Enhanced skills program: Breast Diseases Goals and Objectives by CanMEDS Roles

Rotations:

Mandatory 4-week block:

1. Diagnostics Intro block: Pathology, Radiology, Genetics, Nurse Practitioner-led Rapid Diagnostic Clinic
2. Surgical Oncology
3. Medical Oncology
4. Radiation Oncology and Plastic Surgery
5. Palliative, Survivorship Care and Diagnostics
6. Elective: Elective in areas pertaining to breast health (i.e. menopause clinic, Bay Centre IUD insertion/endometrial bx) or career exploration in community breast centers for example.

Goals of the Program:

To provide enrichment in the area of benign and malignant breast disease and exposure to issues facing breast cancer survivors. This PGY3 program provides an opportunity to develop competency in the area of breast cancer prevention, screening, risk-assessment, diagnosis, management, surveillance, palliation and survivorship care. The six-month training program enables family physicians to develop a skill set necessary to be a leader in breast cancer risk reduction, high-risk assessment, timely detection and management. Graduates will be able to perform at the level of a consultant in a shared-care model with the primary care physician and the oncology team. Moreover, they will be able to promote excellence in breast health through education and advocacy to both patient and primary care inter-professional health providers.

Medical Expert:

The resident in the Breast Diseases PGY3 Enhanced Skills Program will:

1. Demonstrate expertise in the identification, diagnosis and management of common and uncommon family medicine problems

2. Engage patients in health promotion, including prevention and screening according to evidence based family medicine guidelines

3. Be able to describe the pathological characteristics of benign and malignant breast disease.

4. Demonstrate competence in breast assessment and the ability to investigate and manage common breast-related patient presentations such as:

           a. A palpable breast mass or skin change

           b. Indeterminate breast imaging abnormality

           c. Nipple discharge

           d. Breast pain

           e. Pathological indicators of high-risk or patient with strong family history of breast cancer

5. Demonstrate expertise in the assessment and clinical management of benign breast diseases such as:

           a. Cysts

           b. Fibroepithelial lesions

           c. Mastitis or breast abscess

           d. Atypia or lobular carcinoma in situ

           e. Papillomas

           f. Mammographic abnormalities ie. microcalcifications

          g. Pathological benign diagnoses ie. radial scars and pseudoangiomatous stromal hyperplasia

6. Demonstrate the ability to investigate and manage patient presentations suspicious for breast cancer.

7. Demonstrate competence in selecting appropriate breast imaging modalities.

8. Demonstrates competence in interpretation of findings and management of results from mammogram, tomosynthesis, ultrasound, and MRI studies.

9. Demonstrate knowledge of indications, contraindications, risks and benefit of cyst aspiration, fine-needle aspiration biopsy, and skin (punch) biopsy procedures.

10. Demonstrate technical proficiency in fine-needle aspiration, fine-needle aspiration biopsy and skin (punch) biopsy procedures.

11. Demonstrate clear understanding of breast sampling techniques in order to counsel patients on the following tests:

          a. cyst-aspiration

          b. fine-needle aspiration biopsy

          c. ultrasound-guided core biopsy

          d. stereotactic core biopsy

          e. skin/punch biopsy

          f. mri-guided biopsy

12. Demonstrate consultancy-level skills in the assessment and quantification of breast cancer risk using IBIS, Breast Cancer Risk Assessment Tool (BCRAT), and/or BOADACEA tools, in order to adequately counsel patients on prevention and surveillance strategies.

13. Effectively discuss breast cancer risk reduction lifestyle and pharmacotherapy strategies and management in the high-risk patient setting.

14. Appropriately identify candidates for consideration of genetic testing

15. Be comfortable discussing the value of preventative surgeries in mutation carriers.

16. Appropriately refer patients to the high-risk screening program through the Ontario Breast Screening Program.

17. Demonstrates accuracy in interpreting the surgical pathology report to inform management of breast cancer or benign breast disease.

18. Demonstrate the ability to counsel patients on the surgical management of breast cancer (including indications and rationale for breast surgical procedures including benign excisional biopsy, needle localization, lumpectomy, duct excision, mastectomy, sentinel node biopsy, axillary node dissection).

19. Demonstrate appropriate management of post-operative patient follow-up including management of lymphedema and seroma.

20. Demonstrate the ability to discuss rationale of common options for breast reconstruction.

21. Demonstrate knowledge of the indications, contraindications and approach to chemotherapy and hormonal or targeted therapy for breast cancer risk-reduction and treatment.

22. Describes and manages potential toxicity and side-effects of chemotherapy or hormonal therapy treatments.

23. Demonstrates knowledge of the principles of care in the metastatic breast cancer setting.

24. Demonstrate an understanding of principles of care in medical and radiation oncology, and exhibit competency in patient support, symptom and side-effect management.

25. Counsel patients on indications and contraindications of radiation therapy following lumpectomy, mastectomy, chest wall recurrence, or in an emergency/palliative setting.

26. Demonstrate knowledge of acute and long-term side effects of radiation therapy.

27. Describe different options available for breast reconstruction including rationale for timing (immediate versus delayed) or procedure (TRAM, tissue expander, implant, DIEP, LATs, mastopexy, and nipple reconstruction).

28. Demonstrate comprehensive knowledge of the principles of palliative care management.

29. Demonstrate a clear approach to symptom management, grief, and supportive care in the palliative setting.

30. Demonstrate a clear approach to survivorship care following breast cancer diagnosis.

Communicator:

The resident in the Breast Diseases PGY3 Enhanced Skills Program will:

1. Build rapport through empathetic and therapeutic relationship with patients and families to effectively develop a shared care plan whenever possible.

2. Appropriately councel patients on breast cancer prevention and risk reduction.

3. Obtain a thorough patient history and communicate the clinical impression to the patient and family in a clear and compassionate manner.

4. Accurately elicit and synthesize relevant information for patients with careful attention to the psychosocial context.

5. Effectively interpret and communicate current screening guidelines with patients and referring physicians to reflect individual patients contexts. 

6. Effectively conveys the difference between screening and the diagnosis process inclusing the role of breast investigations and pathological assessment. 

7. Communicates the clinical impression to patients and families in a clear and compassionate manner.

8. Communicates the breast cancer diagnosis to patients and their families in a patient-centred manner.

9. Engage patients and their families in patient-centered challenging conversations i.e. malignant diagnoses.

10. Resolve conflicts in a manner that respects those involved.

Collaborator:

The resident in the Breast Diseases PGY3 Enhanced Skills Program will:

1. Participate effectively and efficiently within an inter-professional healthcare or family health team.

2. Demonstrate the ability to effectively collaborate with inter-professional team in breast cancer diagnosis.

3. Liaise with, and refer appropriately to members of the breast oncology team for patient management when warranted, and assist patient through the breast cancer journey.

4. Communicate necessary information with inter-disciplinary team members.

5. Present clinical cases to medical team members in a clear and organized manner.

6. Communicate the clinical impression in a clear and comprehensive manner to the referring physician and to members of the medical team via the dictated clinical note and direct communication as needed.

Leader:

The resident in the Breast Diseases PGY3 Enhanced Skills Program will:

1. Recognize and address patient concerns with attention to the judicious use of healthcare resources and effectiveness of individual breast investigations in the management of breast disease.

2. Recognize patients who are ready for discharge to their primary care providers, in order to help manage overall clinical volumes and access to breast assessment.

3. Manage time to maintain comprehensive family medicine skills in addition to dedicated training in Breast Diseases.

4. Appropriately refer to the Rapid Diagnostic Clinic or conventional radiology for breast investigation by balancing the need for timely access to care with overall program effectiveness and efficiency.

5. Actively engage and participate in interdisciplinary rounds with the minimum of 2 cases presented at radiology review rounds and subsequent documentation of outcome.

6. Participate in central department leadership skills develop program

Health Advocate:

The resident in the Breast Diseases PGY3 Enhanced Skills Program will:

1. Promotes the health of individual patients, communities, and populations

2. Advocates for patients to consultants as well as third parties such as insurance companies and outside agencies

3. Elicit patient concerns and anxieties relating to the breast clinical presentation, and respond to these needs as a part of ongoing patient care.

4. Identify and help manage the medical and psychosocial needs of patients receiving both benign and malignant breast diagnoses.

5. Participate in health promotion by counselling patients on lifestyle changes that may mitigate breast cancer risk or breast symptomatology.

6. Encourage and participate in discussions on breast cancer screening with both patients and family medicine colleagues.

7. Recognize and respond to the priority health needs of the patient within their communities’ practice resources.

8. Advocate for ongoing community education, research, and support for breast diseases in the community and/or nationally.

Scholar:

The resident in the Breast Diseases PGY3 Enhanced Skills Program will:

1. Demonstrate skills in the critical appraisal of literature

2. Contributes to the scholarly activities of the breast centre and family practice unit, including rounds, teaching and supervision of residents and medical students in the clinics as appropriate.

3. Participate in clinical and/or didactic teaching about breast diseases to medical students, clinical clerks, or family medicine residents.

4. Exhibit an understanding of current NCCN guidelines when formulating management plans in the diagnostic, treatment, and surveillance settings.

5. Promote and support survivorship care in the community primary care setting through education or communication with community physicians.

6. Engage in a small academic project during the 6-month training period i.e. writing case report, patient education materials, or other mutually agreed upon endeavours.

Professional:

The resident in the Breast Diseases PGY3 Enhanced Skills Program will:

1. Demonstrate professionalism in both clinical and educational roles (punctuality, responsibility, accountability, honesty, integrity, compassion)

2. Demonstrates a commitment to their patients, profession, society and the population of women through ethical practice

3. Conduct his or herself respectfully and compassionately with patients and colleagues.

4. Meet college standards for appropriate and timely record keeping and follow-up of results.

5. Show respect for patient confidentiality and consent.

6. Inform supervisory team when faced with a conflict of interest

7. Recognize own limitations and seeks appropriate help while accepting constructing feedback.

8. Maintain appropriate boundaries in work and learning situations.

9. Dress in appropriate business professional attire for patient-care context.

10. Attend regularly scheduled rounds.