athlete’s creed

An early medical rage of this century was the move to electronic medical records (EMR) and the digital practice of medicine. But I’d like to say a few words about some rather different digits. One in particular.

Patients may not be afraid of the doctor touching the computer keyboard to bring up their personal information, but many of them certainly are afraid of the docs touching certain personal body parts and telling them something is wrong. To be specific, men are especially ticklish about another person putting their hands anywhere near their underwear-absent bottom.

Computer digits are OK, but human digits to perform the routine prostate exam, aka the single-finger digital rectal exam — no thank you. As Shakespeare would say, “There’s the rub.”

A 2011 Esquire Magazine internet survey sheds some light on this dark place in doctor-land. The survey should not be interpreted as gospel since it was taken by 519 internet-connected US males, a sampling technique that would tilt the results toward the young and relatively affluent, as well as more educated individuals than might be found in a more representative selection of the male population. That said, it does support the notion that males are touchy about being touched.

When men were asked which medical tests give them the most anxiety, two were tied for the top spot: the digital prostate exam and a colonoscopy, each chosen by 36% of the sample. By comparison, only 23% found a dental checkup to be the most upsetting, and just 5% admitted to being threatened by a hernia exam. Consistent with these results only 30% reported having had the rectal (prostate) exam of those men between ages 41 and 50 who participated in the research.

What might this suggest about the avoidance of doctors by some males?

Conventional wisdom tells medical professionals that stereotypical men identify themselves as “tough” and don’t like appearing vulnerable. They are taught early some version of “the athlete’s creed:” if you are injured don’t complain, rub some dirt on the wound and get back into the game; don’t be a sissy, a wuss, a wimp, a pussy, a weakling, a girly-man or however else being “less than a man” might be characterized.

By that standard, going to a doctor when you feel relatively fine is a sign of weakness or fear, a source of shame. And indeed, there is data to suggest that lots of men do tend to delay seeing physicians even when they are sick; at least until some time passes and the distress can’t be ignored any longer.

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The digital advances brought by computer technology (rather than the MD’s advancing digit) hold no such threat. Immediate access to your medical history no longer depends on your memory or that of the physician. Drug interactions are more easily avoided. Computers may even help in suggesting diagnoses consistent with your recorded symptom profile. Medical errors should be reduced. All the computerized data also make medical research easier.

What medical apps won’t be able to do is get you to make an appointment with your doctor if you are afraid of either what he might do to you or what he might say about your condition. Many people would prefer to assume that if they feel good, doctors can be avoided. They like to think the medical community is too much like any other business and that what passes for evaluation and treatment is just another way to make a buck. Trust is needed if you are going to put yourself in the doctor’s hands.

Literally.

But what would make the digital rectal exam (or its even more invasive cousin, the colonoscopy, particularly scary? After all, the former takes just a few seconds, the doctor uses a lubricated glove to do it, and it isn’t painful.

Well, probably a couple of things.

First, men and women generally rate cancer as the disease they most fear. Since possible cancer detection is the usual reason for the routine digital rectal exam in men, it could be one of those things men believe to be better left alone. In other words, don’t look for trouble, and “If it ain’t broke, don’t fix it.”

But there is more. It might be an instinctive fear of assault from the rear.

It is probably scary enough for many men to stand with their private parts exposed to another man, but likely even worse to be positioned with your back to him while he fingers enter you. I’m not talking here only about homophobia, but equally about an instinct for self-preservation causing a kind of automatic terror of being injured.

“Wild Bill” Hickok, the legendary gunfighter of the Old West, is a possible example of this kind of concern. Hickok is said to have always been careful to sit with his back to the wall. But on August 2, 1876, he joined a saloon card game where the only remaining seat placed his back toward the entrance. Twice he asked others to change seats, but no one did.

He was shot in the back of the head by a man entering from the door, just as he feared.

Lots of my male patients postponed or avoided the kinds of examinations I’ve described here, even quite a number who knew very well that it was a good idea to obtain them. Some were ultimately persuaded by their wives to go to the doctor.

Others might have been influenced if one appealed to the desire to be alive long enough to care for their family or see their grandchildren grow up. But, part of the dilemma is that men tend not to talk to potential persuaders about matters as private as this. And, if you don’t have a doctor (45% of the Esquire sample did not), she or he cannot advise you to do what is needed.

Clearly, early detection of serious medical problems represents a desperately important area for research into how to motivate terrified folks to do what is best for them. As much as we read about the advances expected from medical research, it might be useful to hear a bit more about what is being done to reduce the fear of medicine done with digits; a fear that remains in the shadows — an “unmanly” quality in some of the very same men who portray themselves as macho.

If, as I’ve suggested, men avoid these tests out of age-old instincts for self-preservation, one can only be struck by the irony that their efforts at such self-defense increase the chance of early and avoidable death.

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As with all such sensitive and very personal areas of life, however, there is always room for a joke. My own physician told me the following:

I had a patient who came in for a routine digital rectal exam as a part of his annual physical. After that portion of the evaluation was completed, he asked me a question: “Doc, how many fingers did you use?” “One,” I answered. “Why didn’t you use two?” “Because the exam is done with just one finger,” I said. “Yeah, I know, but I wanted a second opinion!”

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For a very funny but also serious take on getting a colonoscopy, read Dave Barry’s A Journey into My Colon — and Yours. The top image is called Index Finger by Cherubino, sourced from Wikimedia Commons.

It is easy enough to hold a low opinion of the athlete. Society is prone to stereotype, and the athlete easily becomes a “dumb jock.” He is the one, says commonly accepted “wisdom,” who can only get into college because of his physical talents, who will amount to nothing after his athletic gifts are gone, and who must be managed by an agent without whom he would be lost.

As the old Gershwin song says, “It ain’t necessarily so.”

Let’s start with what it takes to be a successful athlete. There is actually a joke about this, but it pertains to classical music. A young man from out-of-town is walking down the streets of New York. He stops a stranger, presumably a New York native, and asks: “How do I get to Carnegie Hall?”

“Practice, practice,” says the New Yorker.

So it is with the athlete. He learns to practice, improve, and practice some more, until he gets it right. Beyond getting it right, to the point of nearly obsessive perfection.

Elite competitors also know that they must prepare the same way that they intend to play. Not just going through the motions, but with the same mindset and physical intensity that they will bring to the game. It is well-known that the Chicago Bulls dynasty of the Jordan era was created, in part, by Michael Jordan’s relentless competitive demands on his teammates in practice. If they could take him on with even a small measure of success, their chances against the rest of the league were quite good.

Have you ever watched an NBA player shoot free throws? He does it identically every time. The number of times he dribbles the ball, the moment when he takes his breath, the time he takes to ready himself, and the way that he shoots the ball are always the same; the product of thousands of repetitions during practice.

This dedication extends to stretching, running, and weight training. A look at the bodies of today’s athletes creates a striking contrast with the physiques of their predecessors 50 years ago. The muscle and strength do not come without great effort and regular training. If you have ever lifted weights or done scheduled aerobic exercise, you have at least some idea of what is required.

Then there is the purely mental part of the game. Having the strength of character not to be intimidated by your opposition. And the concentration to ignore the crowd and stay within oneself, doing what one has prepared to do, not thinking about the last play, but being “in the moment;” not panicking, but reacting instantaneously to the movements of the opposition, your teammates, and the ball.

The athlete, too, must learn quickly and forget quickly.

When he makes an error, as all athletes do, he needs to realize what he has done wrong so as not to do it again. But, before the day is out and before the game is over, he must put his failure out of his mind, relegate that setback to the shadows, and prepare for whatever comes next: the next play, the next contest, the next turning point. To keep thinking about the shortfall will undermine his confidence and reduce his capacity to function at his best when the same situation arises again.

Imagine a relief pitcher in baseball as he enters today’s game — the “closer” who is expected to end the enemy’s rally and hold the lead in the contest — thinking about how he lost the game for his team the day before. If he does that, he will let himself and his team down once again.

The performers’ focus must be extraordinary. Indeed, when they are “in the zone,” they have been known to so “tune out” the sound of the crowd, that overwhelming cheers (when they finally do break through) can startle them, bringing them back to the amphitheater from the smaller arena of man against man. They had lost awareness that they were in a stadium full of observers.

Moreover, in the world of “biggest-strongest-fastest,” one cannot allow oneself to become too high or too low. The best athletes are characterized by emotional control, so that they permit only brief enthusiasms and try to limit any tendency toward dejection. Opening themselves to the more routine vacillation of mood known to most of the rest of us can undermine their ability to perform. You cannot easily, for example, hit a baseball well if you are too excited, or too “down.”

Diet also comes into play, especially in activities like body building, where what you put into your body affects your ability to build muscle and highlight the definition of those muscles so as to make them stand out. For a serious body builder who avoids banned substances, the severity of his weight training is matched by his ability to eat differently than all the rest of us do. He stays away from foods that will compromise the development of his physique and its appearance.

My brother Jack, an amateur body builder who has won numerous competitive awards in his age bracket, tells me that his training routine typically includes five days per week of work with weights for 1.25 hours per day. His low fat-high protein diet requires that 50% of his calories come from protein, 30% from carbohydrates, and 20% from fats. He drinks a gallon of water a day. Within 10 weeks of his competition, he ups his protein to 60% and lowers carbohydrate sources to 20%.

Actual meal choices are restricted to the following:

protein: fish, lean red meat, chicken breast, turkey breast, cottage cheese

fats: flaxseed oil, olive oil, fats from lean meats/foods

carbs: sweet potatoes, grapefruit, white rice, oatmeal

vegetables: lettuce, cucumber, broccoli, cauliflower, string beans

Clearly, extraordinary discipline is involved.

In addition, elite competitors ignore minor injuries, and sometimes ones not so minor; they must be played through for the good of the team. No wonder that the “athlete’s creed,” involves “rubbing some dirt on (the wound) and getting back into the game.”

The champion hungers for formidable competition. He does not want the contest to be too easy, a challenger who does not test his skills. For him, the point is to be the best among the best, not a big fish in a small pond.

Philosophers of antiquity used the jock as an example of what other philosophers and their students should strive for. They cited the man of physical culture for his excellence, observed him striving to improve himself, and advised the rest of us to perfect the skills of the mind just as the athlete seeks to perfect the body. With respect to the challenges of living, they exhorted the novice philosopher to behave like the wrestler who, when thrown to the mat, gets up instead of giving up, and returns to the battle.

Apart from the possibility of celebrity and fantastic wealth, the athlete profits from the confidence that he has earned by his attitude and effort. He thrives on the exhilaration of a body that responds to his wishes, is finely and precisely tuned and honed, and is not an encumbrance but a tool to achieve his goals.

He is in fact, a model for excellence in living.

No wonder that the rest of us can’t help but watch him.

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The top image — Gilmar Catching a Ball — comes from the 1958 World Cup Final. Source: Scanpix (svt.se) (Public Domain) via Wikimedia Commons.

The bottom image is of Jack Stein.

Dr. Gerald Stein

Blogging About Psychotherapy from Chicago

When Your Doctor Gives You the Finger: Why Men Fear “Digital” Medicine

What Elite Athletes Know (and What They Can Teach the Rest of Us)

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