As a former in-Training staff member and columnist, I gave you A Taste of Your Own Medicine and now it’s time to give you a taste of my own medicine! I started writing for in-Training as a medical student when the site was in its infancy. It’s amazing to see how it’s grown while I have been away in training and now as a breast surgeon. It only feels right to provide some reflections on my journey to breast surgery.
When I entered medical school, I knew I wanted to be a surgeon, even with my very limited knowledge about surgery. My first third-year clerkship happened to be surgery, so I was able to dive right in! My schedule had me start with orthopedic surgery, which wasn’t for me. Fixing broken bones just wasn’t my thing. Then, vascular surgery, which really wasn’t for me. I could not see myself doing leg bypasses, foot amputations and fistulas for the rest of my career. I left that rotation with blood dripping from my shoes, which was standard after a major vascular surgery, especially when the patient is on a heparin drip. Sigh.
Next, was surgical oncology and that’s when it all happened. I ended up working closely with a female breast surgeon and two male surgical oncologists. It wasn’t my first time in the operating room, but I was in shock when the attending surgeons had me assist in their cases. I couldn’t believe it when the surgical oncologist told me to take the Bovie and cauterize in between what he was grasping with his forceps. I was his assistant in a thyroidectomy! Well, at least until the chief resident finished the morbidity and mortality conference and told me to move out of her way. Next, I was in a mastectomy case and I was asked if I wanted to close the long incision. The resident didn’t want to do it because it was tedious, but I was thrilled as a medical student because that meant more practice for me! These instances may seem mundane, but they were exhilarating for me to actively participate in the operating room. After that, I learned how to assist in breast cases and then to perform them with the guidance of my patient attending. I couldn’t believe one Saturday morning after I retracted for my attending as he performed the mastectomy on the left breast, when he told me he would retract for me on the right breast so that I could perform the mastectomy on that side. He was my assistant! Don’t Bovie the skin, he would warn! He said, what do you have to do on a Saturday morning? Watch cartoons? Might as well be operating! I agreed.
The surgical rotation wasn’t all glamor in the OR. We had to round on inpatients and attend clinic. Well, lucky for me, the residents hated breast clinic because they had no interest in breast care and found it boring. That left me alone to shadow the attendings. I got to meet amazing cancer survivors and learn their inspiring stories. I watched my compassionate breast surgery attending connect with her patients on a humanistic level. She had one young female diagnosed with an aggressive breast cancer, underwent a bilateral mastectomy and chemotherapy. She had lost all her hair and suffered from chemotherapy side effects, but maintained a smile and an appreciation for life. She was told that she likely wouldn’t be able to conceive after chemotherapy and she shared that she was pregnant with her first child, which brought her to tears. It was amazing to see hope and happiness come out of this difficult time in her life.
I loved the continuity of care that the surgeon had with their patients. In general surgery, you may perform a cholecystectomy on a patient, see them once post op and never see them again. The breast surgeon and surgical oncologists had patients for years. They had established a trust and bond with each other, which I admired. The surgeons I learned from were patient, understanding, compassionate, listened and were open to feedback. They were my role models.
When I finished my surgical rotation, it solidified my decision to become a breast surgeon, but I wanted to remain open and to learn as much as possible from my other rotations. I had to soak up as much experience and knowledge because I knew I would never get that opportunity again and I suggest the same for all medical students. Not to mention, there is a lot of overlap with the different specialties. For instance, a breast surgeon works closely with the pathologist, radiologist, plastic surgeon, medical oncologist and radiation oncologist. I liked that my attending breast surgeon would go to the nearby reading room and look at mammograms with the radiologist. The surgical oncologist would scrub out of surgery and go down to the basement to review with the pathologist the frozen section of the surgical specimen he just removed. I loved the multidisciplinary approach of breast surgery and that my attendings were proactive. You have to work well with others. As I was told, you have to play nice in the sandbox. Breast cancer patients have a team of physicians that you have to be able to communicate and coordinate care with.
It’s OK if you change your mind once or twice (or more) during medical school. Find the area of medicine that you love. Remember, this will be your career so it helps if you love what you are doing. I recommend exploring as many areas of medicine as possible, including non traditional rotations, like sleep medicine, genetics and allergy medicine. Who knows? You may find your niche!
In order to become a breast surgeon, I had to complete five years of general surgery residency, which was five years of blood, sweat and tears. General surgery training was physically, mentally and emotionally challenging. This is when you are exposed to many aspects of surgery, including trauma, bariatric, pediatric, transplant, colorectal, vascular, surgical oncology and breast. I enjoyed some aspects of general surgery, but I came to the conclusion that I didn’t want to be a garden variety general surgeon and that I wanted to specialize in breast surgery.
That led me to breast surgery fellowship, which is one year. General surgeons can perform breast surgery, but usually a small number of cases a year, because they are performing other surgeries on a more routine basis, such as appendectomies, cholecystectomies and bowel resections. They have not undergone specialty training and therefore do not have all the knowledge and skills of a breast surgeon who has undergone fellowship training. Fellowship allowed me to hone in my skills as a breast surgeon and to learn from the latest research data and experts on how to manage patients with benign and malignant breast disease. Everything I learned during my fellowship, I use on a daily basis, both in clinic and in the operating room. My fellowship training has been instrumental in making me the breast surgeon I am today. I am so grateful for it because not everyone gets that opportunity. Through every step of training, you have to take tests, apply, interview and get letters of recommendations and there’s always more applicants than surgical trainee spots. Ultimately, hard work, perseverance and as cliché as it sounds, believing in myself even if others did not, paid off. I am so appreciative that I can take everything I’ve learned throughout my schooling and training to apply that knowledge and skills to provide better care for my patients.
My daily life as a breast surgeon consists of clinic alternating with surgery. I see patients with benign and malignant breast disease. Patients see me for abnormal mammograms, breast pain, breast lumps, a family history of breast cancer, new breast cancer diagnosis, abnormal breast biopsy, etc. The surgeries I most commonly perform are excisional biopsy, lumpectomy, mastectomy and sentinel lymph biopsy. I am happiest when I’m operating (that should be a bumper sticker).
As you can probably tell, I love being a breast surgeon. I enjoy the surgeries I perform and I even enjoy breast clinic…in moderation. I love helping my patients and giving them the tools and information to guide their decision making and ultimately feel comfortable in the care they are receiving. I love giving lectures on breast education to the community and physicians. I also enjoy giving lectures to students who are interested in surgery. I want to pass down what I’ve learned to the next generation of physicians. I wish everyone luck in their medical journey and careers and may you find a specialty that brings you as much joy as breast surgery does for me!
Image Credit: “Pill Box” (CC BY 2.0) by NIAID
Columnist Emeritus Dr. Valentina Bonev is a board certified fellowship trained breast surgical oncologist. She graduated from the University of California, Irvine and earned her medical doctorate at the University of California, Irvine School of Medicine. After general surgery residency, she completed a breast surgery fellowship at the Lynn Sage Comprehensive Breast Center at Northwestern University, Feinberg School of Medicine in Chicago. She is passionate about surgical education and community outreach on breast health. In her spare time, she enjoys writing and scrapbooking.