1. 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

2. 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

3. 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.

4. Hypothesis Implementation of an OBJECTIVE and IMMEDIATE feedback system using a MRH improves the thoroughness of CBE Reflected in learners of higher professional levels

5. 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

6. Virtual PatientLife-sized Mannequin Mixed Reality Human (MRH)

7. Breast Simulator Foam rubber breast overlying a silicone implant –24 pressure sensors –Interchangeable masses Breast Masses –M1 periareolar, deep, hard –M2 UOQ, superficial, soft

9. 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

10. 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 ± 1.960.047 Faculty (n=5)12.90 ± 11.220.062 * p value<0.05, data analyzed by repeated measures ANOVA

11. Most Commonly Missed Areas * p value<0.05, data analyzed by repeated measures ANOVA Percentage of Participants Missing Area of Examination

12. Palpation of Masses During CBE * p value<0.05, data analyzed by repeated measures ANOVA Percentage of Participants Palpating Masses

13. Masses Palpated by Patient Experience Reported as percentage of participants * p value<0.05, data analyzed by repeated measures ANOVA Participants Palpating M1Participants Palpating Both Masses Number of CBE on Real Patients

14. Conclusions 1.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