Future Breast Surgeons will be...

[Impressions]

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http://www.nytimes.com/2009/10/10/opinion/10DeVries.html?_r=1&em

An interesting article from an OB/GYN physician at the University of Michigan. Based on the article's logic, if the OB/GYNs do not refer patients to surgeons they can do the breast surgery themselves. In fact, there are breast fellowships that are run by OB/GYN departments.

Very, very interesting.

Future Breast Surgeons will be from Ob/Gyn.

 

[filter07]

There is always overlap in procedures considered easy and lucrative. Turf wars are not new.

I can only hope that OBGYNs handle surgeries for all female patients. I would love for them to take care of women's cutaneous fistulas, abdominal hernias, labial abscess, perirectal abscess...

ER: doc we have a perirectal abscess in the ED
surgeon: is it a woman?
ER: yes
surgeon: call OBGYN!

wouldn't that be great

 

[Wrigleyville]

That article is a poorly researched piece of crap. I am amazed the NY Times printed it. A false negative mammogram is a machine failure? How can a physician write such nonsense?

The article, of course, offers no reason why ob/gyns should do breast surgery other than that there are breasts attached to the women who's uterus they are working on. Why not CABG or brain surgery? Their patients have hearts and brains, there would be more continuity of care and fewer communication problems if the ob/gyns trained up on open heart and brain surgery.

As far as the mammograms, by law they have to read several hundred a year to be certified, and studies have shown the plateau for image interpretation quality is that a doctor needs to read north of 2000+ studies a year to minimize errors. Good luck finding OR time if you're in a dark room reading that many films.

Of course, the nail in the coffin is that most places already have specialized breast clinics for mammos/breast eval/biopsy by subspecialty trained radiologists and surgeons.

 

[Winged Scapula]

I don't have time to formulate a well-thought out, comprehensive response at this time.

However, I will note, that in addition to the above comments (a false negative is a mammogram machine failure?), Mark Pearlman is NOT the PD of the Breast Fellowship at the University of Michigan, nor is he the Director of the Breast Care Center as claimed in the article. Perhaps that is the writer's error and he cannot be blamed for such.

Lisa Newman, MD, a *very* well known and well regarded Surgical Oncologist is the PD and Director of the BCC. To publish this article, without her input seems a tad self-serving.

The subspecialization because of gender seems ridiculous to me. Are we then to send all women to an Ob-Gyn for their choles? After all, most patients with gallstones are female, right? How about thyroid cancer? More women than men suffer. And I guess the corollary is true - all inguinal hernias and CABGs should go to male surgeons.

 

[JackADeli]

before anyone jumps on my response and tries to link out of context another posting I made.... I view breast surgery as cancer surgery..

However, I believe the techniques of surgical excision are in fact something someone with good surgical training could aquire. Can an Ob/Gyn be taught the techniques? Yes. Can a urologist be taught the techniques? Yes. Can a Family Medicine doctor be taught the techniques? Yes.

I don't think that is all there is to it. A GSurgeon that has spent countless hours of mentored training during residency excising malignancy and following cancer principles is very qualified to perform breast surgery. Better yet, a GSurgeon that has taken the additional step to endure additional training so as to understand not just the techniques of excision but the pre-op therapeutic options, operative options, post-op therapeutic options, and longterm follow-up is that much better. If an Ob/Gyn would like to venture into this realm, more power to them. However, I find it wholely innapropriate to venture into this purely to snatch the billing for the biopsy and then pass it off to someone that actually has a clue what to do with the path results....

Which brings me to my next point. The vast majority of late diagnosis breast cancer I have seen (anecdotal) was in women that found a lump during pregnancy, brought it to the attention of the OB and was told it was normal hormonal changes!!! Or, the Ob's that send all pregnant ladies with a breast lump to GSurgeons for evaluation**...

I just don't see the fact that you take care of reproductive health to be the blessing for breast oncology management. I have watched too many OBs call themselves the patients' PCP until there maybe some liability (i.e. love the OB that refers patient to endocrin for HRT cause doesn't want liability). I love the love the OB that is the "PCP" until the patient has diabetes and or hypertension and/or GERD and/or hemorrhoids....

Ultimately, I don't care who takes care of my loved one's breast disease as long as they are FULLY trained and focused on that field of disease (i.e. cancer). It doesn't pass the sniff test that someone will spend the years they do focused on uterus & vagina and fertility and delivery to then put that aside to focus on breast lumps and cancer conferences and chemo follow-up. Do you think an OB in the community is going to have a banging oncology practice or just dabbling in biopsies??? Has anyone been called on consult for the Ob/Gyn performed colectomy for incident identified colon cancer? Was there a true oncologic resection or a for lack of better description "colon lumpectomy"/wedge resection? How many nodes did they get????

It really isn't about turf and those looking to dabble should be honest and admit their dabbling really isn't about providing high quality care.....

JAD

**PS: who is teaching the breast exam portion of physical exam in medical school now? It wasn't the Ob/Gyns when I was in medical school.

 

[ChiDO]

**PS: who is teaching the breast exam portion of physical exam in medical school now? It wasn't the Ob/Gyns when I was in medical school.

FM doctors at my school.

 

[Winged Scapula]

There is always overlap in procedures considered easy and lucrative. Turf wars are not new.

Missed the bolded part above my first time through.

If Ob-Gyns are doing this because they think its lucrative, they'd better run the other direction. Imaged guided biopsies are by far much more lucrative than surgical intervention. I am fairly certain they can make more money doing Gyn procedures than breast.

And JAD: like ChiDO FM taught us the breast exam. Many women who come into my office tell me that their Ob does NOT do breast exams.

 

[JackADeli]

...like ChiDO FM taught us the breast exam...

Which just supports my point..... just cause OBs deal with the vagina/etc.... does not mean they are the most experienced and likely to identify a lump and/or diagnose a lump well. They are excellent at what they do. I just think the logic that takes them from one job to then biopsying breasts is flawed. During all my experiences with OB, they were not the experts teaching me physical exams above the waist.

...Many women who come into my office tell me that their Ob does NOT do breast exams.

which is why I bristle and baulk when I hear some OBs talking about being a woman's primary care provider. By their logic, I am a patients primary care provider... for the abdomen, or you, WS are the primary care provider for the breast... We may be the specialist focused on these areas. But, it is deceptive marketing to try and prance around the "primary care provider" title under these conditions.

IMHO, if a specialist wants to prance around the title of primary care provider, he/she had better be willing AND able to do at least the following:
1. anual complete physicals (including rectal, vaginal, Pap, breast exam, heart exam, lung exam, head & neck exam),
2. read an EKG, and
3. manage meds for chronic disease (i.e. hypertension, cholesterol, DM, depression, etc...).
4. monitor & manage basic health maintenance schedules to include mammograms, clonoscopies, dexa scans, etc...



JAD

 

[maxheadroom]

IMHO, if a specialist wants to prance around the title of primary care provider, he/she had better be willing AND able to do at least the following:
1. anual complete physicals (including rectal, vaginal, Pap, breast exam, heart exam, lung exam, head & neck exam),
JAD

I agree, except that there is a large population of PCPs (especially the Internal Medicine-trained ones) who don't do Gyn exams & Paps.

Also, in Europe most of the mastectomies are done by OB/Gyns. Granted, their training includes that as part of their discipline.

 

[JackADeli]

...Also, in Europe most of the mastectomies are done by OB/Gyns. Granted, their training includes that as part of their discipline.

As I noted, I am fine with whoever doing the procedure as long as actually trained and actually doing it. If the community practice in Europe is for OB/Gyns to do mastectomies, I presume the OB/Gyns actually practice a significant volume. However, I suspect in the USA, this idea of biopsies by OB/Gyns is not necessarily a group seeking to become expertes and incorporate this as a significant component of training and practice. Rather, someone is looking for a product line to sell.

Again, I don't care if urologists are providing breast cancer/surgical pathology care.... as long as they are trained and actually meeting the standards of cancer eval, care, and surveillance.

JAD

 

[Winged Scapula]

Like JAD, I have some problem with holding oneself out as a PCP without actually doing primary care. However, I am not sure anyone, including Ob-Gyns, want to take charge of managing HTN, DM and the like so don't see this as necessarily part and parcel of being a "woman's health PCP".

Interestingly, most of the OB-Gyns I work with want nearly nothing to do with breast. Some do breast exams, some do not and the quality varies widely. What most of them I've talked to have said, though, is that they do not want the liability of breast in addition to their already high rates for Ob. Why in the world anyone would want to add that on is beyond me.

For my High Risk patients choosing increased surveillance, one of the major problems I have is getting the OBs to do a breast examination. I'm starting to wonder if I should just require all of these patients to have an FM or IM physician to assist with this.

I have no problem with someone who is well trained doing what is right for the patient. I have enough confidence in my skills to accept others doing biopsies, surgeries, etc. as long as they are well trained and am not threatened.

But the fact remains that Ob-Gyns, whether or not they are trained in or continue to do clinical breast examination, do NOT do breast or axillary surgery in their residency. They have no vascular surgery experience and no experience handling the potential complications and common post-operative course. Now, this isn't (with the exception of the ax dissection) technically challenging, at least not grossly.

The major complaint breast fellowships who accept Ob-Gyn residents have is two fold:

1) the fellowship is not entirely surgical and they are starting from scratch teaching these residents how to do the common procedures, biopsies, and surgeries...stuff the Gen Surg residents already have some exposure to

2) difficulty in finding jobs in academics...most want someone who will also take GS or Surg Onc call, which obviously they can't.

There have been rumblings that if there is such a push to allow more Ob-Gyn residents to do these fellowships that the programs will have to be extended to include the basic surgical training along with the Med Onc, Rad Onc, Genetics, Plastics, etc.

 

[JackADeli]

...I have no problem with someone who is well trained doing what is right for the patient. ...as long as they are well trained and am not threatened.

But the fact remains that Ob-Gyns [in USA], ...do NOT do breast or axillary surgery in their residency. They have no vascular surgery experience and no experience handling the potential complications and common post-operative course...

Agreed. A GSurgery resident does breast surgical care (exam, biopsy, resection, reconstruction, follow-up, etc...) as an integral part of their residency training. It is so integral it is guaranteed portion of your certifying examination!!! This basic foundation of training all comes before you even step into an additional year of advanced training such as what WS has done in fellowship.

...The major complaint breast fellowships who accept Ob-Gyn residents have is ....

...difficulty in finding jobs in academics...most want someone who will also take GS or Surg Onc call, which obviously they can't.

There have been rumblings that if there is such a push to allow more Ob-Gyn residents to do these fellowships that the programs will have to be extended to include the basic surgical training along with the Med Onc, Rad Onc, Genetics, Plastics, etc.

Thus, I guess the costs of such extended training for OB/Gyns will be covered/off-set by the fellows taking .... L&D call????

 

[thedrjojo]

FM doctors at my school.

My school, OB/GYN teaches the breast exam, has it as a guaranteed 1 of the 6 stations in the OSCE (standardized patient exam) at the end of the rotation, and has a requirement to perform at least 10 during your 6 week rotation (based on student patient/procedure logs). Our school's OSCE program, particularly the gynecology teaching assistants, is (or so we are told) highly regarded and recognized amongst medical schools.

That being stated, during the surgery rotation we are required to see 2 patients in breast clinic, but are not given any instruction on proper exam technique, and really, can easily get away without doing any exam.

I don't have a problem with OB/GYN having a breast fellowship, but believe it should probably be a 2 year fellowship which would allow both teaching of surgical technique as well as rotations in Med Onc, Rad Onc, etc (like is required during a Surgical Oncology Fellowship). While I am a simple medical student and might not really know what I am talking about (but do have some residents input, although they might not know what they are talking about either), Breast Surgery, technically speaking, is not difficult procedurally. At this residency program, it is typically the PGY1 who perform lumpectomies and PGY2 who perform mastectomies (with the attending scrubbed but never touching the bovie or scalpel). The fellowship is more about the pre-op and post-op management aspects for the General Surgeon. The OB Resident, doesn't get the experience of doing lumps and mastectomies (or Axillary Dissections/SLNB) and that accounts for the extra time that should be needed.

And to comment on the article, there are "Mammogists" as there are many Fellowship trained and solely specialized Breast Surgeons. That article is FUBAR

 

[JackADeli]

...While I am a simple medical student and might not really know what I am talking about ...., Breast Surgery, technically speaking, is not difficult procedurally. At this residency program, it is typically the PGY1 who perform ...The OB Resident, doesn't get the experience of doing lumps and mastectomies (or Axillary Dissections/SLNB) and that accounts for the extra time that should be needed....

way beyond your position to comment on that (i.e. technical components and/or training needs and/or overall care).

 

[maxheadroom]

way beyond your position to comment on that (i.e. technical components and/or training needs and/or overall care).

Agreed

 

[Winged Scapula]

The more you know, the more you realize how much you don't know.

I used to think breast surgery was easier than it is but you'd be amazed at the number of seemingly well trained general surgeons who don't do a good job. I'm not talking about the adjuvant care, I'm talking about things like marking margins, taking excessively wide margins (when there is no data that you need that much), taking out "random" lymph nodes without benefit of technetium99 or blue dye or lymphoscintigraphy and calling it a sentinel node biopsy, etc.

And don't get me started on the adjuvant care and treatment that patients AREN'T getting because the surgeon didn't think they needed it (I get a lot of these when the PCPs find out what's going on). Clearly, it isn't technically difficult on the order of many things, but that's why its so appalling when its done badly.

So I'd surmise that:

a) academic medicine is not always the best place for standard of care. Just because interns are doing lumpectomies doesn't mean that they, or the attending doing them, is doing the latest and greatest. Sometimes the breast cases are left to the "retiring" or elder statesmen of the department and they tend to do the cases the same way they did 20 years ago. Its a nice way to transition from general surgery to retirement. As a matter of fact, when you go to conferences you see two groups:

1) men in their late 50s and 60s
2) young surgeons, fellowship trained, mostly female but a significant number of men who do a lot of breast

b) the residents really don't know what they don't know. I know I didn't.

I am sure anyone here who had done advanced training has gained a great appreciation of how much they (and perhaps even their surgery attendings) didn't know whilst a resident.

 

[JackADeli]

The more you know, the more you realize how much you don't know.

...you'd be amazed at the number of seemingly well trained general surgeons who don't do a good job...

And don't get me started on the adjuvant care and treatment that patients AREN'T getting because the surgeon didn't think they needed it...

...I am sure anyone here who had done advanced training has gained a great appreciation of how much they (and perhaps even their surgery attendings) didn't know whilst a resident.

Which is why you find the paradox at the certifying exam. The surest way to fail is to answer a breast question (and others) with the correct answer and current standard of care recommendations.... because the grey haired "expert" asking you the question is actually looking for the 10 year old answer.

I always love the "senior surgeons" at M&M. They have experience and wisdom.... but they teach you the "wrong things that will get you a pass on the oral exam..." There is definately something to be said about the recent implementation of MOC exams....

JAD

 

[Winged Scapula]

Which is why you find the paradox at the certifying exam. The surest way to fail is to answer a breast question (and others) with the correct answer and current standard of care recommendations.... because the grey haired "expert" asking you the question is actually looking for the 10 year old answer.

Yep...one of them quizzed me about axillary staging for palpable DCIS diagnosed with needle biopsy (when I mentioned I'd do it). Shut him up when I whipped out some data.

They also gave me grief about using ultrasound for a thyroid biopsy - until I mentioned that I can document the procedure, show the needle in the appropriate position (I didn't also mention that I can bill for it and that the reimbursement is more for the US than for the FNA).

So, yes...you are so right.

[/QUOTE]

 

[maxheadroom]

Which is why you find the paradox at the certifying exam. The surest way to fail is to answer a breast question (and others) with the correct answer and current standard of care recommendations.... because the grey haired "expert" asking you the question is actually looking for the 10 year old answer.

I always love the "senior surgeons" at M&M. They have experience and wisdom.... but they teach you the "wrong things that will get you a pass on the oral exam..." There is definately something to be said about the recent implementation of MOC exams....

JAD

Does the ABS require that Board Examiners do the MOC program? In Plastics you can't be an examiner if you don't participate, even if you were certified in the era of lifetime certification. Heck, you can't hold an office in the major societies if you don't participate in the MOC stuff, either.

 

[JackADeli]

Does the ABS require that Board Examiners do the MOC program? In Plastics you can't be an examiner if you don't participate, even if you were certified in the era of lifetime certification. Heck, you can't hold an office in the major societies if you don't participate in the MOC stuff, either.

I believe so. The ABS is requiring continued MOC to include written re-examination and submission of ccurrent case logs/practice and CME work..... But, I can't speak for the Grandpas....