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I thank the authors for their timely commentary on the declining frequency of performance of the digital rectal examination and the potential impacts that this may have on patient care. However, I am concerned that they neglected to comment on a clinical scenario in which a digital examination is frequently indicated, yet rarely performed. Many readers may not be aware that HPV-related anal cancers, though rare in absolute incidence, are becoming steadily more common over the last decades, likely due to changes in sexual behaviour and exposure to high-risk HPV strains (see, for example, https://www.cancerresearchuk.org/health-professional/cancer-statistics/s...). Chiu et al. have already described in these pages how anal cancer is often diagnosed late due to the attribution of typical symptoms (anal discomfort and bleeding) to non-malignant causes, and due to the lack of performance of a thorough digital ano-rectal exam, or DARE (note the added emphasis on the anal canal in this acronym). (1)
I wholeheartedly believe that family medicine trainees should have adequate exposure to clinical situations which encourage the proper performance of digital anorectal exams, which include a thorough palpation of the mucosa of the anal canal. Encouraging DAREs in those who are at high risk for anal cancer, such as people living with HIV, people practicing...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: Drs. Lass & Raveendran on teaching/learning DRERE: Drs. Lass & Raveendran on teaching/learning DRE
Dr. Quest,
I think that one aspect of that is right. When we went into Sim-lab with you 2 days ago, it was tough to feel the abnormality, and perhaps it was because it was not a real human. However, we certainly would need a lot more experience to determine whether a prostate examination was pathological or not. Today I had the opportunity to feel an ovary during anatomy lab which had nodules, so it was quite clear upon clear exposure that there was pathology. In the same sense, we certainly need that kind of exposure to real DRE exams that are normal and those that would be pathological. Secondly, it may be a dying art, but I think that if machines were to crash and electricity were to say good bye, what else do we have left to use other than our physical examinations? It should still be held important and critical over all. If we don’t know how to do something from scratch, there is very little point in using equipment. For example, in orthopedics, we use O-arms and heavy amounts of navigation to ge the screws into spinal pedicles with higher accuracy, but before that, we had to extrapolate from multiple X-ray views on what the best approach was, so its important that we learn the “from scratch” methods before we jump forward and skip it overall. I can definitely see how many would feel normal though, but with heavier exposure, patient after patient, I think we could definitely get the hang of it.Competing Interests: None declared. - Page navigation anchor for RE: Drs. Lass & Raveendran on teaching/learning DRERE: Drs. Lass & Raveendran on teaching/learning DRE
Just finished instructing DRE prostate on low-fidelity mannequins after
reading that even urologists have low interrater agrement in ascertainment of
induration, asymmetry, nodularity (PPV 28%) vs primary care physicians (PPV
5-30%); Sensitivity about 59%.I think the authors are saying that DRE is not often useful, but should still
be learned, although perhaps not learned best from the way it’s
traditionally being taught.
They ask, “…what to do with low-usefulness procedures that capture
low-prevalence diseases; procedures whose function is reserved for unique
situations?”My thoughts: To the extent that proficiency and diagnostic utility depend on
recent relevant experience to detect potential pathology with reasonable
sensitivity and specificity, perhaps gastroenterologists, urologists,
colorectal surgeons and such perform DRE with sufficient frequency, and they
might proceed to use other tools that are seldom available or used in primary
care. In instances you think DRE is likely to guide clinical decisions, do
it if you have expertise, otherwise hand it off to someone who does have
expertise to detect potential pathology with reasonable sensitivity and
specificity.Competing Interests: None declared.