Use of Manikins to Improve Confidence of Core Surgical Trainees Performing Digital Rectal Examinations


 Background: DRE is an important skill across a variety of medical and surgical specialties. Previous research has shown that structured teaching and practice on mannequins is of benefit when teaching the skill to medical students. The current literature does not demonstrate any research into post-graduate teaching and assessment of doctors. Methods: New core surgical trainees from within the Health Education East of England post-graduate surgical school attended a regional induction day, which included a clinical skills circuit. One station focussed on DRE, where participants were asked to complete a pre-teaching survey, they then received a brief teaching session which included simulation with manikins, and subsequently completed a post-teaching survey. Results: 48 core surgical trainees participated in the training session and completed the survey. All bar one had had formal teaching on DRE previously, however only 5 had had teaching on the subject at postgraduate level. After teaching/simulation the mean self perceived competency level rose from 6.25 to 8.92 (of 10) p<0.001. Discussion: Survey findings indicated that participants were likely to overestimate their competence at DRE, but that a brief structured teaching session including practice on manikins was effective in improving confidence. Written feedback was positive and highlighted previously poorly taught/understood aspects of a neurological DRE.

Results: 48 core surgical trainees participated in the training session and completed the survey. All bar one had had formal teaching on DRE previously, however only 5 had had teaching on the subject at postgraduate level. After teaching/simulation the mean self perceived competency level rose from 6.25 to 8.92 (of 10) p<0.001.
Discussion: Survey ndings indicated that participants were likely to overestimate their competence at DRE, but that a brief structured teaching session including practice on manikins was effective in improving con dence. Written feedback was positive and highlighted previously poorly taught/understood aspects of a neurological DRE.

Background
Digital rectal examination (DRE) is an important examination across a variety of medical and surgical specialties. It is an important examination which aides diagnosis of pathologies of the anus, rectum, and prostate, as well as gynaecological and spinal pathologies. Effective technique is particularly important in the setting of spinal injuries and Cauda Equina Syndrome (CES). One paper states "It is possible that a proportion of established CES may be avoidable with appropriate and timely management." 1 Which is ultimately guided by a proper examination. Furthermore, adequate documentation can prove important medico-legally, particularly in the context of CES and delayed diagnosis/treatment. A number of papers have looked at attitudes of medical students towards intimate examinations nding they are generally very anxious about such examinations, and that anxiety impedes learning [2][3][4][5] . As such, teaching techniques have been developed to reduce anxiety levels, these include the use of lectures/seminars, mannequins, and some schools have used live models. These teaching methods have generally proven to be successful in reducing anxiety levels in medical students.
There appears to be very little evidence of ongoing teaching of DRE after medical school. Anecdotally, teaching is in the form of informal bedside teaching (where the clerking junior doctor may perform the intimate examination, and subsequently a more senior doctor will repeat the examination and compare ndings). In this way junior doctors will examine a breadth of pathologies and with time gain con dence in their ability to accurately make a diagnosis.
This paper looks at the previous DRE teaching experience of new core surgical trainees at Norfolk and Norwich University Hospital (NNUH), and goes on to assess the e cacy of a further structured teaching session with practice on mannequins. On entering the DRE station, participants were rst given a short anonymous survey; which collected a mixture of qualitative and quantitative data, including; previous DRE teaching methods; any formal teaching on DRE as a post-graduate; perceived importance of DRE as a skill; and the frequency with which participants currently perform DRE in clinical practice. Finally they were asked to put a numerical value on self-perceived competency at DRE (0-10).

Methodology
Participants then had a 25-minute structured teaching session on DRE, beginning with indications (with a focus on CES), communication skills and consent, technical aspects, and interpretation of ndings (particularly regarding neurology). Participants then practiced the examination on 2 manikins. The rst manikin was able to simulate anal sphincter contraction (with manual input) and so was used to practice neurological DRE and simulate abnormal ndings. The second manikin simulated a variety of normal and abnormal prostates.
After the teaching session, participants were given a further survey (Appendix 1B), asking them to review their pre-teaching DRE competency level, and to estimate competency post-teaching. They were also asked to provide feedback on the most useful parts of the teaching session and what they had learnt.
Finally they were asked a simple yes/no question on whether they thought the teaching session was useful, and they had the opportunity to provide general feedback.
The survey was developed by the faculty following 3 iterations. It was made clear to participants that by completing the survey they were consenting to their data being used for research, however it was not compulsory that they do so.

Results
There were 48 new CT1 doctors at the induction day. All participants completed the survey in full. There was an average 2.5 years practice (range 2-5 years) post medical school. Their intended specialties were as follows: Trauma & Orthopaedics 15, general surgery/breast 11, Ear Nose & Throat 7, Plastic surgery 6, Urology 4, Vascular 3, Other/unsure 2. 65% (31/48) of participants recalled having structured seminars/lectures on DRE while at medical school, 90% (43/48) had been taught on manikins, 23% (11/48) had been taught using live models. One participant recalled no formal teaching on DRE whatsoever. Only 10% (5/48) reported any formal teaching on DRE after medical school, however 98% (47/48) of participants considered DRE to be an important skill. 81% (39/48) of participants performed DRE at-least weekly prior to the teaching session, with the mean estimate being 3 times per week (range of 0-15). 95% (45/48) con rmed that after the teaching, their competency at DRE had improved, again, Fig. 1 shows the mean improved from 6.25 to 8.92/10, p < 0.001.
100% of participants considered the teaching session to be useful. 88% (42/48) of participants con rmed they had learned something new. Qualitative feedback was utilised to expound upon the teaching elements that were considered most useful. The most common positive themes mentioned were the use of simulation and emphasis on the neurological DRE.

Discussion
The majority of participants had previously had teaching on manikins during medical school, however very few had received formal teaching after graduating medical school. Most participants performed DRE regularly in clinical practice, and thought it to be an important skill. When considering participant's self-reported competency levels, results suggest that they were over con dent in initial estimates, indicating a degree of unconscious incompetence. This notion was reinforced when reviewing the feedback comments; in particular the neurological DRE was frequently mentioned as a new or improved skill.
It is clear that the teaching session improved participant competency levels (as evidenced by improved mean competency pre teaching and post teaching), and that the participants thought it to be bene cial.

Limitations
The main limitation of this study is the lack of objective measure of competency. Unfortunately the short time allowed for each rotation of doctors meant that formally assessing each doctor was impossible, and so not within the scope of this study.
One other limitation was the survey, which we drafted, but was not externally validated. However we were unable to nd any validated alternative surveys.
A limitation of the qualitative data was its brevity, with each reply generally being very short sentence or one-word answers. More useful information could have been gathered using a focussed questionnaire, semi structured or structured interviews. This however would not have been feasible within the time constraints of the session.
Additionally the manikin simulation was a medium delity simulation. Anal tone was easy to simulate, however lack of anal tone (to the degree seen in CES) was not possible to accurately simulate with the rectum manikin available. High delity simulations are superior to medium delity; however there were no high delity manikins available to us, and other higher delity simulation methods such as cadavers or animal tissue were not within the scope of the teaching session.
Conclusions DRE remains an important clinical examination, and while efforts have been made in medical schools to improve teaching, it is still imperfectly taught and understood. The aim of this study was to assess the need for ongoing teaching of DRE at a post-graduate level, and we have demonstrated that structured teaching in small group sessions, and practice on manikins is effective in improving the con dence of junior surgical trainees at DRE, particularly regarding the more in-depth neurological DRE. Feedback was overwhelmingly positive and con rmed that junior surgical trainees perceived the session to be of bene t.