The Male Physical

There have only been a few things in medical school for which I've shown apprehension (besides tests, of course). I was nervous for the first standardized patient we encountered, the first Community Week, and certainly the first round of Asheville interviews that were conducted last week. But I would say the Men's Health Exam was the cause of the most foreboding. The female pelvic exam? Not so much. I hadn't even seen a pelvic exam, and that probably mediated my apprehension. Perhaps it was the fact that I've seen the male exam, experienced parts of it myself, and have seen patients endure it rather uncomfortably that made me antsy. I have seen a number of patients go through this awkward encounter (the prostate exam specifically), empathizing with their plight. These patients were uncomfortable, but not in the same way as a kid getting a couple stitches after falling off a bike. It wasn't pain. They are placed in an unenviable situation that cultural norms identify as a degrading rite of passage: now at the mercy of your body, you now accept preventative medicine to its fullest. You're 50 years old; prostate exams are the beginning. Next come PSAs, colonoscopies, statins, aspirin, and Centrum Silver. And it all begins with your pants on the floor.

As a patient, the entire male exam is met with trepidation. A 13 year old is worried he might get an erection during the exam.  If my physician is a female, will I'll be embarrassed? If my provider is a male, does that mean I'm gay? What if I'm not normal? What if it hurts? Will my mom still be in the room? Will my dad still be in the room? Etc. And these concerns continue throughout life, even though the specifics usually evolve. What if I pass out? What if I have an STD? What if I have cancer?

So it was with this internal conversation and foreboding in mind that I learned the the Men's Health Exam on Wednesday night. My concerns were different, but directly correlated to those of the patient. What if I hurt them? What do I do/say if they get an erection?  What do I do if I find an STD? Or cancer? What if the patient defecates? What if the patient has been sexually abused? What if the patient thinks I'm coming on to them? All these concerns are real and honest, and they were also all addressed.

For all you guys out there, think about how long your male exam takes at the doctor's office. The full exam should comprise of a penile exam, testicular exam, inguinal hernia check (the "turn and cough" thing), digital prostate exam, and rectal wall sweep. Five parts. Now as a young, healthy 24 year old, I've only routinely received the first three. But even then, I only vaguely remember my pediatrician doing a quick "penis check" (tighty-whiteys flipped down, tighty-whiteys flipped back up, penis is there, everything checks out). I think at one point I remember turning my head to cough, but I also had an obvious inguinal hernia when I was nine. If my memory is correct, most Men's Health Exams as a child took less than a second or two (and my doctor was one of the top docs in the DC area; check the Washingtonian). My pediatrician in community week is similar, although I watch him check to make sure both testicles have descended in the young'ns. (I assume that my doc back home did the same thing, and was just too young to remember. If not, he got lucky, because I have two happily and healthily descended testicles today, just hanging out in my scrotum.). The rectal exams I've seen as a student have been relatively quick too.

So why did we take more than four hours to learn an exam that takes a second or two to perform? Answer: it shouldn't take "1 Mississippi, 2 Mississippi" to do!

One of the things that I love about UNC is that it's a patient-centered school. We did not discuss one technical aspect of the exam for first two and a half hours. Instead, we talked about the patient's concerns (sexual orientation, sexual function, confidentiality, finding pathology), the provider's concerns (see above), how to take a sexual history from a new patient ("do you have sex with men, women, both, or none?"), and ways to put the patient at ease. We learned how to normalize, intellectualize, educate, and acknowledge. We learned about some of the ways patients may describe or engage in sex. Some new ones for me at least were "docking," "felching," and "frottage" - nota bene: looking these up is only for the adventurous. We also heard about the patient who was worried she might have contracted HIV during "oral sex." A few minutes into the conversation, the provider (who was thoroughly confused at that point) asked what she meant by "oral sex." "Why of course! My boyfriend and I were talking dirty on the phone!"

Communication is key.

So it was not until then that we began learning the technical aspect of the exam. We learned how to examine the penis (inspection always before palpation): how to visualize the meatus, how to ask about tattoos, Prince Albert's, and look for pearly papules. We learned how to palpate the epididymis, testicles, vas deferens, and inguinal ring. I now know how to "make a gun" with my pointer finger and thumb, and perform a prostate exam. I now know that even though you may feel like you have to pee during the exam, you won't (because my finger is firmly pressing down on your urethra). And we learned how to correctly do a rectal sweep. All in all, this took me a good 10 minutes (mostly comprised of Parts I through III). It's not fast, but it's thorough...

I now see the patient's fears in a new light, along with my own. Those four hours didn't teach me how to do a perfect prostate exam, but at least I feel more comfortable doing it, and, in addition, I have the tools to put the patient at ease. In the words of the great Daniel Tosh, "And for that, we thank you."


Oh, and on an unrelated note: next year I'll be in Asheville :)