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
0
20
40
60
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