Impact of Health Literacy on Patient-Reported Outcomes in Benign Gynecology: A Systematic Review.

The objective of this study was to systematically review the relationship between low health literacy and patient-reported outcomes in patients with benign gynecologic conditions. In this specific population, we also sought to determine the current reported prevalence of low health literacy, examine demographic characteristics that may be related to low health literacy, and collate any health literacy interventions described in the literature. A systematic search of MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, The Cochrane Library, Web of Science, PubMed, and clinicaltrials.gov was performed on July 12, 2021, and repeated on October 13, 2023, for terms related to health literacy, specific health literacy measures, and benign gynecologic conditions. There were language or publication period restrictions. Inclusion required primary literature to report associations between health literacy and patient-reported outcomes, using validated tools to quantitatively measure each, in adult women with benign gynecologic conditions. Title screening, abstract screening, and full-text review were conducted with Covidence software (Melbourne, Australia) assisting with the review process. Of the 18,701 studies returned using our search strategy, 25 were selected for full-text review. Of these, no studies met inclusion criteria and reported an association between health literacy and patient-reported outcomes. This study identified a large gap in the literature. Future work should be directed at evaluating the association between health literacy and patient-reported outcomes in benign gynecology to inform patient-centered interventions and care provision.

Virtual Mindfulness-Based Therapy for the Management of Endometriosis Chronic Pelvic Pain: A Novel Delivery Platform to Increase Access to Care.

OBJECTIVES: This study assessed the effectiveness of a virtual mindfulness-based stress reduction (MBSR) program to improve quality of life and pain in people with endometriosis. METHODS: This was a multiple-method, before and after study design. Fifteen patients with a clinical or surgical diagnosis of endometriosis were recruited from a Canadian outpatient gynaecology clinic. Participants completed the Endometriosis Health Profile, a validated survey tool, and a pain medication use questionnaire before and after a virtual 8-week MBSR program run by an experienced social worker. A focus group was held upon completion of the program to assess participants' experiences using mindfulness for management of endometriosis symptoms. Quantitative data was analyzed with paired-samples t tests. Qualitative data was thematically analyzed. RESULTS: A total of 67% of people enrolled completed the MBSR course (10/15). Following the MBSR program, participants had a statistically significant decrease in 4 components of the Endometriosis Health Profile: control and powerlessness (P = 0.012), emotional well-being (P = 0.048), social support (P = 0.030), and self-image (P = 0.014). There was no change in pain scores or medication use. Participants felt the program's benefits came from a sense of community, education about their condition, and application of mindfulness tools when approaching pain. Participants felt more comfortable with the virtual format over in-person sessions. CONCLUSIONS: A virtual MBSR course can improve quality of life domains in people with endometriosis. The virtual format was effective and preferred by participants. Virtual MBSR programs may increase access to this type of care.

The Tailored Opioid Reduction Strategy (TORS): A Quality Improvement Initiative to Reduce Opioid Prescription Following Hysterectomy.

OBJECTIVE: To evaluate a tailored opioid reduction strategy (TORS) in minimizing opioid prescriptions for patients undergoing hysterectomy. METHODS: This quality improvement initiative was developed by multiple stakeholders at an academic hospital in a Canadian urban centre. The intervention consisted of a three-pronged approach: (1) patient and provider education, (2) perioperative multimodal analgesia, and (3) a targeted opioid reduction strategy. All eligible patients were asked to fill pre- and postoperative questionnaires. Analysis of outcomes pre- and post-TORS implementation as well as intervention compliance was performed. RESULTS: From September 2020 to April 2021, 133 patients who underwent hysterectomy were included in the study, 69 in the pre-intervention group and 64 in the post-intervention group. Of 133 hysterectomies, 78 (58.6%) were performed laparoscopically, 16 (12%) open, 14 (10.5%) vaginally, and 25 (18.8%) robotically. The rate of discharge opioid prescriptions was significantly reduced in the post-intervention group compared with the pre-intervention group (37/64, 58% versus 62/69, 90%, respectively, P < 0.001), as well as the amount of opioid prescribed in oral morphine equivalents (OME) (mean 47 mg pre-intervention, 28 mg post-intervention, P < 0.001). There was no significant difference in patient satisfaction or postoperative pain scores between groups. Overall, compliance with 2 or more components of TORS intervention was seen in 64/64 (100%) cases. CONCLUSION: TORS implementation was successful in reducing the rate of discharge opioid prescriptions and the total amount of opiates prescribed in patients undergoing hysterectomy with no decrease in patient satisfaction or change in postoperative pain scores. We believe it can be applied more broadly across different surgical patient populations to prevent opioid abuse.

Evaluating Surgical Complexity of Endoscopic Hysterectomy: An Inter-rater and Intra-rater Agreement Study of Novel Scoring Tool.

STUDY OBJECTIVE: Evaluate inter-rater and intrarater reliability of a novel scoring tool for surgical complexity assessment of endoscopic hysterectomy. DESIGN: Validation study. SETTING: Academic medical center. PARTICIPANTS: Total of 11 academic obstetrician-gynecologists with varying years of postresidency training, clinical practice, and surgical volumes. INTERVENTIONS: Application of a novel scoring tool to evaluate surgical complexity of 150 sets of images taken in a standardized fashion before surgical intervention (global pelvis, anterior cul-de-sac, posterior cul-de-sac, right adnexa, left adnexa). Using only these images, raters were asked to assess uterine size, number, and location of myomas, adnexal and uterine mobility, need for ureterolysis, and presence of endometriosis or adhesions in relevant locations. Surgical complexity was staged on a scale of 1 to 4 (low to high complexity). MEASUREMENTS AND MAIN RESULTS: Number of postresidency years in practice for participating surgeons ranged from 2 to 15, with an average of 8 years. A total of 8 obstetrician-gynecologists (72.7%) had completed a fellowship in minimally invasive gynecologic surgery. Six (54.6%) reported an annual volume of >50 hysterectomies. Raters reported that 95.4% of the images were satisfactory for assessment. Of the 150 sets of images, most were found to be stage 1 to 2 complexity (stage 1: 23.8%, stage 2: 41.6%, stage 3: 32.8%, stage 4: 1.8%). The level of inter-rater agreement regarding stage 1 to 2 vs 3 to 4 complexity was moderate (κ = 0.49; 95% confidence interval [CI], 0.42-0.56). Moderate inter-rater agreement was also found between surgeon raters with an annual hysterectomy volume >50 (κ = 0.49; 95% CI, 0.40-0.57) as well as between surgeon raters with fellowship experience (κ = 0.50; 95% CI, 0.42-0.58). Intrarater agreement averaged 80.2% among all raters and also achieved moderate agreement (mean weighted κ = 0.53; range, 0.38-0.72). CONCLUSION: This novel scoring tool uses clinical assessment of preintervention anatomic images to stratify the surgical complexity of endoscopic hysterectomy. It has rich and comprehensive evaluation capabilities and achieved moderate inter-rater and intrarater agreement. The tool can be used in conjunction with or instead of traditional markers of surgical complexity such as uterine weight, estimated blood loss, and operative time.

Utilizing the Operating Room Black Box to Characterize Intraoperative Delays, Distractions, and Threats in the Gynecology Operating Room: A Pilot Study.

Introduction Operating Room Black Box (ORBB) technology can be used to capture information during surgery for analysis and potential identification of root causes that jeopardize safety and efficiency. In this study, our objective was to identify and characterize procedural steps, intraoperative distractions, errors, and threats, as well as the non-technical skills of the team during a common minimally invasive gynecologic procedure. Methodology This was a cross-sectional pilot study of 25 patients undergoing total laparoscopic hysterectomy between May 2019 and February 2020 at a Canadian tertiary care academic hospital. Video, audio, and patient physiologic data from all procedures were obtained through a multichannel synchronized recording device (ORBB). Trained analysts reviewed and coded the recordings. Results The median total case time was 165 minutes (interquartile range [IQR]: 160-178 minutes) with the shortest step being cystoscopy and the longest being vaginal cuff closure. Time pressure and device absence or malfunction occurred in 48% of the cases, and a median of 262 (IQR: 228-304) auditory distractions were noted per case. There was a median of 3 (IQR: 2-4) safety threats identified per case and at least one error was identified in 11/25 cases (44%). Only two adverse events were noted among all 25 cases. Observed non-technical skills were mainly positive, and observations were the highest for situational awareness and leadership among the surgical team and communication and teamwork among the nursing/scrub technician and anesthesia teams. Conclusions This study is a novel application of the ORBB in the gynecology operating room to capture information regarding procedure times, intraoperative distractions, errors, and non-technical skills of the team. Frequent intraoperative cognitive and auditory distractions were noted. Although adverse events were rare, safety threats were identified. Ongoing and future research from our group will aim to identify key areas for organizational, technological, and team improvement to minimize inefficiencies and optimize patient safety in the operating room.

Clinical Conundrum: A 39-Year-Old With Chronic Retained Products of Conception and Concurrent Uterine Arteriovenous Malformation.

A 39-year-old woman presented with bleeding 4 months after a surgical termination of pregnancy. Persistent beta-human chorionic gonadotropin levels were suggestive of retained products of conception (RPOC). However, multimodal imaging revealed a concurrent uterine arteriovenous malformation (AVM). Although most stable AVMs can be managed conservatively, the need for surgical management of chronic RPOC and consequential hemorrhage risk complicates this approach. Patient-determined management prioritized blood conservation while minimizing risks to fertility. This case is discussed with respect to the rare concurrent existence of RPOC and AVM. Little is known regarding the optimal tandem therapeutic approach. As depicted, successful treatment requires careful diagnostic workup and a multidisciplinary approach.

The Use of In Situ Simulation to Enhance COVID-19 Pandemic Preparedness in Obstetrics.

Simulation's benefits in medical education are well established. However, its use for pandemic preparedness in obstetrics is lacking. Management of obstetrical patients with suspected COVID-19 infection is a complex task with safety considerations for mother, fetus and healthcare workers. Implementation of new workflow algorithms to ensure safety is critical but is challenging to implement in real-time. We sought to improve pandemic preparedness by designing and deploying a high-fidelity simulation exercise involving the admission of a labouring obstetrical patient with suspected COVID-19 into a labour room, urgent transfer to the operating room and neonatal resuscitation. The creation of the simulation scenario was a multi-disciplinary effort with input from a focus group of key clinical stakeholders from within and outside of our centre to ensure clinical validity. Simulations were performed on the clinical unit during regular work hours so workflow could be observed in real-time with access to the equipment and personnel in which this clinical scenario would occur. We completed a total of 11 simulation sessions involving 42 participants. Feedback, obtained from debrief sessions and anonymous surveys, was categorized based on the human factors framework, and used as part of an iterative process to adapt, revise and improve the simulation scenario. The result of this iterative process was the creation of validated departmental infection control protocols that continue to be implemented through the second wave of the COVID-19 pandemic.

Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery: An AAGL White Paper.

This is the first Enhanced Recovery After Surgery (ERAS) guideline dedicated to standardizing and optimizing perioperative care for women undergoing minimally invasive gynecologic surgery. The guideline was rigorously formulated by an American Association of Gynecologic Laparoscopists Task Force of US and Canadian gynecologic surgeons with special interest and experience in adapting ERAS practices for patients requiring minimally invasive gynecologic surgery. It builds on the 2016 ERAS Society recommendations for perioperative care in gynecologic/oncologic surgery by serving as a more comprehensive reference for minimally invasive endoscopic and vaginal surgery for both benign and malignant gynecologic conditions. For example, the section on preoperative optimization provides more specific recommendations derived from the ambulatory surgery and anesthesia literature for the management of anemia, hyperglycemia, and obstructive sleep apnea. Recommendations pertaining to multimodal analgesia account for the recent Food and Drug Administration warnings about respiratory depression from gabapentinoids. The guideline focuses on workflows important to high-value care in minimally invasive surgery, such as same-day discharge, and tackles controversial issues in minimally invasive surgery, such as thromboprophylaxis. In these ways, the guideline supports the American Association of Gynecologic Laparoscopists and our collective mission to elevate the quality and safety of healthcare for women through excellence in clinical practice.

Impact of a Blood Conservation Bundle Checklist on Perioperative Transfusion Rates during Myomectomy.

STUDY OBJECTIVE: The primary objective was to introduce an intraoperative blood conservation bundle (BCB) checklist into clinical practice and assess its impact on perioperative blood transfusion rates during myomectomy. DESIGN: Prospective cohort study with retrospective control group. SETTING: A Canadian tertiary-care teaching hospital. PATIENTS: One hundred and eighty-six women who underwent myomectomy. INTERVENTIONS: The BCB is a physical checklist attached to the patient chart and consists of evidence-based medical and surgical interventions to reduce intraoperative blood loss. It was introduced in October 2018, and data were collected prospectively during a 12-month period for all open, robotic, and laparoscopic myomectomies at our institution. The primary outcome was the perioperative transfusion rate, and the secondary outcomes included estimated intraoperative blood loss, perioperative complications, readmissions, and BCB usage rates. Data were compared with those of a historic control group for a 24-month period before the BCB introduction. MEASUREMENTS AND MAIN RESULTS: In the pre-BCB period, 134 myomectomies (90 open, 31 robotic, and 13 laparoscopic) were performed, and during our study period, 52 myomectomies (33 open, 10 robotic, and 9 laparoscopic) were performed. There was a decrease in transfusion rate from 15.7% (21/134) to 7.7% (4/52) after introduction of the BCB; however, this was not significant (p = .152). The mean estimated blood loss was lower postintervention (491 mL ± 440 mL vs 350 mL ± 255 mL; p <.05) as was the mean delta hemoglobin (-28 g/L ± 13.0 g/L vs -23 g/L ± 11.4g/L; p <.05]. The checklist was used in 92.3% of cases (48/52). There were no differences in intraoperative or postoperative complications or readmission rates. CONCLUSION: Best practice care bundles can improve knowledge translation of guidelines into care delivery. The introduction of the BCB was successful in reducing intraoperative blood loss during myomectomy at our institution. The BCB is a simple, effective tool that can be easily adopted by gynecologic surgeons to guide intraoperative decision-making during myomectomy.

Robotic-Assisted Laparoscopic Hysterectomy for Endometrial Hyperplasia or Grade 1 Endometrial Adenocarcinoma: A 10-year, Single-Centre Experience.

OBJECTIVE: To describe the outcomes of patients undergoing robotic-assisted laparoscopic hysterectomy for grade-1 endometroid endometrial cancer or endometrial hyperplasia at our centre. METHODS: Retrospective chart review was completed for 160 patients who underwent robotic-assisted laparoscopic hysterectomy by 5 general gynaecologists in a tertiary care setting between September 2008 and September 2018. Outcomes collected included operative time, estimated blood loss, length of stay, perioperative complications, readmissions, and recurrences. Subgroup analysis was completed after stratifying by body mass index (BMI; 3 groups: A, <40 kg/m2; B, 40-50 kg/m2; and C, >50 kg/m2). Subgroups were compared with ANOVA or Fisher exact test. RESULTS: The intraoperative complication rate was 3%. The rate of conversion to laparotomy was 2%, and the rate of bowel injury, 1%. The postoperative complication rate was 8%. The rate of major postoperative complications was 4%, and 3% of patients required readmission postoperatively. The mean BMI was 43 (range 21-71) kg/m2. There were no differences in perioperative complication, readmission, or recurrence rates between subgroups. Groups B and C were more likely to have had an ASA of 3-4, suggesting a higher burden of comorbidity. Operating room time, procedure time, and estimated blood loss were higher in group C. CONCLUSION: Despite this cohort's mean BMI falling within the category of class III obesity, complication and conversion rates were similar to those reported in the literature and did not increase with BMI, despite an increased comorbidity burden. These results suggest that robotic surgery is a safe and effective method for providing minimally invasive surgery to a technically challenging population.

Measures to Reduce Perioperative and Intraoperative Blood Loss at Myomectomy: A Survey of Obstetrician-Gynaecologists.

OBJECTIVE: This study sought to determine current techniques used by Canadian obstetrician-gynaecologists (OB/GYNs) to medically optimize patients undergoing myomectomy during the perioperative and intraoperative periods and to identify gaps in knowledge or barriers to access of blood conservation methods. METHODS: From September to December 2016, a self-administered electronic questionnaire was distributed to 120 Canadian OB/GYNs who perform myomectomies and who practise in either academic, community, or community academic-affiliated hospitals. RESULTS: A total of 68 of 120 (57%) completed responses were analyzed. Most respondents were general OB/GYNs (72.1%; n = 49) who worked in the community (70.6%; n = 48) and had practised >10 years (67.7%; n = 46); 79.4% (n = 54) delayed surgery to correct anemia. The most common preoperative medical agents used included tranexamic acid (94.1%), ulipristal acetate (92.6%), gonadotropin-releasing hormone agonist (79.4%), and combined hormonal contraception (58.8%). The majority had access to hematology (83.8%; n = 57) and intravenous iron (82.4%; n = 56). However, respondents had variable knowledge of oral and intravenous iron dosing and administration. The most common intraoperative agents used included vasopressin (94.1%; n = 64 [subserosal, 59.4% vs. intramyometrial, 40.6%]), vasopressin with epinephrine (26.6%; n = 17 [subserosal, 58.8% vs. intramyometrial, 41.2%]), intravenous tranexamic acid (73.5%; n = 50), mechanical tourniquet (66.2%; n = 45), misoprostol (33.8%; n = 23), uterine artery ligation (22.1%; n = 15), topical sealant (17.6%; n = 12), and intraoperative blood salvage (11.8%; n = 8). CONCLUSION: Most OB/GYNs delay surgery to correct anemia, but they are uncertain of personal and institutional transfusion rates, iron dosing and administration, and optimal multimodal approaches to minimize intraoperative blood loss during myomectomy. Education and creation of a clinical pathway to address blood conservation may decrease perioperative morbidity for patients undergoing myomectomy.

Tyrosine Phosphorylation Determines Afterdischarge Initiation by Regulating an Ionotropic Cholinergic Receptor.

Changes to neuronal activity often involve a rapid and precise transition from low to high excitability. In the marine snail, Aplysia, the bag cell neurons control reproduction by undergoing an afterdischarge, which begins with synaptic input releasing acetylcholine to open an ionotropic cholinergic receptor. Gating of this receptor causes depolarization and a shift from silence to continuous action potential firing, leading to the neuroendocrine secretion of egg-laying hormone and ovulation. At the onset of the afterdischarge, there is a rise in intracellular Ca2+, followed by both protein kinase C (PKC) activation and tyrosine dephosphorylation. To determine whether these signals influence the acetylcholine ionotropic receptor, we examined the bag cell neuron cholinergic response both in culture and isolated clusters using whole-cell and/or sharp-electrode electrophysiology. The acetylcholine-induced current was not altered by increasing intracellular Ca2+ via voltage-gated Ca2+ channels, clamping intracellular Ca2+ with exogenous Ca2+ buffers, or activating PKC with phorbol esters. However, lowering phosphotyrosine levels by inhibiting tyrosine kinases both reduced the cholinergic current and prevented acetylcholine from triggering action potentials or afterdischarge-like bursts. In other systems, acetylcholine receptors are often modulated by multiple signals, but bag cell neurons appear to be more restrictive in this regard. Prior work finds that, as the afterdischarge proceeds, tyrosine dephosphorylation leads to biophysical alterations that promote persistent firing. Because this firing is subsequent to the cholinergic input, inhibiting the acetylcholine receptor may represent a means of properly orchestrating synaptically induced changes in excitability.

Implementation of a Same-Day Discharge Protocol Following Total Laparoscopic Hysterectomy.

OBJECTIVE: Previous studies have demonstrated that outpatient total laparoscopic hysterectomy (TLH) is both safe and feasible. Our objective was to decrease length of stay for patients undergoing TLH by implementing a same-day discharge protocol at two Canadian teaching hospitals. METHODS: We conducted a prospective cohort study assessing length of stay (primary outcome), perioperative complications, and readmission rates over a 12-month period following implementation of a same-day discharge protocol for TLH. These data were compared with pre-intervention baseline data collected retrospectively over a 12-month period immediately before protocol introduction. Our protocol consisted of patient education, instructions for perioperative care, and close follow-up. RESULTS: In the year prior to our protocol, 256 TLHs were performed. Forty-seven patients (18.3%) were discharged the same day, 191 patients (74.5%) were discharged on the first postoperative day, and 18 patients (7%) were admitted for 2 or more days. In the year following implementation, 215 patients underwent TLH of which 129 were enrolled in our study. The overall outpatient hysterectomy rate during that time period was 62% (134/215 patients). Among study participants, 102 patients (79.1%) were discharged the same day, 22 patients (17.0%) were discharged on the first postoperative day, and 5 patients (3.9%) were admitted for 2 or more days. There were no significant differences in perioperative complications or readmission rates and patient satisfaction scores were high. CONCLUSION: Implementation of a same-day discharge protocol successfully increased the rate of outpatient TLH without impacting patient safety. This protocol was acceptable to both surgeons and patients and can be easily adapted for use at other centres.

Effect of magnesium sulphate on fetal heart rate parameters: a systematic review.

OBJECTIVE: To examine the potential effects of intravenous magnesium sulphate (MgSO4) administration on antepartum and intrapartum fetal heart rate (FHR) parameters measured by cardiotocography (CTG) or electronic fetal monitoring (EFM). METHODS: We undertook a systematic review of randomized controlled trials, observational studies, and case series. Studies were reviewed independently by two reviewers and qualitatively analyzed with regard to CTG/EFM parameters (baseline FHR, variability and acceleration-deceleration patterns), types of participants, interventions offered, and outcomes reported. RESULTS: Of 18 included studies, two were RCTs (72 women); 12 were prospective observational studies (269 women), 10 of which were of a pre- and post-intervention design; one was a prospective cohort study (36 women) and three were retrospective cohort studies (555 women). Lower baseline FHR was associated with MgSO4 exposure in seven of nine relevant studies. Decreased FHR variability was reported in nine of 12 relevant studies. Reductions in reactivity or acceleration pattern were seen in four of six relevant studies without an increase in decelerative patterns. All changes were small and not associated with adverse clinical outcomes. CONCLUSION: Maternal administration of MgSO4 for eclampsia prophylaxis/treatment, tocolysis or fetal neuroprotection appears to have a small negative effect on FHR, variability, and accelerative pattern, but is not sufficient clinically to warrant medical intervention.

Objectif : Examiner les effets potentiels de l'administration de sulfate de magnésium (MgSO4) par voie intraveineuse sur les paramètres de la fréquence cardiaque fœtale (FCF) antepartum et intrapartum mesurés par cardiotocographie (CTG) ou monitorage fœtal électronique (MFÉ). Méthodes : Nous avons mené une analyse systématique ayant porté sur des essais comparatifs randomisés, des études observationnelles et des séries de cas. Ces études ont été analysées de façon indépendante par deux arbitres scientifiques; de plus, elles ont fait l'objet d'une analyse qualitative en fonction des paramètres de la CTG / du MFÉ (FCF initiale, variabilité et profils d'accélération-décélération), des types de participantes, des interventions offertes et des issues signalées. Résultats : Parmi les 18 études admises à l'analyse systématique, on comptait deux ECR (72 femmes); 12 études observationnelles prospectives (269 femmes), dont 10 comptaient un devis préintervention et postintervention; une étude de cohorte prospective (36 femmes); et trois études de cohorte rétrospectives (555 femmes). Une FCF initiale moindre a été associée à l'exposition au MgSO4 dans le cadre de sept des neuf études pertinentes. Une variabilité moindre de la FCF a été signalée dans neuf des 12 études pertinentes. Des baisses des profils de réactivité ou d'accélération ont été constatées dans quatre des six études pertinentes, sans hausse des profils de décélération. Toutes les modifications ont été faibles et n'ont pas été associées à des issues cliniques indésirables. Conclusion : Bien que l'administration de MgSO4 à la mère à des fins de prophylaxie / prise en charge de l'éclampsie, de tocolyse ou de neuroprotection fœtale semble exercer un faible effet négatif sur la FCF, la variabilité et le profil d'accélération, cet effet n'est pas suffisant sur le plan clinique pour justifier la tenue d'une intervention médicale.

A survey of digital rectal examination training in Canadian medical schools.

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.