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Hi, Asher. How's it going? Thank you. Thank you for giving the opportunity. You know, I'm really excited to, you know, talk through breast and I was um listening to val and the previous speaker as well. So they have covered, you know, many of the aspects, but I will try and concentrate on breast and give you a flavor of breast surgery. Thank you. Do you need any help with presenting your slides at all? Um I have got results and PDF and I'm going to try and um if it works, it works. If not, then I'll ask for your help. Let's try. Ok. And let me know all the way that you can see. Yes, I can see it. The floor is all yours in that case. So thank you as um John uh introduced me as an um uh known as Ash um in a hospital and in among friends of an ST eight in breast surgery and in north of Scotland. Um so I'll run through this slide where I'll talk about a little bit of myself and then consideration of um the surgical carrier and then especially more into different aspects of breast surgery. It's um requirement of training and um going forward how the consultant practice looks like and a little bit of personal reflection and then um samples you to do different um websites that can help you. So, um I am an international medical graduate. So I have moved to UK in 2016 and I have um gone through the alternative pathway for course surgical training to apply for higher surgical training. And in 2019, I got into D3 program and was placed in Aberdeen. And since then, I'm in north of Scotland. However, I did a little bit of training in Glasgow as well and worked in Nottingham Breast Institute, which has actually um influenced my decision making and made me decide to go for breast surgery just looking at the out excellent outcome of the patients. Um I'm an honorary associated of University Aberdeen with um as like any other trainee registrars, I get involved into teaching and training, which where is offered in the university. Currently, I'm pursuing in an online master's uh being a full time trainee. So it's an oncoplastic breast surgery trainee, which you can um go through a different university. The most popular one is University of East. And um I'm the Secretary of Mammary Fool, which is a trainee association of Association of Breast Surgeons. And above all, I'm a wife and a mom. I've got a 14 years old and a seven years old. So um I'm sure going through the presentation since morning, you guys have realized that the length of training is required in surgery is considerable. So it cannot be done by yourself. Only. I think we need a support network. Um your partner, your friends, your family, you know, your child, minor, everybody is important in your life. Uh It's the surgical outcome for your patient and their uh poster journey is excellent in comparison to many other surgical specialty. Obviously, any surgical training costs and it's not only financial, it's your personal time resource, et cetera needs to be considered as well. Um Interestingly in along with all the other surgical specialties, I think breast is now going through heavy changes with new technologies and we are getting newer and newer gadgets every day that gets added to your list. So you need constantly need to be retrained yourself going through the process of your training and even when you become a consultant. Um So why breast surgery? Breast is a really, really personalized treatment for um the patient? No, no single patient will have it, you know, the same um the treatment program because it has got multi modality of treatment. Breast surgery is one of it, but you are um y your patient will have many other modality of treatment, but you are their doctor, you, you know, they are under your name and you have to coordinate all those treatment. Um The main thing we do for our oncological patient is surgery However, because of, you know, the post surgical life and the quality of patient's life is so important. Um now, more and more there is emphasis on oncoplastic and onco aesthetic where comes the role of our plastic surgical colleague and also us getting trained as a plastic surgery, as an oncoplastic breast surgeon. There are new other um B3 le which also takes some time in your um the workload. So these are some indetermined le which are not cancer or not benign disease and you may have to offer surgery or follow up to this patient. So um thi this is one of the the there will be every now and then there will be a few patients in your entity that you need to deal with it. And um it's very, very outpatient heavy. So you have got um quite a lot of clinic throughout your week and there will be, you know, everybody who presents to clinic thinks that they have got a cancer. So, but 90% of them are benign disease. So we have to go through all the process to identify and isolate those patients that need further attention. So any patient who is um referred to specialist for breast opinion, they all go through triple assessment. So triple assessment is an combination of um assessment that you do. So, uh the main, I think the most important part is the clinical assessment by done by ourselves, including history and clinical examination. The same examination that you will learn through your um medical school and that you get um you become more and more slick by doing every day. And then the, the second component is the radiological evolution of the patient. Um Most commonly, the patient will get a mammogram if your patient is about 40 years old and if they are below 40 the f most likely the first I imaging they will get is ultrasound of the breast. Um There are occasions when you need CT scanning and MRI of breast. And the third component of this triple assessment is pathological assessment by um a core biopsy and um like many other uh surgical specialties. Now, we are identifying more and more receptor or target that um we can identify by through the pathology so that we can tailor the treatment for the patient. So the um the most um the ones that we definitely need to know is our hormone receptor status. E RPR status and her two status. This is previously, I was mentioning that there are multi modality of treatment. Um surgery as a surgeon, you will do that, but your patient will go through chemo radio endocrine and immunotherapy. But you are in charge of the patient who coordinates all those things. It's very MDT heavy among the surgery that we offer. Um It's, it's an interesting, it's an single organ surgery. Um like, you know, our plastic surgery colleagues, we don't operate in any other organs. However, it's not just one or two operations. There are no plethora of techniques that you have to get trained for. So the main two headings is completely removing the breast called mastectomy or breast conservation surgery. And among the breast conservation surgery, you can do lumpectomy as an or what is wide local excision and other techniques of oncoplastic surgery. Mastectomy has evolved very much and the historical radical mastectomy, modified radical mastectomy has got neural or in very occasional specific indication for them. Um Now it has moved to nipple sparing, mastectomy, skin scarring mastectomy where you do the mastectomy, remove the breast itself but leave the skin and nipple envelope so that you can reconstruct a like breast. There are newer development of robotic nipple sparing mastectomy, which is not popular at all in UK. I'm not aware of anybody doing it in the UK. However, Italy, France, South Korea, they, they do robotic nipple sperm mastectomy. Um I definitely in the USA. Um the other thing is getting interest and attention is sensation preserving mastectomy where um we do offer Mastectomy for skin reduce um risk reducing patients. In that case, this sensation preserving surgery are getting more and more interest. When we do the mastectomy, you do need need to offer patient reconstruction, which can be either immediate or delayed and it can be an implant based reconstruction or autologous reconstruction. Um Our common theater list will include surgery on the breast and axilla and sometimes axilla is a staging procedure that we are doing or it's a treatment. And the three different variety of x-ray surgery we do is Sentinel in the biopsy, x-ray dissection uh or axillary clearance. So, targeted xray dissection is uh the newer technique where we are um taking a few more lymph nodes than lymph node biopsy but not clearing the axilla. So, trying to preserve as much as axillary um tissue and axillary lymph nodes, we can. So to do the sentinel biopsy, you are very much dependent on your nuclear medicine colleague, and radiological colleague. Uh the new techniques that are coming includes ICG mattress, which makes you a bit more independent in the theater. However, for technetium, you are still dependent on your nuclear medicine colleague. So your timing of surgery, how you organize your list needs to be considered up all those things. So um flat aesthetic um chest. So bilateral mastectomy, there are indications when patient will need. Sometimes it's patient choice that you have to um offer them whether there is a therapeutic mastectomy and the contralateral side can be um it's patient choice or is reducing. There are various other indication um and you can have an implant based reconstruction. Well, if you do are planning or needing to do a partial breast reconstruction, that's a new technique depending on the blood vessels around the breast. Here comes the your knowledge of anatomy and knowing um a newer and newer um identification of loca locations and landmarks of the vessels which helps us to use them in reconstruction. So with the breast conserving surgery, the simplest one you can do is wide local excision where you take out the lump and just close that depending on where is the cancer or the suspected lesion. And then um it can, you, you know, it's just a smaller um cancers, you can have actually acceptable cosmesis. However, you can expect a little bit of dent when the patient has radiotherapy. And in the long run, the scarring has happened. So that's why this um oncoplastic technique has been incorporated into the breast practice by depending on the breast volume and the position or location of the tumor, you can offer them different type of surgery and it called volume displacement technique because what we are doing is we are taking the cancer cell along with a bit of normal tissue and then moving the rest of the breast tissue, we call it glandular mobilization so that we can then again have a breast which looks like breast. So the commoner one is um the round block myoplasty wise pattern or infra radical myoplasty, lateral myoplasty G mammoplasty, um Battery me plasty, et cetera. If you are needing to take more than 20% of breast tissue um in the tumor volume is bigger in comparison to the breast, then you will have to do volume replacement technique. So the for example, this is a partial reconstruction where you have taken the tissue out from your breast. And you're gonna use tissue from the lateral aspect of the breast, which we are called a chest wall or flap to reconstruct it or for you know, total reconstruction, you can use abdominal tissue or tissue from other side. So, autologous flap and uh these procedures are mainly done by our plastic surgical colleague, but this is a combined list or joint list. So you will be going for doing the mastectomy and your colleague, plastic surgery colleagues will be doing the reconstruction. So now how to become a breast surgeon in the UK, um there are four different main routes. So the main route that we all were talking about is going through the standard surgical program where you go through um the CCT in general surgery, you can also become a breast surgeon by doing a CCT and plastic surgery and then completing the oncoplastic fellowship. The other technique is a Caesar pathway where you are not in a formal training program, but you go through um the training uh w you, you work in the different breast unit and you um collect your competencies and prove to apply for your procedure application. And the foot option is you work as a specialty doctor. It it is great doctor who does not necessarily need to go through the CCT or seizure pathway. However, you can still independent prac practice do clinic and depending on your competency, you can um do small theaters, theaters as well. So I think uh previously my colleague has gone through this. Um I won't lot much here. Um So when you have gone through the course surgical training, you've completed your MRC S, then you apply for heart surgical training. Um I think um from a breast trainee, we all talk about, we are a bit. Um The training program is ST three to ST six. You have to do the general surgery training and around ST six time, you have to declare, definitely declare your interest whether you want to do an upper gi lower gi um breast or any other specialty. Um So the d curriculum has changed a little bit where you actually can decide to go for general and breast or you decide to do, can become an oncoplastic breast surgeon. If you are deciding to do general and breast, in that case, you continue to work your emergency work until um ST eight and you in your ST seven and your ST eight, you do breast surgery get trade in breast, but you carry on doing emergency work. Whereas if you're planning to do an oncoplastic breast surgery, in that case, you can declare to stop emergency surgery at ST six and just concentrate on breast surgery in STD seven and ST eight. For example, I stopped my um emergency work after the first six months of 57 because I felt like the the exit exam that we have to do FR CS is very much general surgery based. So, if you have declared your special interest, breast, you'll have breast station and breast academic um virus. But the main exam is general surgery. So I thought it was a good idea to keep in touch with general surgery until I have completed the Fr CS. So, um, it's recommended that you do at least six months to one year of breast surgery in between your ST four to ST six. And then you concentrate on breast only in ST seven and ST eight. So when you have achieved your ST six competency, then you can apply for Fr CS and and then concentrating or ST seven and ST eight. And then when you have gained all the competencies, then you apply for your CCT. So these are the numbers, it doesn't look very, you know, many number here, breast conserving surgery, you just need 100. However, when you are doing emergency work and it's mainly the last two years of your training that you are actually gaining this number. Um it feels actually the time is inadequate. There are um a variation of practice um very much in breast. Some of the centers are very flap heavy. Some of the centers are very mammoplasty heavy. Some of the centers don't do much on plastic procedure currently and this is getting changed because all my bosses are getting training themselves to on plastic breast procedures so that they can actually start doing this technique and train us. So depending on where are you placed, so that will decide what actually you get into your logbook. So if you are in a center who doesn't do implant, um you may have to think about going to another center where they can, you can achieve all those competencies. Um But interestingly, um or, and thankfully for your autologous flaps, you don't have to be level four. That does mean that you don't really have to be completely independent. So level two, you know how to do them and if you are able to discuss that with your patient, um that's acceptable for autologous flaps. However, rest of the basic breast surgical procedure, you have to be level four. So when you have done your CT and you then apply to get into the specialist registrar. And following that, you will attend um consultant interview when you have achieved your consultant's post. Um Obviously, I've not got no experience of this just looking into my boss. Um who um it's a smaller team but well, with breast, the interesting thing is we are very neat team. Um You don't have many trainees working in the unit. Usually it's one or two breast trainee or someone who is rotating through the breast surgery, but actually their special interest is something, but this is a part of the training. They are, you usually have only one or two F two or CT. So it's in a smaller group. Um So we are very um closely bonded. Um The everyday clinical work is mainly outpatient heavy. So you have got 3 to 4 clinics per week. Your inpatient um workload is very minimum because most of the cases are day case. So even with mastectomies, patient usually go home the same day or day after. So it's uh usually one or two inpatient that you have to look after. So as a consultant, your main workload, I think is clinic and um next would be theater. Um it's very much MDT heavy. So every week, it's 3 to 4 hours of MDT work. If you are doing an oncoplastic MDT, then there is additional um hour added to it. And depending on what is your interest, you can concentrate your time and research, get involved into teaching and training, you can become an a um emergency work is very small amount. Um The main emergencies is usually the POSTOP complications that represents themselves are um very minimum. Sometimes it's the breast abscess patient who may need to be admitted for IV. Antibiotic out of hour is covered by most in most of the hospital, it's covered by general surgery. And there is a named on call breast consultant. If they need to discuss things, then they will be consulting with them breast consultant. And then overnight they a get admitted under during surgery and then hand over to the breast in the morning. However, there are difference of practice uh across the UK. So, um I think this is a round three of what I have experienced with the breast um training. However, you know, it can vary, but I feel like the work-life balance is um probably better in comparison to what I had as a general surgery trainee. I've stopped my, um on call now more than six months. So I have got my, you know, evenings and weekends for my family, for myself. Um I am able to know, um give some time to my masters thinking about my research projects, et cetera. Um It's a very much in a patient centered um discipline and the outcome is very beautiful. I have had patients who has been had cancer diagnosis 1520 years ago and coming back with uh with a, you know, a different um issue with their grandchildren. So it's very um rewarding to see those patients. So as a consultant, I think, um you don't have out of hour work, you can decide to work completely in NH or a combination of in, in private or you can go for abroad. And um well before in between your surgical completion of your surgical training and your consultancy job, you may consider doing some fellowship, which is highly recommended. Now because of these oncoplastic procedures that got incorporated. There is a national um the recruitment process, the tigue fellowship and there is other fellowships as well. Um Some popular fellowships in different parts of the Europe and Australia as well. It's a very much evolving surgical specialty. New techniques are getting added every day and see in that our theater, you'll have different gadgets. So while you are doing nuclear medicine, um certainly in the biopsy, you need this grama probe. If you're using a max, see for localization of your breast um lesion, then you will did this. Obviously, it's all image guided surgery. So you need your mammogram to be up in the theater. So it's very much gadget and techniques, technology, um dependent. So um I myself as a trainee are actually en enjoying my um time. So I hope that, you know, people who will decide um to come to breast surgery, I will encourage you to uh w whichever hospital you are working. Um come and visit the breast surgery unit, speak to the bosses, then you can get involved with the um projects that ongoing there, come to the clinic and see how you feel because some people are um enjoy their work in theater. It doesn't really uh enjoy very much talking, but it's um clinics are really heavy. You are discussing with patients in details. And interestingly, it's an oncological diagnosis but the aesthetic takes um a component of your discussion as well. So the discussion can be really complex. However, there are different training program and courses available through the A BS that you can uh, do so, I would encourage you guys to go and join them. Um, if you are considering breast surgery or it's one of your choices, go and visit Mary Fold and you will find, um, for medical students and junior up it free. It is free to join. So I think that's it for myself. Um I don't know whether I have overrun if I'm so um, apology for that. If you got any question, I'm happy to take questions on the chat or you can email me or send an email through um memory fold if there's any specific question from them for you. And um yeah, I'd like um if you guys, I don't know, I can't really see you guys. So I don't know whether um uh you know, if facial expression helps, but thank you, Ashley if you could take time to do something. But yeah, thanks John. No. Thank you so much for uh spending your day. Um telling everyone here about a career in breast surgery. I think it's definitely something that's not spoken so much about in medical school. Um especially since it's something that you get into probably later in the stage of training rather than the other surgical specialties. We don't have any questions in the chat at this moment in time, but I'd really love it if you're happy to stay for one or two moments just in the background in case any pop up. Um But once again, thank you so much for presenting. You. Absolutely enjoyed that. Um John. Um I hope um the the you, you know, it is a successful program and you can carry on doing that in the future as well. So I will try and stop myself. So if you press the um little but of the three, yeah, there we go. Lovely. Thank you so much, Ash.