Role of a mentor in Surgical Residency

I met my mentor yesterday during a conference and introduced him to a few of my students. One of the students asked him about the “role of a mentor in surgical residency?”
I am sharing his reply for the benefit of others.
To mention particularly there is no training in surgery without a mentor. If we try to define “surgical training”, it revolves around the mentor-mentee or guru-shishya relationship. While you may learn certain steps from YouTube and other resources, a few intricate practical details can only and only be taught by a guru. A mentor is a term derived from an old Greek legend in which a king who was heading for a war had to leave his son in the care of his very close friend, instead of leaving him to his wife and Mentor grew up to be a very wise and noble king. 
You watch your mentor operating, walking, talking, his mannerism, his attitude towards care of his patients and virtually follow him in everything you do. The role of a mentor is unlimited. It is vital and mandatory to have a guru in your life.
He ended by quoting Kabir’s famous couplet –

Guru govind dono khade, kaake lagu paaye

Balihari guru aapno, govind diyo bataye
“Teacher and Lord are both there, whom to be adore. but teacher you are great, who told us that god is greater”

Breast Cancer Awareness Talk & Screening OPD’s

Breast Services

To promote Breast Cancer Awareness and Screening, the Department of Breast Diseases & Oncology is organizing a Free OPD & Breast Cancer Awareness Talk on Sunday, 27th September. We will be continuing with the Awareness talks all through October in celebration of the International Breast Cancer Awareness Month.

End of the South Indian Sojourn

Leaving Bangalore after the end of my fellowship turned out to be quite an emotional affair. This was the first time I was away from home for so long and my seniors and colleagues in the department made me feel quite comfortable during the tenure of my course.

Working with each one of them turned out to be an amazing experience in which I learned the necessary skills in the best possible atmosphere and I am definitely going to miss all of them in the future.

Now looking forward to my next stint in America. 🙂

image

With Dr. Anthony - one of the best surgeons I have worked under...cool, calm and composed

image

With Dr. Archana - who was always willing to teach and help

image

Meera ma'am - who was an important link between the doctors and the patients. Learnt a lot about life from her.

image

Breast care nurses - the most dedicated lot I have seen. They were responsible for the seamless functioning of the unit.

Shocking case – Mastectomy done for an 11 yr old girl!!

Every day brings a new surprise in the life of a doctor but there are some cases which just make you feel angry & helpless and today’s case was exactly the same. Our receptionist had fixed an appointment and when she told me that it is for a 11 year old girl, I probably thought that she is going to turn out be a case of juvenile hypertrophy (enlargement) of the breast but what I saw when I examined the patient left me in a state of shock.

This sweet looking 11 year old kid walked in with her parents and they started telling me the history that she underwent a surgery of the right breast to remove a benign lesion (fibroadenoma) 2 months back and they came to our unit because the girl had noticed another lesion on the left side. Breast surgery at 11 years is usually not recommended as it hampers with the development of the breast during puberty and I immediately knew that something will not be right when I examine the patient. Examination of the girl turned out to be quite shocking. The surgeon (who was actually a gynecologist in a rural set-up) removed not only the lump but also the entire breast tissue on the right side leaving behind just a long scar on the chest (image). It took me a couple of minutes to get in terms with what I was seeing and multiple thoughts started running through my head after that:

IMG_20140725_115525

1. My initial reaction was that of anger towards the doctor who had done such a surgery without properly examining the patient or documenting it. Her notes before surgery mentioned no examination findings and the only thing written was ”work-up for surgery”. She had fortunately not examined the other breast, which also had a small lump and I am sure had she examined it, she would have done the same thing on the left side as well.

2. I felt sad for the girl & her parents very well knowing that there is going to be no development of the breast of the right side and the patient will probably have to go for an implant later on in her life.

3. This case reinforced the fact that breast surgery needs to come up as a dedicated branch in India, in order to prevent such cases. Also more awareness needs to be created among people regarding this branch and the fact that it does not deal with only breast cancer. Benign breast diseases are often ignored by patients and they usually approach local doctors for their treatment.

4. This case also reinforced the point regarding proper notes & documentation in all patients. This patient can easily take the doctor who did such a surgery to court and that doctor will have nothing in her defense

5. This case was a real eye opener with regards to the lack of knowledge which general practitioners/ general surgeons / gynecologists have regarding breast disorders and this needs to be addressed by proper refresher courses for these doctors.

 

Importance of regular follow-up after Breast Cancer Treatment

It was quite sad to see this 68 year old lady come to the clinic yesterday. She was diagnosed with left breast cancer two years back and was treated with MRM, adjuvant chemotherapy and hormonal therapy at a private hospital. After her treatment was completed, she did not visit the oncologist again thinking that she has been cured and for the last 6 months she had been harboring this growth over the chest wall, which turned out to be a local recurrence.

Local recurrence after mastectomy

Local recurrence after mastectomy

Patients tend to think that when the treatment is over, they are cured of the disease, but that is not the case. Patients need to visit their oncologists/ doctors regularly after the completion of their treatment and this case points out the importance of correct and regular follow-up after breast cancer treatment.

The current guidelines regarding follow-up of breast cancer patients are:

  1. History & physical examination: Every three to six months for the first three years after the first treatment, every six to 12 months for years four and five, and every year thereafter.
  2. Mammography: If mastectomy has been done, then annual mammograms of the opposite breast. If  breast conservation has been done, then B/L mammography should be done annually.
  3.  Breast self-examination. Perform a breast self-examination every month. This procedure is not a substitute for a mammogram.
  4. Pelvic examination. If the patient is on Tamoxifen, annual gynecological check-up should be done because tamoxifen can increase the chances of uterine cancer.

One reason which deters patients from going on regular follow-ups is the fact that some doctors order unnecessary tests during these visits. One should be aware that the following tests are NOT recommended for regular follow-up care of breast cancer patients:

  • Blood tests like CBC, LFT, KFT
  • Chest x-ray
  • Bone scan
  • CT scan
  • FDG PET scan
  • Breast MRI
  • Breast cancer tumor markers – CA 15-3, CA. 27.29, CEA

39 fibroadenomas removed using just two incisions!!

Yesterday, we performed a marathon fibroadenoma surgery, where we removed 39 fibroadenomas from both the breasts (19 from the right breast and 20 from the left) just by making one incision in each breast. We used a crescent incision in both the breasts and comfortably removed fibroadenomas measuring as big as 5-6 cms through that incision. The entire procedure lasted 2 hours and the patient was discharged the same day.

Although the smaller fibroadenomas could have been left behind (because they are not malignant) but the patient was very apprehensive about them and wanted all of them removed. The importance of the single incision (periareolar crescent) is that it makes the end cosmetic result quite good. I am sharing some intra-operative pictures in this post. Will update the post-operative and follow-up pictures soon.

Marking of the crescent incision.

Marking of the crescent incision.

 Fibroadenomas marked along with the incision. Smaller lesions were not marked.


Fibroadenomas marked along with the incision. Smaller lesions were not marked.

 

6x7 cm fibroadenoma removed through the incision

6×7 cm fibroadenoma removed through the incision

 

5x5 cm lesion removed through the left breast

5×5 cm lesion removed through the left breast

 

Starting the closure. Will share the post-op and follow up pictures soon

Starting the closure. Will share the post-op and follow up pictures soon

Goldilocks Mastectomy – Will it have a fairy tale ending?

Goldilocks mastectomy is a relatively new procedure developed by Dr. Grace Ma and Dr. Heather Richardson. This is a single stage procedure, which gives women facing mastectomy an option that takes the best features of having and not having reconstruction and combining them into a single procedure. This procedure has been a recent topic of debate at many scientific gatherings.

The first question which pops to the mind is that why was this surgery named as Goldilocks mastectomy? The following is the reply given by the surgeons who developed this surgery:

“Most of us are familiar with the story of the young girl faced with uncertainty in the woods and with a big, bad wolf nearby. She had many choices to make, and each time she face a choice, she evaluated the pros and cons; risks and benefits of each one.  Most involved extremes -too hot or too cold; too hard or too soft. But there was a third choice that had attributes of both and fell somewhere in the middle. This was considered “just right”.

We chose this name because this technique embodies the simplicity of not having reconstruction and only having a single surgery with as little as possible discomfort and down time. Yet it preserves as much of the patient as possible and avoids an amputated appearance.

For those who still aren’t quite as large as they would like to be and choose to wear a prosthesis, wearing a bra is much more comfortable and the cleavage much more natural appearing.  Redundant tissue under the arm is avoided and the final result very soft and supple.

When discussing the different choices and options pre-operatively, it is easy to remember what a “Goldilocks” is and how it differs from mastectomy with and without formal reconstruction.”

Not all patients are eligible for Goldilocks mastectomy. It is mainly suitable for patients with large breasts, who have enough tissue left behind after mastectomy, which can be used to reconstruct the breast. It is NOT suitable for patients with small breasts!!

The following are the advantages of this procedure, as highlighted by the surgeons on the website (www.goldilocksmastectomy.com)

  • Can be performed on one or both breasts
  • Can be performed for prophylaxis or treatment of disease
  • No additional surgeries are required
  • No implants or artificial devices are used
  • Decreased pain and shorter recovery time when compared to formal breast reconstruction
  • Surgical removal of breast gland under the skin means:
    • No screening mammograms required
    • Most patients do not require radiation (dependent on the stage of disease)
  • Excellent option for patients who don’t want reconstruction or are otherwise poor surgical candidates for formal reconstruction
  • Patients with extremely large breasts or sagging breasts have the best outcome from this procedure

In this procedure, all the breast tissue is removed and the remaining redundant skin and tissue is mobilized and used to reconstruct the breast, which is usually much smaller than the original size and also in some cases deformed.

As it is a relatively new procedure, long term data is yet to reveal the efficacy and safety of this procedure compared to the conventional mastectomy. Another point which I could gather after reviewing the limited data available on this surgery is that cosmetic results are far INFERIOR than a regular reconstruction (whether implant based or autologous). Another reason for its limited use is that it can only be used in patients with LARGE breasts and a point which has not been highlighted by the authors is the gross disparity in size of the two breasts after the surgery (which is a source of worry to the patient).

It is still early days for this procedure and only time will tell whether it will have a fairy tale ending or not!!

6a00d8354ce17369e20133f1b1e838970b

Is Left-Handedness a Handicap for Training in Surgery?

Despite the progress made by our society, left handedness is still not widely accepted. Parents like to see their children write with their right hand initially and start correcting them if they use their left hand. Despite coming from a family, where my mother is left handed, I have faced the music many times in my life for using my left hand. My teachers at school used to scold me for my awkward way of writing despite having a reasonable hand writing (which is uncommon for doctors 😉 ). In spite of the scoldings, I persisted with my own way of writing and one advantage of my style was that nobody could copy my work during the exams 😉 ;-).

Uncommon way of writing in India but common in the west.

Uncommon way of writing in India but common in the west.

I always wanted to become a surgeon from the second year of medical school and while observing my seniors (who were mostly right handers) operate, the thought of a left handedness being a handicap crossed my mind many times. My teachers, most of whom were right handed, did not have much to say when I approached them with this query as a medical student but none of them discouraged from taking surgery as a career.

The thought of working as a left handed surgeon started haunting me again when I started my residency. Initially, I did find things a bit difficult because all the instruments were designed for right handed surgeons and left handed instruments (like left handed golf clubs) were not widely available. Most of my seniors, initially found it difficult to teach me the basics and used to get a bit annoyed when I used to start operating by standing on the left side of the table (for those who are not aware, most of the procedures are done by standing on the right side of the table). My mother, who is a successful left handed gynaecologist, was a constant source of inspiration during this tough period.

After the initial hiccough’s, my seniors became accustomed to my left handedness and taught me the skills more patiently. In no time, I mastered the techniques with my left hand and then started to hone my skills with the right hand as well. In fact, I tie right handed knots better than left handed knots (probably because I was taught by a right handed surgeon).

Now when I look back, being right handed or left handed really does not matter in the long run (in terms of a surgical career) and I would urge an aspiring surgeon not to give up the dream of pursuing a career in surgery because of being left handed. There have been many studies conducted on this topic and  they have found no difference in surgical outcomes between right and left handed surgeons.

Some helpful points for a left handed surgical trainee:

1. Don’t switch away from your dominant hand. Get good at doing the basics with your left hand (cutting straight with a scalpel, basic dissection, basic suturing), then learn how to do everything right-handed. If you start too early trying to do everything with both hands, you’ll probably flounder around and not improve as quickly as you should.

2. Learn to tie knots right handed first, since you’re going to learn to tie with both anyway.

3. Use scissors with your right hand initially. Learning to cut left handed with right-handed scissors is tricky, especially with heavy Prolene or other sutures.

4. Once you’re good with your dominant hand, by all means work on ambidexterity. Being able to operate with both hands has been advantageous to me as I’ve progressed through residency.

5. Don’t let being a lefty deter you in any way from pursuing a surgical career.

In the end I can just say one thing,

tumblr_lq0xm6aYBy1qfvq9bo1_500

🙂 🙂

Multifocal vs. Multicentric Breast Cancer

multifocal vs multicentric

Multifocal breast cancer is defined as the presence of two or more tumor foci within a single quadrant of the breast or tumor foci within 5 cms of each other.

Multicentric breast cancer is defined as the presence of two or more tumor foci within different quadrants of the same breast or tumor foci separated by more than 5 cms.

With the advent of better imaging modalities, these tumors are being detected more frequently and it is important to understand their impact on the surgical management.

Patients with multifocal breast cancer are eligible for breast conservation surgery (BCS; provided no other contraindications for this procedure are present) whereas BCS is avoided in patients with multicentric tumors. 

Another point of interest to both the patients and the doctors is that the diagnosis of a multicentric or a multifocal tumor does not affect the overall survival of the patient.