to the clinic waiting room until it’s time for my next exam…

The dreaded pelvic exam.

More on that soonish.

Note: The image at the top of this article was found on Flickr. It was taken by the Flickr user “The Doctr” and is titled “275 | Exam.” I have reprinted it here under the Creative Commons attribution-noncommercial-no derivative works 2.0 generic license.

Tags:   anxiety · digital rectal exam · genitourinary exam · ICM · pelvic exam3 Comments