Last Tuesday I went through

Last Tuesday I went through a classic medical school rite of passage. Everybody's favorite... the pelvic/rectal exam! And because everybody loves getting them so much, people are usually really excited to have inexperienced medical students practice on them. In fact, patients often request specifically that a medical student (preferably one in their first or second year) perform their pap smear, testicular exam, or rectal exam. They just can't get enough!

However, it occasionally happens that people find these exams uncomfortable, invasive, and emabarrasing, and if avoiding them at all costs isn't an option, they sometimes prefer that the person performing them has actually done it before. Go figure. Patients are weird. So, to deal with these ornery folks, it is nice as a medical student to get the chance to practice doing things like this in a neutral, educational environment. I have heard stories of some medical schools (hopefully in the distant past) encouraging their students to practice doing pelvic exams on uninformed women who are under general anesthetic for surgical procedures. OHSU takes a different approach. They pay people big bucks to be our guniea pigs.

It went down on a tuesday evening. Because I forgot to sign up for a time, one was appointed to me, and it happened to be the evening before a test (that's what you get for not being proactive about your education). I showed up with a group of students, and we divided ourselves into pairs. Interestingly, we self-divided along gender lines - every single pair was either 2 girls or 2 guys. I don't know why. Maybe that highlights how subconsiously uncomfortable everyone was. I paired up with this girl Sarah, who's in my Medical Students for Choice group. Turns out she's really good at it. Turns out, I'm not so good.

We are guided to a room with a man in a suit and a man in a gown. The man in the suit is a urologist, and he procedes to guide us through how he does a male genital and rectal exam. The man in the gown is the lucky recipient of three of the aforementioned exams. He is really nice and patient. Sarah goes first. She does a good job. Then I go. First you ask the man to stand and hold up his gown, as you are sitting on a stool in front of him. You look first, assessing the distribuition of pubic hair, and the general size and symmetry of all involved structures. Then you procede to squeeze and pull all of said structures, pausing to check for any unusual ulceration, fibrosis, discharge, or asymmetry.

As I don't possess any of these structures myself, it was tough to know just how much pressure I could exert. I think I might have been a bit on the cautious side. Then the whole "turn your head and cough" test. Who knew you could stick your finger so far up there? Man. That was really suprising to me. I guess it shouldn't be, since i knew that the layers of the scrotal wall were contiguous with the abdominal wall, but still.

Then came the rectal and prostate exam. I started by lubing up the wrong finger - see, you do the hernia exam with your middle finger, but the rectal exam with your index finger. You want maximal length for the rectal because that prostate is pretty far up there, and you need to get a good sense of its contours on all sides. As the urologist instructed, I pushed in "to the hilt." This is perhaps unneccessarily graphic, sorry. I then displayed my inexperience by using two hands to fumble with the fecal occult blood card (Sarah only used one). But Sarah and I were even because she inadvertenly pushed the poor guy's testicle up into his abdominal cavity when attempting a hernia exam.

However, she quickly surpassed me after I botched the pelvic exam. This, of course, was done on a different patient. Sarah and I were guided to another room with a woman in a gown, and a woman in some clothes. The woman in the clothes demonstrated her methods of doing a breast exam, followed by speculum exam, pap smear, and bimanual exam. Then I went. I think I may have lost points for failing to check for nipple discharge and for opting to only examine one breast in the interest of time. I also created an akward moment while explaining to the patient that I was "looking at her breasts to make sure everything was symmetrical." Turns out, she had one inverted nipple, so her breasts were clearly not symmetrical. I made some sort of incoherent joke, and moved on.

Then came the speculum exam, something I have both experienced and witnessed, on multiple occasions. Because of this, I assumed it would go smoothly. There's where I was wrong. Dead wrong. The speculum went in without a hitch, but then when I went to open it to look at the cervix... where was it? Just mile after mile of pink vaginal wall, caving in and dead ending, taunting me, hiding from me the object of my pursuit. I instantly panicked and forgot how to manipulate the speculum, that pesky instrument of screws and levers. I followed my instructor's advice to "just relax the speculum," which induced a cry of pain from my poor patient. I had pinched something. It might have been the cervix. I removed the speculum.

Second try. Even less successfull. Still no sign of the elusive cervix, but this time when I was searching around for it I managed to get some of that damn vaginal wall stuck between the beaks of the speculum. Literally stuck! This produced more pain, and requests to have the speculum removed. I complied. By this time I was getting really flustered. I was regressing to my elementary school years, when not being good at something would make me burst into tears of frustration, and then keep crying out of embarassment for crying in the first place (ok, so maybe that lasted into my college years, but I thought I was over it). I was seriously almost to that point. Fortunately, the woman was being kind and patient and said that I could go again. They must have been paying her like thousands of dollars.

"Maybe its the speculum," my guide says. "Sure," I think. Blame in on the piece of metal. She gets out a longer one. Third try. Speculum in. Speculum open. Nothing. NOOOO! What kind of a doctor am I going to be, if I can't even find a fricking cervix! The thoughts are racing through my head. My face is turning hot and bright red. I'm considering dropping out of school. Then the doctor leans over my shoulder and says, "Look, there it is!" And its there, barely. Its like hanging off the wall way to the left, facing down - it doesn't even look like a cervix. Some sort of stupid, gimp cervix that's in the wrong place. I don't think it would even be possible to do a pap smear on that. But I feel triumphant. I decide to stay in school.

Of course, Sarah gets in there, and sees it right away. The cervix just pops right into view. Great. Every other person on earth is good at it. But I don't feel so bad because during the bimanual exam I felt her left ovary when no one else was able to, not even the doctor. I'm sure that some day I will look back on that experience with a happy sigh and a far-off look in my eyes. I will remember what it was like to try this akward thing for the first time. I will probably wish I was back in medical school, practicing pelvic exams and studying for tests because those were probably the best damn years of my life. Hopefully by that time I will be able to find a cervix.
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