The Use of a Mixed Reality Breast Simulator with an Innovative Feedback System (Touch Map) to Enhance Breast

Examination Skills

Angela Gucwa MD, Aaron Kotranza BS, Andrew Raij PhD, Brenda Rosson RN, John Beatty MD, Candelario Laserna MD,

Mary Anne Park RN, MSN, Carla Pugh MD, PhD, Kyle Johnsen PhD, Benjamin Lok PhD, D. Scott Lind MD

*Research supported by CESERT grant

Background

• 10% of palpable breast cancers are not detected by radiography.

• 4.6 - 10.7% of breast cancers are identified by clinical breast examination (CBE) alone.

• “Fear of missing a lesion” as #1 cause of anxiety– 50% of medical students performing CBE

Standardized Breast Curriculum

• Transfer of skills from silicone models to live patients.

• Use of standardized patients (SP) to teach CBE improves student learning.– SP usually have normal anatomy

• Constructive feedback improves performance of CBE.

Hypothesis

• Implementation of an OBJECTIVE and IMMEDIATE feedback system using a MRH improves the thoroughness of CBE

• Reflected in learners of higher professional levels

Our Previous Work

Validation of Virtual Patients (VP)

1. To teach history-taking

and examination skills

2. To decrease anxiety in sexual history-taking

3. To decrease anxiety in intimate examinations

Virtual Patient Life-sized Mannequin

Mixed Reality Human (MRH)

Breast Simulator

• Foam rubber breast overlying a silicone implant– 24 pressure sensors

– Interchangeable masses

• Breast Masses– M1 periareolar, deep,

hard

– M2 UOQ, superficial, soft

Methods• Baseline survey completed

• 10 minute interview and CBE on a MRH patient with a breast complaint

• Feedback of CBE performed– Percentage of breast examined

– Color-coded Touch Map (Figure)• Green = Area palpated

• Red = Area missed

• Second interaction with a different MRH patient

Results• 28 participants

– 19 medical students

– 4 surgery residents

– 5 faculty

• CBE Coverage– 24 of 28 participants

improved

– MRH1 80.92% ± 11.12%

– MRH2 88.26% ± 9.42%

Group Breast Exam (%) p value*

Overall (n=28) 7.34 ± 7.72 <0.001

Students (n=19) 6.75 ± 6.92 <0.001

Residents (n=4) 3.22 ± 1.96 0.047

Faculty (n=5) 12.90 ± 11.22 0.062* p value<0.05, data analyzed by repeated measures ANOVA

Most Commonly Missed Areas

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20

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80

100

Supraclavicular NAC* Parasternal*

Exam 1

Exam 2

* p value<0.05, data analyzed by repeated measures ANOVA

Percentage of Participants Missing Area of Examination

Palpation of Masses During CBE

* p value<0.05, data analyzed by repeated measures ANOVA

0

20

40

60

80

100

M1* M2 BothPalpated*

Exam 1Exam 2

Percentage of Participants Palpating Masses

Masses Palpated by Patient Experience†

† Reported as percentage of participants* p value<0.05, data analyzed by repeated measures ANOVA

Participants Palpating M1

0

20

40

60

80

100Exam 1Exam 2

0

20

40

60

80

100Exam 1Exam 2

Participants Palpating Both Masses

Number of CBE on Real Patients Number of CBE on Real Patients

Conclusions1. CBE thoroughness and palpation of breast

lesions are improved with feedback.– Application to higher levels of learners

2. Supraclavicular, NAC, and parasternal regions most commonly overlooked during CBE.

3. Experience in CBE correlates with improved detection of lesions.– Irrespective of experience, participants improved

with feedback