When I was a medical student I had an attending who would fail medical students who failed to universally perform the rectal examination.

He would gloat on rounds when reviewing admissions with the trainees. Stopping dramatically during the middle of the presentation of the physical exam, he would smile broadly, look around at the team and ask, “So what did the rectal show?”

The rectal examination as a single-minded metric

Waiting desperately for his moment, he was never concerned with pitting edema in the elderly woman admitted with congestive heart failure. What he was concerned with was whether a frightened 79-year-old woman had undergone an unnecessary invasive rectal examination at his expense.

The teaching opportunity, it seemed, was about him and his game of gotchya. It was about the opportunity to catch me as an irresponsible trainee. It was about the opportunity to shame me if I didn’t meet his single-minded metric.

Promoted as a leader and great teacher at that time and place, what he promoted was a cynical view of the world. As a bombastic narcissist, his arrogance attracted the attention of others like him. Consequently, he won every teaching award in the book.

Passing the asshole test

In fairness, he did teach me a few things. He taught me how to be afraid and focus on the wrong things about the patient. I learned clearly who I didn’t want to be as a doctor and a teacher. Maybe the most important thing he taught me was to how to judge a rectum. Not the anatomic kind, the physician kind. He motivated me to shape what I call the asshole test. That’s when a medical teacher threatens a medical student’s future over a pet issue. I still see it from time to time.

He never caught me, by the way. I went on to become a gastroenterologist.

It seems that matter how miserable your teacher, there’s always something to be learned.

The protagonist here was an infectious disease attending at what was then the Worcester Memorial Hospital in central Massachusetts. It was the late 1980’s. Maybe you know him.

Image of the rectal examination from page 60 of “The Principles and practice of gynecology : for students and practitioners” (1904). Believed to be in the public domain.

If you dig this post you might check out our Medical Education Archive. Everything about teachers, learners and what goes right and wrong.