Reduction of Opioid Overprescribing and Use Following Standardized Educational Intervention: A Survey of Patient Experiences Following Anorectal Procedures.

BACKGROUND: A pilot study conducted at our institution showed that a significant amount of prescribed postoperative opioids is left unused with the potential for diversion and misuse. OBJECTIVE: This study aimed to evaluate the impact of provider- and patient-targeted educational interventions on postoperative opioid prescription and use following anorectal procedures. DESIGN: Patients were enrolled on July 2019 through March 2020 after implementing educational interventions (study) and were compared with the pilot study group (control) enrolled on August 2018 through May 2019. A telephone survey was conducted 1 week postoperatively. SETTINGS: This study was conducted at a 600-bed, safety-net hospital in southern California. PATIENTS: Adult patients undergoing ambulatory anorectal procedures were included. Patients who had undergone an examination under anesthesia, had been incarcerated, and had used opioids preoperatively were excluded. INTERVENTIONS: Educational interventions were developed based on the pilot study results. Providers received education on recommended opioid prescription quantities and a multimodal pain regimen. Standardized patient education infographics were distributed to patients pre- and postoperatively. MAIN OUTCOME MEASURES: The primary outcomes measured were total opioid prescribed, total opioid consumed, pain control satisfaction levels, and the need for additional opioid prescription. RESULTS: A total of 104 of 122 (85%) patients enrolled responded to the survey and were compared with the 112 patients included in the control group. Despite similar demographics, the study cohort was prescribed fewer milligram morphine equivalents (78.8 ± 11.3 vs 294.0 ± 33.1, p < 0.001), consumed fewer milligram morphine equivalents (23.0 ± 28.0 vs 57.1 ± 45.8, p < 0.001), and had a higher rate of nonopioid medication use (72% vs 10%, p < 0.001). The 2 groups had similar pain control satisfaction levels (4.1 ± 1.3 vs 3.9 ± 1.1 out of 5, p = 0.12) and an additional opioid prescription requirement (5% vs 4%, p = 1.0). LIMITATIONS: This study was limited by its single-center experience with specific patient population characteristics. CONCLUSION: Educational interventions emphasizing evidence-based recommended opioid prescription quantities and regimented multimodal pain regimens are effective in decreasing excessive opioid prescribing and use without compromising satisfactory pain control in patients undergoing ambulatory anorectal procedures. See Video Abstract at http://links.lww.com/DCR/B529. REDUCCIN DE LA SOBREPRESCRIPCIN Y EL USO DE OPIOIDES DESPUS DE UNA INTERVENCIN EDUCATIVA ESTANDARIZADA UNA ENCUESTA DE LAS EXPERIENCIAS EN PACIENTES POSTOPERADOS DE PROCEDIMIENTOS ANORRECTALES: ANTECEDENTES:Un estudio piloto realizado en nuestra institución mostró que una cantidad significativa de opioides posoperatorios recetados no se usa, con potencial de desvío y uso indebido.OBJETIVO:Evaluar el impacto de las intervenciones educativas dirigidas al paciente y al proveedor sobre la prescripción y el uso de opioides posoperatorios después de procedimientos anorrectales.DISEÑO:Los pacientes se incluyeron entre julio de 2019 y marzo de 2020 después de implementar intervenciones educativas (estudio) y se compararon con el grupo de estudio piloto (control) inscrito entre agosto de 2018 y mayo de 2019. Se realizó una encuesta telefónica una semana después de la cirugía.ENTORNO CLÍNICO:Hospital de 600 camas en el sur de California.PACIENTES:Pacientes adultos sometidos a procedimientos anorrectales ambulatorios. Los criterios de exclusión fueron pacientes que recibieron un examen bajo anestesia, pacientes encarcelados y uso preoperatorio de opioides.INTERVENCIONES:Se desarrollaron intervenciones educativas basadas en los resultados del estudio piloto. Los proveedores recibieron educación sobre las cantidades recomendadas de opioides recetados y un régimen multimodal para el dolor. Se distribuyeron infografías estandarizadas de educación para el paciente antes y después de la operación.PRINCIPALES MEDIDAS DE RESULTADO:Opioide total prescrito, opioide total consumido, niveles de satisfacción del control del dolor y necesidad de prescripción adicional de opioides.RESULTADOS:Un total de 104 de 122 (85%) pacientes inscritos respondieron a la encuesta y se compararon con los 112 pacientes incluidos en el grupo de control. A pesar de una demografía similar, a la cohorte del estudio se le prescribió menos miligramos de equivalente de morfina (MME) (78,8 ± 11,3 frente a 294,0 ± 33,1, p <0,001), consumió menos MME (23,0 ± 28,0 frente a 57,1 ± 45,8, p <0,001) y presentaron una mayor tasa de uso de medicamentos no opioides (72% vs 10%, p <0,001). Los dos grupos tenían niveles similares de satisfacción del control del dolor (4,1 ± 1,3 frente a 3,9 ± 1,1 de 5, p = 0,12) y la necesidad de prescripción de opioides adicionales (5% frente a 4%, p = 1,0).LIMITACIONES:Experiencia en un solo centro con características específicas de la población de pacientes.CONCLUSIÓN:Las intervenciones educativas que enfatizan las cantidades recomendadas de prescripción de opioides basadas en la evidencia y los regímenes de dolor multimodales reglamentados son efectivas para disminuir la prescripción y el uso excesivos de opioides sin comprometer el control satisfactorio del dolor en pacientes sometidos a procedimientos anorrectales ambulatorios. Video Resumen en http://links.lww.com/DCR/B529.

Development and emergency implementation of an online surgical education curriculum for a General Surgery program during a global pandemic: The University of Southern California experience.

BACKGROUND: Physical distancing required by coronavirus disease 2019 (COVID-19) has limited traditional in-person resident education. We present our novel online curriculum for incorporation into traditional surgical educational programs. METHODS: The online curriculum utilized weekly sub-specialty themed faculty and resident created lectures, ABSITE practice questions, and weekly sub-specialty synchronized readings. Attendance, resident and faculty surveys, and completed ABSITE practice questions evaluated for curriculum success. Curriculum was adapted as COVID-19 clinical restructuring ended. RESULTS: 77% and 80% of clinical residents attended faculty lectures and resident led topic discussions as compared to 66% and 48% attending traditional in-person grand rounds and SCORE curriculum (both p > 0.05). 71.9% of residents and 16.6% of faculty reported improved resident participation while none reported decreased levels of participation (p < 0.001). 87.1% of residents and 66.7% of faculty preferred the online curriculum (p = 0.374). Completed ABSITE practice questions per resident increased from 21 to 31 questions/week (p = 0.541). CONCLUSION: Our online educational curriculum demonstrates success and can serve as a model for online restructuring of resident education.

COVID-19 Impact on Colorectal Daily Practice-How Long Will It Take to Catch Up?

BACKGROUND: All elective surgeries have been postponed at our institution starting 3/16/20 due to the COVID-19 pandemic. We assessed changes in hospital resource utilization and estimated the future backlog of cases in the colorectal surgery division of a large safety-net hospital. METHODS: Patients undergoing colorectal procedures from 3/16/20 to 4/23/20 (COVID) were compared with those from January through June 2018 (historical). Resource utilization rates were calculated by weekly case volumes and hospital stay in each group. A future catch up timeframe and new wait times from scheduling to surgery dates were calculated. RESULTS: The COVID and historical groups included 13 and 239 patients, respectively. The COVID group showed a 74% relative decrease in weekly surgical case rates (9.2 to 2.4 patients per week). Both groups had similar lengths of stay. The COVID group had a longer average ICU stay (1.4 ± 2.5 days vs. 0.4 ± 1.2 days, P = 0.016) and a 132% increase in ICU resource utilization. Overall, the COVID group had a 48% relative decrease in hospital resource utilization, owing to reduced volume but higher acuity. If the surgery numbers returns to pre-COVID volumes, the calculated "catch up" times range from 4.6 weeks to 9.2 weeks. Wait times for new cases may increase by 70% compared with pre-COVID levels. CONCLUSION: Cancelling elective colorectal surgeries results in a decrease in overall but increase in ICU-specific resource utilization. Though necessary, cancellations result in an increasing backlog of cases that poses significant future logistical and clinical challenges in an already overburdened safety-net hospital. Effective triage systems will be critical to prioritize this backlog.

Outcomes of colostomy takedown following Hartmann's procedure: successful restoration of continuity comes with a high risk of morbidity.

AIM: Restoration of bowel continuity following a Hartmann's procedure is a major surgical undertaking associated with significant morbidity. The aim of this study was to review the authors' experience with Hartmann's reversal. METHOD: This was a retrospective review of consecutive patients from institutional databases who were selected to undergo open or laparoscopic Hartmann's reversal at two tertiary academic referral centres and a public safety net hospital (2010-2019). The main outcome measure was the rate of successful stoma reversal. Secondary outcomes included 30-day postoperative outcomes and procedural details. RESULTS: One hundred and fifty patients underwent attempted reversal during the study period, which was successful in all but three patients (98%). Patients were 59% Hispanic and 73% male, with a mean age of 48.7 ± 14.1 years, mean American Society of Anesthesiologists classification of 2.2 ± 0.6 and mean body mass index (BMI) of 28.6 ± 5.3 kg/m2 , with 39% of patients having a BMI > 30 kg/m2 . The mean time interval between the index procedure and reversal was 14.4 months, 53% of the index cases were performed at outside institutions and the most common index diagnoses were diverticulitis (54%), abdominal trauma (16%) and colorectal malignancy (15%). In 22% of cases a laparoscopic approach was used, with 42% of these requiring conversion to open. Proximal diverting stomas were created in 32 patients (21%), of which 94% were reversed. The overall morbidity rate was 54%, comprising ileus (32%), wound infection (15%) and anastomotic leak (6%), with a major morbidity rate (Clavien-Dindo ≥ 3) of 23%. CONCLUSION: Hartmann's reversal remains a highly morbid procedure. Our results suggest that operative candidates can be successfully reversed, but there is significant morbidity associated with restoration of intestinal continuity, particularly in obese patients. A laparoscopic approach may decrease morbidity in selected patients but such cases have a high conversion rate.

Percutaneous drainage for hinchey Ib and II acute diverticulitis with abscess improves outcomes.

BACKGROUND/AIMS: The role of percutaneous drainage in Hinchey Ib and II diverticulitis is controversial. The aim of the present study was to clarify the indications for percutaneous drainage in such circumstances. MATERIALS AND METHODS: This was a single-center retrospective review at an academic tertiary care hospital. All Hinchey Ib and II diverticulitis cases admitted from 2012 to 2014 were considered. RESULTS: Overall, 104 (78%) patients underwent successful conservative treatment, whereas 30 (22%) patients underwent surgery during admission. During the index admission, abscess drainage was performed in 21 patients, of which 19 patients were successfully managed without surgery on the index admission and two patients ultimately required surgery. Elective versus same-admission surgery resulted in an increase use of laparoscopy (p=0.01), higher rate of restoration of gastrointestinal continuity with the index operation (p=0.04), and lower rate of diverting stoma formation (p<0.01). CONCLUSION: Percutaneous drainage may diminish the need for emergent surgery for Hinchey Ib and II diverticulitis. Elective surgery following conservative management increases the use of laparoscopy and decreases the rates of stoma formation.

Operative management of diverticulitis in a tertiary care center.

BACKGROUND: Diverticulitis has become a medically managed disease process; the indications and timing of surgical intervention have evolved. METHODS: We retrospectively reviewed all patients who underwent surgical intervention due to diverticular disease by the Division of Colon and Rectal Surgery from 2012 to 2014. RESULTS: Ninety-eight surgeries were performed. Indications included colovesicular fistula, multiple recurrences of diverticulitis, medically refractory diverticulitis, stricture, abscess, colocutaneous fistula, and colovaginal fistula. Average length of stay was 5.7 ± 5.9 days (range, 1 to 51). Eighteen patients (18%) required an ostomy. Postoperative complications occurred in 18% of patients, including anastomotic leak (3.3%), wound infection (7.1%), acute kidney injury (5.1%), and urinary tract infection (2.0%). Thirty-day readmission rate was 7.2%; unplanned 30-day reoperation rate was 3.1%. There were no deaths. CONCLUSIONS: The type of patient undergoing surgery for diverticulitis has changed, with selection bias toward chronic, advanced disease due to the proliferation of medical management strategies.

Long-term follow-up of Fournier's Gangrene in a tertiary care center.

BACKGROUND: After surgical debridement, the use of fecal diversion systems (such as an endo-rectal tube or surgical colostomy) in Fournier's Gangrene (FG) to assist with wound healing remains controversial. METHODS: A 6-y retrospective review of a tertiary medical center emergency surgery database was conducted. Variables abstracted from the database include patient demographics, laboratory and physiological profiles, hospital length-of-stay, intensive care unit length-of-stay, operative data, time to healing, morbidity, and mortality. RESULTS: Thirty-five patients were treated. Seventy-seven percent (n = 27) required some form of fecal diversion (21 patients using an endo-rectal tube and six patients undergoing construction of a surgical colostomy). One patient had a pre-existing colostomy before the development of FG. The remaining seven patients underwent conservative wound care with multiple daily dressing changes (no diversion system). Twenty-eight of the 35 patients (80.0%) had long-term follow-up with 100% having completely healed surgical wounds at the final clinic visit. Average time to complete wound healing was 4.8 ± 1.0 mo (range, 1.0-31.0). Of the six patients who underwent colostomy formation, two had their colostomies reversed, two were unacceptable surgical risk and did not undergo reversal (due to uncontrolled diabetes and cardiovascular disease), and two were lost to follow-up. Of the two patients who had their colostomies reversed both had complications from their reversal (leak and urinary retention). CONCLUSIONS: Surgical colostomy may not be mandatory (and might be associated with a high additional morbidity) in FG. With appropriate patient selection, it may be possible to avoid colostomy formation using a less-invasive diversion technology without compromising patient outcomes.

Factors Associated with a Short (<2 Days) or Long (>10 Days) Length of Stay after Colectomy: A Multivariate Analysis of over 400 Patients.

A prospectively maintained database of 415 patients undergoing colectomy was evaluated. We performed a logistic regression analysis to identify factors associated with 1) length of stay (LOS) of 2 days or less and 2) LOS of 10 days or more. Investigated variables included demographics, American Society of Anesthesiology (ASA) score, diagnosis, operative procedure, approach and time, transfusion requirements, and occurrence of any complications. Factors associated with a LOS of two days or less included ASA [odds ratio (OR): 0.34, 95% confidence interval (CI): 0.208-0.576], use of transversus abdominis plane block (OR: 5.259, 95% CI: 2.825-9.791), and operative time (OR: 0.98, 95% CI: 0.974-0.986). Age >65 had an OR of 1.73, though this did not reach statistical significance. Factors associated with LOS >10 days included ASA (OR: 2.152, 95% CI: 1.245-3.721), anastomotic leak (OR: 2.163, 95% CI: 1.486-3.148), ileus (OR: 8.790, 95% CI: 4.501-17.165), and surgical site infection (OR: 5.846, 95% CI: 2.764-12.362). Cancer and transfusion status were associated but did not reach statistical significance. Although operative time was longer in left-sided resections, no differences in LOS were observed. In conclusion, numerous factors are associated with short or long LOS and may help stratify resource utilization after colectomy. Further study is needed to confirm our findings.

A novel approach to assessing technical competence of colorectal surgery residents: the development and evaluation of the Colorectal Objective Structured Assessment of Technical Skill (COSATS).

OBJECTIVE: To develop and evaluate an objective method of technical skills assessment for graduating subspecialists in colorectal (CR) surgery-the Colorectal Objective Structured Assessment of Technical Skill (COSATS). BACKGROUND: It may be reasonable for the public to assume that surgeons certified as competent have had their technical skills assessed. However, technical skill, despite being the hallmark of a surgeon, is not directly assessed at the time of certification by surgical boards. METHODS: A procedure-based, multistation technical skills examination was developed to reflect a sample of the range of skills necessary for CR surgical practice. These consisted of bench, virtual reality, and cadaveric models. Reliability and construct validity were evaluated by comparing 10 graduating CR residents with 10 graduating general surgery (GS) residents from across North America. Expert CR surgeons, blinded to level of training, evaluated performance using a task-specific checklist and a global rating scale. The mean global rating score was used as the overall examination score and a passing score was set at "borderline competent for CR practice." RESULTS: The global rating scale demonstrated acceptable interstation reliability (0.69) for a homogeneous group of examinees. Both the overall checklist and global rating scores effectively discriminated between CR and GS residents (P < 0.01), with 27% of the variance attributed to level of training. Nine CR residents but only 3 GS residents were deemed competent. CONCLUSIONS: The Colorectal Objective Structured Assessment of Technical Skill effectively discriminated between CR and GS residents. With further validation, the Colorectal Objective Structured Assessment of Technical Skill could be incorporated into the colorectal board examination where it would be the first attempt of a surgical specialty to formally assess technical skill at the time of certification.

Elective versus emergency surgery for ulcerative colitis: a National Surgical Quality Improvement Program analysis.

BACKGROUND: It is unclear whether advances in the medical management of ulcerative colitis (UC) have altered outcomes for medically intractable disease. Therefore, it is essential to understand the current impact of elective versus emergency surgery for UC. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to compare outcomes for elective versus emergency UC surgery between 2005 and 2010. RESULTS: Four thousand nine hundred sixty-two patients were eligible for study (94% elective and 6% emergent). Emergency surgery patients were significantly older and frequently underwent open surgery. Emergency cases were associated with a higher frequency of cardiac, pulmonary, and renal comorbidities; postoperative complications; longer hospital stays; and higher rates of return to the operating room. CONCLUSIONS: In the era of advanced UC medical therapy, the need for emergency surgery still exists and is associated with substantial morbidity and mortality. Data are needed to determine if earlier selection of surgery would be beneficial.

Laparoscopic versus open colon resections in California: a cross-sectional analysis.

Laparoscopic surgery is associated with decreased hospital length of stay, improved perioperative morbidity, and faster return to work compared with open procedures. Despite these benefits, laparoscopy has not been universally adopted with recent implementation estimates ranging from 10 to 30 per cent. The purpose of this study was to analyze the adoption of laparoscopic techniques for colon resections in California in 2009 based on institutional colectomy volume status. A total of 14,736 patients from 320 hospitals was analyzed. The laparoscopic to open case ratios for the low (zero to 17 cases/year), medium (18 to 50 cases/year), and high (greater than 50 cases/year) volume centers were: 0.32, 0.50, and 0.92, respectively. Although the data confirmed that a laparoscopic approach reduced length of stay (LOS) regardless of volume, lower adopters of laparoscopic colectomy had a longer overall total LOS, likely related to preponderance of open cases. Therefore, the data show that higher-volume institutions appear to have implemented laparoscopic colectomy for more of their case volume, and this adoption may account for the better institutional outcomes observed in these centers.

Rectal foreign bodies: what is the current standard?

Rectal foreign bodies represent a challenging and unique field of colorectal trauma. The approach includes a careful history and physical examination, a high index of suspicion for any evidence of perforation, a creative approach to nonoperative removal, and appropriate short-term follow-up to detect any delayed perforation.

Colorectal procedures: what proportion is performed by American board of colon and rectal surgery-certified surgeons?

PURPOSE: The surgical workforce within the United States is moving rapidly toward increasing subspecialization. We hypothesized that over time an increasing proportion of colorectal procedures is performed by subspecialty-trained colorectal surgeons. METHODS: We used data from the Surveillance, Epidemiology, and End Results-Medicare program to examine the treatment of patients who underwent a colorectal surgical procedure between 1992 and 2002. We established whether the surgeon responsible for the patient's initial care was a board-certified colorectal surgeon based on a linkage with 2 overlapping data sources: 1) historical data from the American Board of Colon and Rectal Surgery and 2) the American Medical Association Physician Masterfile. RESULTS: We examined a total of 104,636 procedures; overall, 30.6% of anorectal procedures, 22.0% of proctectomies, 14.0% of ostomy-related procedures, and 11.5% of colectomies were performed by board-certified colorectal surgeons. Procedures in regions with lower population density or during urgent/emergent hospitalizations were more likely to be performed by a noncolorectal surgeon. Operations for cancer and those performed on an elective basis were more likely to be performed by a board-certified colorectal surgeon. Over time, the proportion of each of these types of cases performed by a colorectal surgeon increased. This increase was fastest for anorectal procedures. CONCLUSIONS: During the 11-year period of our study, there was a significant increase in the proportion of colorectal surgical procedures performed by board-certified colorectal surgeons.

Inflammatory bowel disease in the United States from 1998 to 2005: has infliximab affected surgical rates?

The treatment costs for patients in the United States with inflammatory bowel disease (IBD) exceed 1.7 billion dollars/year. Infliximab, an antibody to tumor necrosis factor-alpha has been extensively used to treat IBD, with 390,000 IBD patients receiving the drug since its FDA approval in 1998. We sought to determine the impact of infliximab on population-based rates of hospitalizations and surgical care for patients with IBD in the United States. We used data from the Nationwide Inpatient Sample to analyze patterns of hospital-based treatment provided to patients with IBD between 1998 and 2005. Data from this analysis were combined with census data to calculate trends in population-based rates of treatment. Overall rates of hospitalization for patients with Crohn's disease and ulcerative colitis increased significantly between 1998 and 2005 (5.1%/year and 3.4%/year respectively, P < 0.001 for each). During the same time period there were no changes in the overall rates of surgical care. The expanding use of infliximab has not significantly impacted the use of surgical procedures for patients with either ulcerative colitis or Crohn's disease, and rates of nonsurgical hospitalizations have actually increased. Even in the era of infliximab, surgical care remains a mainstay in the treatment of IBD.

Impact of the aging population on the demand for colorectal procedures.

PURPOSE: With the baby boomers entering retirement age, the United States population is seeing a dramatic increase in the number of elderly individuals. We hypothesized that as a result, during the next 20 years, the demand for colorectal procedures will grow rapidly. METHODS: We used the 2005 Nationwide Inpatient Sample and the Florida State Ambulatory Surgery Database as source data. From these two data sources, we identified commonly performed inpatient and outpatient colorectal procedures, as well as associated diagnoses. These data were combined with census projections to generate projected volumes for the selected procedures and diagnoses. RESULTS: Between 2005 and 2025, the United States population is expected to grow by 18 percent, with disproportionate growth in individuals aged 65 to 74 years (92 percent) and those aged 75+ years (54 percent). We forecast that growth in outpatient procedures and inpatient procedures will be 21.3 percent and 40.6 percent, respectively. Inpatient operations for colon cancer and rectal cancer show the greatest growth. CONCLUSIONS: During the next two decades, demographic changes in the United States population will lead to a marked increase in the use of colorectal surgical services, especially inpatient and oncologic procedures. The ability of the surgical workforce to meet this projected growth in demand should be assessed.

Adenocarcinoma arising in the middle of ileoanal pouches: report of five cases.

Restorative proctocolectomy with ileal pouch-anal anastomosis with or without mucosectomy has become the procedure of choice in patients with long-standing ulcerative colitis complicated by malignancy or medically refractory disease and for familial polyposis syndrome. Some reports have demonstrated the development of malignancy at the ileoanal anastomosis. We present a recent series of five patients who developed adenocarcinoma in the middle of their ileal pouch including the first case of pouch carcinoma in a patient who underwent pouch formation for ulcerative colitis. We discuss their presentation and management. Development of ileal pouch cancers, while rare, has been seen with increasing frequency in our practice. Patients with long-standing ileal pouches may benefit from routine surveillance of the pouch as often as every six months, which can be performed quickly and easily in the office using flexible endoscopy.

A focused breast skills workshop improves the clinical skills of medical students.

PURPOSE: The aim of this study was to determine the effectiveness of a focused breast skills workshop for teaching clinical skills to third-year medical students. METHODOLOGY: One hundred twenty-four third-year medical students involved in the surgical core clerkship were randomly assigned to two groups. Group 1 (n = 67) participated in a 2-h focused breast skills workshop. Group 2 (n = 57) received "traditional" ambulatory teaching for a period of 4 h in the breast clinic. The focused workshop consisted of a series of encounters concentrating on mammogram and ultrasound interpretation, physical examination skills, lump detection, and workup of a breast mass. Both groups received a didactic core curriculum lecture from surgical faculty. All students completed a satisfaction rating scale and a subset of students completed a pre- and postencounter self-efficacy rating scale on several aspects of breast skills. Student's t test was used to compare the groups in the areas of clinical skills as evidenced by performance on the breast-specific items on the end of the clerkship Objective Structure Clinical Examination and student satisfaction as evidenced by their response on a satisfaction rating scale. ANCOVA (controlling for preencounter self-efficacy rating) was used to compare the change scores between pre- and postencounter self-efficacy ratings. RESULTS: Students in Group 1 performed significantly higher than the students in Group 2 in the areas of clinical examination skills (t = -2.99, P < 0.05); in sensitivity (t = -5.82, P < 0.05) and specificity (t = -7.27, P < 0.05) in the examination of breast models; and with their satisfaction with the encounter (t = 10.72, P < 0.05). Students in Group 1 also demonstrated a higher level of confidence in their breast skills at the end of the clerkship than students in Group 2 (F = 6.22, P < 0.05). CONCLUSIONS: The focused breast skills workshop is more effective than the traditional ambulatory setting for teaching clinical breast examination skills. This setting also demonstrated the development of higher confidence in breast skills than the traditional ambulatory setting.