Documentation of rectalexamination performance inthe clinical teaching unit of

a university hospitalHugh James Freeman MD

272 Can J Gastroenterol Vol 14 No 4 April 2000

Department of Medicine (Gastroenterology), University of British Columbia, Vancouver, British ColumbiaCorrespondence and reprints: Dr Hugh Freeman, ACU F-137, University Hospital, 2211 Wesbrook Mall, Vancouver, British Columbia

V6T 1W5. Telephone 604-822-7216, fax 604-822-7236Received for publication January 15, 1999. Accepted November 22, 1999

ORIGINAL RESEARCH

HJ Freeman. Documentation of rectal examination perform-ance in the clinical teaching unit of a university hospital. Can JGastroenterol 2000;14(4):272-276. Digital rectal examinationis used to evaluate the distal rectum and other organs, includingthe prostate gland. It may be combined with fecal screening for oc-cult blood loss, and annual performance has been recommendedfor asymptomatic individuals over age 40 years for cancer screen-ing. In this study, documentation of digital rectal examinationswas assessed through a review of hospital medical records of a ran-domly selected group of 100 patient discharges (55 females and 45males) from a total of 896 patients admitted through a hospitalemergency room to a medical clinical teaching inpatient unit of auniversity hospital during a six-month period. In this group, 26%were admitted for a gastrointestinal disorder, but only 17% of allhospitalized patients had rectal examinations done by the medicalresident house staff and/or attending medical staff directly respon-sible for the care of these patients. Occult blood testing was donein 15 patients. Pelvic and breast examinations were rarely docu-mented. The majority of rectal examinations (ie, 13 of 17) were‘same sex’ examinations, appeared to be used largely for testing orconfirmation of grossly visible blood loss and were never con-firmed by attending staff. The presence or absence of nursing staffduring examinations was not documented. The prostate examina-tion was normal in one patient but not documented in the other44 males (ie, 26 patients over age 60 years). In conclusion, rectalexaminations (as well as breast and pelvic examinations) wererarely documented in the medical teaching unit by medical resi-dent house staff or their attending staff.

Key Words: Colon; Colon cancer; Occult blood testing; Prostate can-

cer; Rectum

Notes relatives au toucher rectal dans uneunité d’enseignement clinique d’un centrehospitalier universitaireRÉSUMÉ : Le toucher rectal permet d’évaluer le rectum distal et d’autresorganes, dont la prostate. Il peut être associé à un examen des selles à larecherche de sang occulte, et il est recommandé de le pratiquer une fois parannée chez les personnes de plus de 40 ans qui ne présentent pas desymptômes comme mesure de dépistage du cancer. Dans la présente étude,on a évalué les notes relatives au toucher rectal en passant en revue ledossier médical d’un groupe de 100 patients choisis au hasard (55 femmeset 45 hommes) sur un total de 896, qui se sont présentés à l’urgence et quiont été admis dans une unité d’enseignement clinique d’un centrehospitalier universitaire sur une période de six mois. Dans ce groupe depatients, 26 % ont été admis pour troubles gastro-intestinaux, maisseulement 17 % de tous les patients hospitalisés ont subi un toucher rectaleffectué par le résident ou le médecin traitant. Un examen des selles à larecherche de sang occulte a été fait chez 15 patients. L’examen pelvien etl’examen des seins étaient rarement notés. La plupart des touchers rectaux(13 sur 17) ont été effectués par des personnes de même sexe, ils semblentavoir été effectués pour vérifier ou confirmer la présence de pertessanguines nettement visibles et ils n’ont jamais été confirmés par lesmédecins traitants. La présence ou l’absence de personnel infirmier durantl’examen n’était pas notée. L’examen de la prostate s’est avéré normal dansun cas, mais non noté dans les 44 autres cas (26 patients de plus de 60 ans).En conclusion, le toucher rectal, de même que l’examen pelvien etl’examen des seins, était rarement noté par les résidents ou les médecinstraitants à l’unité d’enseignement clinique.

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Periodic rectal examinations in asymptomatic personshave been widely recommended by the American Can-

cer Society and the National Cancer Institute (UnitedStates) for cancer screening (1-4). Specific guidelines haveincluded an annual digital rectal examination for men orwomen over age 40 years as well as an annual fecal occultblood test for those over age 50 years. It is believed that thispart of the physical examination may result in earlier detec-tion and more effective therapy for prostate cancer as well aspolyps and cancer of the distal rectum (5,6). Fecal occultblood testing, done under specific conditions, has also beenreported to be a useful screening tool in the detection of co-lorectal cancer, with a resultant reduction in mortality (7,8).

In recent years, some hospital institutions have insistedthat every history and physical examination on a patient ad-mitted to hospital include a rectal examination, but a recentstudy from a teaching centre in Pittsburg revealed that 56%of all admissions did not document a digital rectal examina-tion (9). Because results from the Pittsburg study were fromall teaching services, both medical and nonmedical, thepresent investigation evaluated the performance frequencyand description of rectal examinations by resident housestaff physicians and attending medical staff physicians on pa-tients admitted to the medical clinical teaching unit of auniversity hospital.

PATIENTS AND METHODSThe medical records of 100 patients discharged from a medi-cal teaching unit were retrospectively reviewed. Charts wereindependently selected from a total of 896 patient dischargesduring a six-month period, from October 1, 1996 to March31, 1997, inclusive, by a medical records technician. Nomore than 20 patients from each calender month were used.The physician chart reviewer had no knowledge of the pa-tient before the chart review, and the medical records tech-nician had no knowledge of the objectives of the review. Allpatients, except for one (transferred from a hospital in theUnited States), were admitted through the hospital emer-gency room to the medical clinical teaching unit. The struc-ture of this unit includes staffing by medical house staff(senior year medical students and medical residents at in-creasing levels of seniority), while the final physician re-sponsibility for the patient’s hospital care was assumed byone of 12 different attending staff (10 males and two fe-males) with certification from the Royal College of Physi-cians and Surgeons of Canada in Internal Medicine. Two ofthe 12 attending staff were responsible for all medical pa-tients on a two-month rotation basis at any one time. Allemergent medical problems were referred by an emergencyroom physician to this medical clinical teaching unitbecause there were no designated subspecialty medical bedsin the hospital, except for a small number devoted to the in-vestigation and treatment of chronic or degenerative neuro-logical disorders. After complete evaluation by the medicalresident in the emergency room, patients were admitted forongoing care to the medical clinical teaching unit. Consul-tation services were available to this medical teaching unit

through subspecialty services from the teaching faculty, in-cluding all medical, surgical and psychiatric subspecialties.

RESULTSPatient characteristics: Fifty-five females and 45 males,ranging in age from 18 to 95 years, were studied. All patientsrequired admission for an emergent medical problem; 99 pa-tients were admitted through the hospital emergency roomafter evaluation by an emergency room physician and laterreferral to the medical resident for the general medicalteaching unit. One patient with an emergent medical prob-lem was transferred from an Oregon hospital and entered thehospital through the emergency room. Figure 1 shows thedistribution of patients classified into different subspecialtygroups. These included cardiorespiratory disorders, gastroin-testinal disorders and neurological disorders. Other condi-tions that required admission included a variety of medicaldisorders, such as diabetic ketoacidosis, renal failure, fever ofunknown cause and systemic lupus erythematosis. Althoughcardiorespiratory disorders accounted for most admissions tothis medical teaching unit, 26% were admitted for a gastro-intestinal, hepatobiliary tract or pancreatic disorder. Theseadmissions included patients with gastrointestinal bleeding,complex inflammatory bowel disease, abdominal pain due tobiliary tract lithiasis and pancreatitis, and complicated, usu-ally chronic, liver disease.

Overall, the consultation rate to subspecialty services forthese 100 patients was 43%. For some of these 43 patients,consultant physicians from more than one medical subspe-cialty evaluated the medical problems. In addition, seven pa-tients were referred to other nonmedical services, includingsurgery, urology, orthopedics and psychiatry. Figure 1 alsoshows the consultation rates for the different subspecialtygroups. Almost 80% of all patients admitted with a gastroin-testinal disorder had consultations. Although the reasons forgastrointestinal consultations were not specifically evaluatedin this study, it appeared that the majority of consultation re-quests to the gastrointestinal service were for performance of

Can J Gastroenterol Vol 14 No 4 April 2000 273

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Figure 1) Distribution of subspecialty system and consultation rate for100 patients in a medical clinical teaching unit. The left columnrepresents the total number of patients in the system category, while theright column represents the number of specialist consultations. Card-RespCardio-respiratory disorders; Gastro Gastrointestinal, hepatobiliarytract and pancreatic disorders; Neuro Neurological disorders; OtherOther disorders

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investigative procedures (eg, upper gastrointestinal endo-scopy, colonoscopy) or to initiate nutritional support, spe-cifically, total parenteral nutrition.

Of the 100 patients evaluated, 95 were discharged fromhospital or sent to a chronic care facility. Five patients died,including two due to a cerebrovascular accident, one due torenal failure, one due to a pulmonary embolism and one dueto a lung carcinoma. One of these five patients had anautopsy performed.Rectal examination performance: Figure 2 shows the docu-mentation of rectal examinations, occult blood testing andpelvic examinations in the 100 patients evaluated. A total of25 patients had a rectal examination documented in the hos-pital medical record during their hospital admission; ofthese, 21 had an occult blood test performed or had frankblood detected. The precise method of testing for occultblood was never recorded. The frequency of rectal examina-tion performance was also compared in this group of 100 pa-tients with the frequency of breast and pelvic examinations.One female had a pelvic examination documented; this wasdone by a surgical resident. No patient in the medical clini-cal teaching unit had a breast examination documented by amedical student or any physician in the hospital medical rec-ord.

Performance of rectal examinations by the resident medi-cal staff was limited to 17 patients; of these, 15 also had anoccult blood test performed or had frank blood detected.None of the 12 general internists who directed the care ofthe patients during their hospital admission documentedperformance of a rectal examination. In most instances, arectal examination was performed only in patients with find-ings that implicated a gastrointestinal cause for the admis-sion of the patient to hospital. Of 17 patients who had digitalrectal examinations performed by medical resident housestaff, six had already undergone a rectal examination by anemergency room physician and five of these had a fecal oc-cult blood test performed. Except for one patient who had arectal examination performed by a urologist and one otherpatient who had a rectal and pelvic examination performed

by a surgical resident, rectal examinations performed by sub-specialty consulting physicians were done only by one of sixdifferent consultant gastroenterologists who also functionedon a service rotational schedule. Of 20 referrals to the gastro-intestinal service, 16 had rectal examinations but four pa-tients had no rectal examination. These included twopatients with severe chronic liver disease reviewed by gastro-enterologists for a specialized liver transplant service, onepatient with an actively bleeding duodenal ulcer and one pa-tient with gallstone-associated pancreatitis. Of the six pa-tients with a gastrointestinal disorder who requiredadmission to the hospital but without a referral to the gastro-intestinal service, none had a rectal examination performedby the medical resident or attending staff in the medicalclinical teaching unit. Of the 16 rectal examinations done bygastroenterologists, eight also had occult blood tests per-formed.Rectal examination descriptions: Rectal examinations wererecorded by the medical resident house staff as ‘negative’,‘zero’ or ‘clear’ in three charts, ‘occult blood negative’ in four,‘occult blood positive’ in five and ‘frankly bloody stool’ intwo. Two charts recorded ‘no masses’, with either ‘occultblood negative’ or ‘occult blood positive’, while one chart re-corded ‘occult blood negative and prostate normal’. Indeed,the word ‘prostate’ appeared only once in the record of thephysical examination for all 45 male patients, and 26 ofthese 45 male patients were over age 60 years.Patient and examiner sex: Figure 3 relates the number ofmale or female patients with either male or female medicalresident examiners to the performance frequency of rectalexaminations. Ten of 34 male patients examined by a malephysician had a rectal examination (ie, 29.4%), while onlytwo of 13 male patients examined by a female physician hada rectal examination (ie, 15.4%). Four of nine female pa-tients examined by a female physician had a rectal examina-tion (ie, 44.4%), while only two of 44 female patientsexamined by a male physician had a rectal examination (ie,4.5%). These differences were statistically significant(P<0.05).

274 Can J Gastroenterol Vol 14 No 4 April 2000

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Figure 2) Distribution of rectal examinations, occult blood (Occ Blood)testing and pelvic examinations for emergency room physicians (ERMD’s), medical resident and attending staff physicians in the medicalclinical teaching unit (CTU MD’s) and subspecialty physician consult-ants (Spec MD’s)

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Figure 3) Distribution of examinations based on sex of the patient and thephysician examiner. FE Female examiner; FP Female patient; ME Maleexaminer; MP Male patient; Rect Exam Rectal examination

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Nurse documentation: No physician documented the pres-ence of another medical or nursing staff member during thepatient’s physical examination, and in particular rectal ex-aminations, either for same or opposite patient sex. No nurs-ing staff member documented their presence in the nursingrecord during rectal examinations done by physicians.

DISCUSSIONOver 80% of patients admitted to the medical clinical teach-ing unit in a university hospital had no documentation ofperformance of a rectal examination by the medical residentphysician or the attending staff directing the care of the pa-tient, while breast and pelvic examinations appeared to beeven more rarely done. These results are consistent with pre-vious observations at a Pittsburgh teaching hospital thatdocumented the failure to perform rectal examinations in56% of patients requiring hospital admission (1). In the pres-ent evaluation, however, the observations were even morestriking because the patients were admitted to a generalmedical service in a university teaching hospital that ex-cluded hospitalized patients from other services, such as psy-chiatry. Although it is conceivable that the performance ofrectal examinations in general medical services may behigher at other teaching hospital sites for this university de-partment, this is probably quite representative of all of themedical teaching units. The medical resident staff rotatethrough these teaching units at other hospital sites, andsome of the attending staff also perform identical functionsat the other teaching hospital sites.

This study also demonstrated that rectal examinationsdocumented by medical residents appear to be largely fo-cused on the detection of blood loss rather than a true ‘physi-cal examination’ of the rectum, anus or prostate gland.Moreover, the absence of rectal examinations by attendingstaff physicians indicates that the results of these rectal ex-aminations done by medical residents were not confirmed byattending staff physicians, even in patients who were admit-ted with a primary gastrointestinal disorder. Instead, mostrectal examinations for patients with gastrointestinal disor-ders appear to be almost entirely dependent on subspecialtyconsultation from the gastrointestinal service or a surgicalservice. Similarly, there was a failure to document a clinicalevaluation of the prostate gland in 44 of 45 males in thisstudy, including 26 patients over the age of 60 years. ManyUnited States hospitals now insist that a complete generalmedical examination document a rectal, breast and pelvicexamination in patients who require hospital admission.The data indicate that complete examinations were not per-formed in a clinical teaching setting on a general medicalward and confirm the observations previously noted in aPittsburg hospital for both medical and nonmedical services.

The precise reasons for the limited number of rectal ex-aminations documented in the present study group are notclear. While limited supervision by attending staff may bepartly responsible, the data also appear to suggest that medi-cal resident physicians may experience significant discom-fort with opposite sex examinations, or, possibly, for

medicolegal reasons, these examinations are being avoided.Compared with male physicians, female physicians per-formed rectal examinations on males about 50% less thandid male physicians. This difference was even more dramaticfor female patients. Female physicians performed rectal ex-aminations in about 45% of the female patients, whereasmale physicians performed rectal examinations in less than5% of the female patients admitted. Breast and pelvic exami-nations were even more rarely documented (this lack ofdocumentation was equal in male and female resident physi-cians). The reasons for these apparent ‘sex-based’ differencesin examination rates require further elucidation. It has beenrecently recommended by the local provincial licensingbody, the British Columbia College of Physicians and Sur-geons and the Canadian Medical Protective Associationthat a member of the nursing staff be present for such inpa-tient examinations, largely for physician protection, espe-cially for male physicians who are performing femaleexaminations. In this study, no documentation was evidentin the chart record that a member of the nursing staff waspresent and, conversely, no nursing record documented theirpresence during the physician examination. Instead, it ap-pears that female patients are most likely to be incompletelyexamined in a teaching hospital setting if initially seen on amedical ward by a male resident physician. Because there areapparently increasing numbers of complaints, particularlytoward male physicians with respect to sexual harassment, afear of potential consequences, including litigation, mayhave been partially responsible for the results observed. If so,a greater documentation of nursing staff presence would beexpected, but this did not occur. Alternatively, some physi-cians, anticipating that a subsequent referral to a gastrointes-tinal subspecialist or a surgeon will result, may feel that anadditional examination may be superfluous. If so, patientsnot referred for subspecialty consultation with a gastrointes-tinal disorder would be expected to have had a rectal exami-nation. This did not occur.

The results of this performance evaluation of a generalmedical teaching unit seem surprising given that the cancerscreening guidelines for many national organizations, such asthe American Cancer Society, recommend annual digitalrectal examinations for patients over the age of 40 years. Inpart, this recommendation has been made because of the be-lief that digital rectal examination is one of the best methodsto screen for prostate cancer. Additional studies are neededto clarify the limited documentation of this portion of theclinical examination in patients admitted to teaching hospi-tals and the reasons for the apparent reluctance of medicalresidents and general internist attending staff to perform rec-tal examinations.

REFERENCES1. ACS Guidelines. New York: American Cancer Society, 1986.2. Mettlin C, Jones G, Averette H, et al. Defining and updating the

American Cancer Society guidelines for the cancer-related checkup:prostate and endometrial cancers. CA Cancer J Clin 1993;43:42-6.

3. Levin B, Murphy GP. Revision in American Cancer Societyrecommendations for the early detection of colorectal cancer.CA Cancer J Clin 1992;42:296-9.

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4. Working Guidelines for Early Cancer Detection: Rationale andSupporting Evidence to Decrease Mortality. Bethesda: NationalCancer Institute, 1987.

5. Friedman GD, Hiatt RH, Quesenberry CP Jr, et al. Case-control studyof screening for prostatic cancer by digital rectal examinations. Lancet1991;337:1526-9.

6. Cher ML, Carroll PR. Screening for prostate cancer. West J Med1995;162:235-42.

7. Selby JV, Friedman GD, Quesenberry CP Jr, et al. Effect of fecal occultblood testing on mortality from colorectal cancer: a case-controlstudy. Ann Intern Med 1993;118:1-6.

8. Winawer SJ, Fletcher RH, Miller L. Colorectal cancer screening:clinical guidelines and rationale. 1997;12:594-642.

9. Leff DB, Azzouz M, Molloy PJ, Kania RJ. Attitudes toward vsperformance of rectal exams. Gastroenterology 1997;112:A25.(Abst)

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