A survey of digital rectal examination training in Canadian medical schools

physical level the and behaviours of of physical clerkship their skills often enough to have the confidence and expertise to perform the examination in clinical practice. Studies have shown that effective teaching and enhanced confidence in ability requires both the use of a wide variety of instruction techniques as well as increased performance frequency (3,6). The present study was an analysis of the current practices in DRE teaching and evaluation in undergraduate medicine programs in schools across Canada. It aims to provide a comprehensive review of the methodologies used for teaching the DRE, the amount of time students spend practicing their skills and the types of evaluation methods used to assess proficiency in performing the DRE to identify possible areas for future curriculum improvement. medical schools, students are performing very few DREs before graduation. Medical schools should objectively evaluate proficiency to give meaningful feedback and improve competence in their students as well as provide more opportunities for students to obtain the necessary experience performing DREs during their clinical training.

T he digital rectal examination (DRE), a common physical examination manoeuvre, is important for the diagnosis of a variety of gastrointestinal, urological and gynecological disorders. While the DRE is a standard part of a complete physical examination, recent literature suggests that it is significantly underperformed in clinical practice, even in academic centres. In one study, less than onequarter of patients presenting with urological symptoms received a DRE before referral to a specialist (1), while another study reported that more than 80% of patients admitted to hospital did not undergo a documented DRE (2). This underperformance has been attributed to a variety of reasons, with one of the most common being low comfort level among residents and medical students with performing the examination due to lack of adequate education and practice (3)(4)(5). A report of the attitudes and behaviours of medical students and recent medical graduates suggested that <30% of students routinely performed DREs on physical examination (6). Another study demonstrated that one-half of graduating fourth-year students had never performed a DRE during their clerkship and 86% had never palpated a malignant prostate (7).
The DRE is an essential part of a physical examination and, should therefore, be included as part of the medical school clinical skills curriculum; however, it appears that students are not being adequately formally taught nor being provided the opportunity to practice their skills often enough to have the confidence and expertise to perform the examination in clinical practice. Studies have shown that effective teaching and enhanced confidence in ability requires both the use of a wide variety of instruction techniques as well as increased performance frequency (3,6).
The present study was an analysis of the current practices in DRE teaching and evaluation in undergraduate medicine programs in schools across Canada. It aims to provide a comprehensive review of the methodologies used for teaching the DRE, the amount of time students spend practicing their skills and the types of evaluation methods used to assess proficiency in performing the DRE to identify possible areas for future curriculum improvement. BACkGrouNd: The digital rectal examination (DRE) is important for the diagnosis of a variety of gastrointestinal, urological and gynecological disorders. However, it appears that Canadian medical students may not be adequately taught nor provided the opportunity to practice their skills often enough. The present study was an analysis of the current practices in DRE teaching and evaluation in undergraduate medicine programs across Canada. Methods: Clinical skills coordinators from the 14 English-speaking medical schools in Canada were invited to participate in the survey and to respond to questions regarding DRE teaching at their respective schools. results: Thirteen of the 14 schools (93%) responded to the survey. The DRE is taught in various ways: 69% of schools use anatomical rectal models, 62% use video tutorials and 62% involve physician instruction. Most schools (85%) offer one formal teaching session before clerkship. Generally, there is no formal DRE teaching session during clerkship. Preclerkship students in 62% of the schools perform ≤1 DRE during their training, and clinical skills coordinators in 85% of the schools expected that clerkship students perform ≤2. The training is evaluated in a variety of ways, with most schools (77%) only requiring mandatory attendance. disCussioN: Although a variety of techniques are used to teach and evaluate DRE training in Canadian medical schools, students are performing very few DREs before graduation. Medical schools should objectively evaluate proficiency to give meaningful feedback and improve competence in their students as well as provide more opportunities for students to obtain the necessary experience performing DREs during their clinical training.

Methods
Undergraduate medicine clinical skills coordinators from the 14 Englishspeaking medical schools in Canada were invited to participate in the survey ( Figure 1) and respond to questions regarding DRE teaching at their respective schools.
The questionnaire aimed to collect the qualitative and quantitative details of each school's clinical skills sessions during which students were taught how to conduct DREs, including prostate and rectovaginal examinations. Information about clinical skills training during both preclerkship and clerkship was obtained. Respondents were given the option of completing the survey online, by telephone or to decline to participate.

results
Survey responses were obtained from clinical skills coordinators from 13 of 14 (93%) of the English-speaking medical schools in Canada.
The DRE is taught to preclerkship students in various combinations of methods across the country (Figure 2), with many schools using visual and kinetic teaching aids in addition to theoretical instruction. Some other reported teaching techniques included urologic teaching assistants for male examinations and pelvic teaching assistants for female examinations.
Before starting clerkship, most of the schools surveyed (85%) offer one formal teaching session as part of their clinical skills curriculum. Combined with the information regarding length of time of the teaching sessions, this was equivalent to a mean of approximately 2.15 h of DRE training during preclerkship. Most schools surveyed did not offer a formal DRE teaching session during clerkship ( Figure 3). Preclerkship students in 62% of the schools performed one or fewer DREs during their training, and clinical skills coordinators in 85% of schools expected that clerkship students performed two or fewer ( Figure 4). DRE proficiency is evaluated in a variety of ways across the country (    the schools surveyed reported that they taught the specialized skills of female rectovaginal examinationss before clerkship (54%), while the rest of the schools reported that it is taught as part of their obstetrics and gynecology or family medicine clerkship rotations. A summary of survey responses grouped according to medical school is presented in Table 1.

disCussioN
The DRE is taught to preclerkship medical students in Canada using a variety of methods. Most schools provided one formal DRE teaching session before clerkship and do not offer formal DRE training during clerkship. Methods of evaluation of the DRE training were also variable across the country, with most of the schools simply requiring mandatory attendance at the sessions and very few performing any formal evaluation. Information about the theoretical usefulness of the DRE and prostate screening was included in most of the medical school curriculums.
A study by Popadiuk et al (3), comparing the effectiveness of a variety of teaching methods for the DRE, found that a combination of lecture and teaching-assistant instruction was more effective and more preferred by students than any of the other teaching methods in isolation. Effective DRE teaching requires a multifaceted approach, using a wide variety of teaching techniques to address all aspects of the examination. This includes models and videos for technique, physician instruction for theoretical knowledge and standardized patients to allow for feedback on examination technique, improvement of interpersonal communication skills and comfort performing the procedure. While our results indicate that many medical schools do offer a formal training session using a wide variety of teaching methods, it is also apparent that medical students do not have the opportunity to actually perform a DRE very frequently during their undergraduate training. In addition, most schools only require attendance at training sessions and do not administer a proficiency-based type of evaluation to assess the skills developed during teaching. Previous studies have shown that medical students' confidence in their ability to perform a DRE and identify malignancy is correlated with the number of DREs they performed (6), and our results show that students are performing very few before they graduate. During preclerkship, students generally undergo only one training session, and during clerkship the number of DREs performed is likely dependent on whether a supervisor is willing to teach and whether the clerk is sufficiently comfortable to perform it. While previous research has shown that clinical skills training using a wide variety of methods is a very effective teaching tool (8,9), it appears that students are not developing the competence or experience to translate their knowledge of the examination into practice.
The response rate to our survey (92.8%) was highly satisfactory; however, limitations of the present study revolve mainly around the accuracy of the responses to our survey by the clinical skills coordinators at each of the schools. It is possible that the actual practice and delivery of curriculum objectives could differ from what is mandated. In addition, as mentioned above, experiences during clerkship are more supervisor-dependent than preclerkship training and, therefore, more variable (10). Similar to other studies using questionnaires that have not been externally validated, unknown limitations may exist based on question selection or scope (11).
It is our recommendation that DRE training should be given the same priority and importance as other clinical skills taught as part of the undergraduate medical education curriculum with regard to number of practice sessions and formal evaluation of proficiency. Similar to the way in which other physical examination skills are taught, we recommend that the topic should be introduced with a formal lecture followed by a session during which students can practice on standardized patients with physician supervision. Students should have additional opportunities to practice this skill on standardized patients during clinical skills sessions in preclerkship training. Their technique and ability to detect pathology should be examined during the preclerkship Observed Standardized Clinical Exam. In addition, students should be encouraged to perform as many DREs as possible on real patients during clerkship, including some with physician supervision to confirm the technique and findings. This is the same way in which other skills, such as taking blood pressure or conducting a cardiac examination, are taught and evaluated in Canadian medical schools. Changing the curriculum to include DRE as one of the clinical skills that is taught repeatedly and evaluated objectively will ensure that students are just as proficient with this manoeuvre as with other clinical skills at the time of graduation.

CoNClusioN
The present study demonstrated that while a broad range of techniques are used to teach and evaluate DRE training in Canadian medical schools, students are not actually performing very many examinations before they graduate. Moreover, students are required to attend the training sessions, but are not given proficiencybased evaluation afterward. Students who get more practice and are more comfortable performing rectal examinations during their training are more likely to continue performing them during their clinical practice (6). For this reason, it is imperative that medical schools objectively evaluate proficiency to give meaningful feedback and improve competence in their students while also providing more opportunities for students to obtain the necessary experience performing DRE during clinical training.