Editor’s Note: This article is adapted from a presentation given by Dr. Robertson at the Oncology Nursing Society’s Cancer Prevention and Early Detection Program for HBCU/MSI Nurses: Dissemination Colloquium, May 3-4, 2002 in Miami.
Recent studies have shown that racial and ethnic minority patients are more likely to choose a minority physician for their health care.1 Consequently, physicians of color must be educated to assume a prominent position on the front lines of the war against minority health disparities by providing the best possible preventive education, early detection and treatment options for diseases that disproportionately affect minority populations. One such target disease is breast cancer. According to the Centers for Disease Control and Prevention, white women have the highest incidence rate of breast cancer, yet black women have the highest death rates from the disease.
Meharry Medical College in Nashville, Tenn., the nation’s largest private, historically black institution exclusively dedicated to educating health care professionals, is answering this call by updating its curriculum to include information on breast cancer morbidity and mortality in African Americans and by strengthening its course in physical diagnosis for African-American medical students. What is particularly noteworthy about these initiatives is that they were developed and implemented by nurse practitioners.
The role of nurse practitioner faculty in Meharry Medical College is a very important one. Nursing practice is based on nursing theory, which encompasses scientific research, intellectual judgment, tested hypotheses and human understanding. It is creative, imaginative, practical and flexible. Nurses employed in medical schools have a unique opportunity to bring nursing theories, as well as a strong emphasis on patient advocacy, into the teaching environment.
In the case of breast cancer screening, teaching medical students to conduct clinical breast examinations properly and to interview their patients to obtain the necessary diagnostic information is extremely crucial. In addition, our goal was to teach the students how to communicate effectively and sensitively with their patients about breast cancer risks and the importance of early detection, and how to teach the women to perform breast self-exams.
Nurses are in an ideal position to accomplish this task because we base our actions upon the work of nursing theorists such as Dorothea Orem and Martha Rogers. Orem’s idea of empowering patients can be established by an agreement between the patient and the provider as they work together to outline health care goals.2 Rogers held that equipping patients with information could be powerful because knowledge is power.3 Based on this theoretical foundation, nurses at Meharry Medical College are able to help minority medical students learn to teach women of color to take control of their own breast health.
The targeted community our institution serves is Davidson County in Nashville, a racially and ethnically diverse area that is home to 68,685 African-American men and 79,038 African-American women. According to the Tennessee Department of Health, the second leading cause of death among black Americans in Davidson County is cancer.
The health care disparities identified in the federal Healthy People 2010 report--i.e., unequal access to providers, screening and diagnostic tests because of financial, personal, physical and structural barriers--hold true for many underserved African-American women in the North Nashville area. In addition, lack of knowledge and education concerning breast cancer risk reduction, screening, early detection and treatment options is a formidable barrier that can render these women powerless.
Today’s medical schools are extremely concerned about their students mastering large amounts of information, utilizing technological interventions and passing comprehensive examinations to prove that they are competent. However, far less attention is paid to the students’ development of communications skills and effective physician-patient relationships. To ensure that minority doctors are able to form partnerships of empowerment with female patients, their medical school education must include training in therapeutic communication skills, patient education and compassionate attitudes and behaviors.
The breast cancer education program we designed for the Meharry students encompasses several different instructional formats. As part of the curriculum update, nurse practitioner faculty developed new breast and lymphatic student learning objectives and incorporated them into the 2001-2002 Freshman II syllabus. Lecturers--who have included the chief medical officer from a major local hospital--are given a copy of the new objectives to ensure that the prescribed information is covered in the classroom. We also supplemented the standard Physical Diagnosis History and Examination textbook by Swartz with additional materials that are required reading.
In addition, the Bates Breast Physical Examination Video is available for all students to review. They can take notes while watching the video and faculty members are present to answer students’ questions. Thirdly, each student must participate in a breast exam practice session, using standardized patients, in which the instructor demonstrates techniques in both breast assessment and patient communication.
Educator H.S. Barrows pioneered the use of standardized patients, who are trained by medical experts and used in practice sessions to facilitate teaching and evaluation of medical students’ clinical skills. They can be professional actors, educated patients or simply normal everyday people, and they are carefully coached to accurately portray an actual patient during the practice encounter. Often they are so well trained that skilled clinicians cannot detect their simulation. Standardized patients are also taught to evaluate medical students’ performance, based on predetermined criteria, and provide a written or verbal assessment.
After the practice session, the students are encouraged to continue to practice these techniques on their own. If they need additional help, medical education faculty is available to provide one-on-one instruction.
Finally, the students must perform a skills session to demonstrate what they’ve learned. Each student takes on the role of the physician and conducts a complete breast exam on a standardized patient in an actual examination room. A faculty member is present during the exam to assess the student’s work. The exam room is also equipped with a video camera to record the session, in case there is later any discrepancy, concern or question about a student’s performance.
The reason why we gave our program this multifaceted structure was to accommodate the different learning styles of individual students. A 1993 study on learning styles revealed that most faculty members believe students learn important content most effectively through the traditional lecture system.4 Clearly, this method works best for some students but not necessarily for the majority. Because students need to become lifelong learners, teaching methods must encourage self-directed learning.
In our program, each student is responsible for the reading material. In addition, breast exam videos are available to meet the needs of visual learners. Tactile/sensing students who prefer direct, concrete learning experiences have the opportunity to learn from hands-on instruction and role-playing. Intuitive learners have the option of receiving open-ended instruction and having some autonomy with the standardized patient during the practice session.
Independent learning experiences outside the classroom are still another key component. We encourage the students to utilize the information they’ve learned by teaching peers, friends and family members. After the students see the breast examination performed in the practice session, they do the exam themselves. They are then able to teach others--and eventually, their patients--to perform the exam with competence and confidence.
Although the impact of the breast cancer education project at Meharry Medical College is still being evaluated, our initial results have been very positive. Students have reported that they enjoyed the sessions and that the combination of lectures, reading materials, the video and the practice session has been extremely helpful.
Based on our experience with this program, we believe that nursing schools as well as medical schools can benefit from this approach, which focuses on developing students’ ability to internalize knowledge and to become both clinically competent and patient-focused. These skills are essential in helping students make a smooth transition from academic theory into practice.
If we are to train a new generation of minority health care providers to play leading roles in the fight against racial and ethnic health disparities, updating curricula to reflect the breast cancer morbidity and mortality faced by African-American women is essential. Arming our students with knowledge of real health care barriers, preventive measures, updated treatment options and the importance of patient education and empowerment will equip them to truly make a difference in eradicating unequal health outcomes in underserved minority communities.
We also believe that the use of standardized patients in clinical training to make the learning experience more “real” to students and provide assessments of students’ performance from the patient’s viewpoint may prove to be as beneficial for student nurses as it is for medical students. According to McGraw and O’Conner, the fact that students are spread throughout the hospital seeing patients may limit the opportunity for faculty to observe the students’ clinical skills.5
Our final recommendation is that medical colleges and nursing schools take full advantage of opportunities to use minority nurse practitioners as an important resource for both teaching and curriculum updating. With their unique grounding in the worlds of both medicine and nursing, they can play a crucial role in helping to create health care professionals who will treat minority women patients with dignity and respect, who are competent and compassionate, and who are skilled not only in diagnosing and treating breast cancer in women of color but also in empowering them to save their own lives through early detection.
1. Freeman, J., Loewe, R., & Bensin, J. (1998). “Training Family Medicine Faculty to Teach in Underserved Settings.” Family Medicine, 30(3).
2. Orem, D.E. (1991). Nursing: Concepts of Practice (4th ed). St. Louis: C.V. Mosby Books, Inc.
3. Rogers, M.E. (1970). Introduction to Theoretical Basis of Nursing. Philadelphia: F.A. Davis Co.
4. Schroeder, C. (1993). “New Students--New Learning Styles.” Change, 25(5).
5. McGraw, R. & O’Conner, H. (1999). “Standardized Patients in the Early Acquisition of Clinical Skills.” Medical Education, 33.