The Substitute Teacher

We step into the room, and after a few words of greeting, the medical student informs her patient of the assessment we had developed together in the hallway. She confidently rattles off the sudden drop in hemoglobin she had noted on his morning labs, the blood thinner he is on for his history of clotting, the steroids we have had him on since admission—all adding up to our concern for an occult bleed.

Her confidence falters, however, as she approaches the topic we had just discussed outside the room.

“We’ll have GI see you, but…one last thing…we just need to…uh…if you can just…”

I step in, as she trails off.

“We need to do a rectal examination to see if the bleeding could be in your GI tract.”

He looks skeptical but nods his acquiescence.

I ask if it is okay if the student does the examination with my guidance.

He studies her. And despite the barely suppressed panic in her eyes, he nods again.

As I walk her through the preparation and positioning, I make sure to project a calm assurance. Because I remember my own first time so well.

***

We huddled in the crowded examination room, checking our watches and chatting. Quietly. Nervously. The boldest of the 5 of us swiveled atop the round metal rolling stool reserved for the absent clinician. The rest of us leaned against walls or the examination table, shying away from the pile of water-based lubricant packets lying atop it. Through the thin walls, we could hear the rise and fall of preceptors’ voices in other examination rooms already giving our classmates an introduction to the examination maneuver we had come to the urology clinic to learn.

I had been dreading the arrival of this strange medical school milestone. Fumbling my way through such an invasive physical examination maneuver in front of a group of peers made me intensely uncomfortable. The mood in the room as we waited suggested that the other members of my small group felt the same.

“It’s almost 7:15. Someone should ask what’s going on.”

Before we could come to a consensus on exactly who that someone should be, there was a knock on the door.

We came to attention, expecting a figure in scrubs and a long white coat to stride in and authoritatively guide us through the exercise. Instead a small man in faded jeans and a black leather NASCAR jacket entered. He smelled strongly of cigarette smoke. The hair peeking out from under his Tennessee Titans cap was graying, but his horseshoe mustache was still a dark brown.

Our standardized patient surveyed the room. “Where’s the boss?” he asked. His broad Middle Tennessee drawl was a good match for his attire.

“No one has shown up yet,” my classmate on the stool answered.

“Dang doctors. Never on time,” he said with a wink.

He disappeared into the hallway. Through the cracked door we could hear him talking to the staff member at the front desk.

“Your preceptor got tied up,” he said as he returned to the room. “Looks like it’s just us.”

His relaxed tone was a poor match for the rising unease in the room.

“Uh…we can just email the course director and try to come to another session,” I said, hoping that I might be able to delay the awkwardness, if only for another day or so.

“Or we can see if we can join the other groups,” offered one of my peers.

“Nah. I’m here. You’re here. That’s all we really need,” he replied. “Students have been learning this on me for years. I can teach y’all better than any resident. So, who’s going first?”

I looked to my classmates, seeking solace but finding only a matching of my own alarm. This was not how the morning was supposed to go.

“Don’t be shy now. One of y’all put gloves on and get over here. Or I’m going to pick one of you.”

No one moved. No one spoke.

The silence amplified the awkwardness. And my anxiety.

“No takers?” My panic spiked as his eyes locked on mine. “This guy, then,” he said pointing at me.

I was terrified, but he was clearly the one in charge. I reached for a pair of gloves.

He tossed me a packet of lubricant. “Be sure to use a lot. A dry glove is bad news for both of us.”

He unbuckled his worn black belt. Unbuttoned and unzipped his jeans. Let them fall in a bunch around his ankles. He didn’t bother to remove his NASCAR jacket. Jeff Gordon’s number 24 car sped toward me as he turned around.

He bent over, bracing himself against the edge of the table.

“Ready?” he asked.

“Not really.” I said, trying and failing to match his joking tone.

“It’s no big deal,” he reassured me. “It’s just an asshole. We’ve all got one.”

I let out a chuckle and felt the knot of the tension in my body begin to fray–—more from his casual use of profanity than from his reminder of the mammalian universality of anuses.

“So I just…go for it?”

“Nah. Finding the right spot can be pretty hard unless you want to get eye to eye with it. Just start toward the top and move your finger down until you feel it give.”

I followed his instructions and slowly moved my tremulous finger inferiorly along the gluteal cleft.

“You don’t have to be so precious about it,” he chided. “Just swipe it like a credit card. You’ll know when you’re in the right spot.”

The remaining tension in the room evaporated as my classmates erupted in laughter at the absurdity of the analogy.

I swiped. Not confidently. And not exactly like a credit card. But close enough to find the target.

“There it is,” he said. “Now just ease it in. Try to be slow and smooth about it. It won’t hurt if you take your time.”

“There you go. Nice and easy.” he said. “Okay then, sweep from side to side…Feel that smooth, firm area. Yep, you got it. That’s the prostate right there. And that’s it. You’re done. No big deal, right?”

I agreed and stepped aside, relieved.

As I removed my gloves and washed my hands, my classmates lined up to take my place. He stayed in position as one by one, they repeated the process.

***

I don’t recount any of this to the student or our patient, but I channel my unlikely teacher’s calm nonchalance in an attempt to pass along to her what he taught me—that robbed of the awkwardness we project onto it, this is, ultimately, an examination maneuver like any other.

I can sense her anxiety dissipate as I walk her and our patient through the steps that I learned while staring at the number 24 car embossed on black leather. She uses plenty of lubricant. She moves superior to inferior until she identifies the sphincter. She applies steady and gentle pressure.

And just like that, she is done.

No big deal.