A Description of Breast Models Used to Teach Clinical Skills

Abstract

Background:

Health care trainees lack opportunities to practice breast assessment and clinical skills with patients, making breast models significant for hands-on training. Insufficient training leads to low competence across practitioners in breast health areas of practice, including clinical lactation. The aim of this review was to describe types of breast models used to teach clinical skills of the breast across breast health areas. The secondary aims were to describe education interventions that included each model and identify whether multiple skin tones were available in models.

Methods:

Authors conducted a scoping review to identify which types of breast models are used to teach clinical skills across breast health areas of practice and determine gaps in literature regarding how clinical lactation skills are taught. The literature search was conducted in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, MedLine, and ProQuest. Inclusion criteria were students/professionals engaging in breast model simulation. Eighteen studies were reviewed. Authors extracted data on participants, breast health area, breast model, intervention, evaluation, general outcomes, skin tone, and research design.

Results:

The most common skill area was clinical breast exam (n = 7), while least was breastfeeding education (n = 1). Most models were commercial (n = 12). Zero studies described skin tone. Generally, breast model simulations were correlated with increased clinical skills and confidence regardless of model used.

Conclusions:

Despite demonstrated gain of skills, this review reveals inconsistent use of breast models and evaluation, exclusion of diverse skin tones, and lack of breast models reported to teach clinical lactation skills.

Introduction

Hands-on clinical and surgical training for intimate body parts including the breast are limited because patients are hesitant to reveal an intimate body part to health professional trainees.¹ Performing a clinical breast exam is a necessary skill of health practitioners for routine physical examinations for all women; in particular, it is significant for breastfeeding management or for screening and diagnosing breast anomalies.^2,3 For example, a female patient might have interaction with medical trainees in the hospital setting within the context of a breastfeeding assessment in the early post-partum period. However, these real-life patient interactions are often not feasible during medical training.⁴ As a result, health care trainees have a limited number of opportunities to interact with patients and practice hands-on breast assessments. Clinicians without adequate training for clinical skills with an intimate body part have low competence and confidence and are at risk of making errors in clinical decision making, resulting in morbidities that may have otherwise been preventable.^5–7

High-fidelity simulation, which represents the psychological, environmental, and situational factors within clinical scenario, is the gold standard for clinical skills acquisition in nursing and medical education.^8–10 Therefore, high-fidelity breast models should appropriately represent anatomy, physiology, and racial/ethnic backgrounds through realistic features and abilities (look, feel, and functionality), such as expression of milk from nipples by hand, use of a breast pump with different flanges, multiple skin tones, ability to perform a biopsy, and ability to aspirate fluid.^10–12

However, the training that is provided to pre-licensure or practicing health practitioners for breast assessments vary and include low- (i.e., unrealistic) or high-fidelity simulators, passive learning (e.g., watching a video), or a hybrid approach (i.e., using two or more approaches).¹³ For simulated experiences, hospitals and training programs have used sock puppets, the instructors' or learners' own elbows, cloth dolls, poultry breasts, and silicone models for teaching breast assessments or surgical skills of the breast.¹⁴ Without the standardization of teaching methods or wide-spread use of high-fidelity simulators, health professional students, medical students, and residents enter their field with varying skill and confidence levels for breast assessments or surgical techniques.¹⁴

One example of a field in which breast assessment skills are repeatedly reported as insufficient is clinical lactation.¹⁵ The lack of appropriate health professional care is one of the top barriers reported for early cessation of breastfeeding by new mothers even though several leading health organizations have called out the importance of physician education in clinical lactation.^16–18 The use of high-fidelity breast models has recently been reported in midwifery students to result in efficacy and development of clinical lactation skills,¹⁹ yet widely speaking health professionals are still reporting a lack of confidence and ability to appropriately care for breastfeeding patients.^20,21 With a lack of ability across health professions to manage breastfeeding patients' care, breastfeeding rates will continue to be inadequate and continue to feed into disparities we see across populations.⁷

To unveil the types and number of breast models being reported to teach clinical lactation skills, we conducted a scoping review of breast models used for training of clinical skills in breastfeeding management, the general breast exam, and surgery. The primary aim was to describe the types of breast models used to teach clinical skills of the breast across different breast health areas. The secondary aims of this review were to describe the education intervention that included each breast model and to identify whether multiple skin tones were available in the model used.

Methods

Research design

The authors conducted a scoping review to describe the types of breast models used to teach clinical skills across various breast health areas of practice. The authors could not conduct a meta-analysis due to the inconsistency of the type of research studies utilized for the various educational interventions and diverse types of breast models used within each intervention. The scoping review allowed the authors to identify which types of breast models were used to teach clinical lactation skills across various breast health areas of practice and to determine gaps in the literature regarding how clinical lactation skills were taught and reported on. Additionally, it is of significance to understand across breast health areas including lactation/breastfeeding, general clinical breast exams, breast surgery, radiology, and biopsy, whether diverse skin tones are being utilized to identify if this is a gap in health profession training that could ultimately reduce health disparities, including disparities in breastfeeding, if addressed.

Sample

A total of 713 articles resulted from our initial search (Fig. 1). The inclusion criteria were determined before the literature search was initiated to best capture the study aims. The inclusion criteria included: (1) use of a breast model in an educational setting, (2) an education intervention with proposed outcomes, (3) undergraduates, graduate students, trainees, or professionals engaging in the education intervention, (4) original research publication in English, and (5) a study published in a peer-reviewed journal between 2011 and 2019. Exclusion criteria were studies published before 2011 and those utilizing virtual or mathematical simulation models.

FIG. 1.

Sample selection process.

The author who did the initial search excluded duplicated search results and those articles that were published before 2011 (n = 378). The article titles (N = 713) were screened by this author and one more. Articles were excluded (n = 643) after title screening if they there was not an indication of potential use of a breast model or an area of breast health was not indicated in their title. Article abstracts (N = 70) were then screened. Articles were excluded (n = 41) after the abstract screening for the following reasons: education intervention missing (n = 19); virtual/digital breast models used (n = 7); breast model missing (n = 5); subject/participants were patients (n = 4); described mathematical models of imaging technology (n = 3); conference abstract (n = 2); manuscript not available in English (n = 1).

The remaining full articles were screened (N = 29) after which 11 were excluded for the following reasons: education intervention missing (n = 6); breast model missing (n = 3); conference abstract (n = 1); and article not available in English (n = 1). Any discrepancies in exclusion strategies were discussed between the two authors. The final sample consisted of 18 studies that matched the inclusion criteria and were fully reviewed by the authors (Fig. 1).

Data collection

One author conducted the initial literature search in January 2020. The search terms were developed with assistance from a Health Sciences Informationist/Librarian at the author's institution. The search was conducted in the following five databases: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, MedLine, and ProQuest. The search strategy for each database was developed, finalized, and stored within a Google sheet. Upon completion of a search within a database, the items were downloaded into a Zotero library.

The search strategy used Boolean techniques. An example of the terms included are represented here in our MEDLINE search: (“Simulation Training”[Mesh] OR “Simulation Model” OR “Simulation Models” OR Simulator*[All Fields] OR Simulation* OR “Task trainer” OR “Task trainers” OR Manikin*) AND (“breast feeding”[mesh] OR “breast feeding” OR “breastfeeding”[all fields] OR “breast model”[all fields] OR “lactation”[all fields] OR “Breast”[TW] OR “Mammary gland”) AND (“Education” OR “Training” OR ((Knowledge OR Skill*) AND (Master* OR Acquir* OR Build*)) OR “Learning” OR “Education medical” OR “education professional” OR “students health occupations”). Please note that breastfeeding terms were specifically used to eliminate other non-human mammal articles.

Measurement

To determine the extent of breast models being used to specifically teach clinical lactation skills and what types of models were being used, the specific variables analyzed by the authors included type of research design, breast model, education intervention, evaluation techniques, and model skin tone. The main types of research design included were case study, correlational, longitudinal, experimental, or clinical trial (Supplementary Table S1). The types of breast models were defined as simulators but excluded computer-based simulated algorithms. The education intervention was defined as the study participants acting as learners by using the breast model to gain knowledge or skills. The evaluation techniques were defined as assessing learner knowledge or skills after interacting with the breast model. Skin tone was determined by mention of the model's skin tone in each article's Methods or Results sections.

Data analysis

The authors used a Google Sheet as a data abstraction tool for real-time collaboration. The Google Sheet contained a table with the following variables for each column: (1) Research aim/question, (2) Study design, (3) Learner type (including profession), (4) Location, (5) Type of breast health care, (6) Type of breast model, (7) Breast model manufacturer (if described, we explicitly included in our table), (8) Education intervention description, (9) Evaluation description, (10) Validity of evaluation tools, (11) Reliability of evaluation tools, (12) General direction of learning outcomes, (13) Appropriate conclusions, (14) Potential biases, and (15) Breast model skin tone (if applicable or stated; yes/no).

We critically analyzed the sample of articles by first deconstructing the data variables within each article.²² The deconstructed variables were analyzed by two investigators for methodological congruence to ensure the research aim, study design, data collection, and analysis were in alignment. The two investigators also cross-examined each other regarding potential biases, appropriateness of stated conclusions, and the validity and reliability of the evaluation tools. The investigators cross-examined each other and discussed discrepancies. The learning outcomes were generalized regarding direction. The frequencies for research study design type, breast model type, potential biases, valid and reliable evaluation tools, and skin tone were calculated. The variables were reconstructed across the articles to compare contexts and identify strengths, weaknesses, and gaps in the literature.

Results

Characteristics of the sample

A total of 18 articles matched the inclusion criteria and underwent a full review (Table 1). Twelve (67%) of reviewed articles were quasi-experimental studies (Tables 1 and 2),^23–34 4 (22%) of the articles were case studies,^4,35–37 and 2 (11%) were experimental studies with clearly defined controls.^38,39

Table 1.

Characteristics of the Articles Reviewed (N = 18)

First author (year)	Study aim	Participants (N)	Type of research design
Angarita (2019)²³	Determine if standardized simulation and multi-media-based training resulted in better examination scores and detection of abnormal findings than the traditional teaching method	Fourth Year Medical Students (N = 120)	Quasi-experimental
Browne (2017)³⁵	Evaluate role of an anthropomorphic breast sonography device in training and assessment in a clinical environment	Radiology Trainees (n = 4) and Radiologists (n = 4)	Case
Browne (2019)³⁶	Evaluate impact of a breast ultrasound training workshop, using anthropomorphic breast phantoms simulating sonographic characteristics of breast tissue, including benign and malignant lesions, in radiology residents	Second to Fourth Year Radiology Residents (N = 9)	Observational case
Giles (2017)²⁴	Assess impact of simulation scenario on attitudes and knowledge of radiographers and sonographers toward interprofessional learning in breast cancer care pathways	Postgraduate Medical Imaging Students (N = 35)	Quasi-experimental
Jain (2014)²⁵	Determine if incorporation of inanimate breast simulation helped medical students: improve clinical skills, confidence levels, and understanding during their facilitated sessions and improve professional behavior and prep for the facilitated session and perform better on patient exams in their third-year clerkships; find out if simulation continued to yield results when used in curriculum for all second-year medical students before the facilitated session	Second Year Medical Students (N = 43)	Quasi-experimental
Kazan (2016)²⁶	Develop part-task trainer that allows plastic surgery trainees to acquire skills necessary for augmentation mammoplasty and assess its value as a training tool	Plastic Surgeons (N = 4)	Quasi-experimental
Kazan (2018)²⁷	Perform face, content, and construct validations of Montreal mentation mammoplasty operation simulator for subpectoral breast augmentation procedures and assess reliability of assessment scales used	Plastic Surgery Residents (n = 14) and Expert Plastic Surgeons (n = 7)	Quasi-experimental
Laufer (2015)²⁸	Evaluate recommendation patterns of different specialties for work-up of a palpable breast mass using simulated scenarios and CBE models	Physicians (N = 318)	Quasi-experimental
Leff (2016)²⁹	Evaluate the construct validity of technical skills assessments in wide local excision	Physicians (N = 318)	Quasi-experimental
Mazurkiewicz (2016)³⁰	Determine residents performance of ambulatory procedures following a case-based, interactive module on key ambulatory procedures, featuring faculty demonstrating said procedures on realistic, full-body manikin patient care simulator	Internal Medicine Residents (N = 66)	Quasi-experimental
Meng (2011)³¹	Determine if resident understanding of the American College of Radiology practice guideline for the performance of utlrasound guided percutaneous breast interventional procedures and confidence is improved with implementation of simulation exercise	Radiology Residents (n = 11)	Quasi-experimental
Murthy (2020)³²	Evaluate skill acquisition, confidence, and safety, comparing low-cost low-fidelity models to expensive high-fidelity models when performing breast core needle biopsy	Surgery or Obstetrics and Gynecology Residents (N = 36)	Quasi-experimental
Nassif (2019)³⁸	Study hybrid simulation as a tool for teaching CBE, particularly lesion detection, by incorporating a trained SP wearing a breast simulator jacket	Third Year Medical Students (N = 82)	Randomized experimental
Schubart (2012)³⁹	Determine if teaching CBE using full-torso simulator results in detection of abnormal findings and examination scores that are as good or better than traditional technique of using a SP; assess impact of simulator on self-reported comfort levels	Third Year Medical students: Control Group (n = 141), Experimental Group (n = 134)	Randomized experimental
Terzioğlu (2016)³³	Examine effect of three different instructional environments on development of psychomotor and communication skills and their levels of anxiety and satisfaction	Nursing Students (N = 30)	Quasi-experimental
Veitch (2019)⁴	Design, develop, and establish a test to determine if students can, by touch alone, identify and discriminate between simulated lesions at different adiposity levels	Fourth Year Medical Students (n = 20), Breast Surgeons (n = 5)	Case
Wang (2017)³⁴	Develop psychomotor skills after practicing endoscopic-assisted transaxillary dual-plane technique for breast augmentation on a low-cost and home-made simulator	First Year Residents of Plastic Surgery (N = 50)	Quasi-experimental

CBE, clinical breast exam; SP, standardized patient.

Table 2.

Description of the Variables Analyzed Within the Articles Reviewed (N = 18) by Breast Health Area Including Breast Model Type, Educational Intervention, Summary of Intervention Results, and Critical Appraisal

First author (year)	Type of breast model (manufacturer)^a	Intervention description	Evaluation tools	Results (indicated if significant)^b	Critical appraisal
Clinical Lactation Skills
Terzioğlu (2016)³³	Wearable breast model, plus infant simulator (not indicated in article)	Students placed in all groups: (1) nursing skills lab: watch videos, faculty demonstrate skills using breast model and wearable model, students practice skills under supervision; (2) SP lab: students counsel SPs on breast self-exam and breastfeed while SP wears model; (3) clinical practice environment: students match with real patients and repeat skills learned in skills lab and with SP, debrief with faculty	Cognitive, psychomotor, communication skills checklistSpielberger's State and Trait Anxiety InventoryStudent satisfaction form: 11 items on 3-pt scale plus open-ended questions	Psychomotor and communication skills increased as progressed in interventions (p < 0.05)Incremental decrease in anxietyIncremental increase in satisfaction as environments increased toward reality	Methodological congruence: yesPotential bias: noneValidated and reliable evaluation tools
Clinical Breast Exam
Angarita (2019)²³	Silicone breast model (not indicated in article)	Multistep curriculum: (1) anatomy reviewed using illustrations and photos, models of healthy breasts presented; (2) benign and malignant breast pathology reviewed, interchangeable materials in silicone breast models used to simulate pathologies, students instructed on how to report findings; (3) overview of CBE technique instructed via 10-minutes video; (4) individual instruction with breast model	Written examSatisfaction evaluationOSCE	Increased knowledgeConsistent CBE performanceHigher satisfaction with multistep curriculum vs. traditional	Methodological congruence: yesPotential bias: noneWeaknesses: unclear if evaluation tools are validated or reliable
Jain (2014)²⁵	Simulation breast model (Gaumard)	Participants (G1) volunteered for simulation-based workshop before gynecological teaching assistant sessions.Controls (G2) did not attend workshop.	Pre-, post-questionnaires and blinded evaluationsG1 students completed anonymous online survey asking if simulation workshop was helpfulEvaluation, with yes/no questions regarding professionalism, communication, and clinical skill	G1 group had improved knowledge (p < 0.001), clinical skill (p < 0.001), confidence (p < 0.001)G1 group performed better in all aspects of CBE	Methodological congruence: yesPotential bias: noneWeaknesses: unclear if evaluation tools are validated or reliable
Laufer (2015)²⁸	Silicone-based breast model superficial mass vs. chest wall mass (not indicated in article)	Conference attendees read case, performed CBE on breast models, completed clinical findings diagram, and recommendation form.Repeated for each model. Station-to-station progress proceeded in randomized fashion	Pre-survey (demographics, CBE experience)Documentation of mass on location diagramRecommendation form	Recommendation patterns differed across two modelsDifferences in practice patterns between primary care and specialty providers	Methodological congruence: yesPotential bias: selection biasValidated and reliable evaluation tools
Mazurkiewicz (2016)³⁰	Full-size, adult mannequin patient simulator (Gaumard)	1.5-hour case-based, interactive module on ambulatory procedures, with faculty demonstrating procedures on full-body manikin followed by direct observation of resident competence by faculty	Direct observation procedure checklistsPre-, post- surveys	CBE performance improved for each procedureComfort, confidence, intent to perform CBE increased	Methodological congruence: yesPotential bias: noneWeaknesses: unclear if evaluation tools are validated or reliable
Nassif (2019)³⁸	Tabletop breast model (MammaCare); breast simulator jacket on SP (Limbs & Things)	Breast pathology lecture and exam followed by tutorial videos on CBE and culturally sensitive communicationRandomization into hybrid simulation or control arm. Controls used low-fidelity tabletop breast model vs. intervention used SP wearing breast simulator jacket	SP graded CBE performance with CBE checklistParticipant in-clinic note and self-reported performance surveyScores and grades averaged from all OSCE stations	Higher lesion identification in hybrid simulation (p < 0.001)Likely to recommend hybrid simulation as part of curriculum (p = 0.004)Hybrid simulation developed confidence in clinical (p = 0.02), integrated theory and practice (p = 0.03)Higher satisfaction with hybrid simulation (p < 0.001)	Methodological congruence: yesPotential bias: noneValidated evaluation toolsWeaknesses: unclear if evaluation tools are reliable
Schubart (2012)³⁹	Full torso simulator (Gaumard)	Controls taught CBE using SP in 1-hour tutorial. Each student performed CBE with feedback from instructor and SPExperimental group taught CBE using full-torso simulator in 1-hour tutorialStudents performed CBE individually followed by feedback by surgeon	Pre-survey on comfort level of identifying lesion and number of CBEs performed previouslyBreast surgeon observed CBE with a checklistIndividual feedback	Higher CBE scores in experimental vs. controlExperimental group scored higher examining neck nodes, nipple retraction, skin changes, axillary evaluationNo difference in findings detected or comfort level	Methodological congruence: yesPotential bias: noneWeaknesses: evaluation tools were not externally validated; unclear if evaluation tools are reliable
Veitch (2019)⁴	Layered silicone on sloping wooden ribbed base (made by study investigators)	30-Minutes CBE training followed by demo on SP with hands-on practice. Nurse introduced students to model and explained identifying and discriminating “breast masses,.” Student guided to calibration object. Nurse observed students for 11-minutes	Testing and marking protocol determined degree of skill	Experts indicated 100% of lesionsStudents indicated 65%	Methodological congruence: unclear; small samplePotential bias: researcher influenceValidated and reliable evaluation tools
Breast Surgery and Imaging
Non-biopsy surgical procedures
Kazan (2016)²⁶	Silicone breast model: mammoplasty part-task trainer (made by study investigators)	Mock unilateral subglandular breast augmentation performed using standard instruments	Procedure scored using 5-pt Likert where 5 = most satisfactoryPost-survey with 16 items under 7 domains, open-ended responses to comment on attributes	“Value” as training tool, “relevance to practice,” “physical attributes” scored highest“Realism of experience,” “ability to perform tasks,” “realism of material” scored >3.7Average “global assessment” of trainer was 4.3	Methodological congruence: unclear; small samplePotential bias: researcher influenceValidated evaluation toolsWeaknesses: unclear if evaluation tool is reliable
Kazan (2018)²⁷	Silicone breast model (made by study investigators)	Perform subpectoral breast augmentation on simulator	Performance assessed by objective structured assessment of technical skills that encompassed: (a) GRS, (b) surgery-specific MOAT, (c) surgery-specific checklist	Experts' performance higher than residents' according to GRS, MOAT, Checklist scoresFace and content validations showed excellent results	Methodological congruence: unclear; small samplePotential bias: researcher influenceValidated evaluation toolsWeaknesses: unclear if evaluation tool is reliable
Leff (2016)²⁹	Silicone breast model on top of a gypsum casting (not indicated in article)	Perform WLE from start to finish or “skin to skin” on oncoplastic simulator	Video-based ratings of performanceODS	Differences observed between operators in performance scores on each phase of WLE procedure (p < 0.05)Differences observed between operators in ODS scores (p < 0.05)	Methodological congruence: unclear; small samplePotential bias: researcher influenceValidated and reliable evaluation tools
Wang (2017)³⁴	Fiberglass mannequin wearing compression garments with anatomical drawings (made by study investigators)	30-Minutes lecture on breast anatomy, chest and endoscopy use during breast augmentationPerform dissection on breast model to create dual plane and hemostasis of potential bleeding spot 30 × . Instructor guidance on procedure with feedback	Pre-, post- 5-item evaluation: 10-pt Likert-scale where 10 = very much	Difference (p < 0.05) before and after training regarding confidence, anatomical awareness, endoscope control including dexterity and hand-eye coordination	Methodological congruence: yesPotential bias: researcher influenceValidated and reliable evaluation tools
Ultrasound-guided biopsy procedures
Meng (2011)³¹	Turkey breast phantom with pimento olives simulating solid breast masses and tied-off, water-filled, latex glove tips simulating cysts (not indicated in article)	One resident acted as US technologist and one as physicianDirected to perform: (1) fine-needle aspiration of cyst with labeled pre-, post-aspiration images, (2) 14-gauge automated core biopsy of solid mass with labeled images of pre-, post-fire orthogonal views, (3) 10-gauge vacuum core biopsy of solid mass with images of needle positioned beneath mass centered in troughSwitched roles, repeated	Pre- and post-survey (confidence and knowledge)	Increased confidence performing biopsies, operating biopsy devices and US equipmentIncreased knowledge of needle positioning, image annotation, documentation	Methodological congruence: unclear; small samplePotential bias: researcher influence, selection biasValidated evaluation toolsWeaknesses: unclear if evaluation tools are reliable
Sutcliffe (2013)³⁷	Gel phantom breast model (Associated Brands)	Individually trained in freehand technique of US-guided core biopsy of deep breast mass overlying simulated chest wall, wire localization of deep breast mass, and fine-needle aspiration of deep breast cystTrained to perform same procedures over simulated saline implant. Taught to core biopsy enlarged axillary nodes without causing injury to axillary vessel	Pre-, post- questionnaire (confidence)Staff objectively assessed safety and competency in performing procedures, provided immediate feedback	Increased confidence for performing procedures with phantom simulation trainingIncreased confidence to volunteer for US-guided proceduresStaff were confident to allow residents to perform US-guided procedures for lesions	Methodological congruence: yesPotential bias: researcher influenceValidated and reliable evaluation tools
Biopsy procedure without ultrasound guidance
Murthy (2020)³²	High-fidelity silicone-based breast biopsy phantom (Limbs & Things); low-fidelity chicken breast and olives (made by study investigators)	1-Day, 5-hour BCNB training course: (1) perform baseline BCNB exam on model to which were randomized, (2) 4-hour lecture, (3) 60-minutes hands-on training with simulator to which originally randomized, (4) take second BCNB exam, (5) participate in third BCNB exam where crossed over to other model	Baseline examPost-examPost-intervention cross over model examPost-survey	No difference in exam scores after use of high- or low-fidelity modelsOverall increase from exam 1 to 2 and 1 to 3 (p < 0.001)Increase in mean exam scores between pre-, post-cross over intervention scores·Improved confidence in performing steps of the procedure	Methodological congruence: yesPotential bias: noneValidated evaluation toolsWeaknesses: unclear if evaluation tools are reliable
Ultrasound without associated surgical procedures
Browne (2017)³⁵	Water-based agar, silicon carbide and aluminum oxide phantom models, devices I–III (made by study investigators)	Baseline assessment of device I, followed by six 1-hour sessions on device II, and final assessment on device III	Pre-, post-training performance of trainees compared via scores on lesion detection and accurate characterization	Improved lesion detection abilityImproved lesion characterization	Methodological congruence: unclear; small samplePotential bias: researcher influenceValidated evaluation toolsWeaknesses: unclear if evaluation tools are reliable
Browne (2019)³⁶	Water-based agar, glycerol, aluminum oxide, and silicon carbide phantom models (Made by study investigators)	Overview of anthropomorphic breast US phantom design and workshop, description of pre-simulation training task2-Hour self-directed training using phantom with support material	Pre-, post-training performance of trainees compared via scores based on lesion detection and accurate characterizationTrainee evaluation of workshop (usefulness, confidence)	Increased detection and characterization scores from pre to postImproved manipulation skills demonstrated by decrease in lesions detected more than onceImproved scanningUsefulness, confidence not reported	Methodological congruence: unclear; small samplePotential bias: researcher influenceValidated evaluation toolsWeaknesses: unclear if evaluation tools are reliable
Giles (2017)²⁴	Positional mannequin, synthetic breast task-trainer phantom, and breast US phantom (not indicated in article)	2-Days of didactic sessionsParticipants divided into MDTs and defined roles of each member. MD learning required each team to adopt individual roles and identify related part in managing patient	Pre-, post-workshop questionnaires (MD and collaboration scale)Knowledge quiz gauged pathway-specific content related to professional roles	Deepened understanding of role of MDT and of own roles within MDT in patient-centered care for breast cancer management	Methodological congruence: yesPotential bias: noneValidated evaluation toolWeaknesses: unclear if evaluation tools are reliable

“Not indicated in the article” means that the authors did not state the manufacturer of the breast model.

The results are indicated in directionality of outcomes.

BCNB, breast core needle biopsy; CBE, clinical breast exam; G1, intervention group, G2, control group; GRS, global rating scale; MD, multi-disciplinary; MDT, multi-disciplinary team; MOAT, mammaplasty objective assessment tool; ODS, oncoplastic deviation score; OSCE, objective structured clinical examination; SP, standardized patient; US, ultrasound; WLE, wide local excision.

Six (33%) of the studies were conducted in the United States,^{25,28,30,31,37,39} while two (11%) took place in Ireland^35,36 and two (11%) took place in Canada (Table 1).^26,27 The remaining studies took place in the following locations: China, Turkey, Lebanon, Rwanda, Columbia, Australia, and the United Kingdom.^{23,24,29,32–34,38} The study in Rwanda represented health professional breast health interventions in a developing, low-income country (n = 1, 6%).³² The location of one study could not be determined.⁴

Twelve (67%) of the studies were determined to have methodological congruence (Table 2).^{23–25,28,30,32–34,36–39} The six (33%) that were unclear regarding methodological congruence was due to small sample size.^{4,26,27,29,31,35} Two types of biases within the studies included investigator influence (n = 9, 50%)^{4,26,27,29,31,34–37} related to the breast model being made by the investigator and selection bias for the education intervention (n = 2, 11%).^28,31 Fourteen (78%) of the investigators used validated evaluation tools^{4,24,26–29,31–38} while only 6 (33%) investigators used reliable evaluation tools.^{4,28,29,33,34,37} Six (33%) investigators used both validated and reliable evaluation tools.^{4,28,29,33,34,37} Three (17%) investigators used neither validated or reliable evaluation tools.^23,25,30

The areas of breast health investigated by each article included breastfeeding education (n = 1, 6%),³³ clinical breast exam (n = 7, 39%),^{4,23,25,28,30,38,39} breast surgery and imaging (n = 10, 56%) including the sub-categories of non-biopsy surgical procedures (n = 4),^26,27,29,34 ultrasound-guided biopsy procedures (n = 2),^31,37 biopsy procedure without ultrasound guidance (n = 1),³² and biopsy without associated surgical procedures (n = 3) (Table 2).^24,35,36

Breastfeeding education

Only one article described models used in breastfeeding management skills (n = 1 of 18, 6%; Table 2).³³ The breast model in this study came from a manufacturer, but the investigators did not mention which manufacturer it was. The intervention included a didactic portion in addition to the simulation. The surveys measured learners' skills, confidence, and satisfaction. This article did not describe skin tone of the model.

Clinical breast exam

Of the seven articles using breast models in the context of clinical exams, three of the seven described the use of a silicone-based model (n = 3 of 7, 43%),^4,23,28 while the others included a torso model (n = 1, 14%),³⁹ a jacket (n = 1, 14%),³⁸ an adult mannequin (n = 1, 14%),³⁰ or one just described as a “breast model” (n = 1, 14%; Table 2).²⁵ Of the these models six came from a manufacturer (86%),^{23,25,28,30,38,39} although two studies did not mention the manufacturer specifically,^23,28 and one was made by the investigators (14%).⁴

The interventions described were mostly traditional didactic learning environments (e.g., lecture plus simulation) (n = 6, 86%)^{4,23,25,30,38,39} and one was a validation study in which conference attendees were tasked to perform a clinical breast exam (14%).²⁸ Two studies (29%) utilized a clinical skills evaluation for baseline assessment of a model.^28,30 Four of the interventions (57%) utilized pre- and post-surveys.^25,28,30,39 One of the studies (14%) utilized practicing medical professionals (i.e., not students or residents) to evaluate the breast simulator in the intervention.²⁹ Most of the surveys measured learners' skills and confidence (n = 5, 71%).^{23,25,30,38,39} Two surveys (29%) measured learner satisfaction.^23,38 Zero studies (0%) reviewed described the skin tone of the model.

Breast surgery and imaging

Non-biopsy surgical procedures

Four of the articles reviewed described simulation of non-biopsy surgical procedures (n = 4 of 18, 22%).^26,27,29,34 Three of the four articles on surgery interventions were focused on breast augmentation (n = 3 of 4, 75%)^26,27,34 and one on oncoplastic surgery (n = 1 of 4, 25%; Table 2).²⁹ Silicone-based models were the most common type of models used for surgery training (n = 3 of 4, 75%),^26,27,29 while one used a mannequin made of fiberglass (25%).³⁴ Of these models one came from a manufacturer (25%),²⁹ although the study did not mention which manufacturer it was, and three were made by the investigators (75%).^26,27,34

Most interventions described did not include a didactic portion but rather only the simulated task (n = 3, 75%),^26,27,29 while one described a traditional didactic learning environment (i.e., lecture plus simulation) (25%).³⁴ One of the interventions (25%) utilized pre- and post-surveys.³⁴ Three of the studies (75%) utilized practicing medical professionals (i.e., not students or residents) to evaluate the breast simulator in the intervention.^26,27,29 One survey measured learners' skills and confidence (25%).³⁴ Zero studies (0%) reviewed described the skin tone of the model.

Ultrasound-guided biopsy procedures

Two articles described ultrasound-guided needle biopsies (n = 2 of 18, 11%; Table 2).^31,37 All interventions described used a breast phantom, but each consisted of unique materials. Both phantoms came from a manufacturer, although one study (n = 1 of 2, 50%) did not mention the manufacturer specifically.³¹ Both of the interventions described did not include a didactic portion but rather only the simulated task. One of the studies (50%) utilized a clinical skills evaluation for baseline assessment of a model.³⁷ All interventions utilized pre- and post-surveys. One survey measured learners' skills (50%).³¹ The surveys used in both interventions measured learners' confidence. Zero studies (0%) reviewed described the skin tone of the model.

Biopsy procedure without ultrasound guidance

Only one article described a needle biopsy without ultrasound guidance (n = 1 of 18, 6%; Table 2).³² The breast model in this study was made by the investigator. The intervention included a didactic portion in addition to the simulation. The investigators described an intervention that utilized a clinical skills evaluation for baseline assessment of a model and utilized pre- and post-surveys. The surveys measured learners' skills and confidence. This article did not describe skin tone of the model.

Ultrasound without associated surgical procedures

Three articles focused on screening procedures through ultrasounds unrelated to surgical procedures (n = 3 of 18, 17%).^24,35,36 All interventions described used a breast phantom, but each consisted of unique materials. One of the phantoms came from a manufacturer (n = 1 of 3, 33%),²⁴ but did not mention the manufacturer specifically and two were made by the investigators (67%).^35,36 One of the interventions described did not include a didactic portion but rather only the simulated task (33%)³⁵ and two described a traditional didactic learning environment (67%).^24,36 Two of the studies (67%) utilized a clinical skills evaluation for baseline assessment of a model.^35,36 All interventions utilized pre- and post-surveys.^24,35,36 One study specifically utilized the pre- and post-surveys to evaluate interprofessional collaboration and communication in breast cancer management (n = 1, 33%).²⁴ One survey (33%) measured learner satisfaction.²⁴ Zero studies (0%) reviewed described the skin tone of the model.

Discussion

This scoping review of studies that used breast models within the context of an educational experience for health professionals revealed a variety of models used, variability on the inclusion of manufacturer type in the methods, and a surprising propensity for the handmade construction of breast models by the investigators. Further, a multitude of evaluations, which were not always validated or reliable, were administered to assess participants' outcomes, even within the same field of breast health. The inconsistent features for comparison across these studies of breast models and health care professional education and assessment as well as lack of breast models reported for clinical lactation skills necessitate further discussion.

Quasi-experimental study design is commonly utilized across educational interventions, because randomized assignment to an experimental group is typically difficult or unethical due to the possible exclusion of learners to an intervention that could benefit their education.⁴⁰ Quasi-experimental design often induces selection bias,⁴¹ particularly in the case of our reviewed sample, given that the learners are in training or experts within a self-selected health field. Developing interventions that allow for randomized groupings with a well-defined control group would alleviate bias and allow researchers to determine a clearer cause and effect relationship between the breast model intervention and learning or skill outcomes.

The use of different breast models within or across disciplines to learn skills that support breast health may result in variation of competence and clinical decision making among providers. Learning and practicing skills with different types of models could potentially lead to disparities of or inaccurate care.¹⁴ This can further impact the communication or interpretation of care when health professionals of different areas of health must collaborate.⁴² In this review, the reported interventions consisted of a breast model simulation conducted within one type of health profession, whereas simulations used in interprofessional education have evidenced their success in the development of collaborative and communication skills across disciplines that work in the same health area.⁴³ In addition to the varying breast models used across interventions, the assessments also differ. This disjunction brings into question the reliability of the standards expected of health professionals who are training in a breast health field.^44,45 Future interventions should be designed based on evidence presented from validated and reliable breast models and associated assessments.

In our review, investigators that used low-fidelity or low-cost, investigator-developed models reported successful outcomes in the learners. As pointed out by Wang et al, this may be useful for institutions in developing countries where resources are limited. The preference for investigators to construct their own tabletop, low-fidelity breast models out of either turkey breasts or silicone does, however, underscore the lack of commercial breast models available for breast health simulations.

Although using low-fidelity models do show improvements in knowledge, learner satisfaction, and confidence, high-fidelity models that are realistic continue to be the gold standard.^46,47 For example, the Medical Education Technologies Inc. (METI) Human Patient Simulators (HPS) are used as a teaching tool for medical students to experience trauma scenarios and develop essential medical skills like intubation.⁴⁸ The METI HPS are designed to resemble reality and complement multiple learning strategies that foster better retention of clinical knowledge in students.⁴⁹ Realistic models foster a progression in learning to a high level of competence that transfers to patient care and retainment of skills over time.⁵⁰ Investigators should explore cost-effective use of high-fidelity breast models, such as conducting interventions with a group of individuals rather than one-one-one training.⁵¹

It has been established that there is a lack of hands-on learning of breastfeeding management skills in the education of health care professionals.¹⁴ In this study, we identified only one article that reported using a model to support clinical lactation skills.³³ About 13% of women will be diagnosed with breast cancer over their lifetime, while 86% of women give birth, and of those, up to 92% have at least one concern with breastfeeding after birth.⁵² Further, breastfeeding reduces maternal risk of maternal hypertension, type 2 diabetes, and ovarian cancer.^53,54

The insufficient focus on and inclusion of breastfeeding skills in breast health education simulations speaks to a greater narrative of the lower priority for breastfeeding in promoting population health.⁵⁵ Furthermore, this presents a missed opportunity to support the development of skills needed across health professions that are critical to support mothers and are necessary to increase breastfeeding rates and duration. The success identified by Terzioğlu et al, (2016) in utilizing integrated simulations with standardized patients, wearable breast models, and real-life scenarios with patients demonstrates both the feasibility of including breastfeeding and clinical lactation education into health professional education and the measurable benefit in increasing provider confidence and communication skills.

The lack of reviewed studies in which investigators mentioned skin tone in their breast models is exemplary of the significant underrepresentation of racial diversity in simulation training⁵⁶ even though medical and nursing educators are encouraged to include diversity across simulation training.^57,58 Simulation is well-documented to support the development of skills needed in real-life clinical scenarios; however, the lack of diverse skin tones is perpetuating systemic disparities in health care that lead to unequal treatments and outcomes for different racial and ethnic groups. Missed opportunities to be hands-on with a physical human breast with variation in skin color limits the educators' abilities to represent the full array of patients, conditions, and scenarios encountered in medicine and training and can lead to medical errors.⁵⁹ Initial diagnosis of breast cancer, in addition to clinical progression and treatment, is associated with skin color changes and dermatologic sequelae.⁶⁰

Limited exposure to patients and simulation models with different skin types may inhibit timely diagnosis of various breast cancers. When learners are only presented with white models, the retention rate of health profession trainees who are minorities is compromised.⁶¹ Conversely, for example, when presented with a Black manikin and/or a Black preceptor, Black students are better able to connect with the learning experience and it fosters a sense of belonging to the health care field as a competent provider with the ability to provide care to diverse populations.⁶² Better representation of various skin tones on realistic, high-fidelity breast models should be integrated into breast health education.

Limitations

We recognize some limitations to the design and interpretation of the studies evaluated in this literature review. First, the lack of consistency in validated or reliable evaluation tools and diverse use of breast models across different areas of breast health makes it difficult to compare the learner outcomes across the interventions. The final sample size of eighteen studies may not represent all types of breast model interventions utilized in health professional education to support breast health. In other words, interventions aimed to develop clinical skills to support breastfeeding, clinical breast exams, screening, or surgery that are incorporated into curricula or continued education may not be formally evaluated and formally disseminated for other health professional educators to understand their purpose, feasibility, and outcomes. Lastly, this review was conducted before evaluative studies that were published on the use of high-fidelity simulation clinical lactation and we believe the readership should be aware of these data.^12,14,51

Conclusion

This work provides baseline information about the use of breast models in health profession education settings and demonstrates inconsistent evaluation and a need for consistent, reliable models that can be adopted across many settings. Even though it is clear the adequate breastfeeding rates will impact public health, there is still an obvious scarcity of interventions described in medicine or allied health professions for the development of clinical lactation skills. As breast models continue to be unrepresentative of the population (i.e., representation of skin tones), breast health care will continue to be inequitable across patients.

Footnotes

Acknowledgments

We would like to acknowledge Emily Ginier, a Senior Health Sciences Informationist at the University of Michigan for her consultation for our search strategy and Anna Sadovnikova for her feedback on the written article.

Authors' Contributions

C.F.M.: Conceptualization, Writing—original draft preparation, Data curation, Visualization; C.L.: Writing—original draft preparation, Data curation; B.G.: Writing—Resources, Review and editing; O.S.A.: Conceptualization, Writing—original draft preparation, Methodology, Validation.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

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