Rescuing the Clinical Breast Examination: Advances in Classifying Technique and Assessing Physician Competency

Ann Surg. 2017 Dec;266(6):1069-1074. doi: 10.1097/SLA.0000000000002024.


Objective: Develop new performance evaluation standards for the clinical breast examination (CBE).

Summary background data: There are several, technical aspects of a proper CBE. Our recent work discovered a significant, linear relationship between palpation force and CBE accuracy. This article investigates the relationship between other technical aspects of the CBE and accuracy.

Methods: This performance assessment study involved data collection from physicians (n = 553) attending 3 different clinical meetings between 2013 and 2014: American Society of Breast Surgeons, American Academy of Family Physicians, and American College of Obstetricians and Gynecologists. Four, previously validated, sensor-enabled breast models were used for clinical skills assessment. Models A and B had solitary, superficial, 2 cm and 1 cm soft masses, respectively. Models C and D had solitary, deep, 2 cm hard and moderately firm masses, respectively. Finger movements (search technique) from 1137 CBE video recordings were independently classified by 2 observers. Final classifications were compared with CBE accuracy.

Results: Accuracy rates were model A = 99.6%, model B = 89.7%, model C = 75%, and model D = 60%. Final classification categories for search technique included rubbing movement, vertical movement, piano fingers, and other. Interrater reliability was (k = 0.79). Rubbing movement was 4 times more likely to yield an accurate assessment (odds ratio 3.81, P < 0.001) compared with vertical movement and piano fingers. Piano fingers had the highest failure rate (36.5%). Regression analysis of search pattern, search technique, palpation force, examination time, and 6 demographic variables, revealed that search technique independently and significantly affected CBE accuracy (P < 0.001).

Conclusions: Our results support measurement and classification of CBE techniques and provide the foundation for a new paradigm in teaching and assessing hands-on clinical skills. The newly described piano fingers palpation technique was noted to have unusually high failure rates. Medical educators should be aware of the potential differences in effectiveness for various CBE techniques.

Publication types

  • Observational Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Breast Neoplasms / diagnosis*
  • Clinical Competence*
  • Female
  • Fingers / physiology
  • Gynecology
  • Humans
  • Male
  • Movement
  • Obstetrics
  • Palpation / classification
  • Palpation / methods*
  • Palpation / standards
  • Physicians, Family
  • Surgeons