Lower Gastrointestinal Physiology 1 —
Training activity: 7

Details

Perform anorectal physiology investigations according to department protocol

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

• What does success look like?
  • Identify what is expected of you in relation to accurately performing anorectal manometry, rectal sensation testing, and balloon expulsion testing according to department protocol.
  • Consider how the learning outcomes apply, specifically in relation to adapting the procedure to meet the patient’s needs and answer the scientific question, recognising and addressing potential artefacts and demonstrating sensitivity.
  • Discuss with your training officer to gain clarity of what is expected of you in relation to the standard protocol steps, required manoeuvres (e.g., maximal squeeze, strain), and how to provide appropriate reassurance and support to the patient during the procedure.
• What is your prior experience of this activity?
  • Think about what you already know about the standard protocol steps, required manoeuvres, and data recording procedures for these investigations. Have you observed or assisted with these investigations before?
  • Consider possible challenges you might face during the activity, such as an uncooperative patient, patient pain that limits manoeuvres, or equipment issues that lead to artefacts.
  • Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example if severe, persistent equipment issues compromise data integrity, or if a patient’s inability to perform manoeuvres requires a significant adaptation to the procedure.
  • Acknowledge how you feel about performing the full investigation.
• What do you anticipate you will learn from the experience?
  • Consider the specific skills you want to develop, such as conducting the required manoeuvres accurately, managing data acquisition, identifying common artefacts, and adapting procedures in real-time based on patient response.
  • Identify the specific insights you hope to gain into patient interactions and adapting procedures in real-time, and how different patient conditions or anatomies affect the investigation process.
• What additional considerations do you need to make?
  • Consult actions identified following previous experiences of technical performance of physiological studies or observation of these specific procedures.
  • Identify important information you need to consider before embarking on the activity, such as reviewing the department’s detailed investigation protocols, ensuring all necessary equipment is prepared and calibrated, and reviewing the specific patient’s history or referral question that might influence the procedure.

In action

• Is anything unexpected occurring?
  • Are you noticing anything surprising or different from what you anticipate whilst performing the investigation manoeuvres?
  • Are you encountering situations such as:
    • The patient is unable to cooperate with required manoeuvres (e.g., maximal squeeze, simulated defecation), challenging your ability to follow protocol and requiring immediate adaptation of the procedure?
    • Significant artefacts (e.g., movement, baseline drift) appear on the data trace, compromising the quality and accuracy of the measurements, despite initial setup checks?
    • The equipment fails to record specific measurements accurately during the procedure, requiring real-time technical troubleshooting.
• How are you reacting to the unexpected development?
  • How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to patient instruction, pacing of the test, or technical troubleshooting?
  • Consider the steps you are taking in the moment, such as:
    • Immediately pausing the test to adjust the patient’s position or providing tailored instructions to improve cooperation for a specific manoeuvre
    • Making real-time adjustments to recording parameters or checking electrodes to mitigate noise while documenting the rationale for these change
  • How are you feeling in that moment? For instance, are you finding it difficult to maintain technical precision while adapting the procedure for patient needs? Is it affecting your confidence in obtaining diagnostically reliable data?
• What is the conclusion or outcome?
  • Identify how you are working within your scope of practice. For example, are you successfully adapting the procedure and troubleshooting minor artefacts? Or are you needing support because a persistent, major equipment issue or patient distress requires senior clinical intervention or termination of the study?
  • What are you learning as a result of the unexpected development? For example, are you mastering a more effective technique for identifying and eliminating movement artefacts? Or gaining insight into the critical adaptations required to meet specific patient tolerance limitations?

On action

• What happened?
  • Begin by summarising the key steps you took when executing the department protocol, including instructing the patient on required manoeuvres (e.g., maximal squeeze, simulated defecation), monitoring the data trace for quality, and completing sensation and balloon expulsion testing.
  • Consider specific events, actions, or interactions which felt important, such as how you provided clear, concise encouragement to the patient during maximal squeeze, or how you systematically reviewed the data trace for technical artefacts.
  • Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately altering the investigation protocol when the patient was unable to perform the sustained Valsalva manoeuvre due to discomfort, switching to a modified technique.
  • How did you feel during this experience, e.g., did you feel acutely aware of the patient’s effort and tolerance or focused on obtaining diagnostically reliable data?
• How has this experience contributed to your developing practice?
  • Identify what learning you can take from this experience regarding the performance and adaptation of complex investigations and the management of technical quality.
  • What strengths did you demonstrate, e.g., ability to coach the patient through difficult manoeuvres?
  • What skills and/or knowledge gaps were evident, e.g., uncertainty about identifying specific movement artefacts that mimic pathological patterns?
  • Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved?
  • Has your practice improved in adapting the procedural flow to meet the patient’s individual needs while still answering the scientific question?
  • Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding whether severe, persistent baseline drift compromised the integrity of the study data to the extent that termination or re-commencement was required, and how you reacted to this.
• What will you take from the experience moving forward?
  • Identify the actions you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to enhancing your ability to adapt the procedure safely and effectively manage technical artefacts.
  • What will you do differently next time you approach performing anorectal physiology investigations, for instance, by proactively reviewing the patient history for factors (e.g., joint pain) that might require early adaptation of patient positioning?
  • Do you need to practise any aspect of the activity further, such as recognising and eliminating electrical interference or key learning outcomes related to performing investigations in a range of patient conditions?

Beyond action

• Have you revisited the experiences?
  • How have your subsequent experiences of analysing results or encountering different patient conditions since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, encountering highly specific artefacts that were difficult to exclude during analysis, forced you to re-evaluate the procedural steps taken during data acquisition to minimise noise during your first attempt at this training activity.
  • Considering what you understand about protocol adherence, adaptation to patient needs, and managing data quality now, were the actions or considerations you identified after your initial reflection on this training activity sufficient?
  • How have you since implemented or adapted improvements in your procedural execution and real-time problem-solving based on further learning and experiences? For example, how you proactively developed a modified sequence for the balloon expulsion test for patients who struggle with specific positioning.
  • Has discussing challenging investigations (e.g., patient management issues, equipment issues) or the impact of procedural adaptation on the scientific question with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a situation where an uncooperative patient required significant procedural deviation, refined your understanding of the critical nature of balancing protocol adherence with compassionate patient adaptation.
• How have these experiences impacted upon current practice?
  • How has the learning from this initial training activity, in combination with subsequent interpretation experiences and patient interaction skills, contributed to your overall confidence and ability in performing investigations and managing patient flow, particularly in preparing for assessments like Direct Observations of Practical Skills (DOPS)? For example, how your accumulated ability in adhering to protocol and adapting to patient needs now enables you to confidently perform the required investigation components, such as applying appropriate infection control precautions, during a DOPS assessment.
  • How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to procedural execution and problem-solving in real-time?
  • How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice from the Training Officer or medical staff immediately when a patient exhibits unmanageable pain or distress that requires termination of the investigation, recognising this falls outside routine procedural modification scope.
  • Looking holistically at your training journey, how has this initial investigation performance experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to performing, analysing, and reporting investigations and demonstrating sensitivity? For example, how this foundational experience has supported your development in practicing safely by providing the necessary knowledge base for the subsequent learning outcomes focused on accurately analysing and interpreting the resulting data.

Relevant learning outcomes

#	Outcome
# 1	Outcome Describe the requirements of anorectal physiology investigations including indications and contraindications, and take a patient history.
# 5	Outcome Perform, analyse and report anorectal physiology investigations in a range of patient conditions adapting the procedure to answer the scientific question and to meet the patient’s needs.
# 6	Outcome Perform routine maintenance and calibration of anorectal manometry equipment, recognising problems and artefacts which may result in an inaccurate study being performed.
# 7	Outcome Apply and adapt their approach to the patient’s individual tolerance, personal experience and anxieties, demonstrating sensitivity to the emotional implications of intimate and invasive investigations on a patient’s wellbeing.