Biomedical subjects
Publications and source records attributed to C A Pilgrim.
Literature documenting the breadth and quality of prevalent clinical breast examination (CBE) practice is briefly reviewed. A more thorough procedure, emphasizing training in tactile discrimination, is described and illustrated.
Two experiments were conducted to assess the relative thoroughness of three search patterns for breast self-examination (BSE). Experiment 1 compared the commonly taught concentric circles (CC) pattern to a new pattern composed of vertical strips (VS). Experiment 2 compared a radial spoke (RS) pattern to the VS pattern. Twenty-eight female subjects participated in each experiment. Each learned BSE and was post-tested using the two patterns under investigation; order of presentation was counterbalanced. BSE thoroughness was measured with the aid of a numbered grid projected on the subject's chest allowing an observer to mark each square of the grid palpated on a congruently gridded scoresheet. The percentage of the cone of the breast and of the totality of the breast tissue examined was calculated for each exam. Experiment 1 showed that the VS pattern engendered more thorough coverage of the total breast area (64.4% vs. 38.9%) and of the cone (64.1% vs. 48.7%). The results of Experiment 2 were similar: the VS pattern produced more thorough coverage of the total area (67.9% vs. 44.7%) and of the cone (70.3% vs. 57.2%). All differences were statistically reliable. Of 112 intrasubject comparisons involving the VS pattern, it produced more thorough coverage in all but nine. These results indicate that the VS pattern is the pattern of choice for maximally effective BSE.
OBJECTIVE: Manufactured silicone breast models were used to compare the accuracy of breast examination by 300 women and 62 internal medicine residents. DESIGN: The study design was cross-sectional. SETTING: The study took place in two teaching-hospital general medicine clinics. PATIENTS/PARTICIPANTS: Women were continuing care patients, ages 40 to 68, with no current breast complaint; 300 of 467 (66%) randomly selected women participated. Physicians were internal medicine residents with at least one-half day per week of ambulatory care practice; 62 of 64 (97%) participated. MEASUREMENTS AND MAIN RESULTS: Sensitivity equalled the percentage of 18 lumps correctly detected in examination of six silicone breast models. Specificity equalled the percentage of six models examined without a false-positive detection. Women's sensitivity was lower than physicians' (40% vs. 58%), but their specificity was higher (66% vs. 52%). For both women and physicians, sensitivity varied according to lump size, hardness, and depth, with women's sensitivity lower than physicians' for each characteristic. Examination duration was the technique most strongly and consistently related to accuracy. Physicians spent more time examining models than did women (2.5 vs. 2.1 minutes per model). For both groups duration related positively to sensitivity (r = 0.46, women; 0.55, physicians) and negatively to specificity (r = -0.35, women; -0.59, physicians). After adjusting for differences in technique, women's sensitivity remained lower than physicians', whereas specificity generally remained higher. The sensitivity of physicians with prior tactile experience with breast lumps was higher than that of physicians without such experience (60% vs. 51%, p = 0.01). Too few women (2%) had prior tactile experience to permit analysis. CONCLUSIONS: Women's and physicians' breast examination accuracies differ, but for the two groups accuracies vary similarly by lump characteristics and examination technique. Programs to improve breast examination should focus on specificity as well as sensitivity. Training that includes tactile experience may be important.
Health professionals' clinical breast examination accuracy and skills are not optimal. We conducted a randomized trial to evaluate changes in physicians' and nurses' lump detection accuracy and examination skills after a training program emphasizing development of tactile skills and using silicone breast models containing lumps of varying sizes, degrees of hardness, and depth of placement. Sensitivity, specificity, and examination technique were measured before and four months after training in 43 experimental group and 46 control group participants. Mean sensitivity increased from 57% to 63% in the experimental group but decreased from 57% to 56% in the control group (P less than or equal to .05). The experimental group's posttest sensitivity was better for each lump characteristic, with statistically significant improvement for the very small (0.3 cm) and medium hard lumps. Duration of examination independently predicted sensitivity. Specificity decreased from 56% to 41% in the experimental group while it increased from 56% to 68% in the control group (P less than or equal to .05). Physicians had significantly higher mean sensitivity than nurses overall, as well as for the larger (1.0 cm), very small (0.3 cm), and softer lumps, but significantly lower mean specificity (33% versus 57%, P = .03). The experimental group improved significantly in five of six technique components while the control group improved in only one. To determine the effect of training on specificity in the clinical setting, we examined medical records of women seen by a subset of experimental and control physicians during the six months following training. There were no significant differences in the proportion of abnormal breast examinations reported or the number of mammograms ordered by experimental and control physicians. Our results show health professionals can be taught successfully to improve their clinical breast examination accuracy and skills.