On the frontiers of change: breast surgeons' views on demarcation between surgical sub‐specialties in Australia

Abstract

Background The emergence of breast oncoplastic surgery provides women with more surgical options for improved aesthetics following breast‐conserving surgery and for breast reconstruction (BR) following mastectomy. For some established breast and plastic surgeons, this development may be perceived as increasing competition for patients and raises the potential for demarcation issues between and within surgical sub‐specialties. The objectives of the study were to document surgeons' views on demarcation between general/breast, oncoplastic/breast and plastic reconstructive breast surgeons in Australia, to examine the potential impact demarcation issues may have on informed patient choice and to recommend ways of reducing them. Methods In‐depth qualitative interviews were conducted with a convenience sample of 31 (22 oncoplastic and nine plastic reconstructive) surgeons who performed BR. Results Descriptive analysis of the interviews revealed a range in the perceptions of the extent of demarcation. Six common themes were identified: oncoplastic techniques are unnecessary and potentially unsafe; reconstructive surgery should be left to ‘the experts’; non‐referral of patients for discussion of surgical options they do not offer; professional jealousy; workload capacity; and the old versus the new guard. Potential solutions suggested by the participants focused on improving relations between oncoplastic and plastic reconstructive surgeons and changes to breast surgical training. Conclusion While most surgeons were optimistic about the current divide diminishing with time, a more pro‐active stance is required if patient‐centred care is to be improved. Roundtable discussions with a broad range of stakeholders are planned to begin this process.

Re: On the frontiers of change: breast surgeons' views on demarcation between surgical subspecialities in Australia

“…We read with interest the article by Kovoor et al regarding the screening of patients scheduled for surgery during the coronavirus disease 2019 (COVID-19) pandemic. 1 Our oncological thoracic surgery unit was not designed for the treatment of COVID-19 patients. The aim during the pandemic was to maintain a high volume of oncological surgical procedures using adequate policies.…”

“…We would like to thank Dr Flitcroft et al for their article. 1 The potential changes in clinical practice highlighted in this article rightfully need both oncological and reconstructive input to be balanced and ensure the best outcomes for breast cancer patients. Many plastic surgeons and breast surgeons already work closely together to provide excellent services for patients with breast cancer.…”

Oncoplastic Reconstructive Breast Surgeon (ORBS) Performance and Impact on Breast Reconstructions: Clinical Outcome, Learning Curve, and Patient Reported Aesthetic Results- An analysis of 451 Procedures

“…Breast reconstructive procedures and related surgical trainings have traditionally been performed by plastic surgeons, however, a paradigm shift has recently taken place [1][2][3][4]. A formal inter-specialty training program has been established in UK since 2002 [2,5].…”

“…Oncoplastic and reconstructive breast surgeon (ORBS) aimed to incorporate aesthetics and plastic technique into breast cancer operations to not only achieve the oncologic safety and cosmetic outcome simultaneously, and also to promote breast reconstructions [3,[6][7][8]. The ORBS training program was started in England and Europe, and now became widespread around the world [1][2][3][4][5][6][8][9][10][11]. The program incorporated lectures and training courses to assist breast surgeons to acquire breast reconstruction techniques and plastic surgeons to be familiar with breast cancer operations (dual trained system) [1,3,[8][9][10]12].…”

General practitioners are key to increasing Australia’s low rate of breast reconstruction

“…11 A range of demarcation issues between surgical oncologist/ oncoplastic surgeons and plastic surgeons have been identified; these act as a further barrier to access when surgeons are unsupportive of each other in a hospital or are unwilling to refer to colleagues. 16 A further challenge is that some referral centres do not accept patients who reside outside the area, which may limit the options, especially for women in rural areas.…”