Trainee versus Expert Assessment of Digital Rectal Examination (DRE) for Anorectal Dysfunction: Does Experience Matter? A Prospective Study

Abstract

Purpose: DRE is useful for assessing anorectal complaints. Because it requires clinical skills, its yield may depend on the examiner's experience and training. Whether DRE findings differ between trainee and expert is not known. Aim: To prospectively assess DRE findings in anorectal disorders and examine agreement between trainee and expert. Methods: Gastroenterology Fellows (trainee) received coaching on a 3 step DRE program: Inspection, digital palpation/maneuvers and changes during straining. Patients were assessed independently and DRE findings including diagnosis-normal, weak sphincters, fecal incontinence or dyssynergia- were recorded. Analysis: Kappa statistic examined agreement between expert and trainee and data analysis by independent observer. Kappa < 0.4 was classified as fair, 0.4-0.6 moderate, 0.6-0.8 substantial and >0.8 as perfect agreement. Results: Over 18 months, 110 subjects were examined (M/F 12/ 98). Agreement was substantial for anal inspection (k=0.63, 0.48-0.78), and moderate for anocutaneous reflex (k=0.51, 0.36-0.66), fair for anal resting and squeeze tone (k=0.36-0.46) and bearing down (k=0.21-0.47). There was substantial agreement for diagnosis of fecal incontinence(k=0.59, 0.43-0.75) but fair for normal DRE (k=0.30, 0.09-0.51) or dyssynergia (k=0.35, 0.17-0.52). Conclusion: Although coached trainees can perform an adequate DRE, there was only fair agreement with that of an expert. Trainees were less likely to identify normal DRE or dyssynergia, but were more reliable in identifying fecal incontinence. There is significant room for improvement and experts should spend more time coaching trainees.