Turn Your Head and Cough

School starts early here in the South, with my kids starting school this next week.  This means that we have the honor of doing sports participation physicals to a throng of uncomfortable teens.  I can\’t say this is a bad thing, as these exams are really quite simple to do – usually taking less than 5 minutes to complete.

Here are my thoughts on this yearly ritual.

Who decides what is included on these exams?

The standard form is simple enough – just an exam of the head, chest, heart, abdomen, joints, and (for boys) a hernia check.  Some forms, however, contain strange details – asking for exams of the breast, comments on the immune system, emotional state, and other mysteriously important systems.  Let me state clearly that I will never do a breast exam or a female genital exam in these visits, nor am I able to conjure up an exam of the immune system.  If I think it is irrelevant or inappropriate, I ignore it.  I have yet to bear repercussions for this decision.

Somewhere there is someone who thought this was important enough to include on the exam.  My suspicion is that this is not a medical person, but instead some commissioner gives the task to one of their underlings who thinks back to what was done when they were young.  I don\’t know, but it often seems very random and sometimes bizarre as to what is included.  In my opinion, the most important things for sports physicals are:

  • Is the child at risk for heart disease?  I have to look for signs of hidden heart problems that could lead to an arrhythmia.  We do this by asking if there is a family history of people under 50 having heart problems, and by listening carefully.  Unfortunately, the exam itself won\’t always show that the person is at risk.
  • Is the child able to physically handle the vigors of sports participation?  This is not really addressed in many of these forms, nor does it seem there is formal education as to how to handle strenuous physical activity.  The summers are very hot and humid here and football practice is an incredibly strenuous thing.  I wonder who prepares these kids for this kind of stress, and if the coaches have a clinically appropriate set of guidelines to follow in leading the practices.
  • The joint exam.  Joints are the most likely thing to be injured – especially in females, whose ligaments are more lax.  The exam is not itself important (\”wow, your knee really bends well!\”) but the history of previous joint problems and education as to prevention of joint injury is important.

Why are we so fixated on hernias?

It seems to me that the hernia exam on boys is some sort of rite of passage to manhood.  Why is this?  Who made me the high priest of hernias?  The focus on this part of the exam seems way out of proportion with its actual importance.

Yes, hernias are bad things, but they are hardly subtle.  Usually the boy has a large bulge in his groin area that may or may not hurt.  Either way, boys are not likely to see this large bulge as something that is a normal part of growing up.  Boys value their genitals, and are unlikely to sit passively as they change their form.

It seems to me that someone in the past felt that if we didn\’t make sure boys would have hernias before sports participation, we\’d have sporting events interrupted by a mass of kids with their intestines spilling out of their groins.

Still, the experience is unique in its own ways.  It is hilarious to see boys react to their first hernia check.  This is usually a 6th grader who is still quite boyish – both physically and emotionally.    The interaction goes like this:

The parent or older sibling in the room has not informed the boy of his upcoming rite of passage.  I am not sure why they don\’t prepare kids for this, but it probably is because they wouldn\’t otherwise go.  It seems kind of like when I take my dog to the vet.

\”OK, now we have to do a hernia check\” I say, putting a glove on my hand.

The other person in the room stands up, grinning, and says \”I\’ll go out for this part.\”

\”Try and ignore the screams\” I joke to them, getting a chortle.

The boy eyes me suspiciously, \”What\’s a hernia check?\”

\”I have to check for a bulge in your groin area.  Can you stand up and pull down your pants?\”

His eyes get huge and his face turns pale.  \”w..w…w…what do you need to do?  No!  You\’re kidding.\”

\”I am serious.  This is part of the exam.  I have to check for a hernia.\”

\”No…really? I\’m not doing that!\”  He starts giggling.

\”Yes.  If I don\’t do this, you can\’t participate in sports.  Please pull down your pants.\”

He then pulls his pants down half of an inch, showing the band of his underwear.

\”All the way down,\” I say.

\”Do you have to do this??  No…\”  Giggles.

\”Yes, pull your pants and underwear all the way down so I can check for a hernia.\”

\”What?  My underwear too???  No!  You\’re kidding!\”  Giggles more.

I sigh.  \”Yes, this is just part of the exam.  Please pull them down.\”

He pulls it down a few more inches, not coming close to exposing enough for me to do my exam.

\”All the way down!\” I repeat.

Reluctantly and slowly the pants and underwear drop .  I gently push in the groin where hernias are prone to occur (not on the genitals themselves, by the way).  \”Turn your head and cough.\”

He giggles and lets out a little cough.

\”Bigger cough.\”

More giggles and a slightly harder cough.

I put my hand on the other side and he instinctively turns his head the other direction when I direct him to cough.

Let me mention that the only reason we have boys turn their heads during this exam is so that they don\’t cough on us.  Most people seem to believe that somehow turning the head to the side stretches something that goes down to the groin area.  To my knowledge there is no cerebro-scrotal ligament.  I just don\’t like spit on my head.

That\’s about all I have to say about these exams.  We allow them to be done as walk-ins and these are the only visits that we open to non-patients.  They usually come in large bunches, as kids decide late to participate, neglect telling their parents about the form until the day before they are due, or parents forget.  In any case, they are laid-back and often entertaining.

I am not going to turn away the business.

So all you men out there, in honor of this great exam please push down the \”Space\” key on your computer, turn your head, and cough.

Good.

Now you can comment on this post.

37 thoughts on “Turn Your Head and Cough”

  1. Ok* – it’s a dumb question but i’m going to ask it anyway: do girls get hernia too?
    * i DID turn my head and cough before commenting on this post! LoL

  2. Ok* – it’s a dumb question but i’m going to ask it anyway: do girls get hernia too?
    * i DID turn my head and cough before commenting on this post! LoL

  3. Cerebroscrotal** ligament…hilarious! I’ve answered this exact same question, and my answer was to ensure they looked away to force them not focus in on the business of the exam (at that age, easily embarassed, easily distracted). I think yours is probably more practical and more realistic!
    (**although there’s plenty of jokes in there about “inter-brain” communication 😉 )

  4. Cerebroscrotal** ligament…hilarious! I’ve answered this exact same question, and my answer was to ensure they looked away to force them not focus in on the business of the exam (at that age, easily embarassed, easily distracted). I think yours is probably more practical and more realistic!
    (**although there’s plenty of jokes in there about “inter-brain” communication 😉 )

  5. I got a hernia in my lower abdomen when I was 11 years old. They think it was because I was always picking up and carrying around little kids. Which was most likely true because I did pick up little kids and carry them around (a lot). It was quite painful.

  6. I got a hernia in my lower abdomen when I was 11 years old. They think it was because I was always picking up and carrying around little kids. Which was most likely true because I did pick up little kids and carry them around (a lot). It was quite painful.

  7. LOL
    The parent or older sibling in the room has not informed the boy of his upcoming rite of passage. I am not sure why they don’t prepare kids for this…

    Having never been a little boy, I had no idea this was part of a boy’s sports physical.

  8. LOL
    The parent or older sibling in the room has not informed the boy of his upcoming rite of passage. I am not sure why they don’t prepare kids for this…

    Having never been a little boy, I had no idea this was part of a boy’s sports physical.

  9. Hi, Dr. Rob!!
    Man, I’m 30 and I’ve never had one of those — am I lucky? I don’t know. I feel lucky, but opinions may vary.

    Also, if you get the urge, feel free to visit my blog about healthcare reform. I’ve been very depressed reading Medpolitics, and I would love to get feedback from a doctor like you!

    B ig ups,

    Nick

  10. Hi, Dr. Rob!!
    Man, I’m 30 and I’ve never had one of those — am I lucky? I don’t know. I feel lucky, but opinions may vary.

    Also, if you get the urge, feel free to visit my blog about healthcare reform. I’ve been very depressed reading Medpolitics, and I would love to get feedback from a doctor like you!

    B ig ups,

    Nick

  11. Bwahahaha – cerebroscrotal ligament! That is awesome. People really think that?My husband had an inguinal hernia repair while we were dating. He did comment how annoyed he was that after all those years of turning and coughing, no one mentioned the hernia til he met me. Well ok it was quite some time after we MET that I spotted it 🙂 Of course he also said it had bothered him for years and he never told anyone so shame on him, right?

  12. Bwahahaha – cerebroscrotal ligament! That is awesome. People really think that?My husband had an inguinal hernia repair while we were dating. He did comment how annoyed he was that after all those years of turning and coughing, no one mentioned the hernia til he met me. Well ok it was quite some time after we MET that I spotted it 🙂 Of course he also said it had bothered him for years and he never told anyone so shame on him, right?

  13. Do you screen for Brugada/WPW other than the history question? a 12-lead is pretty cheap if you’re not sending it out for a read…

  14. Do you screen for Brugada/WPW other than the history question? a 12-lead is pretty cheap if you’re not sending it out for a read…

  15. Sounds smarter than a hernia check, although I don’t know if it is an effective screening tool. The problem is that it is not recommended for all athletes and it would triple the amount of time we take. The history question (Has anyone in your family under 50 died suddenly of a heart attack) is all that is recommended.

  16. Sounds smarter than a hernia check, although I don’t know if it is an effective screening tool. The problem is that it is not recommended for all athletes and it would triple the amount of time we take. The history question (Has anyone in your family under 50 died suddenly of a heart attack) is all that is recommended.

  17. I always felt sorry for the boys when they had to go. Word goes around very fast amongst the students, and they would both giggle and recoil in horror when it was time to have their physicals. When they would come back in, they would give knowing looks to each other of the horror they encountered. I would hear repeatedly, “Why do that have to do that to us?”

  18. I always felt sorry for the boys when they had to go. Word goes around very fast amongst the students, and they would both giggle and recoil in horror when it was time to have their physicals. When they would come back in, they would give knowing looks to each other of the horror they encountered. I would hear repeatedly, “Why do that have to do that to us?”

  19. And then we “boys” get to have more fun later on in life, when we meet “Mr Jellyfinger”.
    Still, I certainly wouldn’t trade it for the more-frequent gynecological exam!

  20. And then we “boys” get to have more fun later on in life, when we meet “Mr Jellyfinger”.
    Still, I certainly wouldn’t trade it for the more-frequent gynecological exam!

  21. For more fun, with boys or “real men” when checking for a hernia try this…When I was an intern, some thirtysomething years ago, I asked a patient to cough and wound up with the flu for a week, since then I merely ask them to hold their breath and bear down. “No, HOLD your breath.” They try again. “NO, you’re letting the air out through your nose, you know, like you’re going under water.” Again air out the nose. They try again and just hold their breath. “Ok, now PUSH down AND hold your breath.” I then look up, hold my breath, and demonstrate the perfect Valsalva maneuver for them. It’s amazing what we take for granted.

  22. For more fun, with boys or “real men” when checking for a hernia try this…When I was an intern, some thirtysomething years ago, I asked a patient to cough and wound up with the flu for a week, since then I merely ask them to hold their breath and bear down. “No, HOLD your breath.” They try again. “NO, you’re letting the air out through your nose, you know, like you’re going under water.” Again air out the nose. They try again and just hold their breath. “Ok, now PUSH down AND hold your breath.” I then look up, hold my breath, and demonstrate the perfect Valsalva maneuver for them. It’s amazing what we take for granted.

  23. Any physician who exposes and humiliates a patient when they know the exam is worthless and unnecessary is a disgrace. The obvious amusement on your part is sickening. These exams scar children, have you no conscience?

  24. I encourage you to read http://patientmodesty.org/teenagers.aspx and Sports Physicals Are They Needlessly Embarrassing? By Dr. Joel Sherman (http://patientprivacyreview.blogspot.com/2011/01/sports-physicals-are-they-needlessly.html). Dr. Sherman is a cardiologist. He talks about how hernia exams are not necessary for sports physicals. Boys have the right to decline the hernia exams. Boys should be given literature about how to examine themselves for hernias. If they find a hernia, they can come back to the doctor.

  25. For some reason this post has suddenly gotten attention, so I will answer to those who think I am disrespectful (hopefully preventing needless further scolding). First, the post was written not as a “how to” guide, but as a light commentary on an embarrassing situation most of us men have gone through. Second, I was recounting from a doctor’s perspective the shock I see in boys going through this for the first time. It is quite funny to see this. It is not funny because these boys are weak or bad, but because they are incredibly modest about their bodies – something which I think is good, not bad. Any humor I use in the exam room is not meant to belittle or embarrass, but to lighten the mood (and it generally works quite well, actually). I often tell the boy of how mortified I was, and how I would have walked right out of the exam room if a woman came to do the exam.

    To those who think doctors shouldn’t laugh at funny things (like a boy doing everything in his power to keep his genitals hidden), I am sorry. It is funny from my perspective, as are many things I see. The nature of this blog (should you read more than just this post) is that of a doctor talking as a person, expressing my emotions about situations and showing that the doctor-patient relationship is between two people, not a provider and a patient. Perhaps the writing in this post misled readers to think I disrespect people. Reading the other posts I’ve written should tell you otherwise.

    The fact is, the exam room is one place where people must bare themselves in many ways. They physically bare themselves (although I do what I can to minimize this), emotionally bare themselves, and open up to me about their vulnerability as a person. They get sick and die. The exam room is one place where this fact is not ignored. For me, this is a very sacred trust I am given; but sacred does not mean I am always solemn and serious. That attitude is part of what makes people uncomfortable opening up about themselves and makes them uncomfortable around doctors.

  26. I think it’s so wrong that the parents would help make their sons the butt of jokes and not be offended that the doctor would say something like “ignore the screams.” It’s totally the parents’/coaches’ fault that the kid in question is totally unprepared and has no idea what is to come. There would be no way for the doctor in that situation to make the kid feel better. I haven’t heard of this exam being “traumatic” or “scarring” but for sure, even a girl’s first period is both of those things if she is totally unprepared for what is happening to her body. Shame on those parents.

  27. You state “Let me state clearly that I will never do a breast exam or a female genital exam in these visits, nor am I able to conjure up an exam of the immune system. If I think it is irrelevant or inappropriate, I ignore it. I have yet to bear repercussions for this decision.” In light of this criteria, why are you still doing the hernia exam? Why put a child through obvious distress for an exam that is unnecessary? I don’t care how you handle it, I simply want to know why you and other physicians would involve themselves in “rites of passage” that embarrass kids and are of no benefit to the patient.

  28. You state “Let me state clearly that I will never do a breast exam or a female genital exam in these visits, nor am I able to conjure up an exam of the immune system. If I think it is irrelevant or inappropriate, I ignore it. I have yet to bear repercussions for this decision.” In light of this criteria, why are you still doing the hernia exam? Why put a child through obvious distress for an exam that is unnecessary? I don’t care how you handle it, I simply want to know why you and other physicians would involve themselves in “rites of passage” that embarrass kids and are of no benefit to the patient.

  29. Concerned Parent

    Why are you choosing to do an intimate exam on a child that you in your own article have evidenced as unnecessary? Are the parents told prior to the exam that it is unwarranted? Should parents trust doctors with their kids who coerce them to expose their genitals by threatening to withhold sports unless they comply? Should a doctor be trusted who finds the distress of his patients “hilarious”? The logical conclusion of this article should have been something to the affect of “this is therefore why I refuse this unwarranted exam for my patients……” Instead, we don’t get a doctor advocating for his male patients, but one who finds great amusement at their humiliation.

  30. I was a Hospital Corpsman at a Coast Guard Training Center in 1968 and 1969. Every Monday, we’d receive 80 to 160 new recruits for physicals. We closed both entrances to sick bay. We’d pack all of the recruits in a room that was about 20′ x 20′. They’d be standing shoulder to shoulder and almost chest to back. A Corpsman would start things by shouting “Shut up! When I give ya the word, strip to the waist – from both ends. Put your shoes on the deck and put your clothes on your shoes. Put your valuables in the little paper bag you were given. When you’re naked, step into the hallway and form a line.” Sometimes, a recruit would ask what to do if the little bag fell off. When everybody was in the hall, the line would snake down one side of the hall and back up the other side. Each room they passed was an examining station. At the pharmacy, a recruit would stand naked in front of an eye chart and a Farnsworth Lantern. At another room, blood pressure was taken. At one office a Corpsman sat 15 feet from the door. He’d softly whisper “Next.” When a recruit came in, the Corpsman would write on the recruit’s exam sheet, “Whispered voice test 15/15.” If anyone asked what that meant or when the exam would be given, the Corpsman snarled, “Ya heard me say next! Now go back to the line.” At the lab, the floor was covered in butcher paper while groups of five guys peed into specimen bottles. Height and weight were recorded in another office.
    Before the recruits returned to the room where their clothes had been swept into a tangled pile, two doctors stood at opposite sides of the doorway. Standing parallel, they’d each check a recruit for hernias. Once a doctor professed uncertainty. He asked his partner to check. The second doctor also told the young man to turn his head and cough. He also said he wasn’t sure. He called a third doctor out of a treatment room to also check for hernia. The third doctor said, “Turn your head and cough.” As the third doctor removed his glove, a fourth doctor walked up to the hapless recruit and said, “How long have you had this cough?”

  31. Dr. Rob,
    I wanted to encourage you to watch a video we recently put up about why breast and genital exams are unnecessary for sports physicals and what exams ARE necessary for sports physicals. You can find it at http://www.youtube.com/watch?v=J5glh0ulBjo. We need to work to end unnecessary genital exams. You can also read another article about why breast and genital exams are not necessary for sports physicals at http://www.patientmodesty.org/sportsphysicals.aspx.

  32. I have done some polls to investigate what is really done during exams of children and adolescents at verious stages of development. I can tell that there is a huge variety between different societies, both regarding what authorities demand and what is practically done. In some societies extensive ultrasound exams are used, both externally and internally Some societies take specimens with catheters. Some use rectal speculums, Some take bacteriological specimens with swabs and instruments from any body opening, some perform a rectoscopic exam, and the list go on an on. What is really done of the more intrusive ordeals are seldome told openly, though. No society finds it practically feasble to do all thinkable intrusive exams, so there is somewhat arbitrary exactly what is selected to occur in any specific society.

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