Breast surgery

[StarboardMD]

Can someone just say a little about breast surgery? Reading some of the previous posts has left me a little confused as to how someone gets there.

What I think I've learned (please correct me): you can do surg onc or general surgery residency and then follow with breast fellowship (1 yr?) or you can just do a gen surg residency and limit your cases to just breast.

Is this a competitive field? For anyone with experience, does it become monotonous?

I'm interested in it because it's rumored to have a relatively good lifestyle for me as a wife and mother, and because it will involve a lot of patient face time, which I think I'm interested in. Unfortunately, I'm afraid I'm not going to be a very competitive applicant, but I really want to do surgery!!!

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[Winged Scapula]

Can someone just say a little about breast surgery? Reading some of the previous posts has left me a little confused as to how someone gets there.

What I think I've learned (please correct me): you can do surg onc or general surgery residency and then follow with breast fellowship (1 yr?) or you can just do a gen surg residency and limit your cases to just breast.

There are 3 routes:

1) do a general surgery residency and limit your practice to just breast. This can be difficult when you are just starting out because many places will require you to take Gen Surg Call, and some patients will prefer a fellowship trained surgeon.

2) do a general surgery residency and a breast surgery fellowship (this is what I did); this is the easiest way to limit your practice to breast only

3) do a general surgery residency, a surgical oncology fellowship (there is no surg onc residency) and then limit your practice to breast surg onc; if in an academic medical center you may have to take general surg onc call

Is this a competitive field?

I assume you mean the fellowships. Breast is not particularly competitive, although there are more applicants than positions, so it is more competitive, especially at places like MD Anderson and Memorial, than fellowships with fewer applicants and more spaces.

Surg Onc is a competitive fellowship.

The field can be competitive depending on where you practice. I chose a location where there are few people doing only breast and where my partner and I are the only fellowship trained surgeons just doing breast, so we get a lot of business. In some other areas you may compete with general surgeons who do a lot of breast and aren't willing to give it up. You have to analyse the market and referral patterns.

For anyone with experience, does it become monotonous?

Not really. Everything can become monotonous in time. I figure that while the cases are not particularly highly varied, every patient is different and its a trade off for the lifestyle and doing something I find mentally stimulating (I think to do a good job you have to be facile with office based procedures and adjuvant therapy, which many surgeons are not). I have noted however, that things are more interesting as an attending, perhaps because I see nuances that I did not as a student or resident.

I'm interested in it because it's rumored to have a relatively good lifestyle for me as a wife and mother, and because it will involve a lot of patient face time, which I think I'm interested in. Unfortunately, I'm afraid I'm not going to be a very competitive applicant, but I really want to do surgery!!!

The first step is to get into a general surgery residency or consider some of the surgical subspecialties (although those tend to be more difficult matches than gen surg). There are lots of fellowships which can be tailored to a practice as a wife and mother, so I wouldn't worry about whether or not you would be a competitive fellowship candidate since that will 5 or more years from now, and the field(s) may change radically.

 

[StarboardMD]

Thanks SO much! Exactly the kind of info I was looking for. Now back to studying for Step 1...

 

[rox]

WS, can you please tell us about the duration of breast surgeries in terms of average, the shortest and longest?

Generally speaking, as a subspecialized surgeon, what determines weather you take calls from ER or not? Is it your wish or the kind of place you work at(private vs academic)?

 

[Winged Scapula]

WS, can you please tell us about the duration of breast surgeries in terms of average, the shortest and longest?

That depends on the practitioner and the case. There is a poster here on SDN who claims his SO can do an excisional breast biopsy in 10 minutes. Frankly, unless someone else is closing the skin, she doesn't place any deep dermal sutures and uses Dermabond and she isn't getting specimen mammography, I don't know how that is possible. I regularly wait 20 minutes for the call back from Rads (standard at every hospital I've worked at). Perhaps she has a FAXitron in the OR.

A lot of surgeons like to talk about how fast they can do the case; the trouble is, you have to include the time it takes to get the patient back to the room, set up, asleep, woken up, transported to the PACU, etc. It is not fair to tell the family it takes 30 minutes to do the case, if in fact, the patient is gone for 60 minutes because of all the rest, non-operating time.

But in general, my shortest cases I book for 1 hour (so as to have time for above) and my longest can be 6 hours - if I'm doing a bilateral skin or nipple areolar sparing mastectomies, sentinel lymph node bx and/or axillary node dissections with immediate reconstruction. A redo axillary surgery may take me 1.5 hrs or 3 hrs, depending on how much scarring there is. Radiated skin takes longer.

But I would say for most people, the shortest cases are going to be under an hour to an hour (depending on speed of everyone else) and the longest will be upwards of 4 hrs (for the types of cases described above). I'm new so I'm going to be slower on the bigger cases, although I think my time for the shorter ones is not too far off from the more experienced surgeons.

Generally speaking, as a subspecialized surgeon, what determines weather you take calls from ER or not? Is it your wish or the kind of place you work at(private vs academic)?

It has nothing to do with private vs academic. It has everything to do with cultural and political environment, hospital staff by-laws and how you negotiate your contract. A hospital here that I was planning on getting privileges at changed their by-laws to require anyone with general surgery training to take ER call. That was fine by me because I am not a employee of that hospital and can simply say, "Thanks but no thanks, I'll go elsewhere." On the occasions I've been there with my partner (who was grandfathered in because she had been there so long), the staff always asks why I don't operate there. Let them and patients tell the medical staff that they are making a mistake because they need another surgeon.

You are much more limited if you HAVE to choose a certain location or hospital to work at. Then you do not hold the upper hand in negotiations. Hospitals should not want a subspecialist to take ED call; I haven't taken a gallbladder out in 2 years, do you really want me to be the guy taking that call from the ED?

So, in some respects, yes...it is up to you. If not taking gen surg ED call is your "walking point" then you had better make sure that you are comfortable walking out of contract negotiations when that becomes a sticking point. Hospitals and especially recruiters will lie to you, figuring that you'll get there and change your mind. If you are female, I suspect they think we are stupid and will take less money, more responsibility, etc. than our male colleagues because we are traditionally more eager to please and if married or with an SO, more dependent on their need for work (so will choose any job just to be close).

I know a lot of surgeons who are required to take ED call and nearly all of them regret it as a mistake in contract negotations. Only a couple really wanted to still be doing it and actively looked for jobs. Some are in community settings and others at academic medical centers; so there is no hard and fast rule.

Therefore, you have to understand what cards you are holding and what the employer is. Right now, its a buyer's market for fellowship trained breast surgeons. There are fewer grads than jobs available and these places will bend over to get you. The sticking point may be their medical staff rather than the employer, so make sure you look at the by-laws and requirements for being on staff before someone sells you a job that you don't really want.

 

[rox]

That was quite informative. It's really amazing to know how such things are managed.

 

[Syranope2]

One more question while we're on the topic. WS, when you do a case with immediate reconstruction, who does the reconstruction? Do you do it? Do you have a specific plastics guy you always use? Does the patient choose their plastics person independent of you?

Thanks!

 

[Winged Scapula]

One more question while we're on the topic. WS, when you do a case with immediate reconstruction, who does the reconstruction? Do you do it? Do you have a specific plastics guy you always use? Does the patient choose their plastics person independent of you?

Thanks!

Plastics does it. I do not have the training and would be a sitting duck for liability if I attempted them. While local plastics guys have been interested in teaching me (its almost all tissue expander-implants here), I have been reticent because all it takes is one complication and the plantiff's attorney asking me "Tell me Dr. Cox, where did you get your training to do breast reconstruction?" to ruin my career, IMHO. What some surgeons don't realize is that while it may not be technically difficult a procedure to do, when complications arise that's when your training comes in handy and without adequate training you would not know how to handle these.

I do have a specific plastics guy I refer all my patients too for several reasons.

1) I want someone I have worked with before so we understand each other's needs
2) I want someone who works well with my office
3) I want someone who takes insurance; most of the PRS guys here do not take insurance and want my office to do all the work for getting approval for out of network benefits for them. As far as I'm concerned, since they are benefitting their office should do it.
4) The guy I use is technically great, has a very warm personality, is on most insurances and will gladly drive a long way to service patients in my area of the Valley. He is also willing to get on staff at whatever hospital I use; most of the other guys do not.

Most patients have no idea about plastic surgeons so go with my recommendation. On the rare occasion, they want to use someone else, I have to explain to them that they should prefer a surgeon I know and work well with. Patients also do not understand the issue of hospital privileges and so I also have to explain that surgeons just can't operate anywhere they want, so if their surgeon does not go to the hospitals I go to, then they will have to have delayed reconstruction if they prefer to stay with him.