Effectiveness of a dynamic breast examination training model to improve clinical breast examination (CBE) skills

A Surrogate Model Based on a Finite Element Model of Abdomen for Real-Time Visualisation of Tissue Stress during Physical Examination Training

Robotic patients show great potential for helping to improve medical palpation training, as they can provide feedback that cannot be obtained in a real patient. They provide information about internal organ deformation that can significantly enhance palpation training by giving medical trainees visual insight based on the pressure they apply for palpation. This can be achieved by using computational models of abdomen mechanics. However, such models are computationally expensive, and thus unable to provide real-time predictions. In this work, we proposed an innovative surrogate model of abdomen mechanics by using machine learning (ML) and finite element (FE) modelling to virtually render internal tissue deformation in real time. We first developed a new high-fidelity FE model of the abdomen mechanics from computerized tomography (CT) images. We performed palpation simulations to produce a large database of stress distribution on the liver edge, an area of interest in most examinations. We then used artificial neural networks (ANNs) to develop the surrogate model and demonstrated its application in an experimental palpation platform. Our FE simulations took 1.5 h to predict stress distribution for each palpation while this only took a fraction of a second for the surrogate model. Our results show that our artificial neural network (ANN) surrogate has an accuracy of 92.6%. We also showed that the surrogate model is able to use the experimental input of palpation location and force to provide real-time projections onto the robotics platform. This enhanced robotics platform has the potential to be used as a training simulator for trainees to hone their palpation skills.

Perception by Palpation: Development and Testing of a Haptic Ferrogranular Jamming Surface

Tactile hands-only training is particularly important for medical palpation. Generally, equipment for palpation training is expensive, static, or provides too few study cases to practice on. We have therefore developed a novel haptic surface concept for palpation training, using ferrogranular jamming. The concept’s design consists of a tactile field spanning 260 x 160 mm, and uses ferromagnetic granules to alter shape, position, and hardness of palpable irregularities. Granules are enclosed in a compliant vacuum-sealed chamber connected to a pneumatic system. A variety of geometric shapes (output) can be obtained by manipulating and arranging granules with permanent magnets. The tactile hardness of the palpable output can be controlled by adjusting the chamber’s vacuum level. A psychophysical experiment (N = 28) investigated how people interact with the palpable surface and evaluated the proposed concept. Untrained participants characterized irregularities with different position, form, and hardness through palpation, and their performance was evaluated. A baseline (no irregularity) was compared to three irregularity conditions: two circular shapes with different hardness (Hard Lump and Soft Lump), and an Annulus shape. 100% of participants correctly identified an irregularity in the three irregularity conditions, whereas 78.6% correctly identified baseline. Overall agreement between participants was high (κ= 0.723). The Intersection over Union (IoU) for participants sketched outline over the actual shape was IoU Mdn = 79.3% for Soft Lump, IoU Mdn = 68.8% for Annulus, and IoU Mdn = 76.7% for Hard Lump. The distance from actual to drawn center was Mdn = 6.4 mm (Soft Lump), Mdn = 5.3 mm (Annulus), and Mdn = 7.4 mm (Hard Lump), which are small distances compared to the size of the field. The participants subjectively evaluated Soft Lump to be significantly softer than Hard Lump and Annulus. Moreover, 71% of participants thought they improved their palpation skills throughout the experiment. Together, these results show that the concept can render irregularities with different position, form, and hardness, and that users are able to locate and characterize these through palpation. Participants experienced an improvement in palpation skills throughout the experiment, which indicates the concepts feasibility as a palpation training device.

A Thorough Analysis of the Current State of Cancer Education in Medical Schools and Application of Experimental Teaching Techniques and Their Efficacy

Newly diagnosed cases of cancer are expected to double by the year 2040. Although many different oncology teaching initiatives have been implemented, many students continue to report uncertainty when dealing with patients with cancer. Through this review, we aim to find the most effective teaching methods to better prepare future physicians. Papers studying different methods of teaching oncology were identified through a thorough review of specific electronic databases. Each study was analyzed and sorted into one of ten unique categories created by the authors specifically for this review. If portions of the study fit into multiple categories, relevant results would be analyzed in all applicable areas. Additionally, papers were separated and analyzed by country of origin, preclinical or clinical interventional basis, and quantitative versus qualitative form of statistical analysis. A total of 115 papers from 26 different countries and regions were included in the final analysis. 91.4% of papers analyzing Lecture and Small Group Discussions indicated a positive impact. 97.1% of papers analyzing Clinical Practice and Simulation indicated a positive impact. 100% of papers analyzing Early Experience and Mentorship, Summer Programs and Voluntary Electives, use of Multidisciplinary Teams, and Role Play stated that these methods had a positive impact. 50% of papers analyzing Computer/Web Based Programs indicated a positive impact. Clinical Practice and Simulation, Role Play, Summer/Elective Programs and interventions involving Multidisciplinary Team Work all appeared to be most effective. Intensive Block Programs, Didactic Lectures/Small Group Discussions, and Computer/Web Based Education tools as a whole were variable. General Review papers showed continued variability in domestic and international oncology curricula. Incorporation of effective teaching interventions should be highly considered in the future creation of standardized oncology curricula in order to best prepare the next generation of physicians. Future studies could explore the differing efficacies of teaching interventions in the postgraduate versus graduate realms.

Diagnostic Accuracy of Breast Medical Tactile Examiners (MTEs): A Prospective Pilot Study

Background

The usefulness of clinical breast examination (CBE) in general and in breast cancer screening programs has been a matter of debate. This study investigated whether adding vision-impaired medical tactile examiners (MTEs) improves the predictiveness of CBE for suspicious lesions and analyzed the feasibility and acceptability of this approach.

Methods

The prospective study included 104 patients. Physicians and MTEs performed CBEs, and mammography and ultrasound results were used as the gold standard. Sensitivity and specificity were calculated and logistic regression models were used to compare the predictive value of CBE by physicians alone, MTEs alone, and physicians and MTEs combined.

Results

For CBEs by physicians alone, MTEs alone, and both combined, sensitivity was 71, 82, and 89% and specificity was 55, 45, and 35%, respectively. Using adjusted logistic regression models, the validated areas under the curve were 0.685, 0.692, and 0.710 (median bootstrapped p value (DeLong) = 0.381).

Conclusion

The predictive value for a suspicious breast lesion in CBEs performed by MTEs in patients without prior surgery was similar to that of physician-conducted CBEs. Including MTEs in the CBE procedure in breast units thus appears feasible and could be a way of utilizing their skills.

Granular Jamming Based Controllable Organ Design for Abdominal Palpation

Medical manikins play an essential role in the training process of physicians. Currently, most available simulators for abdominal palpation training do not contain controllable organs for dynamic simulations. In this paper, we present a soft robotics controllable liver that can simulate various liver diseases and symptoms for effective and realistic palpation training. The tumors in the liver model are designed based on granular jamming with positive pressure, which converts the fluid-like impalpable particles to a solid-like tumor state by applying low positive pressure on the membrane. Through inflation, the tumor size, liver stiffness, and liver size can be controlled from normal liver state to various abnormalities including enlarged liver, cirrhotic liver, and multiple cancerous and malignant tumors. Mechanical tests have been conducted in the study to evaluate the liver design and the role of positive pressure granular jamming in tumor simulations.

Novel Approaches To Undergraduate Oncology Education

With the increasing incidence of cancer and related survival, junior doctors are more commonly involved the management of oncology patients. A comprehensive oncology curriculum has been developed and adopted across medi-cal schools in Australia. However, it was not designed to inform how medical students should be taught, and whether curriculum content translates to knowledge and competency can depend on its implementation. We have conducted a literature review of PubMed, Embase and Cochrane databases to identify and summarise the evidence for novel approaches to delivering the undergraduate oncology curriculum. Numerous effective approaches have been developed across areas of prevention, clinical examination through simulation, the multidisciplinary team, psycho-oncology, palliative care and even research. There is growing focus on a holistic and multidisciplinary approach to cancer education although direct clinical exposure and interactions with cancer patients is still crucial. Medical schools may also have an under-recognised role in promoting positive health behaviour if their graduates are to convey these preventative measures to their patients. Application of such methods relies upon clinicians and medical educators to consider the practicability and relevance of specific implementation in their local context.

Use of a novel assay to measure pre- to posttraining palpatory skills of first-year osteopathic medical students

CONTEXT

Although palpation is a central skill in the practice of osteopathic medicine, few data are available on factors affecting the development of palpatory skills.

OBJECTIVE

To use a novel palpatory skills assay to assess the role of training and practice in the development of palpatory skills in an osteopathic medical student population.

METHODS

The palpatory skills of first-year osteopathic medical students were assessed using a simple, objective palpation assay that consisted of locating a dime placed under sheets of copy paper at depths of 50, 100, 150, 200, 300, and 400 sheets. Two trials were performed at each depth. The assay was performed at the beginning and at the end of the students' first term. To determine whether practice with the assay impacted participant performance, a third assay was conducted to compare the performance of students who completed the assays at the beginning and at the end of the term with that of students who had never completed the assay.

RESULTS

Sixty-three participants completed the assays at the beginning and end of the term. Fifty-seven of those 63 participants and 192 participants who had not previously completed the assay completed the third assay. A wide variability in number of correct responses per participant was observed at both the beginning (range, 0-11 correct) and the end (range, 2-12 correct) of the term. The mean (SD) number of correct responses per participant increased from the beginning (5.49 [2.78]) to the end (7.17 [2.27]) of the term. Analysis using the generalized estimating equation model demonstrated that both paper depth and experience (ie, beginning vs end of the term) were statistically significant determinants of the number of correct responses (P<.001). The Kaplan-Meier method indicated that the median paper depth at which participants first scored no correct responses increased from 200 sheets (95% CI, 171-229) at the beginning of the term to 300 sheets (95% CI, 232-367) at the end of the term (P<.001). In the third assay, no significant differences were noted in the performance of students who had completed the 2 previous assays vs participants who had not completed the previous assays (P=.136).

CONCLUSION

Participants' palpatory skills improved from the beginning to the end of the term. The range of participants' palpatory skills at the beginning of the term suggests that other factors in addition to training influenced participants' palpatory skill level. Additional research is needed to identify and investigate factors that influence the development of palpatory skills.

The educational utility of simulations in teaching history and physical examination skills in diagnosing breast cancer: a review of the literature

This paper is a review of the literature examining the use of medical simulations to teach our future healthcare providers how to diagnose breast cancer. MEDLINE and Embase databases were searched to identify the literature published between 1990 and 2014. In total, 113 articles were retrieved and evaluated for their relevance to the topic. Simulation methods, such as standardized patients and breast models were found to enhance students' abilities to perform patient histories and physical examinations to detect breast cancer. In addition, simulation can help trainees learn how to communicate bad news to patients effectively. There is an abundance of literature supporting the continued use of simulations in the curricula of medical schools. However, future studies based on sound theoretical frameworks are needed to evaluate the positive effects of simulation-based education on patient outcomes.

Simulation training for breast and pelvic physical examination: a systematic review and meta-analysis

BACKGROUND

Breast and pelvic examinations are challenging intimate examinations. Technology-based simulation may help to overcome these challenges.

OBJECTIVE

To synthesise the evidence regarding the effectiveness of technology-based simulation training for breast and pelvic examination.

SEARCH STRATEGY

Our systematic search included MEDLINE, EMBASE, CINAHL, PsychINFO, Scopus, and key journals and review articles; the date of the last search was January 2012.

SELECTION CRITERIA

Original research studies evaluating technology-enhanced simulation of breast and pelvic examination to teach learners, compared with no intervention or with other educational activities.

DATA COLLECTION AND ANALYSIS

The reviewers evaluated study eligibility and abstracted data on methodological quality, learners, instructional design, and outcomes, and used random-effects models to pool weighted effect sizes.

MAIN RESULTS

In total, 11 272 articles were identified for screening, and 22 studies were eligible, enrolling 2036 trainees. In eight studies comparing simulation for breast examination training with no intervention, simulation was associated with a significant improvement in skill, with a pooled effect size of 0.86 (95% CI 0.52-1.19; P < 0.001). Four studies comparing simulation training for pelvic examination with no intervention had a large and significant benefit, with a pooled effect size of 1.18 (95% CI 0.40-1.96; P = 0.003). Among breast examination simulation studies, dynamic models providing feedback were associated with improved outcomes. In pelvic examination simulation studies, the addition of a standardised patient to the simulation model and the use of an electronic model with enhanced feedback improved outcomes.

AUTHOR'S CONCLUSIONS

In comparison with no intervention, breast and pelvic examination simulation training is associated with moderate to large effects for skills outcomes. Enhanced feedback appears to improve learning.

Use of breast simulators compared with standardized patients in teaching the clinical breast examination to medical students

OBJECTIVE

Simulators have replaced some standardized patients in medical student teaching, and their use seems to decrease anxiety related to the clinical breast examination (CBE). We compared learning the CBE on a breast palpation simulator with learning on a standardized patient with respect to skill acquisition and comfort level.

METHODS

At Penn State College of Medicine, the class of 2008 (historical control group, n = 113) learned the CBE on a standardized patient, whereas the class of 2009 (experimental group, n = 131) learned on the breast palpation simulator. We used measures of the process (conducting the CBE) and measures of the outcome (examination scores and detection of abnormal findings). During their third-year surgical clerkship, students in both groups completed a questionnaire reporting the number of CBEs performed and confidence in performing the CBE. The students then performed an observed examination on the simulator, and the number of positive findings detected was recorded. The mean number of positive findings was compared between groups, and an economic analysis was conducted.

RESULTS

The experimental group had a significantly higher mean examination score than the historical control. In subgroups, this difference was significant for those who reported performing 0-5 clinical examinations but for not those who had performed >6 examinations. On individual items, the experimental group scored significantly higher in examining for neck nodes, nipple retraction, skin changes, and axillary evaluation. The 2 groups did not differ significantly in the mean number of positive findings detected or in ratings of comfort level.

CONCLUSIONS

Medical students who learned the CBE on breast palpation simulators performed as well or better than those who learned on standardized patients; however, a subgroup analysis revealed that the benefit was limited to students with less clinical experience.

Characterizing the range of simulated prostate abnormalities palpable by digital rectal examination

BACKGROUND

Although the digital rectal exam (DRE) is a common method of screening for prostate cancer and other abnormalities, the limits of ability to perform this hands-on exam are unknown. Perceptible limits are a function of the size, depth, and hardness of abnormalities within a given prostate stiffness.

METHODS

To better understand the perceptible limits of the DRE, we conducted a psychophysical study with 18 participants using a custom-built apparatus to simulate prostate tissue and abnormalities of varying size, depth, and hardness. Utilizing a modified version of the psychophysical method of constant stimuli, we uncovered thresholds of absolute detection and variance in ability between examiners.

RESULTS

Within silicone-elastomers that mimic normal prostate tissue (21kPa), abnormalities of 4mm diameter (20mm(3) volume) and greater were consistently detectable (above 75% of the time) but only at a depth of 5mm. Abnormalities located in simulated tissue of greater stiffness (82kPa) had to be twice that volume (5mm diameter, 40mm(3) volume) to be detectable at the same rate.

CONCLUSIONS

This study finds that the size and depth of abnormalities most influence detectability, while the relative stiffness between abnormalities and substrate also affects detectability for some size/depth combinations. While limits identified here are obtained for idealized substrates, this work is useful for informing the development of training and allowing clinicians to set expectations on performance.

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 (Delta value = 1.05 +/- 1.28, P < .05) and CBE skills (Delta value = 1.14 +/- .91, P < .05) and less anxiety when performing a CBE (Delta 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.

Educating undergraduate medical students about oncology: a literature review

PURPOSE

This article is a review of the literature regarding teaching oncology to undergraduate medical students.

METHODS

MEDLINE, Psychinfo, ERIC, TIMELIT, EMBASE, CINAHL and the Cochrane CENTRAL Register of Controlled Trials (CENTRAL) were searched, using the search terms cancer, oncology, education, undergraduate, and teaching.

RESULTS

The main findings can be summarized as follows: the involvement of patients in teaching is popular with students and portfolio learning is a successful way of involving patients; the use of standardized patients to teach breast examination improves students' performance in clinical assessment; the use of silicone models to teach breast examination improves students' sensitivity for detecting breast lumps; computer aided learning modules have a role, but are not superior to other types of learning; learning about cancer screening and prevention increases students' knowledge, improves their self rated skills, and changes their behavior; and cancer patients have an important role to play in teaching undergraduate communication skills.

CONCLUSION

We have found 48 articles on undergraduate teaching in oncology. Oncology teachers should consider adopting the evidence based approaches outlined in this review, and there should be more emphasis on educational research within the field of oncology.