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

Abstract

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. In-depth qualitative interviews were conducted with a convenience sample of 31 (22 oncoplastic and nine plastic reconstructive) surgeons who performed BR. 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. 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.