Lets talk about Breast Surgery fellowships

[toxic-megacolon]

Does anyone have inside or insightful information about any of the 30 or so SSO-approved breast fellowships? Not so much the vague, "official" information on the website but the other stuff.... prestige, quality of OR training, amount of clinical time versus research, lifestyle/call schedule, presence/absence of general surgery responsibilities, personalities of the attendings, autonomy versus adequate backup, experience with radiology/image-guided biopsies, etc etc....

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[BlondeDocteur]

I've heard rave reviews about the John Wayne Cancer Center breast fellowship. One of my senior residents here just did an "audition" down there, and fell in love with the place. Great case mix, breast surgeons do their own biopsies, clinic is a marvel of efficiency, sunny Santa Monica, good research if you're so inclined...

 

[Smurfette]

+1. Have a friend who just matched in breast who loved John Wayne as well and was extremely impressed by them.

MSK and MDAnderson are also good breast fellowships from what she told me. She told me that just about every place she interviewed at seemed like they gave good training, she eventually divided them up by 'more cancer focus' and 'more benign disease focus'. Obviously cancer predominates in all, but she found some programs had more benign breast disease components that she felt were good for a private practice scenario whereas the 'more cancer focussed' involved more research and the like.

 

[thedrjojo]

One of my chiefs just matched at Yale (a non-sso program, but she was like, "its yale, no one is going to care its not sso"). Her impression of MSK was that while the training is great, they really work the fellows... something to keep in mind

 

[Winged Scapula]

As a former member of the SSO/ASBS Education Committee, I have some insight into the programs. However, because my identity is fairly open I am loathe to post negative stuff about some big name programs.

I can verify what was written above about JW is true. But suffice it to say that the larger the cancer center, the less likely you are to get *any* hands on image guided experience. This is a MAJOR issue in the world of Breast Fellowship - to the extent that the SSO was considering not accrediting those fellowships that did not provide any hands on-image guided biopsy experience. Trouble was/is, it doesn't look good to pull accreditation from some of the biggest name places in the country.

I do not recommend doing a fellowship at a non-accredited program; given the talk about obtaining a Board for Breast Surgery/Surg Onc, those trained at non-accredited programs are said to not be candidates for BC in Breast Surgery/SSO.

The key really is to train at a program that will prepare you for *any* practice scenario. MOST breast fellowship trained surgeons are not in academics but rather private practice. You will find it difficult to sustain a practice if you don't do any in office/image guided biopsies. If you are certain you want an research based/academic career, then this may not be as important (provided you never change your plans).

The SSO requires research, but there are only 2 programs in which you spend a year in the lab. For the others it is optional. A few require general surgery call as a junior attending (there is at least 1 I am aware of that does not publicize this); others require Surg Onc call.

I know people who have trained all across the country; for specifics about certain programs, feel free to PM me.

 

[Scrubbed In]

At the risk of sounding naive -- what operative techniques or patient management do you learn in a breast fellowship that you can't or don't learn during general surgery residency?

Have most attendings currently practicing breast completed a breast fellowship? Or even a surg onc fellowship? None of the breast attendings at either of the 2 institutions in which I've trained have had formal training. Is this a consequence of the 80-hour work week and residents not feeling comfortable at the end of their training, or the trend of sub-specializing? Just curious...thanks!

 

[Winged Scapula]

At the risk of sounding naive -- what operative techniques or patient management do you learn in a breast fellowship that you can't or don't learn during general surgery residency?

The breast fellowship is not necessarily about learning new techniques but honing them. You will do more axillary dissections, SLNBx, wire localizations and depending on the program, learn image guided biopsies.

What is different is that you learn more multidisciplinary management: you rotate on med onc, rad onc, path, plastics, etc.

Have most attendings currently practicing breast completed a breast fellowship? Or even a surg onc fellowship? None of the breast attendings at either of the 2 institutions in which I've trained have had formal training.

Most younger faculty are breast or surg onc trained. There is the observation that breast surgeons tend to be younger females and older men (males who often were trauma surgeons or other call heavy specialties who wanted a better lifestyle). My faculty was a mix of endocrine, surg onc, breast fellowship trained. Fellowship faculty were all surg onc trained.

Is this a consequence of the 80-hour work week and residents not feeling comfortable at the end of their training, or the trend of sub-specializing? Just curious...thanks!

Breast fellowships have been around for 25 years so its not something new. I might posit that you don't know what you don't know. I work with some fine general surgeons; however, daily I am faced with information and technique issues that I learned in fellowship that they clearly did not learn in residency.

 

[kirurg]

I've seen some general surgeons make pretty significant mistakes.

A patient in her 60s had a palpable breast mass and the general surgeon excised it, thinking it was benign although it was never biopsied. He did not mark the specimen for orientation, did not leave any clips at the excisional site, never did a SLNB. Turned out to be invasive cancer. I scrubbed with him and a 2nd year resident on the take-back (I was an intern at the time) for a MRM.

If the patient had been biopsied first, maybe she could have had breast conservation or at least saved herself a trip to the OR. I don't know if the outcome would have been different, but it just didn't seem right that someone who obviously was working outside of his specialization drifted so drastically from standard of care.

Many of the older general surgeons (male) have also told me that they lost almost all of their breast patients to younger, fellowship-trained female surgeons. They think it's the because the patients are picking female surgeons, but it may also be that patients prefer fellowship-trained specialists.

The breast fellowship is not necessarily about learning new techniques but honing them. You will do more axillary dissections, SLNBx, wire localizations and depending on the program, learn image guided biopsies.

What is different is that you learn more multidisciplinary management: you rotate on med onc, rad onc, path, plastics, etc.



Most younger faculty are breast or surg onc trained. There is the observation that breast surgeons tend to be younger females and older men (males who often were trauma surgeons or other call heavy specialties who wanted a better lifestyle). My faculty was a mix of endocrine, surg onc, breast fellowship trained. Fellowship faculty were all surg onc trained.



Breast fellowships have been around for 25 years so its not something new. I might posit that you don't know what you don't know. I work with some fine general surgeons; however, daily I am faced with information and technique issues that I learned in fellowship that they clearly did not learn in residency.

 

[Buzz Me]

Can I also mention the often-overlooked fact that a fellowship is good for marketing? Good for attracting patients? Or is that the elephant in the room?

 

[igap]

In respnse to the poster asking about what is learned ina breast fellowship:

While I do not know what the curriculum of a breast surgery fellowship is, I can say that there is a difference in operating with general surgeons doing breast surgery and breast surgeons doing breast surgery.

When I reconstruct a breast in concert with a general surgeon who does the mastectomy, it amazes me how poor some mastectomies are compared to those done by breast fellowship trained surgeons.

I recently watched a general surgeon do a mastectomy on a patient where she essentially left dermal flaps. This was in a patient with around a cm of subcutaneous fat. I wonder why general surgeons think that it is necessary to raise such thin mastectomy flaps on a prophylactic mastectomy???

Then there are the times where the general surgeon does not wait for me to mark the breasts and so I walk in the room to find a ridiculously long, poorly located, totally unnecessary skin incision. Then there is the handling of tissue...

Unfortunately because of referral patterns being what they are, it is very difficult and potentially problematic to comment on the surgical technique of your general surgery colleague without risking losing the recon referrals.

The fellowship breast trained surgeon that I have worked with is better about planning mastectomies, and dissecting the gland, and is better at tissue handling. I see less mastectomy flap necrosis and wound complications with the fellowship guy.

 

[Winged Scapula]

Can I also mention the often-overlooked fact that a fellowship is good for marketing? Good for attracting patients? Or is that the elephant in the room?

I don't think its an elephant in the room; I've said it is good for marketing in other threads. This is true for many GS fellowships.

 

[Winged Scapula]

When I reconstruct a breast in concert with a general surgeon who does the mastectomy, it amazes me how poor some mastectomies are compared to those done by breast fellowship trained surgeons.

I recently watched a general surgeon do a mastectomy on a patient where she essentially left dermal flaps. This was in a patient with around a cm of subcutaneous fat. I wonder why general surgeons think that it is necessary to raise such thin mastectomy flaps on a prophylactic mastectomy???

We were just talking about this issue at a conference here in DC (a combined PRS/Breast Surgeon conference).

As general surgeons we were all taught that breast tissue goes up to the clavicle, down to the anterior abdominal wall, out to the axilla and that you need extremely thin flaps for oncological reasons and no one ever says anything about the IMF.

However, most women have subcutaneous fat and no breast tissue right up to the dermis, or up to the clavicle, or out past the anterior axillary line. Each case needs to be evaluated independently. Sometimes I do make very thin flaps because the tumor comes close to dermis; but doing that routinely, or dissecting up to the clavicle in a woman with Grade 3/4 ptosis and all of her breast tissue sitting in a puddle on her belly is unnecessary especially in a prophylactic mastectomy.

Yours is a common complaint and harks back to "not knowing what you don't know."

A patient in her 60s had a palpable breast mass and the general surgeon excised it, thinking it was benign although it was never biopsied. He did not mark the specimen for orientation, did not leave any clips at the excisional site, never did a SLNB. Turned out to be invasive cancer. I scrubbed with him and a 2nd year resident on the take-back (I was an intern at the time) for a MRM.

Hmmm...while I cannot condone (in most cases):

1) excisional biopsy for something accessible with a needle
2) not marking margins
3) not leaving any clips (although this is somewhat up for debate and more and more Rad Oncs don't need clips for conformal modeling)

but, I guess I would question why was the woman then committed to a MRM? There should be some image evidence of where the surgical cavity was, even if you had to reexcise the whole cavity (not knowing what margin(s) were positive) and she would still be a candidate for SLNB after ExBB. Still not sure she was managed correctly at the take back (but of course I wasn't there and Monday morning quarterbacking isn't the right thing to do here).

 

[ESU_MD]

. But suffice it to say that the larger the cancer center, the less likely you are to get *any* hands on image guided experience. This is a MAJOR issue .

Is this because it is essentially an awake procedure? I guess its the toughest to teach, esp at a major center where patients travel far to see a big name and feel entitled to have the attending do it?

 

[Winged Scapula]

Is this because it is essentially an awake procedure? I guess its the toughest to teach, esp at a major center where patients travel far to see a big name and feel entitled to have the attending do it?

Nope. It all has to do with turf wars. In these major centers, radiology controls the biopsies. Very few surgeons do any image guided biopsies and therefore, don't train their fellows to do them and IMHO, the radiologists are loathe to train them to do so.

The issue is not one of private pay, VIPs but rather access to the equipment. I was not allowed to be trained in stereotaxis (a technique developed in Sweden but brought to the US by a SURGEON, not a radiologist - Dr. Kambiz Dowlatshahi) and had to learn elsewhere; we had our own sonogram in the Surgery Clinic so my attendings taught me that modality.

This is a major issue which is why many PP breast surgeons around the country have set up mini-fellowships and will take residents and fellows for rotations for the express purpose of getting them experience doing these things.

 

[smq123]

Many of the older general surgeons (male) have also told me that they lost almost all of their breast patients to younger, fellowship-trained female surgeons. They think it's the because the patients are picking female surgeons, but it may also be that patients prefer fellowship-trained specialists.

I think that it's probably that patients prefer fellowship trained surgeons.

It's probably easier on the ego to tell yourself that you lost a patient because of your gender, rather than admitting that you lost a patient to someone who is younger and has had more training than you.

Sure, there are some women who will "only" see a female physician for their breast/GYN issues, but I think it's pretty overblown. I routinely refer all of my patients who need GYN surgery to an all-male OB/gyn group, and I've never had to talk anyone into it or have anyone refuse to see a male. They just want someone who is competent and nice....and a lot of the female OB/gyns in my region are pretty mean, even to their patients.

And most of the women who need to see a breast surgeon are older, have had children, and are no longer hung up on the whole "OMG A MAN IS LOOKING AT MY LADY PARTS!!!" thing.

 

[JackADeli]

I think that it's probably that patients prefer fellowship trained surgeons...

I agree. Hospitals market/promote the fellowship trained component accross specialties.

I see patients preferring a fellowship trained surgeon for their gall bladder. I see patients prefering fellowship trained for their colectomies. etc, etc....

...harks back to "not knowing what you don't know." ...

I agree with WS.

Also, if physicians, i.e. someone within the medical field often fail to recognize what they don't know, you can only imagine patients knowledge set. You have to love the patients being encouraged about "knowing their bodies better then anyone else" and trying to extend that statement into ~knowing more about medicine....

 

[ESU_MD]

she eventually divided them up by 'more cancer focus' and 'more benign disease focus'.

How can you focus on benign breast disease, other than negative biopsies? The ultimate form of "psychology with a knife"

 

[Smurfette]

How can you focus on benign breast disease, other than negative biopsies? The ultimate form of "psychology with a knife"

I meant relative to each other....fellowships where the vast majority is cancer (and a little benign) vs fellowships where there is a fair amount of benign disease (and a lesser, but still a majority, is cancer). For example 85/15 vs 70/30. Don't know the actual percentages. The breast surgeons at my residency program got a lot of referrals for 'breast pain', abscesses, nipple discharge, etc. Not everything goes to the OR, but managing these things are still important in building a practice and establishing referral patterns. And learning to do things like duct excisions and/or duct explorations well (they're not nearly as common as biopsies and lumpectomies and it can be tricky to identify the responsible duct)...usually these are papillomas, not carcinomas.

My friend knew she'd learn how to manage the cancer aspect no matter where she went (that's the main focus of the fellowship)....but she also knew that the benign component is still important to a breast surgeon's practice, which is, I think, why she grouped programs in that way. FWIW, it was her way of distinguishing programs from one another. (FYI she did not end up at a place with a bit more benign disease...she wants to do research and matched at a very research heavy program).

 

[StarboardMD]

Great post! I'm an intern and there aren't any breast surgeons at my hospital and the gen surgeons hate breast cases! There's a lot of good info in this post. Any other places to go to get more info on breast fellowships? Are they competitive? How long are they?

 

[Pir8DeacDoc]

Great post! I'm an intern and there aren't any breast surgeons at my hospital and the gen surgeons hate breast cases! There's a lot of good info in this post. Any other places to go to get more info on breast fellowships? Are they competitive? How long are they?

http://lmgtfy.com/

 

[droliver]

I recently watched a general surgeon do a mastectomy on a patient where she essentially left dermal flaps. This was in a patient with around a cm of subcutaneous fat. I wonder why general surgeons think that it is necessary to raise such thin mastectomy flaps on a prophylactic mastectomy???

I've actually had the opposite observation. Most of the breast onc fellows I've ever worked after were MUCH more aggressive in thinning out the flaps then most general surgeons. I've seen a lot more dead skin flaps from the 4-5 breast onc folks I have experience with then the general guys. With general surgeons it's more all over the map. Some are thin, some are thick.

The hardest thing to get across to your colleagues is the whole anterior axillary line concept IMO. Particularly on fat patients I'm stunned when the dissection for a simple mastectomy doesn't go well past the latissimus muscle.