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Background  Emergency medicine practice in the UK and Ireland offers a junior and middle grade doctor great learning opportunities that force engagement with multiple specialties, life-saving procedures, exposure to a myriad of patient presentations, and opportunities for best practices in medicine.    Main body  The emergency department (ED) can be a hectic and dynamic environment; communication from the ED to specialists is essential to ensure best clinical outcomes for patients. The “per rectal” (PR) or “digital rectal exam” (DRE) can be a very difficult diagnostic test for even the most skilled operator to discern pathological versus normal; we propose this is especially the case in the emergency department patient population. Some specialists require this exam performed by an unskilled junior doctor with varying results prior to reviewing a referred and sick patient. The PR/DRE benefits may be limited in the ED setting for some pathologies, and the result of the exam may have limited impact in the overall treatment plan in the ED.    Conclusion  This short paper reviews the indications, benefits, shortfalls, and limitations of the PR/DRE in the emergency department setting and offers novel alternatives to maximize best practice, ensure best clinical outcomes for patients, and, to first, do no harm.

Debate: the per rectal/digital rectal examination exam in the emergency department, still best practice?