In August, the U.S. Preventive Services Task Force, a government-sponsored panel of medical experts, issued new recommendations regarding prostate cancer screening: Men ages 75 and over should no longer be screened for prostate cancer with the PSA blood test or digital rectal exam.
An unexpected benefit may be an improvement in the doctor-patient relationship. The rectal exam can be one of the odder moments between a patient and his doctor. Not long ago, for example, I saw a 75-year-old for his routine annual visit. Things were not going well for him.
His wife's dementia was worsening daily. She would leave the stove on, accuse him of stealing her things, holler at him day and night. And yet he could not imagine putting her in a nursing home.
His eyes, usually sparkling with delight, were dull. As I examined his heart and lungs, neck and belly, ankles and feet, he heaved a long sigh. I felt gloomy about his wretched situation.
I must have been preoccupied, because when it was time for the rectal exam, I bumbled my words. I asked him to lower his pants, but instead of saying "Lie on the table," I told him to lie on the floor. The patient and I burst out laughing.
Still chuckling, I stepped out of the room so he could get ready. To be sure, my bumble had brought levity to a traditionally awkward moment -- but why, I asked myself, did this encounter have to end with an examination of his anus?
I was drawn to primary-care medicine by the human connection that comes with the white coat and stethoscope, the prospect of people willing to share their everyday thoughts and deepest secrets, and their expectation that I would use this information to help them.
What I didn't fully grasp was that this intimacy also had a critical physical component -- one that came gloved and lubed.
I'd never imagined that performing rectal exams would become a daily reality. Most of my patients are men over 50, which means that I ask them if they'd like to be screened for prostate cancer.
Some inquire whether the PSA (prostate-specific antigen) blood test alone will suffice. I explain that it's most informative to have both the PSA and the digital exam: Some cancers hide in prostate nodules in men whose PSA readings are normal.
So for men under 75 and over 50 (earlier for higher-risk men) who wish to be screened, just as important as the PSA is the old-fashioned, low-tech way with a pair of rubber gloves, a foil packet of lubricating jelly and an index finger.
