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Assessment of clinical breast examination training in a Colombian medical school: Is there room for improvement?

Sergio A. Acuna, MD ; Fernando A. Angarita, MD ; Mauricio Tawil, MD ; Diego Buitrago, MD ; Juan Carlos Ayala, MD ; Lilian Torregrosa, MD 1




As screening mammograms (SM) have proven to be highly sensitive in detecting non-symptomatic abnormalities, the use of clinical breast exam (CBE) has steadily declined. Based on current evidence, the American Cancer Society has included it, along with breast self-examination and mammograms, as a tool in the early detection of breast cancer. In Colombia, an adequate CBE is even more important due to the unequal access women face to get SM. In such cases, an accurate CBE will be the only initial detection instrument given to them. To face this, the Colombian National Cancer Institute has gone on to include it in its current guidelines. Though structured CBE training is generally included in medical schools abroad, in Colombia, medical students are often left to learn how to perform it through incidental opportunities during rotations, leading them to posses modest skills and confidence in their technique. Thus, in order to improve current CBE proficiency amongst medical students in our medical school, it is important to know what has been achieved by traditional teaching methods and what a structured teaching course can accomplish in our center.

Standardized Simulation and Multimedia-Based Instruction of CBE This training session was carried out by two attending breast surgeons and consisted of the following steps:

STEP 1 Lecture and Instruction Video

STEP 2 Silicone Model Workshop

1. Evaluate current knowledge of CBE in medical students taught by traditional means. 2. Examine the effectiveness of introducing standardized simulation and multimedia-based instruction (SSMBI).

Students were individually instructed by one of the surgeons. A fellow classmate would wear the silicone model and act as a patient.

STEP 3 Individual Practice Session

STEP 4 OSCE and Feedback Session

After obtaining verbal consent, medical students in clinical clerkship years (Year 3 to Last Year+) [n=341] were surveyed using a tool that asked about the technique and its role in clinical practice, as well as the level of exposure they had during rotations. Traditionally, students are given a 10 minute lecture in their physical examination class in Year 3 and practice throughout rotations in general surgery and obstetrics/gynecology by sporadic patient contact. Results were manually entered into a data base (Excel, Microsoft Co, USA) and analyzed by the authors who did not participate in the second phase of this study.

Fifty-two students were randomly selected from the traditionally trained group and compared with a group of Year 4 medical students who had not been exposed to traditional CBE training (n=68). The latter group would undergo SSMBI. Both were evaluated with the same written test and Objective Structured Clinical Examination (OSCE).

Traditionally Trained Medical Student N=52

Theoretical Evaluation

Structurally Trained Medical Students



Traditionally Trained Medical Student’s CBE Knowledge

Students who underwent SSMBI fulfilled all the basic steps in CBE and scored higher than traditionally trained students (100% versus 69%, p<0.00001).

Do you consider you know how to properly carry out a CBE?

12% 53 of these students participated in Phase 2, and only 20% proved to really know the correct technique.

No Yes 88%

✓ Average number of steps described: 1.2 (SD: 1.2, Range: 0-4). ✓ Average number of justifications mentioned: 1.3 (SD: 1, Range: 0-4) ✓ Average number of CBE seen per student: 6.2 (SD: 7.8, Range: 0 – 35)

Students had an appropriate time to practice.

✓ Last year students marked significantly higher scores in all aspects of the survey when compared to other years (p=0.0001). How do you grade your CBE Training during school?

Phase I: CBE Knowledge Amongst Medical Students

Phase II: CBE Traditional Training versus SSMBI

OSCE Scores

✓ Average number of CBE performed by students, with or without staff physician supervision: 2.9 (SD: 4.9, Range: 0 – 30).

Materials and Methods With review board approval from the Pontificia Universidad Javeriana School of Medicine in Bogotá, Colombia, a two-part prospective study was carried out between October 2008 and June 2009.


Small groups (4-5 students) attended a one-hour lecture with two breast surgeons, followed by a ten-minute instruction video which was developed by out group.

General Objectives:

20 Question Survey


Department of Surgery, Pontificia Universidad Javeriana, Bogota, Colombia; 2 Breast and Soft Tissue Clinic, Centro Javeriano de Oncologia – Hospital Universitario San Ignacio, Bogota, Colombia


Year 3 – Year 6 Medical Students N=341


The OSCE was set up so that the examiner (staff breast surgeon) was in one room watching the examine perform CBE in different simulated clinical settings medical, via a closed-circuit broadcasting. Following this, students were given scores and recommendations.






• After formalized CBE instruction, students dramatically improve their ability to detect breast masses.


Very Necessary

1.7 0








70.1 0









Sixty percent of surveyed students considered that the training they received was “insufficient” and 70% considered it a “very necessary” skill.

Traditional Training versus SSMBI Table 1. Theoretical Test Results distributed by training method

Measures Average Number of Steps Described

Traditional (n=52) N(%)

SSMBI (n=68) N(5)


• A single focused breast skills workshop is more effective than the traditional ambulatory setting for teaching clinical breast examination skills.





• Students taught by traditional methods obtain performance as they gain more clinical experience.

How do you grade your CBE Training during school? Completely Unnecessary



p value

• SSMBI is limited because experience in actual breast examination settings is required in order to: • Perfect this skill and consolidate physician-patient interaction. • Teach patients about the importance of breast cancer, its symptoms, risk factors, and other early detection strategies. • Discuss the benefits and limitations of self examination and to improve the technique for those patients who desire to practice it.





31 (59.6)

66 (97.1)



30 (57.7)

59 (86.8)



36 (69.2)

67 (98.5)



17 (32.7)

42 (61.8)




18 (34.6)

60 (88.2)


The ability to execute appropriate CBE was evaluated taking into account the following objectives:





• Association of American Medical Colleges. The AAMC Project on the Clinical Education of Medical Students. Washington, DC: Association of American Medical Colleges; 2005.

Correct Number of True/False Questions




• Flegg KM, Rowling YJ. Clinical breast examination. A contentious issue in screening for breast cancer. Aust Fam Phys 2000;29:343–6.

❑ Identifies the steps prior to beginning CBE (washes hands, explains what the examination will consist of to the patient, and obtains verbal consent). ❑ Identifies the adequate positions to carry out CBE.

Significant improvement in the number and description of CBE steps described by those students who participated in SSMBI.

Traditionally trained students failed to:

❑ Carries out visual inspection of the breast, taking into consideration and mentioning anatomical limits of the breast, symmetry and contour, and dermatologic signs of disease.

✓ Identify why CBE is justified.

❑ Performs accurate physical examination of the breast using an appropriate palpation pattern.

✓ Describe the axilla examination as part of CBE.

✓ Recognize the importance of different levels of pressure to identify deep versus superficial lesions


• Meissner HI, Breen N, Yabroff KR. Whatever happened to clinical breast examinations? Am J Prev Med 2003;25:259 –63. • Smith RA, Cokkinides V, von Eschenbach AC, et al. American Cancer Society guidelines for the early detection of cancer. CA Cancer J Clin 2002;52:8–22.

• Park BW, Kim SI, Kim MY, et al. Clinical breast examination for screening of asymptomatic women: the importance of clinical breast examination for breast cancer detection. Yonsei Med J 2000;41:312–8. • Moskowitz M. Screening for breast cancer: how effective are our tests? A critical review. Cancer 1983;32:26–39. • Baker LH. Breast cancer detection demonstration project: five year summary report. Cancer 1982;32:194–225. • Park BW, Kim SI, Kim MY, et al. Clinical breast examination for screening of asymptomatic women: the importance of clinical breast examination for breast cancer detection. Yonsei Med J 2000;41:312–8. • Barton MB, Harris R, Fletcher SW. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA 1999;282:1270–80. • Smith RA, Saslow D, Sawyer KA, et al. American Cancer Society guidelines for breast cancer screening: update 2003. CA Cancer J Clin 2003;53:141–169. • Newcomer LM, Newcomb PA, Trentham-Dietz A, et al. Detection method and breast carcinoma histology. Cancer 2002;95:470-477.

❑ Identifies palpable breast lesions in the silicone model and is able to describe them in appropriate medical terminology in the clinical chart. Each component was marked as competent, needs more practice, and incompetent. A general score was given to the examinee and it determined whether or not the student qualified as having appropriate CBE skills.

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