Context. Breast cancer morbidity and mortality disproportionately affect medically underserved women. Most studies of the experience of living with advanced breast cancer do not focus on this population. A deeper understanding of racial/ ethnic minorities' and low-income patients' experiences is needed to reduce breast cancer health and health care disparities. Objectives. This qualitative, community-based participatory research study explores the lived experiences of medically underserved women with advanced breast cancer. Methods. We conducted in-depth, semistructured interviews with low-income patients from a community clinic and safetynet hospital, focusing on issues related to advanced breast cancer and end of life. Six team members independently coded transcripts, jointly reconciled coding differences, and identified key themes. Results. All 63 participants (83% response rate) had an income #200% of the federal poverty level; 68% identified as a racial/ethnic minority. Four predominant themes emerged: compounding of pre-existing financial distress, perceived bias/ lack of confidence in medical care received, balancing personal needs with the needs of others, and enhanced engagement with sources of life meaning. Conclusion. Participants resiliently maintained engaged lives yet described extreme financial duress and perceived provider bias, which are known contributors to worse quality of life and health outcomes. Participants downplayed their desire to discuss dying to accommodate pressure to ''stay positive'' and to mitigate others' discomfort. Improving care for underserved women with advanced cancer will require addressing disparities from screening through hospice, developing personalized opportunities to discuss death and dying, and enhancing access to and affordability of medical and social support.

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ObjectivesDiscuss the developed case and scoring system that measures the skill of cultivating prognostic awareness. Discuss how we evaluated how well our program taught this skill to our interprofessional fellowship class. Schedule With Abstracts

Context and setting Optimising doctor-patient communication and ensuring that all people receive quality health care requires that doctors understand the influence of social contexts and cultural backgrounds on patients' health beliefs and behaviours. Cross-cultural curricula have often taken a categorical and potentially stereotypical approach to cultural awareness, one that embeds patients within static 'cultures.' Although the notion that members of discrete groups uniformly behave in distinctive ways is an unproductive and potentially dangerous oversimplification, an understanding of the range of variations in cultural beliefs can be helpful in the clinical encounter. Rather than memorising social or cultural 'facts,' students should be aware of the points of variance across a spectrum of socio-cultural contexts. Why the idea was necessary Conventional evaluation methods, such as multiple-choice examination questions, are poorly suited to the kinds of generative thinking and knowledge framework construction that are important in preparing for diverse medical encounters. To assess the evolution of students' knowledge frameworks regarding socio-cultural health care issues, we piloted the use of concept maps, which are visual representations of the cognitive analysis of a case that display both relevant concepts and links between them. What was done The pilot study was conducted over two quarters (autumn of 2006 and 2007) and included two cohorts of Year 4 students who enrolled in an elective course on socio-cultural issues in health care. The full-time, 2-week course included seminars and experiential exercises led by faculty members in medical anthropology and internal medicine. At the beginning of each course, students received brief training in the process of concept mapping, which included identifying discrete ideas, ranking them by importance and establishing hierarchical relations among them. The students were then presented with a short, written case scenario (which included elements related to socio-cultural contexts, health care ethics and culturally responsive health care) and asked to construct a (pre-instruction) concept map. The identical scenario was presented at the end of the course and students constructed a post-instruction concept map. Evaluation of results and impact Twenty concept maps (10 pre-and 10 post-instruction) were analysed independently by two raters who were blinded to both the identity of the student and the temporal order of the map pairs. All maps were correctly categorised as either pre-or post-instruction. Although these students had self-selected to participate in an advancedlevel elective on socio-cultural issues in health care, their concept maps revealed evolution in terms of both complexity and depth, indicating that the degree of potential change in the general medical student population may be even greater. This finding was corroborated by the students' self-assessments that the course furthered their understanding of the 'inter-relationships among health, illness, c...