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Anne Arundel Breast Center Fellowship Program
Spring 2012

Contents


Anne Arundel Breast Center Fellowship Program
Spring 2012

Introduction
The history of the development of breast surgery as a subspecialty of general surgery was begun through various avenues, but the single largest contribution was probably the development of comprehensive cancer centers.  This subsequently led to comprehensive breast centers.  It became clear that multimodality therapy of most cancers leads to improved survival1 and in order to coordinate this care, a multidisciplinary team needed to be established2,3,4. Data has shown that care improves with specialization5,6,7 and further those centers of excellence can propel forward innovation more quickly8,9,10,11,12.  In the multidisciplinary team, the surgeon emerged as a crucial member.  What at first started as an interest grew into a selected subspecialty.  Both the technical as well as the emotional needs of breast patients requires a special kind of surgeon.  Breast surgeons have been trained in the past through surgical oncology fellowships; however, these typically required 2 3 years of training and are not focused on all aspects of breast care.  Breast fellowships have emerged to meet the need for comprehensive fellowships that concentrate only on breast disease management.  We are hopeful that through this educational endeavor, we can better meet the professional goals of surgeons interested in breast disease. 
(1)Stockton, D.; Davies, T. Multiple cancer site comparison of adjusted survival by hospital of treatment: an East Anglican study Br J Cancer 82: 208-12.
(2)Nardone, L.; Pastore, G.; Terribile, D.; Palazzoni, G.; Marmiroli, L.; Ausili-Cefaro, G. The impact of  the new organization on the management of breast cancer. Rays 1999; 24: 435-46.
(3)Lauven, G.; Barg-Hock, H.; Breithaupt, E.; Fiege, U.; Flores, D.; Michels, H.; Pichlo, H. G.; Muller-Held, W. [Quality assurance and teamwork in social medicine expert assessment exemplified by the expert assessment aid "corrective breast surgery" of the North Rhine Health Insurance Medical Service]. Gesundheitswesen 1999; 61: 640-4.
(4) Boman, L.; Bjorvell, H.; Langius, A.; Cedermark, B. Two models of care as evaluated by a group of women operated on for breast cancer with regard to their perceived well-being. Eur J Cancer Care 1999; 8: 87-96.
(5)Nodine, C. F.; Kundel, H. L.; Mello-Thoms, C.; Weinstein, S. P.; Orel, S. G.; Sullivan, D. C.; Conant, E. F. How experience and training influence mammography expertise. Acad Radiol 1999; 6: 575-85.
(6)Taylor, I. Outcome after resection of a solid tumor: volume, specialization, or both? Surg Oncol Clin N Am 9: 27-32.
(7)Wilkins-Haug, L.; Hill, L. D.; Power, M. L.; Holzman, G. B.; Schulkin, J. Gynecologists' training, knowledge, and experiences in genetics: a survey. Obstet Gynecol 95: 421-4.
(8)Hebert-Croteau, N.; Brisson, J.; Latreille, J.; Blanchette, C.; Deschenes, L. Variations in the treatment of early-stage breast cancer in Quebec between 1988 and 1994. Cmaj 1999; 161: 951-5.
(9)Dolan, J. T.; Granchi, T. S.; Miller, C. r.; Brunicardi, F. C. Low use of breast conservation surgery in medically indigent populations. Am J Surg 1999; 178: 470-4.
(10)Heimbach, J. K.; Biffl, W. L.; Mitchell, E. L.; Finlayson, C. A.; Schwartzberg, B. S.; Myers, A.; Rabinovitch, R.; Franciose, R. J. Breast conservation therapy in affiliated county, university, and private hospitals. Am J Surg 1999; 178: 466-9.
(11)Frost, M. H.; Arvizu, R. D.; Jayakumar, S.; Schoonover, A.; Novotny, P.; Zahasky, K. A multidisciplinary healthcare delivery model for women with breast cancer: patient satisfaction and physical and psychosocial adjustment. Oncol Nurs Forum 1999; 26: 1673-80.
(12) Giuliano, A. E. See one, do twenty-five, teach one: the implementation of sentinel node dissection in breast cancer.  Ann Surg Oncol 1999 Sep; 6 (6): 553-61.
Goals
The goal of our fellowship is to rigorously train surgeons for a career in breast surgery and equip them with extensive knowledge and skills to: 1) provide superb and compassionate clinical care, 2) stimulate intellectual curiosity and foster a lifelong commitment to innovation and breast disease research, 3) direct and understand the many facets and multidisciplinary aspects of a Breast Center, 4) provide leadership for colleagues, Breast Center teams, governmental agencies, insurance companies, and industry to improve breast disease care, 5) be an advocate for patients, and 6) articulate research, clinical and patient information in a collaborative, clear and concise manner.  

The Anne Arundel Medical Center (AAMC) Breast Center
The Breast Center at AAMC was established in 1995.  The overall goal of the Center is to provide superb care through dedication, compassion and innovation. The growth of the Center has been exponential, growing from the care of less than 100 breast cancer patients when it first opened to currently over 500.  Approximately 30,000 screening mammograms are done per year at the Breast Center and our 5 outreach centers.  A system has been established whereby dedicated mammographers read all the diagnostic as well as screening mammograms, and all the breast imaging preformed, from all five sites. 
The new Breast Center recently moved in February, 2010, with the grand opening being held in March, 2010.  It is now housed in the recently constructed Health Sciences Pavilion and occupies most of its second floor and includes digital mammography, numerous state-of-the art, as well as investigational biopsy systems, financial and psychological counseling, a high-risk program, nurse navigation, multidisciplinary tumor board, journal club and a dedicated breast disease library for patients and staff and numerous other breast-related programs. The fellow's office is located in the Breast Center.
The Breast Center has as a primary mission, the performance of quality research.  We have been the recipient of numerous grants and have collaborative research affiliations with Johns Hopkins, Walter Reed and East Carolina University.  The clinical research team that includes nurses, data managers, research coordinators and a statistician are also present in the Breast Center.  These staff members help support the fellow and assist in writing and abstracting data for abstract presentation, manuscript publication and grant writing. 
Patient Volume
AAMC manages over 500 breast cancers a year and has approximately 6,000 clinic patient visits per year.  It is anticipated the fellow will perform approximately 400-600 surgical procedures including skin and nipple sparing mastectomies, ultrasound guided and partial mastectomies, nipple explorations, sentinel node and completion axillary node dissections, oncoplastic procedures, assist in reconstructive procedures, and see an extensive variety of patients in clinic.  Extensive experience in image-guided biopsy is obtained. 
The Breast Center's location, in beautiful historic Annapolis, is ideal and its proximity to Baltimore and Washington provide a wide array of cultural activities.
The Breast Center Fellowship
The goal of the Breast Center Fellowship is to provide comprehensive training to men and women interested in specializing in breast surgery.  Through this training, the fellow will develop a thorough understanding of breast disease, the management of all aspects of breast cancer, and the importance of integrative care and innovation in this field of medicine.   The length of the Fellowship is one year and involves rotations on all specialties that deal with breast disease and the management of breast cancer. 

Overview of Program
These surgical rotations take place at AAMC throughout the year exposing the fellow to at least three breast surgeons. Subspecialty rotations include the Risk Assessment and Prevention Program, Pathology, Psychosocial/Counseling, Radiation Oncology, Medical Oncology, Reconstructive Surgery, Breast Imaging, Clinical Trials, and the Lymphedema Clinic.  Rotations outside of AAMC also include Johns Hopkins.  The Faculty consists of renowned experts who have been chosen for passion in their field and their teaching abilities.
Courses and Meetings
It is anticipated the fellow will attend SOBO (School of Breast Surgical Oncology), as well as the American Society of Breast Surgeons Annual Meeting.  Other optional meetings include the National Consortium of Breast Centers, the San Antonio Breast Conference, the Miami Breast Conference, the American Society of Breast Disease, and the Society of Surgical Oncology, as time and budget permit.  It is expected the fellow will take both a national breast ultrasound course and a stereotactic core biopsy course during the fellowship. 
The Fellowship Selection Process
A fellowship candidate must meet the following criteria:

Selection will be based on an interview with a Selection Committee that consists of the Fellowship Advisory Committee.  The candidates will present their reasons for selection of breast disease as a subspecialty.  Supportive documents required will include a letter from the Training Program Director and two faculty members who have worked extensively with the candidate.  A strong bedside manner and sense of compassion is expected.
Our Teaching Philosophy
Our approach to teaching is no different than our approach to patient care kind and supportive.  We train our fellows to be leaders nationally in breast surgical care, advocate for patients, and be on the forefront of breast disease research.
AAMC Breast Center Rotations and Fellow Responsibilities
The rotations through which the fellow will rotate will be tailored to each individual fellow at the onset of the year's program.  They are typically in one to two-month blocks.  Surgical and clinical responsibilities are still expected on certain subspecialty rotations where indicated. Topics that are expected to be covered during the rotations are summarized in Appendix I.  A syllabus containing landmark articles chosen by the Faculty from each of the subspecialties will be given at the start of the fellowship.  It is mandatory reading and the fellow should also add to it, pertinent articles that are published throughout the year.
It will be the responsibility of the fellow to provide and review with the attending physician the Specialty Curriculum Outline, (Addendum I), as well as a copy of the Faculty Evaluation of Fellow form, to ensure their return to the Breast Center following the rotation.  The fellow will also complete and return the Fellow Evaluation of Faculty to the Administrative Assistant upon completion of each rotation.  These documents will be maintained in the fellow's administrative records and reviewed with the Breast Center Director upon completion of each rotation.
The fellow will be responsible for advance review of the AAMC Outlook calendars on a daily basis to be proactive and aware of any changes/conflicts that may arise, and to so advise. 
Breast Surgery:
Throughout the year
This rotation will run throughout the year of the fellowship, except as conflicts with other rotations where indicated.  It is expected that the fellow will participate in the preoperative, postoperative and intraoperative care of as many breast patients as possible and with all surgeons participating in the Breast Center.  The majority of the breast patients will be seen in the Breast Center, but some patients will be seen at satellite sites, as well.  The fellow is responsible for evaluating the patient, reviewing the recent and past imaging studies, reviewing the pathology and reaching a plan that is to be presented to the attending physician.  The fellow is also responsible for the history and physical, the dictation preoperatively and postoperatively, unless the attending surgeon states otherwise.  The fellow will progress in the operating room to operate independently under the supervision of the attending surgeon at his/her own speed as dictated by his/her level of surgical expertise.  Postoperative orders are to be written and communication with the attending surgeon is expected on all aspects of the patients' care.  The fellow will be responsible for assuring discharge and post-op medication for the surgery patients, unless otherwise arranged by the attending physician.   It is expected that the fellow round on in-house patients prior to the clinic or the OR start each morning.
Fellow LOG:
The fellow is responsible for keeping a log of all the newly diagnosed breast cancer patients whom he/she has seen. This should include the date, place seen, impression and plan. This will be recorded by the fellow, using the online SSO website log.  The log will also be a record of all the procedures performed by the fellow.  At AAMC, the tear off card that is present in each patients chart can be used (two should be taken, one for the log, and one to give to the financial coordinator for billing purposes).  At other hospitals, any sticker or card that is available should be used.  All procedures performed should be recorded including all cyst aspirations, core biopsies (and which device used), US guided core biopsies, stereotactic biopsies, excisional biopsies, as well as major surgical procedures.  A copy of this log with the total number of breast cancer patients seen, as well as diagnostic and surgical procedures performed will be required at the end of the year for graduation.
In the log, will also be recorded a Case Management Section.  This portion of the curriculum requires the fellow to follow a minimum of 3 patients from diagnosis through all aspects of care and treatment.  Preferably, the patients will vary with stage of disease.  This segment of the fellowship is designed to gain an appreciation for the individuals' experience in navigating the various aspects of multidisciplinary care.  A written summary of insights, comments, conclusions and thoughts on patients' care and improvements that could be made to the system (from the patients' point of view) will be required for each of these patients.  This is a personal account of the fellow's experience, and although required, not subject to evaluation.
Official Texts: 
It is expected that the fellow will read the entire contents of one of these texts:
"Diseases of the Breast" by Harris, Lippman, Morrow, and Osborne
"The Breast" by Bland and Copeland
"Advanced Therapy of Breast Disease" (2nd Edition) by Singletary, Robb and Hortobagyi
Research:
Throughout the year
It is expected that the fellow will participate in as many clinical research projects as possible.  This will include understanding the organization of clinical trials, use of consents and the IRB process for review of protocols and consents, use of data sheets and the importance of obtaining data. 
The expectation is for the generation of:
3 abstracts (one each to the San Antonio Breast Conference, The Society of Surgical Oncology and the American Society of Breast Surgeons).  It is the responsibility of the fellow to obtain the abstract deadlines at the onset of the fellowship and to work consistently towards meeting those deadlines by meeting with the surgeons for review and editing of abstracts well in advance of deadlines.  If accepted for poster presentation, the fellow will be similarly responsible for ensuring a streamlined process for review/submission.
3 manuscripts with the fellow as the first author; this will require interaction with our statistician and the Breast Center Research Director.  It is the responsibility of the Fellow to coordinate the necessary time for review with this staff.
1 review article of a topic of the fellow's choosing.
Annals of Surgical Oncology:  Written, submitted review of article (s) submitted to this journal per Breast Section Editor, Dr. V. Suzanne Klimberg.
Breast Conference Tumor Board at AAMC:
Throughout the year every Friday
Presence at this conference is mandatory.  While on rotation at AAMC, the fellow will be responsible for composing the case slides and presentations, as well as working with clinical staff to determine cases being submitted, and to advise staff in advance of rotations or meetings away from campus, precluding the fellow presenting the cases. 
Breast Cancer Journal Club Quarterly Dinner Meetings:
Attendance is required at this multispecialty forum to discuss current articles of interest from each specialty; presentation of articles specific to breast surgery.   It is expected the fellow will search out articles of interest and discuss with the Director, in advance of the meetings, for possible review at the meetings.   As time allows, the fellow will be responsible for reviewing breast journals received via US postal service at the Breast Center to advise the Medical Director of particular articles of interest. 
Survivors Offering Support:
AAMC Breast Center
Presentations to mentor training meetings and to patient support groups as requested throughout the year will be expected.  


Addendum I
Anne Arundel Medical Center Breast Fellowship Program
Subspecialty Topics
Pathology Curriculum Outline

Medical Oncology Curriculum Outline

cooperative groups
Radiation Oncology Curriculum Outline

Psychosocial Curriculum Outline

Imaging Curriculum Outline

Breast Surgery Curriculum Outline

Plastics and Reconstructive Surgery Curriculum

Genetics and Prevention

Lymphedema Center Curriculum Outline
Understand the pathophysiology and contributing factors to lymphedema

Research
Understand the need for clinical trials

Leadership

At the completion of the training period, the fellow should be able to demonstrate an understanding of various aspects of leadership as follows:
Politics of Breast Centers
Conflict Resolution