What You’ll Learn

A surgical oncologist offers wisdom and insights about why medical students are drawn to his specialty (innovation and impact), daily challenges (inefficient OR turnaround and coding), the future (minimally invasive surgery and AI diagnostics), and the words that every cancer patient needs to hear first.

Interviewee: I am a surgical oncologist specializing in breast cancer. Our practice is affiliated with the academic medical center. In terms of the surgical oncology, we have about four other physicians that are currently practicing full-time.

VIVO: Do you all focus on breast cancer or does everybody do something different?

Interviewee: Not all of us do breast cancer. Some do, some don’t. I’m very familiar with that – that’s what I do. In terms of the oncology side, we refer patients to radiation oncologists, and we also take care of patients that have metastasis elsewhere in the body. A lot of them get metastasis to the brain, so we send them to neurosurgery and they get either stereotactic radiosurgery or they get masses resected.

VIVO: What’s the last time you were inspired by something, maybe a medical advancement or a patient? What’s the last time you went home and you went, wow?

Interviewee: In surgery in general, every day I have something that either I get wowed by if it’s a good experience or sometimes not so fortunate experience. When my family asks me what I have planned today, I have cases that are planned, but other than that, it’s hard to tell how the day will go. I think that’s with any surgical subspecialty.

We recently had a patient with HER-2 positive breast cancer that we resected, and she was doing very well. My plastic colleagues and I did a mastectomy and they did breast reconstruction. Afterwards the patient was so happy. We followed with her and I still get Christmas cards, New Year cards from her. It’s so nice to keep in touch with her. Recently I was invited to one of her children’s weddings. These things make all the difference because at the end of the day, they were so grateful. To me it was maybe just another day but to her, that procedure changed her life and that was incredible. I’m so humbled to be able to offer that to patients.

VIVO: Is that what drew you to surgical oncology before you started or is that something that happened once you became one?

Interviewee: I knew I wanted to do some surgical subspecialty because I was always interested in the innovation technology side of medicine. With surgical subspecialties, there’s always new tools, new devices that come to the market. Obviously in the medical side there’s new drugs and pharmaceuticals, but what drew me more into surgical oncology — surgery first — was the ability to have a tangible skill that will help patients and can perhaps yield results almost immediately.

That is something that sometimes when I was in medical school and I rotated through the internal medicine side, you treat patients, you give them medication, the patients may still be ill and they may leave the hospital still not doing so well. With surgery, patients sometimes leave the hospital ill, but a lot of times, especially if it’s something inside or something that we got clear margins, the prognosis is very good once we get the pathology back. And so that immediate gratification is something that drew me.

The oncology side of it is because when I was an undergraduate, I did research in oncology, in cancer – it was in glioma in the brain. The constant innovation, the new discoveries – it’s the cerebral part of it that meshes with the surgical skill. That’s something that drew me because there’s always new stuff coming out, and that’s why I decided to go into it.

VIVO: That’s wonderful. Have there been any surprises where you thought, I thought it was going to be this, but turns out it was completely different? Any surprises or is it what you expected even better?

Interviewee: I think the biggest surprise was how early in my training and my career you get thrown into situations where you have to be the one delivering bad news or managing patient expectations. To you it seems like, wow, am I equipped to do this? When you’re so early in your training, now it’s part of my career, but when you’re early in the training and you have to manage patient expectations and deliver bad news and still not rob patients of hope because that’s the last thing we want to take from them, even if we know the prognosis is poor.

I think those two things, it was shocking to me that now I can’t turn to anyone superior. I’m the person and the patient looks up to me and I have to be able to tell them without sugarcoating, tell them the situation as much as they want to hear. That was eye-opening. But I think at the same time it matures you, gives you a different perspective on the important things in life.

VIVO: Are there any challenges that you encounter daily, whether it’s with technology, EMR integration, logistics, the things that keep you from doing all you can do?

Interviewee: I think it’s very institutional specific. With our institution, sometimes the turnaround for the OR, I’m sure it’s in many other institutions, but I feel like it’s not as efficient as it could be. Sometimes myself and the residents and the anesthesia team are able to do cases more efficiently, but maybe there’s not enough staff in the OR to staff another room. Sometimes it’s frustrating to patients because patients sometimes don’t see the full picture. If a patient comes in for an elective surgery and it’s supposed to go in the morning, it goes in the afternoon, or sometimes we even get bumped to the next day, the patient is frustrated, their experience is tainted in that sense. We try to explain some things are beyond our control, but those things are sometimes burdensome.

Obviously there’s a lot of paperwork with every EMR. I don’t know what the workaround would be, but it is so much paperwork and dictation. Obviously dictation speeds things up, but still it doesn’t get rid of all the paperwork.

And I guess the last piece of the puzzle is the coding. I think medical coding is a specialty on its own. Navigating that – when becoming a more senior faculty, that’s something you don’t learn about in residency, how to code a procedure. Those things are important in terms of healthcare and patient delivery.

VIVO: Is there a specific fear that you deal with often? For instance, in your screening response here, you said the emphasis is not only removing the cancer, but also restoring the patient’s sense of self. And then you go on to say, seeing confidence regained and feeling whole again. Is that something you would say is something you see with every patient?

Interviewee: That’s a good question. That leads me to why I chose breast cancer specifically. When I was in undergraduate in college, I started a nonprofit organization the purpose of which was to create for patients that for some reason decided not to undergo reconstructive surgery after a mastectomy and they still wanted to feel whole. They still wanted that confidence. They wanted to not seem as someone less or get weird looks in the street, but for one way or another, they didn’t want to have another surgery. We created, using 3D printing, a 3D silicone replica of the breast.

This is a prosthetic, it’s not an implant or anything. It’s not inside the body. It would be placed underneath the bra, but it would be a 3D scanning of the breast and then would create the 3D replica of it. I think that experience was the foundation for me when I realized how important it is for breast cancer survivors to feel whole. And that feeling goes hand in hand with the feeling of confidence, with the feeling of getting back to life.

We have a lot of patients that surgery is done, they’re doing great, they follow up with a medical oncologist, they’re doing great, but they are depressed, they’re anxious. They start seeing a therapist, a psychiatrist, even if they didn’t before. It’s hard to pinpoint exactly what these stressors can be. Cancer in and of itself can cause that, but I think part of it, from what I’ve heard patients say, is that feeling that something was taken from you.

Being able to provide patients — our plastic surgery colleagues do a phenomenal job with breast reconstruction and surgery. But when I was doing that and then providing patients their replica, it’s so gratifying to get these responses to how invaluable they found it. I think that is something we often undermine. Sometimes we see patients in clinic, we focus a lot on the medical aspect of it, but it’s everything. And I think the anxiety, depression, all these things that many patients go through, they might not express it as often, are things that all clinicians, especially in oncology, should be on the lookout for.

VIVO: Is that something that you express to maybe students around you in the academic setting? Obviously there are a lot of people coming forward in your field. Is that something that you think is being covered very well with people coming forward? Do you think that that’s a general heart with people who are going into surgical oncology?

Interviewee: I think that a lot of doctors have that pure intent and they go into the specialty with that intention. I think especially in oncology, they have that pure mindset that they want to restore patient’s attitude, positivity and those kinds of things. I think a lot of times, this is just me speculating, but the burden from whether it is bureaucratic stuff from the hospital, paperwork, those kinds of things that bog you down – sometimes in the day-to-day, we have our blinders on. We don’t see, we go through the motions from one case to another. It’s hard to take a pause, to take a break and think about the person that’s in front of me and what they’re going through and put myself in their shoes because we have so many things that we have to take care of in addition to the clinical care that we provide.

I think if this was a utopia where we could provide, do the surgery, obviously prescribe the medications and do the clinical aspect of it without having to deal with all the bureaucratic work and the burden of EMR, coding, all of these things — I get maybe 15 emails every day about the code that I mislabeled. These things get to you because these people hunt you down in the hallways and the office administrator, then you have deadlines, you have to correct them. These things take your attention and your mindset off of the things that matter.

I think a lot of people start with that pure mindset and at some point they either get distracted, burned down, and maybe are not so attentive to it. But I think it’s important to, whether it is go on breaks or have conferences or attend sessions that highlight that every once in a while so that spark is restored.

VIVO: To restore that spark, to be able to get past all the logistics that wear you down, what do you do, what do you do to get your inspiration back?

Interviewee: Personally, I meditate. I enjoy meditation. I don’t do it an hour of it every day, but a few minutes here and there. Whether it is in between cases in OR, in between patient visits in clinic every once in a while or at the end of a long day or before I go to work. I think that gives me a clear mind. If work was stressful and I go home to my family, I try to not bring that back home. Or if I had a stressful morning, to not bring it to the next case or next patient. I think that pause, sometimes it’s five minutes or two or three minutes. It helps me clear my mind and then focus once again on that patient and what’s important to them right now.

VIVO: What advice would you give to someone experiencing burnout? 

Interviewee: I think part of it is getting in touch with people in your life. I think we are all busy, obviously we all have a lot of stuff going on, but if I had to give advice to a colleague or even my younger self would be in those times that you’re stressful and you’re burned out and you feel like you don’t have time to see your wife, girlfriend, husband, father, mother, sibling, whoever it may be, or a close friend, I would say pause and do see them because that will give you a better sense of essence and importance and put your priorities straight.

If you were worried about some administrative thing that didn’t matter, but your friend is going through a difficult time, suddenly it puts perspective in your life. Or you were having a difficult day and you catch back with your son or husband or wife and it’s a great time together and you have a good meal – those things will help you rejuvenate. Whether it is a 30 minutes or 10 minutes phone call or a dinner or lunch, I think those things are important. I mean, obviously it can’t be done every day. Everyone is very busy, but even if it’s on a weekend, I think that’s important.

I’ve had many times, I remember even in residency, that I was so busy and I had to maybe study, do more things and you were go, go, go, go, go. But it’s important to take that break because I think a lot of people in medicine are very driven, very competitive, and you’re always on the go, but that pause will get you further than you think. It won’t set you back. I think touch back with someone important in your life.

VIVO: Do you see surgical oncology shifting?  Where do you maybe see it going in 10 years? 

Interviewee: I think there’s always new devices and new drugs into the market, and I think those will push a lot. I think especially in early stages or depending on the stage and the pathology, push away from radiation. I think a lot of the new targeted therapies in terms of oncology are working so well right now and we defer more and more to medical oncology when appropriate rather than radiation. And I think that as they get better and there’s more drugs that are studied better, I think that will be a shift.

In terms of the surgical component, I think there will still be a need for surgery in large disease or symptomatic relief if the mass is causing some symptoms or metastasis. I think in those special scenarios, there would be definitely some need for surgery. I don’t think that will go away, but I think it’s going to be a shift. I think obviously the trend is always to go to more minimally invasive surgeries, so I think we’ll move away from mastectomies. Maybe it’ll be lobectomy, another weird combination of medical therapy, more so than radiation. I think that will be a change in our lifetime.

VIVO: What isn’t being said in your space? Why isn’t anybody thinking about this, or why isn’t this being focused on more? Is there anything that comes to mind ?

Interviewee: If I had something specific, I would get a Nobel Prize. It’s tough in terms of specific medicine and medical management, but I think the more exciting thing that’s now up and coming is the use of AI. In terms of the prediction, recently, Harvard did a study that they were able to predict early breast cancer with AI before any radiologist was able to do. I think that will maybe shift the patients that we would treat, because suddenly we will catch patients at a much earlier stage, and maybe our treatments would be even more minimally invasive.

Maybe we wouldn’t see the big metastases or the big tumors that are much later stage. And so we would shift to maybe not even radiation, maybe medical therapy and a small biopsy and a smaller section of the mass that can be done minimally invasive in the future, maybe in the office. No hospitalization required. I think those are the things that are now being pursued, and if I had the computational help to analyze all of that, I would. I’m not a computer scientist to run all these AI models, but I think that’s very exciting.

VIVO: If you had a 30 second commercial to inspire hope, what message would you give?

Interviewee: If I had a patient come to me with a breast cancer diagnosis, I would tell them: Listen, I don’t know exactly, truly, honestly. I don’t know how all this will turn out, but I can promise you that I and the rest of my team will do everything we can to make sure you feel better. You’re in the best hands possible, getting the best care that we can offer anywhere in the US and it will be okay.

We don’t know exactly how that will turn out, but the most important thing now is we have a path for treatment and we’re going to focus on that. I think that’s the most important thing, and we will revisit it as we go along. We will definitely revisit the path and we’ll talk about this, but I want you to know that this is not a path that you have to go alone. There’s a lot of us behind you supporting and helping you along the way, and I think the biggest fear, the fear of the unknown, we are here to take care of that and to help that fear go away. There’s always people around to answer the questions, so it’s a team effort.

Participant Profile

• Gender & Specialty: Male Surgical Oncologist specializing in breast cancer
• Geographic location: Unspecified (works at an academic medical center)
• Years of experience: Established faculty position (post-residency)
• Practice setting: Academic medical center
• Area of focus: Breast cancer surgery with emphasis on holistic recovery
• Key patient demographics: Breast cancer patients requiring surgical intervention
• Notable priorities: Patient wholeness after cancer treatment, restoring patients’ sense of self, balancing technical excellence with emotional care