Residents' breast examination performance. How often? How well?

Area of Science:

• Oncology
• Medical Education
• Health Services Research

Background:

• The American Cancer Society recommends annual clinical breast examinations (CBE) for women at average risk starting at age 40.
• Adequate performance of CBE by healthcare professionals is essential for early breast cancer detection.

Purpose of the Study:

• To assess the adequacy of clinical breast examinations (CBE) documented by house officers in a community teaching hospital.
• To evaluate methods for improving CBE documentation rates.

Main Methods:

• A retrospective chart review of women aged 50 and older admitted to medical and obstetrics/gynecology services.
• Three audit series were conducted: baseline, after verbal emphasis on CBE, and with dedicated vs. non-dedicated documentation forms.

Main Results:

• Verbal emphasis on CBE during conferences yielded only a slight improvement in documentation.
• Using a history/physical examination form with a dedicated slot for CBE documentation resulted in an 88% documentation rate.
• No CBE documentation was recorded when forms lacked a dedicated slot.

Conclusions:

• Dedicated documentation forms are more effective than verbal reminders in improving house officers' clinical breast examination (CBE) performance and documentation.
• Standardizing documentation tools can enhance adherence to breast cancer screening guidelines.