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.

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