A pilot study to integrate an immersive virtual patient with a breast complaint and breast examination simulator into a surgery clerkship

Background

We aimed to determine if an immersive virtual patient (VP) with a breast complaint and a breast mannequin could prepare third-year medical students for history-taking (HT) and clinical breast examination (CBE) on a real patient.

Methods

After standardized instruction in breast HT and CBE, students (n = 21) were randomized to either an interaction with a VP (experimental) or to no VP interaction (control) before seeing a real patient with a breast complaint. Participants completed baseline and exit surveys to assess confidence regarding their HT and CBE skills.

Results

Students reported greater confidence in their HT (Δ value = 1.05 ± 1.28, P < .05) and CBE skills (Δ value = 1.14 ± .91, P < .05) and less anxiety when performing a CBE (Δ value = −.76 ± 1.10, P < .05). The VP intervention group had a significantly higher mean HT confidence than the control group at the conclusion of the study (4.27 ± .47 vs 3.50 ± .71, respectively, P < .05).

Conclusions

A single interaction with a VP with a breast complaint and breast mannequin improves student confidence in breast HT during a surgery clerkship.     

Education of medical students in clinical breast examination during surgical clerkship

BACKGROUND: Medical student training in clinical breast examination is deficient at most medical schools. The use of silicone breast models may allow the education of abnormal and normal findings. This study examines the efficacy of silicone breast models to educate medical students in clinical breast examinations during their third-year surgical rotation. METHODS: Medical students were randomly selected to participate in formalized training sessions in clinical breast examination or as a control group. Presession and postsession testing with silicone breast models were performed. True positives (masses that were present and documented by the student) and false positives (masses that were not present but were documented by the student) were recorded. RESULTS: Medical students undergoing the training sessions demonstrated improved true positive scores (2.2 to 2.8; P <0.05) as well as improved false positive scores (3.0 to 2.0; P = 0.30) and total scores (-0.8 to 0.8; P = 0.07). Students who documented an increase in the number of breast examinations during their rotations had statistically lower false positive scores. CONCLUSIONS: Students after formalized clinical breast examination sessions do improve their ability to detect breast masses, although they continue to detect masses that are not present. Experience of actual breast examinations during their surgical rotations may refine their clinical skills.     

A simulation-based assessment of clinical breast examination technique: do patient and clinician factors affect clinician approach?

BACKGROUND: Recent publications describing widely accepted clinical breast examination (CBE) techniques have sparked interest in setting standards for CBE. In support of CBE training and assessment, the purpose of our study was to quantify CBE palpation techniques using simulation technology and assess the affects of clinical presentation and clinician background on CBE techniques. METHODS: Three sensored silicone breast models were configured to represent 3 different clinical presentations. The models were examined by 102 clinicians at a local breast cancer meeting, and their performance was captured by using sensored based data acquisition technology. RESULTS: Clinicians had significantly longer examination times on the fatty breast with no masses compared with the breast with a dominant mass and the breast with fibrocystic changes (66.37 seconds, 40.50 seconds, and 42.28 seconds, P < .05). In addition, on average, female clinicians had significantly greater examination times (females = 56.66 seconds, males = 42.09 seconds, P < .05) and touched more sensors (females = 7.97, males = 6.30, P < .05) with greater pressures (females = 5.21, males = 4.82, P < .05) than their male counterparts. CONCLUSIONS: Clinical presentation and clinician background may affect CBE technique yet does not appear to negatively affect clinician accuracy. Additional research quantifying the range of CBE techniques used in medical practice may inform CBE standardization and competency testing.     

Digital documentation of the physical examination: moving the clinical breast exam to the electronic medical record

BACKGROUND: Documentation of the clinical breast examination (CBE) has consisted of simple hand-drawings and stick figures without a common lexicon. There is a need for a device that can accurately depict the CBE in digital format while being objective, reproducible over time, and useable in the electronic medical record. This new device is called palpation imaging (PI). METHODS: We examined 110 patients with a complaint of a breast mass using PI. This laptop-sized device creates a real-time digital display of the palpable area in both video and still formats. The size, hardness, shape, homogeneity, and mass location may be extracted from the image. RESULTS: Of those with a true mass, PI identified the mass in 94% while physical examination identified 86%. The positive predictive value (PPV) for breast cancer using PI was 94% and 78% for physical examination. A survey of primary care physicians revealed the inclusion of the PI record in a consultation note implied competence, experience, and skill by the surgeon. CONCLUSIONS: PI documented the CBE in a timely, efficient, and accurate manner. A reproducible record allows objective review by multiple examiners at varied times. Continued work will optimize examination methods.     

Improving diagnosis in healthcare: Local versus national adoption of recommended guidelines for the clinical breast examination

Background

This study explores the long-term effectiveness of a newly developed clinical skills curriculum.

Development of a fresh cadaver model for instruction of ultrasound-guided breast biopsy during the surgery clerkship: pre-test and post-test results among third-year medical students

Background

The aim of our study was to determine if a fresh cadaver model is a viable method for teaching ultrasound (US)-guided breast biopsy of palpable breast lesions.

Methods

Third-year medical students were assessed both preinstruction and postinstruction on their ability to perform US-guided needle aspiration or biopsy of artificially created masses using a 10-item checklist.

Results

Forty-one third-year medical students completed the cadaver laboratory as part of the surgery clerkship. Eight items on the checklist were found to be significantly different between pre-testing and post-testing. The mean preinstruction score was 2.4, whereas the mean postinstruction score was 7.10 (P < .001).

Conclusions

Fresh cadaver models have been widely used in medical education. However, there are few fresh cadaver models that provide instruction on procedures done in the outpatient setting. Our model was found to be an effective method for the instruction of US-guided breast biopsy among medical students.     

A significant number of women present with palpable breast cancer even with a normal mammogram within 1 year

Background

Although mammography is the gold standard for breast cancer screening, clinical breast examination (CBE) and self breast examination (SBE) are important adjuncts whose utility has been questioned.

Methods

A retrospective review of invasive breast cancer patients from 2000 to 2008 was performed. We compared 3 groups: breast cancer detected by (1) imaging only (nonpalpable) or palpable mass with a normal mammogram (2) ≥1 year (mammogram ≥1 year) or (3) <1 year (mammogram <1 year).

Results

Of 1,222 women, presentation included 67% nonpalpable, 21% mammogram ≥1 year, and 13% mammogram <1 year. Patients presenting with palpable masses on SBE or CBE even with a normal mammogram within 1 year tended to have more aggressive tumors (larger size, lymph node positive, and triple-negative disease) resulting in more aggressive therapy (a higher mastectomy rate and a greater likelihood of chemotherapy).

Conclusion

A significant number of women present with palpable breast cancer within 1 year of a normal mammogram, many with an aggressive cancer. Therefore, we continue to advocate SBE and CBE for breast cancer screening.     

A focused breast skills workshop improves the clinical skills of medical students

PURPOSE: The aim of this study was to determine the effectiveness of a focused breast skills workshop for teaching clinical skills to third-year medical students. METHODOLOGY: One hundred twenty-four third-year medical students involved in the surgical core clerkship were randomly assigned to two groups. Group 1 (n = 67) participated in a 2-h focused breast skills workshop. Group 2 (n = 57) received "traditional" ambulatory teaching for a period of 4 h in the breast clinic. The focused workshop consisted of a series of encounters concentrating on mammogram and ultrasound interpretation, physical examination skills, lump detection, and workup of a breast mass. Both groups received a didactic core curriculum lecture from surgical faculty. All students completed a satisfaction rating scale and a subset of students completed a pre- and postencounter self-efficacy rating scale on several aspects of breast skills. Student's t test was used to compare the groups in the areas of clinical skills as evidenced by performance on the breast-specific items on the end of the clerkship Objective Structure Clinical Examination and student satisfaction as evidenced by their response on a satisfaction rating scale. ANCOVA (controlling for preencounter self-efficacy rating) was used to compare the change scores between pre- and postencounter self-efficacy ratings. RESULTS: Students in Group 1 performed significantly higher than the students in Group 2 in the areas of clinical examination skills (t = -2.99, P < 0.05); in sensitivity (t = -5.82, P < 0.05) and specificity (t = -7.27, P < 0.05) in the examination of breast models; and with their satisfaction with the encounter (t = 10.72, P < 0.05). Students in Group 1 also demonstrated a higher level of confidence in their breast skills at the end of the clerkship than students in Group 2 (F = 6.22, P < 0.05). CONCLUSIONS: The focused breast skills workshop is more effective than the traditional ambulatory setting for teaching clinical breast examination skills. This setting also demonstrated the development of higher confidence in breast skills than the traditional ambulatory setting.     

Does perceived risk predict breast cancer screening use? Findings from a prospective cohort study of female relatives from the Ontario site of the Breast Cancer Family Registry

While the relationship between perceived risk and breast cancer screening use has been studied extensively, most studies are cross-sectional. We prospectively examined this relationship among 913 women, aged 25–72 with varying levels of familial breast cancer risk from the Ontario site of the Breast Cancer Family Registry. Associations between perceived lifetime breast cancer risk and subsequent use of mammography, clinical breast examination (CBE) and genetic testing were assessed using logistic regression. Overall, perceived risk did not predict subsequent use of mammography, CBE or genetic testing. Among women at moderate/high familial risk, those reporting a perceived risk greater than 50% were significantly less likely to have a CBE (odds ratio (OR) = 0.52, 95% confidence interval (CI): 0.30–0.91, p = 0.04), and non-significantly less likely to have a mammogram (OR = 0.70, 95% CI: 0.40–1.20, p = 0.70) or genetic test (OR = 0.61, 95% CI: 0.34–1.10, p = 0.09) compared to women reporting a perceived risk of 50%. In contrast, among women at low familial risk, those reporting a perceived risk greater than 50% were non-significantly more likely to have a mammogram (OR = 1.13, 95% CI: 0.59–2.16, p = 0.78), CBE (OR = 1.11, 95% CI: 0.63–1.95, p = 0.74) or genetic test (OR = 1.29, 95% CI: 0.50–3.33, p = 0.35) compared to women reporting a perceived risk of 50%. Perceived risk did not significantly predict screening use overall, however this relationship may be moderated by level of familial risk. Results may inform risk education and management strategies for women with varying levels of familial breast cancer risk.     

Development and evaluation of an integrated musculoskeletal disease course for medical students

BACKGROUND: A recent survey of medical and surgical residents in the United States suggested that our current training of physicians may be inadequate to meet the increasing demand for diagnosis and treatment of musculoskeletal disorders. In response, we developed an integrated, multidisciplinary course to teach knowledge and skills related to musculoskeletal disease to second-year medical students. A three-year prospective outcomes study was conducted to evaluate the new course. METHODS: The primary outcomes that were studied during the first year of the new course were the gains in knowledge, changes in levels of confidence, and long-term retention of skills. Secondary outcomes consisted of student and faculty satisfaction. Ten-item pre-tests and post-tests covering core course concepts were administered to students. A matched-pairs t test was used to evaluate the difference between pre-test and post-test scores. Students were also asked to rate, on a 10-point scale, how much confidence they had in their ability to perform the musculoskeletal physical examination before and after the institution of the new curriculum. A general linear model analysis with post hoc pairwise comparisons (F test) was used to evaluate the changes in the confidence levels of the students. Also, a knee examination station was organized to compare students' scores before and after revision of the course. At the conclusion of the course, students rated each aspect of it on a scale of 1 to 5. Instructors were asked to rate the effectiveness of all elements of the course on the same scale. RESULTS: On the basis of student satisfaction and confidence and faculty satisfaction, the most effective changes in the curriculum were the introduction of a physical examination workshop and simulated clinical situations. Students' knowledge increased significantly (p < 0.001), and their level of confidence increased significantly in thirteen specifically targeted areas (p < 0.0001). On the end-of-the-year examination assessing retention of physical examination skills, the scores for the skills emphasized in the revised course increased significantly whereas the scores for a skill not emphasized in the course remained the same. Revisions made in the second and third years after implementation of the course expanded the more successful elements and further improved student ratings. CONCLUSIONS: Integration of the three clinical disciplines related to musculoskeletal disease--orthopaedics, rheumatology, and physical medicine and rehabilitation--resulted in a highly effective introductory course for second-year medical students. The heuristic strategy of introducing core content through lectures and workshops followed by small-group teaching sessions for practice with the new knowledge effectively increased students' knowledge, confidence, and satisfaction.     

Assessing medical student knowledge, attitudes, and behaviors regarding organ donation

PURPOSE: To measure medical students' knowledge of the central issues in organ donation and transplantation and to understand their perception of the extent of training they received prior to and during medical school. METHODS: A previously validated, 41-question instrument assessing organ donation, allocation, and transplantation knowledge was directly administered to 537 first- and second-year medical students attending one of three Ohio schools from January through April 2005. Students were also asked about their support for organ donation and the donation training they had received. RESULTS: Two hundred sixty four first-year and 236 second-year students responded (response rate = 93%). Few students to date received donation and transplantation training before (11%) or during (22%) medical school. Second-year students were more likely than first-year students to have received training during medical school (40% vs 6%, P < .001) and to have read articles regarding donation (24% vs 15%, P = .017). However, both first- and second-year medical students answered the majority of the knowledge questions incorrectly (43% vs 48%, P < .002). Knowledge regarding brain death was lower among medical students compared to a random sample of Ohio adults (P < .001). Donation coursework prior to or during medical school was significantly associated with an increased knowledge regarding donation (odds ratio [OR] = 2.01, P = .001) and knowing where to find answers to patients' questions regarding donation (OR = 2.76, P < .001). CONCLUSION: Medical students have significant gaps in knowledge regarding the organ donation and transplantation system. Donation and transplantation education is associated with improved knowledge in the area and comfort in knowing how to address patient questions.     

Increasing disability awareness of future spinal cord injury physicians

OBJECTIVE: This prospective study was designed to evaluate a disability awareness training program for medical students. METHODS: First- and second-year medical school students participated in an interactive disability awareness program consisting of 6 sessions spaced across 1 year. The Modified Issues in Disability Scale (MIDS), administered at program commencement and completion, was used to measure attitudes toward people with a disability. The paired t test was used to compare pre- and posttest data on the MIDS. In addition, gain scores on content-based tests were used to measure learning for each session. Participants also completed evaluation forms for each session. RESULTS: Two hundred and six students completed the MIDS forms at program commencement and completion. Analysis revealed a significant average increase (P = 0.033) in positive attitudes toward people with disabilities between the pre- and posttest data. Content learning also was evidenced by an average 34% gain from pretest to posttest. The participant evaluation summary for the sessions averaged 3.95 on a Likert-type scale of 5, which was characterized as "very good." Subjective evaluations were extremely favorable, as evidenced by requests for more information and exposure. CONCLUSION: This project illustrates the effectiveness of disability awareness training among medical school students during the early period of their training.     

Variables influencing medical student learning in the operating room

BACKGROUND: The operating room (OR) is an important venue where surgeons do much of medical student teaching and yet there has been little work evaluating variables that influence learning in this unique environment. We designed this study to identify variables that affected medical student learning in the OR. METHODS: We developed a questionnaire based on surgery faculty observations of learning in the OR. The medical students completed the questionnaire on 114 learning episodes in the OR. Pearson correlation coefficient was used to establish the strength of association between various variables and the student's overall perception of learning. RESULTS: The students evaluated 27 variables that might impact their learning in the OR. Strong correlations were identified between the attending physician's attitude, interactions and teaching ability in the OR and the environment being conducive to learning. CONCLUSIONS: Surgical faculty behavior is a powerful determinant of student perceptions of what provides for a favorable learning environment in the OR.     

The specialty mentor effect in enhancing surgical experience of medical students: A randomised control trial

IntroductionThe positive learning experiences of students on surgical rotations which subsequently influence career choice may be delineated into practical and interpersonal themed factors. It remains unclear the relative impact each component has on the student experience and subsequent specialisation.AimsWe evaluate the influence of having senior resident mentor during practical simulation in orthopaedic surgery has on medical student interest in surgery; their comfort in theatre; and its role in enhancing knowledge acquisition within the rotation.MethodsMedical students undergoing clinical rotations in a Regional University Hospital were randomised to undertaking a virtual reality simulated operation independently or performing under the guidance of an experienced resident. Baseline levels of interest in surgery, comfort in theatre, perceived barriers to surgical learning and entry to surgery were established and compared to answers following completion of the tutorial. Qualitative feedback was collected regarding the benefits and limitations to the experience. Presented according to CONSORT guidelines.ResultsParticipants in the trainee guided group achieved significantly higher simulated performance scores compared to the control (p < 0001), with an increase in interest in orthopaedic surgery from baseline expressed to a statistically significant degree (p = 0.01). Participants in the unsupervised group demonstrated no significant increase in interest in Orthopaedic surgery (p = 0.3). 100% participants strongly agreed it was a beneficial learning experience which would be useful in surgical curricula.ConclusionSurgical trainee guided simulation led to improved performance and interest in orthopaedic surgery, while virtual practical experience was felt to be a useful learning tool independent of supervision. Further research is needed to establish the role of interpersonal interactions in student surgical experience.     

Effect of a short structured session on medical student breast cancer screening knowledge

Formalized instruction in breast cancer screening during medical school may help improve early breast cancer detection and survival. Physicians-in-training must be proficient in skills relating to breast cancer screening. This study investigates the baseline breast cancer screening knowledge of medical students, the benefit of a structured lecture session, and its effect on improving medical students' knowledge of cancer screening. A self-administrated questionnaire relating to breast cancer screening was given to third-year medical students. A 60-minute structured lecture session was given to the medical students regarding breast cancer screening. A postintervention survey was administered immediately following the session. A total of 27 medical students were evaluated. There was a statistically significant improvement following the formalized teaching session (84% to 93%; p < 0.0016). While few students (15%) reported having previous instruction in cancer screening, most students (96%) felt that a formal session should be offered during medical school. While medical student knowledge of breast cancer screening may be adequate, formalized instruction in breast cancer health practices can improve medical student knowledge. Most students had limited previous instruction in breast cancer prevention and welcomed the opportunity for structured training in breast cancer prevention, education, and detection. Until a formal course becomes a fundamental aspect of medical education, a short structured session should be instituted.     

A peer-designed selective in anesthesiology,critical care,and perioperative medicine for first- and second-year medical students

Study objectiveThe objective of this study was to design and implement a preclinical elective (termed selective) in anesthesiology, critical care, and perioperative medicine and to report survey results assessing the impact of the selective on first- and second-year medical students' understanding of basic concepts, comfort with procedural skills, and interest in the specialty.DesignPreinvention and postintervention survey evaluation was used as the design of this study.SettingThe study was conducted at Mayo Medical School and Mayo Clinic.ParticipantsThe participants in this study are first- and second-year medical students.InterventionsA 1-week introductory anesthesiology curriculum was developed to include didactic sessions, shadowing experiences, lunch and dinner panels, mentorship and networking opportunities, and procedural workshops in airway management, ultrasound, and vascular access techniques.MeasurementsPreselective and postselective surveys using a 10-point scale (1, strongly disagree; 10, strongly agree) were administered 1 week before and after the selective.Main resultsA total of 8 students participated in the selective, with a 100% survey response rate. Students reported significant increases for all survey questions regarding basic concepts and skills. The largest increases were reported in comfort with airway management skills, understanding of the perioperative surgical home model, and vascular access skills. All participants indicated a higher likelihood of pursuing anesthesiology as a career and attributed their increased interest in anesthesiology to the selective.ConclusionsThis new selective was successful in giving first- and second-year medical students a comprehensive overview of anesthesiology and increasing medical student interest in the specialty. The success of this selective leads to promising belief that similar peer-designed educational experiences can be developed at other medical schools to improve education and interest in this area of medicine.     

A minimally invasive breast biopsy clinic: an innovative way to teach breast fellows how to perform breast ultrasound and ultrasound-guided breast procedures

BACKGROUND: The ability to perform breast ultrasound and ultrasound-guided breast procedures are increasingly important skills for breast surgeons. Breast fellowship programs must develop programs to ensure adequate ultrasound training for breast fellows. METHODS: A Minimally Invasive Breast Biopsy Clinic was established at the Los Angeles County + University of Southern California Medical Center to provide breast fellows with comprehensive, hands-on, "live-patient" breast ultrasound training. RESULTS: From December 2004 though February 2005, 5 breast fellows received training in the Minimally Invasive Breast Biopsy Clinic. Each fellow received a minimum of 18 weeks of "live-patient" experience. Although the learning curve varied among the fellows, all showed proficiency in performing breast ultrasound and ultrasound-guided core biopsies by the 12th week. A total of 39 patients with fibroadenomas underwent 62 ultrasound-guided procedures, including 30 vacuum-assisted percutaneous excisions, 16 cryoablations, and 16 core biopsies. CONCLUSION: The Minimally Invasive Breast Clinic model provided breast fellows with sufficient "live-patient" experience to enable confident performance of breast ultrasound and ultrasound-guided breast procedures. The selection of patients with fibroadenomas facilitated safe and efficient training without interfering with the management of cancer patients.     

Knowledge, attitude and practice of breast self-examination in a female population of metropolitan São Paulo

OBJECTIVE: Evaluation of the knowledge, attitude and practice of breast self-examination in different groups of women in S?o Paulo. METHODS: Application of a questionnaire to 392 women divided in four groups. Group one: 101 patients of the National Health Service, Group two: 95 female physicians; Group three: 95 female medical students; and Group four: 101 wives of gynecologists. RESULTS: Self-examination was performed by 90.3% of women, Group 1 having the lowest rate, 69.3%. However, proper self-examination (performed monthly or once per cycle, after menstrual period, with at least one stage in standing or sitting up position) was performed by only 30.4%, the poorest performance being found in Group 1 (15.7%) and the best one in Group 2 (43.6%). For women in Group 1, "mass media" was the most important source of information on breast self-examination, whereas for the other groups, it was "medical sources". CONCLUSION: The majority of women are knowledgeable about breast self-examination but perform it improperly, this finding being more common among women who depend on the National Health Service, who represent a section of the general population. As breast self-examination remains an important tool in countries with limited resources, this study confirms the importance of disseminating proper information, and that more investment should be made in awareness campaigns.     

Assessing the attitudes,knowledge and perspectives of medical students to chiropractic

Objective:

To assess second-year medical students’ views on chiropractic.

Methods:

A three-step triangulation approach was designed, comprising a 53-item survey, nine key informant interviews and one focus group of 8 subjects. ANOVA was used to assess attitude-response survey totals over grouping variables. Constant comparison method and NVivo was used for thematic analysis.

Results:

112 medical students completed the survey (50% response rate). Subjects reporting no previous chiropractic experience/exposure or interest in learning about chiropractic were significantly more attitude-negative towards chiropractic. Thematically, medical students viewed chiropractic as an increasingly evidence-based complementary therapy for low back/chronic pain, but based views on indirect sources. Within formal curriculum, they wanted to learn about clinical conditions and benefits/risks related to treatment, as greater understanding was needed for future patient referrals.

Conclusion:

The results highlight the importance of exposure to chiropractic within the formal medical curriculum to help foster future collaboration between these two professions.