EPA: Benign or Malignant Breast Disease

EPA: Benign or Malignant Breast Disease

Evaluatee Name (Last, First)*

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Evaluator Name (Last, First)*

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Date of Assessment*

Rotation*

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Phase of Care

UPDATE! You can only select one phase of care. Complete an assessment for each phase of case separately.

Intraoperative

Postoperative

Preoperative/Nonoperative

For each category, select the statement that best describes the resident behavior for this patient encounter.

Preoperative: Evaluation*

Obtains history inclusive of breast disease & PERFORMS BREAST-FOCUSED PEX w/ cultural humility; gathers rad & path results but not ABLE TO INTERPRET. Develops LIMITED DIFFERENTIAL

Forms BROAD DIFFERENTIAL (includes benign/malignant dz) for breast mass, erythema, or nipple discharge; interprets breast MMG & US w/ guidance. Develops management plan for benign breast dx & healthy patient w/ ductal breast carcinoma

Independently MANAGES BENIGN BREAST DZ & STRAIGHTFORWARD ductal breast carcinoma. Independently INTERPRETS BREAST MMG & US.

Develops plan to MANAGE COMPLEX BREAST DZ (inflammatory breast CA, lobular carcinoma, locally advanced breast CA); considers sequencing of multimodal therapy & molecular diagnostics. Develops plan to manage comorbid dz that impacts treatment of breast CA

Preoperative: Communication with Patient*

Respectfully COMMUNICATES BASIC FACTS about breast disease to a patient/caregiver(s) but inconsistently uses applicable language services and audio/visual aids.

DESCRIBES A BENIGN OR EARLY CANCER DIAGNOSIS to a patient/caregiver(s) in a culturally sensitive way and answers any questions, consistently using applicable language services and audio/visual aids.

COMMUNICATES A LOCALLY ADVANCED CANCER DIAGNOSIS to a patient/caregiver(s) across barriers and cultural differences and answers any questions; formulates a plan with the patient/caregiver(s) with cultural dexterity using shared decision-making.

DESCRIBES COMPLEX DISEASE PROCESS to a patient/caregivers(s), including recurrences, unexpected metastatic disease, & second opinions; FORMULATES PLAN w/ cultural dexterity BASED ON INDIVIDUAL PATIENT CHARACTERISTICS/PREFERENCES & answers any questions.

Preoperative: Evidence-Based Management*

IDENTIFIES EVIDENCE regarding the differential and management of breast erythema, including abscess and inflammatory breast cancer

ARTICULATES CLINICAL QUESTIONS AND USES EVIDENCE TO DEVELOP A TREATMENT APPROACH for a patient with a breast mass, erythema, or nipple discharge; develops a treatment approach for benign and malignant disease

DEVELOPS AN EVIDENCE BASED OPERATIVE PLAN for a patient with early-stage breast cancer (stage 0-2)

Independently integrates all clinical information and elicits patient preferences to DEVELOP AN EVIDENCE-BASED INTERDISCIPLINARY TREATMENT PLAN for benign and malignant disease

Preoperative: Informed Consent

Communicates the elements that constitute an informed consent discussion but OMITS SOME ELEMENTS when documenting the discussion

Communicates the elements that constitute an informed consent discussion in a STRAIGHTFORWARD CASE and completely documents the discussion

Conducts an informed consent discussion related to the OPERATIVE MANAGEMENT OF BREAST DISEASE with cultural humility and completely documents the discussion

Conducts an informed consent discussion for a COMPLEX PROCEDURE with cultural humility, eliciting PATIENT PREFERENCES and documenting the risks and benefits individualized to the patient

Not applicable

Preoperative: Communication with Others*

SUGGESTS AN INITIAL PLAN for a patient with breast cancer but DOES NOT UNDERSTAND the sequencing of interdisciplinary care, including medical oncology, radiation therapy, and other treatment options

ATTENDS AND ACTIVELY LISTENS TO INTERDISCIPLINARY CARE conferences and presents information from a surgical perspective to other specialists (eg, medical and radiation oncology, pathology, radiology)

PRESENTS PATIENT CASES AT AN INTERDISCIPLINARY CARE conference; DISCUSSES CARE OPTIONS with other specialists (eg, medical oncology, radiation oncology, pathology, radiology)

LEADS AND COORDINATES AN INTERDISCIPLINARY CARE conference; facilitates professional care discussions with other specialists (eg, medical and radiation oncology, pathology, radiology); RESOLVES CONFLICT when needed

Not applicable

Case Difficulty*

Straightforward

Moderate

Complex

Intraoperative: Technical Skills*

Identifies planes w/ ACTIVE GUIDANCE/RETRACTION; removes breast from pectoralis, sometimes VEERING OFF CORRECT PLANE. Handles instruments SAFELY BUT TENTATIVELY and LACKS 2-HAND coordination; demonstrates BASIC SKILLS BUT INEFFICIENT (suturing/knot tying)

MAINTAINS DISSECTION PLANE (can’t independently enter it); visualizes and dissects the correct tissue plane between viable skin and breast tissue WITH MULTIPLE REDIRECTIONS. Handles axillary tissue INCONSISTENTLY. Controls bleeding only WITH DIRECTION.

Performs technical aspects of breast surg (creates mastectomy flaps/performs wire-guided biopsy: req assist to obtain proper margin) w/ occasional guidance. Handles axillary tissue gently & w/o excessive bleeding/trauma to surrounding structures

DEVISES/IMPLEMENTS NEW PLAN WHEN NEEDED. During image-guided biopsy, resects w/ adeq margins, & Troubleshoots Difficulties (Positive Margins On Frozen). During ALND, IDENTIFIES/PRESERVES AXILLARY VEIN, THORACODORSAL & LONG THORACIC NERVES w/ some guidance

Intraoperative: Steps of Operation*

ASSISTS w/ positioning, pt preparation, adequate exposure by providing retraction. Maintains sterile field & performs superficial wound closure. FOLLOWS INTRAOP DIRECTIONS. Performs aspiration/I&D of breast abscess or punch biopsy w/supervision.

Ensures availability of Geiger counter/localization equip. KNOWS POSITIONING OPTIONS (may select incorrectly); protects from nerve/pressure injury (can’t describe resulting morbidity). OMITS SOME STEPS in basic op plan; PROCEED TO NEXT STEPS W/ ASSIST

DRAWS CORRECT SKIN INCISIONS for breast-conserving therapy &mastectomy w/ or w/o reconstruction. PROGRESSES CASE & asks for assistance when needed. PERFORMS WLE & SLNB w/ minimal guidance. Uses lymphoscintigraphy to plan an operative approach for SLNB.

INDEPENDENTLY PERFORMS SIMPLE MASTECTOMY w/ sufficient/viable skin flaps. Independently performs primary closure, simple reconstruction, & skin grafting. IDENTIFIES/REMOVES SENTINEL NODES using radioactive tracer/blue dye/both.

Postoperative: Communication with Patient*

COMMUNICATES postop pain management, drain care, and discharge planning to a patient/caregiver(s) WITH SUPERVISION. Communicates intraop procedures, findings, and complications immediately to a patient/caregiver(s) for BENIGN DIAGNOSES

Immediately communicates operative procedures performed and intraop findings to a patient/caregiver(s) for BENIGN AND EARLY CANCER DIAGNOSES

Communicates intraop procedures, findings, and complications to a patient/caregiver(s) immediately for BENIGN, EARLY, AND ADVANCED CANCER DIAGNOSES

DISCUSSES COMPLEX AND EMOTIONALLY DIFFICULT POSTOP FINDINGS such as advanced disease, positive margins, or metastatic disease with a patient/caregiver(s) with care and cultural dexterity

Postoperative: Management*

MANAGES A PATIENT'S POSTOP pain, drain care, and discharge planning with INDIRECT SUPERVISION. Demonstrates understanding that some form of ADJUVANT THERAPY is typically required for a patient with breast cancer but is NOT ABLE TO DELINEATE PLAN.

DEVELOPS PLAN after BENIGN BREAST LESION (fibroadenoma) EXCISION. Troubleshoots clogged drain & removes drain (limited supervision). DEVELOPs POSTOP ADJ PLAN for early-stage breast CA (XRT/chemotx/hormonal therapy) but w/ some omissions/deficiencies

DEVELOPS AN ADJUVANT CARE PLAN for a HEALTHY POSTMENOPAUSAL patient with HORMONE RECEPTOR-POSITIVE breast cancer

After reviewing surgical pathology, independently develops a postop adjuvant care plan for a patient with LOCALLY ADVANCED CANCER, including consideration for further surgery, chemotherapy, or hormonal and radiation therapies

Postoperative: Complications*

IDENTIFIES EARLY POSTOP complications, including hematoma, infection, seroma, and PE, but is UNABLE TO INITIATE MANAGEMENT.

IDENTIFIES EARLY SURGICAL POSTOP complications, including hematoma and PE, and MANAGES THEM WITH INDIRECT SUPERVISION.

MANAGES POSTOP COMPLICATIONS such as hematoma and flap compromise in a patient with COMPLEX COMORBIDITIES (eg, anticoagulation, prior breast radiation). Identifies when a breast abscess is not adequately controlled after incision and drainage

IDENTIFIES AND MANAGES ALL IMMEDIATE POSTOP surgical complications, including hematoma, infection, and skin necrosis, with limited oversight

Postoperative: Care Coordination*

Demonstrates FOUNDATIONAL KNOWLEDGE OF INTERDISCIPLINARY CARE of a patient with breast cancer and SAFELY DISCHARGES a patient with ROUTINE NEEDS

Coordinates a discharge plan for a patient WITH DRAINS OR WOUND CARE NEEDS

COORDINATES A POSTOP ADJUVANT CARE PLAN for a patient with early-stage breast cancer, including radiation, chemotherapy, or hormonal therapy

CONSIDERS A PATIENT'S PREFERENCES and ability to access, afford, and coordinate transportation for adjuvant therapies such as radiation, chemotherapy, or hormonal therapy

Overall Performance*

Based on your observation, what level of autonomy would you trust the resident to perform this task at the NEXT encounter?

Limited Participation: Learner has basic knowledge and skills, attending does show and tell

Direct Supervision: Attending provides active help

Indirect Supervision: Attending provides passive help

Practice Ready: Attending is available but is not needed for routine cases/presentations, but input may be needed for complex cases

Comment*

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