Expect It


image007A patient came in for evaluation of head congestion. As the nurse was getting his vital signs in the room, he asked her who the emergency physician was.
“Dr. WhiteCoat,” she replied.
He turned his head to the side and asked his wife over his shoulder “Is that the one?”
His wife answered “Yup.”
The nurse asked him if he had a problem with me in the past.
“Not unless you call some guy shoving his fist up your ass a problem.”
The nurse looked shocked.
“I came in here with abdominal pain and I threw up blood. This guy tells me he needs to ‘check my rectum for blood.’ Then he buries his arm in my ass up to the elbow. I could have told him there wasn’t any blood up there. He ain’t coming nowhere near me with a pair of gloves from now on.”

When the nurse relayed this story to me, I looked his old records up on the computer before going into the room. Four years ago he came in with abdominal pain and complained of pus in his stool. He ended up having a GI bleed, but no pus was ever found. So the rectal examination has scarred him for the past 4 years.

The nurse and I laughed for a minute about whether I should walk into the room with a gown, mask, gloves and a tube of KY Jelly.


Then I started thinking.

Not too long ago, another patient whom I evaluated for abdominal pain complained to our hospital administration that he was having “post traumatic stress” from the rectal examination I performed. He was afraid of interacting with men bigger than he was and could no longer stand in lines because he was afraid of what the people standing in line behind him might do.

It’s not like I have gorilla fingers. My finger is about 3 inches long and about 1.5 inches in circumference at its widest. Most formed stool is much longer and much wider than my finger, but I don’t know any adults who have developed post traumatic stress disorder from taking a dump. Reactions like this are why I routinely bring a chaperone with me when I do these exams – just to make sure that I don’t lose my wristwatch doing the exam, you know.


It’s not like doctors enjoy doing rectal exams. I can’t go home and say “Hey kids! I didn’t save anyone’s life, but guess what I did at work today!”
Oh, and clenching your butt cheeks together then arching your back in a seizure position doesn’t make things any easier. If you don’t want the exam, refuse it.

If you go to the emergency department to be evaluated for abdominal pain, vomiting blood, constipation, diarrhea, or abnormal stools, it’s nothing personal, but you’re going to need a rectal examination. It’s part of the job I do.

Expect it.

If you don’t complain about it, neither will I … well … at least not that much.



  1. “could no longer stand in lines because he was afraid of what the people standing in line behind him might do.”
    the visual of someone standing in line anxiously looking at the people behind him at the grocery store fearful of getting wrestled to the ground and forced to have a rectal exam is just too funny.
    I can’t stop laughing.

  2. It never ceases to AMAZE me how uptight (pun intended) males are about the back door exam.

    Um hello?

    I’d love to see a man’s reaction to a speculum approaching any of their precious orifices. 😛

  3. Seems like not enough patients know that they can refuse tests/examinations that they are too uncomfortable with. Enough people know that they can refuse major surgery, why can’t they extrapolate down from that?

  4. I mean this respectfully and sincerely, and I hope it comes off that way: Is it possible that you could adapt your technique in some way that would make rectal exams less traumatic for patients?

    Obviously, you are a skilled and experienced clinician, and I have no doubt that your rectal exams are well-done from a procedural stand point. But it appears that more than one of your patients has felt like the exam was inappropriate, so maybe a better description of what you are going to be doing and why would help them relax? And why not tell them that it will be more comfortable for both of you if they don’t clench?

    I know that you probably don’t write this blog to get random critiques from anonymous readers, but I imagine that at this stage of your career, you don’t get a lot of feedback. On the off-chance that this advice is useful to reducing “traumatic” patient experiences, I thought it was worth writing. I hope you understand that I am not assuming you are doing a bad job, and I agree that the reaction of the patients you describe was a bit over the top, and not due to your exam skills.

    • Some people are so insanely homophobic that anything involving rectal insertion will be a problem. It’s like Ray Romano put it; “I was kind of afraid that it would hurt, but I was kind of MORE afraid that it WOULDN’T.”

      Indeed, that’s why the people in the story were being so weird about it. It was necessary for them to recast the situation as “violent assault” in their memory, so that when they thought about it they didn’t have to confront the notion that things-up-the-butt isn’t some horrible depraved disgusting thing that only perverts would ever do.

    • WC,

      I agree, I have some tips for you on the rectal exam. I have started playing soft music, I turn the lights down, and often we scatter rose petals around the patient (still not sure if it is JCAHO compliant). I really try to make it much less traumatic and welcoming, especially for the GSW to the abdomen patients who just had a drug deal go bad.

      • I’ll have to try this. Maybe my satisfaction scores will go up, too.
        On second thought, rose petals could cause an allergic reaction and could kill people. Also, people could slip on a wayward rose petal and fall on the floor hurting themselves. And the music might cause a patient not to hear a doctor’s instructions clearly. Definitely a patient danger. Low lights might cause us not to see blood pressure readings on the monitor accurately. Then we might give nitroprusside instead of dopamine which could kill someone, too. Yeah, JCAHO would definitely have issues with this.

    • I absolutely write the blog to get critiques. I invite them. Airing opinions and hearing what other people have to say makes me a better doctor.
      It’s not like I walk into the room with my tongue hanging to the side, drool coming out of my mouth and a muffled evil laugh.
      I describe things fully before I do an exam and make sure that patients explicitly tell me that it’s alright that I proceed.
      If someone is clenching, I tell them I won’t be able to do the exam if they’re that uncomfortable with it.
      We’re put in a bad situation, though. If I do the exam and someone doesn’t like it, I get complaints. Doctors have even been sued for performing a rectal exam. If I don’t do the exam and I miss something, then I get complaints and get sued for not doing the exam.
      Sometimes we just can’t win.

      • What about those whose consent doesn’t matter like young teens. At least in my case, my parents decided what happened to my body and I had no say. I was pinned down and forced to have rectal exam at the ER. In my mind I thought I was being raped. I didn’t understand the doctors had to do it. That happened when I was 13 and I’m 17 now. I still can’t get over it. I know it may seem like I shouldn’t be traumatized from just that, but I was. I hope my story persuades any doctors reading to please try to make sure their patients don’t feel forced, unsafe or traumatized when it comes to any invasive exams. Please do not invalidate my pain, you don’t know what I’ve had to go through because of this. Doctors I understand that certain exams are needed and that your scared of being sued, I’m sorry you have these worries and problems. Please try to be more aware of medical trauma and what you can do to lower the risk of mesical related ptsd. For those who think it’s stupid or that these patients need to tough it up and quit being so sensitive, you need to recognize their pain and realize that ptsd is complicated and that these people were truly traumatized even though they have bigger poops than your fingers. I can do invasive exams/procedures such as gettting an IUD placed, but I was consenting, felt safe/comfortable, and was okay with it. These three things will help prevent ptsd in your patients, well I at least feel it will. I’m sorry to doctors and patients who were hurt by being sued or having invasive exams or anything medical related. Don’t joke about the patients in the comments or attack doctors either, this is a complicated situation and you don’t know what they are going through. Please don’t attack me in the comments. I just want people to not get hurt like I’ve been hurt, and I’m not attacking doctors in anyway. I appreciate those who have treated me and stuck by my side with my disease, my medical team have helped me so much and even saved my life. I wish you no harm either, just please try to be more sensitive to people’s hurts and needs.

  5. I had to schedule a clinic appointment to get one a couple of months ago. I didn’t care so much about the anal probing as much as I did about having to awkwardly drop pants in front of another (practically random) dude.

    “Wait I have to pay $20 for you to see *me* naked??”

  6. Damn it “J”, you beat me to the punch! But here’s some additional ideas: candles, lots of ’em. Some pleasant aromatherapy scent…oranges? I hear that’s calming. Speaking of calming, you could offer the probee a cup of Chamomile tea before the exam. Or maybe you just need to hold the patient afterward so they’ll know how much you really care and that you’re not just using them for your own gratification.

    As a veteran of many a DRE, I can tell you (as I’m sure everyone here already knows) THAT IT AIN’T NO BIG DEAL! JESUS CHRIST!!!

    Some years ago, I was talking with a friend about our GPs, and my friend said that he always chose female doctors (because of the DRE) because women had smaller fingers than men. I found this to be a rather odd reason for selecting a doctor, and I told him,”Hey,here’s a tip. If the doctor is stuffing their fist up your ass, they’re doing the exam wrong.”

  7. You know what sucks? Apparently the only reliable way to take a cat’s temperature is rectally. Try telling your CAT to relax >_< It is traumatic for me to watch; poor kitty meows 🙁 At least people have the option to say no.

  8. Hey WC.. don’t let Matt see you suggesting the “ass-clay action-way awsuit-lay”.. it might give him more idea’s than he already has. Then again, he’ll probably tell you that “ass-clay action-way awsuit-lay” is no more painfull than a thoughtfully performed rectal exam. Ohh wait.. I think I CAN see the similarities now.. Where’s Fyrdoc when you need him?

    • I’m right here. Matt just won’t answer me because my explanation to him that most (if not all) physicians regard lawyers in the same fashion that African American urban youth consider the police or the way most people feel about child molesters makes me a “psychopath” or “nut-job”.

      What he doesn’t want to realize, or what he does in the same way that he must know at a visceral level that he is wrong regarding medical malpractice, is that I’m neither crazy nor a psychopath. I’m honest and truthful (behind the anonymity of the web). A psychopath has a altered reality and can not identify where their altered universe ends and the real one begins.

      Matt just can’t fathom that my reality is reality. Physicians hate trial lawyers and honestly would leave them and their families without healthcare in the hopes that the experience would leave them with a new understanding of what their actions have done to restrict access to care for the rest of the population if that could be done in the current legal milieu. Unfortunately, it can’t.

      But hey, what do I know. I’m insane, doctors are all rich, medical malpractice is a wonderful means of quality control, defensive medicine either doesn’t exist or doesn’t cost anything, and doctors all respect attorneys as valuable partners in protecting the health and welfare of the public!

      • Actually, I do fathom that you believe those things. I like to think most physicians don’t have your depth of hate, but I’m open to the possibility that it’s true.

        I also do appreciate the fact you believe that whatever your reality is that you think it is the “reality” shared by all. It’s that kind of misplaced egotism that reminds me just how off your rocker you are!

        One factual note though: there is no shortage of physicians except where there’s a shortage of wealthy people. Lawsuits, or the lack thereof, don’t change that. That’s the actual facts, whether you want to believe them or not.

        Carry on with the rantings! I’ll not interrupt you again.

  9. Funny WC! So ..you do them up to your elbow? I guess you don the monster gloves then. 😉

    Post and comments funny. I appreciated the laugh. 🙂

    And the more serious comments insightful.

  10. For my yearly PAP, I get both a DRE and that damned speculum shoved up my ho-hah. Not a pleasant experience, but a few moments of pain are worth knowing that all is well in my woman regions.

    Men, cease your bitching before I hand you some Hershey’s.

  11. Of course formed stool is bigger than a normal sized finger, and it’s beside the point. They’re not talking about literally feeling like an arm is up their butts, they’re talking about the psych issue of having an area of their body they’ve been conditioned all their lives to regard as intensely private on display under bright lights before a small audience of strangers and then penetrated, not just with an inanimate medical tool but with someone’s – one of said strangers – HAND. I’ve heard many men describe prostate exams in exactly those terms (someone’s arm up their butts) and they mean how it makes them FEEL, EMOTIONALLY, and don’t know any other way to express it. You’re not just treating a de-personed body. If you want to be a good doctor, don’t succumb to the desensitization that too often takes hold in health care workers – nurses included – who poke/prod/stick/stab human beings all day long and forget what it feels like to be on the other end of the needle/cannula/catheter/speculum/scalpel/power saw. Hopefully the anaesthetic is working in the latter two cases, but sometimes it isn’t. And I’ve been there on THAT one.

  12. I had to undergo a rectal/prostate exam for the military. The physician was about 128 years old and he literally shoved most of his hand into my ass. was in pain and later diagnosed with an anal fissure.

    Just because someone is an MD does not mean he/she knows what the heck they are doing/

  13. A while ago I had the misfortune of making an off-airport landing (crashing) a military liason aircraft onto a golf course, The impact was severe enough to totally destroy the plane, but I was surprizingly intact (head lacerations, broken wrist, a few burns, but nothing that was all that bad). I got transported to the nearest hospital ER and the doc on duty examined me; they cut off my clothes/flight suit but were nice about it. The doc told me that she needed to do a rectal exam, I asked it it was really necessary, she replied that it was, pulled the curtain around the bed and gave me a quick explanation. Before doing it, she reassured me that it wouldn’t hurt and asked me if it was o.k. to do it. As fast as I said that it was o.k. she was done, told the nurse that my “tone” or something was o.k. pulled the curtain back and I was off for more tests and scans. I got admitted and that doc came in to see me briefly and explained that I had a concussion and possible minor spinal injury, which turned out to be minor. She also told me that she was sorry about having to do the rectal exam, but that it was necessary. Having a doc who took a few seconds to let me know what was going on made all the difference.

  14. 8th edition of ATLS has changed its position of the DRE recognizing the emotional trauma it inflicts.

    What if your patient was raped as a child and was too embarrassed to disclose this fact? Would you and all these indignant commenters still take the same position?

    What if the patient was a woman?

    Are you implying that the patient suffered no emotional trauma?

    This attitude marginalizes patients and tells them their feelings don’t matter.

    Aren’t physicians taught to “look” and “listen”??? The nurse told you that the first patient may have emotional trauma from the previous DRE you did or he may possibly may have PTSD from childhood rape (maybe?) But instead of asking, you made a joke about it.

    You have shown a complete disregard for your patient? What other subtle cues did you miss?

    What is really frightening is that no other commenters (who claim to be medical professionals), called you out on this.

    • I’m glad to see this final comment, which I note has gone unanswered. You hurt someone and when you were given that rate opportunity to acknowledge your error, you not only mocked the person in between pretending to provide “care” to people also in attendance to him, you could not resist the draw of going online and bragging to strangers about how great you were and how funny and irrational your victim was.

  15. Both my wife and i have issues with rectal/pelvic exams – it doesn’t mean we can’t accept them, but practitioners need to take a bit more time and care over their approach. I was bullied for a period in early teens in an all-male school and penetrated with objects – not sexual, all about power, kind of like college initiation rites. I will not accept the need for asymptomatic DRE, but will go if my PSA level is 4 or above (age 66), or if I had blood or frequent loose stools. I will have my wife with me for emotional support and to get me in the door. My wife – who was a nurse – has had some really unpleasant exams from a couple of doctors who should have done better, as well as some who were ok. After total hysterectomy (1991) she has refused all internal exams. Like me she will go if she is concerned about blood, swelling, weight loss, bowel irregularity. I will accompany her for emotional support. We realise that complete refusal to undergo annual testing in US terms means we had increased risk of undetected disease. Both of use have no significant issues to date, having missed 48 rectal exams in my case, and 26 pelvic exams in my wife’s. We both do 2 yearly FOB/FIT Tests, I’ve had PSA (score3 .8), and we have had other blood/urine tests. From the UK the US system seems more about making people compliant and income than genuine screening. Check out the evidence for the lack of utility of DRE in diagnosis, eg appendicitis and routine pelvic testing, eg ovarian cancer – and yes, there are always some who will have had their lives saved because they were tested annually. I’m sure whitecoat is medically competent, but I think I’d go elsewhere.

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