Rescuing the Clinical Breast Examination

Abstract

Objective Develop new performance evaluation standards for the clinical breast examination (CBE). Summary Background Data There are several, technical aspects of a proper CBE. Our recent work discovered a significant, linear relationship between palpation force and CBE accuracy. This article investigates the relationship between other technical aspects of the CBE and accuracy. Methods This performance assessment study involved data collection from physicians (n = 553) attending 3 different clinical meetings between 2013 and 2014: American Society of Breast Surgeons, American Academy of Family Physicians, and American College of Obstetricians and Gynecologists. Four, previously validated, sensor-enabled breast models were used for clinical skills assessment. Models A and B had solitary, superficial, 2 cm and 1 cm soft masses, respectively. Models C and D had solitary, deep, 2 cm hard and moderately firm masses, respectively. Finger movements (search technique) from 1137 CBE video recordings were independently classified by 2 observers. Final classifications were compared with CBE accuracy. Results Accuracy rates were model A = 99.6%, model B = 89.7%, model C = 75%, and model D = 60%. Final classification categories for search technique included rubbing movement, vertical movement, piano fingers, and other. Interrater reliability was (k = 0.79). Rubbing movement was 4 times more likely to yield an accurate assessment (odds ratio 3.81, P < 0.001) compared with vertical movement and piano fingers. Piano fingers had the highest failure rate (36.5%). Regression analysis of search pattern, search technique, palpation force, examination time, and 6 demographic variables, revealed that search technique independently and significantly affected CBE accuracy (P < 0.001). Conclusions Our results support measurement and classification of CBE techniques and provide the foundation for a new paradigm in teaching and assessing hands-on clinical skills. The newly described piano fingers palpation technique was noted to have unusually high failure rates. Medical educators should be aware of the potential differences in effectiveness for various CBE techniques.

“Princess and the pea” – an assessment tool for palpation skills in postgraduate education

“…Therefore, we have no reproducible clues of the level of agreement between the different groups with respect to palpation techniques. Specific techniques that might have been handed down by tradition and taught as part of the routine clinical training produce different levels of accuracy [12]. If there is agreement between palpation techniques, the accuracy of palpatory findings can be significantly improved [29].…”

“…There is a relationship between search technique, force, and accuracy, as Laufer showed for clinical breast examination (CBE). Her group was able to define a specific range of palpation forces that increase the likelihood of an accurate CBE [12]. Objective assessment of palpation requires assessment methods that are valid, reliable, fair, defensible and evidence-based [13].…”

Modeling Surgical Technical Skill Using Expert Assessment for Automated Computer Rating

“…Fluidity of motion is a measure of hesitancy, pauses, or changes in direction and ''resets,'' which may be a component of Moulton's ''slowing down,'' 35 or contribute to time spent idle. 36 Tissue handling quantifies the appropriateness of the surgeon's force and tension when manipulating the tissue, 37,38 and varies based on the tissue's friability and fragility. 18 Motion economy is defined as efficiency of movement, or conservation of energy in any trajectory.…”

Simulator-Based Metrics for Quantifying Vascular Palpation Skill for Cannulation

“…The relationship between a person's exploratory techniques and their efficacy is a matter of current study, for example, different methods of palpation movement [7]. An example of stiffness-based palpation is its use in breast palpation for identifying tumors [5], [8]- [10].…”

“…Some of the earliest work in palpation skill assessment through sensor recordings was performed on a benchtop model studying pelvic exams [26], where the researchers used force sensors located at strategic points to quantify palpation. Later, clinical breast examination (CBE) and digital rectal examination (DRE) simulators were created using this same approach [5], [8], [29]. These studies have demonstrated that simulators can be effective in assessing aspects of palpation skill.…”