In this episode, we take a look into the typical day of Dr. John Mullinax being a Surgical Oncologist as well as the typical cases they see.
John is a complex general surgical oncologist. He’s going to talk all about his specialty, how he got there, what he loves about it, what he doesn’t like about it, and so much more! If you want more information on the specialty of complex general surgical oncology, go check out absurgery.org.
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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.
[01:10] Interest in Complex General Surgical Oncology
As a general surgery resident, John did a bunch of clinical outcomes research in his first three years. His mentor at the time did a lot of work focused on patients with pancreatic adenocarcinoma and outcomes following what’s called a Whipple operation. It’s a complex resection for patients with pancreatic cancer. So they did a whole bunch of work and wrote a few papers based on that.
He found the field interesting because it involved other specialties. As a general surgeon, one of the things that put him into general surgery was the fact that he could stay broad and have training that was not so focused.'Surgical oncology is broad in the sense that I work very closely with medical oncologists and radiation oncologists to get optimal outcomes for the patient.'Click To Tweet
When thinking about which specialty to choose, John has defined these four quadrants: in the hospital, out of the hospital, procedures, and non-procedures.
So think about which you enjoy more. Do you enjoy being in a hospital setting? Or in an outpatient clinic setting? Then combine that with your interest in doing procedures or not.
Like internal medicine, you can stay broad as a resident. Your training is open-ended and you’re not quite defining yourself yet. And this is what led him to general surgery as a specialty. He did consider orthopedics but he learned pretty quickly in medical school that orthopedics required him to specialize and focus a little earlier than he wanted to.
[04:16] The Biggest Myths or Misconceptions Around Surgical Oncology
One of the biggest misconceptions around surgical oncologists is that all they do is operate.“As a surgical oncologist, what defines you apart from a general surgeon in the care of a cancer patient is that you have training in the nonsurgical components of cancer care.”Click To Tweet
Surgical oncologists know that outcomes for patients with cancer many times are not optimal with surgery alone. So having a good understanding of when and how to incorporate chemotherapy and radiation therapy is crucial.
John’s patients with soft tissue sarcoma absolutely need multidisciplinary care. If you didn’t have the training in surgical oncology, you’d more siloed in the care of your patients. And being able to integrate, understand, and “speak the language” of your colleagues is really helpful.
[05:37] Traits That Lead to Becoming a Good Surgical Oncologist
Like any other specialty, you’ve got to be able to work with others. Medicine is a team sport. Optimal cancer care is absolutely a team sport as well.
So you have to be able to converse openly with not only clinicians, like medical oncologists, radiation oncologists, but also your pathologist and your radiologist.
John operates on patients with sarcoma. These are complex tumors that arise in some complex anatomic constraints.“Communication and collaboration skills are really absolutely crucial.”Click To Tweet
You also have to be willing to take some risks. A lot of these tumors they approach surgically are complex, and there’s significant risk associated with the operation.
And being risk-averse is probably something that is not conducive to this. So you have to understand the risk. You have to be able to describe that risk when you’re contending a patient adequately. So understanding and accepting it is really key.
[07:00] Types of Patients
Colon cancer and breast cancer are probably the number one and number two diagnoses that a complex general surgical oncologist would see. That’s based on the incidence of the disease. Another very common cancer diagnosis is lung cancer and managed mostly by thoracic surgeons, which is a different training pathway.
Other common types of cases are cutaneous or malignant melanoma and sarcoma. These are things that are often referred out of a general surgery practice because they’re rare. The management of them is pretty rapidly changing. And when you have a rare diagnosis, the data changes rapidly. That’s something that oftentimes a general surgeon would refer to a surgical oncologist.“Patients with breast and colon cancer are probably the two most common diagnoses.”Click To Tweet
60% of his patients go to the operating room. Breast cancer, for example, is going to be a lot higher at 90%-95% of patients. So it depends on the diagnoses and the case-mix that you’re seeing in your clinic. But for John, it’s about 60%.
It’s crucial to know who needs an operation and when they need that operation. He tells his patients all the time that the timing of surgical intervention in the continuity of their treatment plan is really crucial because if you do it out of order, it can really set them back.
In his practice, a lot of his patients present with a lump or a mass that was incidentally discovered on either physical exam or imaging performed for another reason. So the vast majority of his patients either come with no diagnosis or a very vague diagnosis and ordering further imaging and biopsy.
The first time he meets them in the clinic, he tells them straight that they’re not going to have an answer today about what they need to do. But he guarantees there are going to be some tests or some other investigation they need to do before they make a final treatment plan. Hence, a lot of his job involves that initial investigation.'Once we tip over one domino, we need to know what we're doing on the other side. So ordering the appropriate imaging and biopsies is really crucial.'Click To Tweet
[10:23] Typical Day
John is a physician-scientist track. He has a lab that does basic science research and he also has a clinical practice. His days seeing patients in the clinic start at 8 am.
On those days he’s seeing patients at his clinic, he starts at 8 am and throughout the day. He sees new patients in the morning and then sees established patients in the afternoon. Established patients are those he has already operated on in the past, and they’re just following them long-term for recurrence. He also sees post-op patients mixed in throughout that day.
When in the operating room, his cases start at 7:17 am and he operates most of the day. The average time of his cases is around 3-4 hours and he usually does three or four cases a day. For instance, he does two big ones two small cases.
Then when he’s in the lab, he gets in at 8 am. The graduate students get a little later and postdocs, maybe later than that. He’s usually in meetings or reviewing data and setting up experimental plans with the team.
This is a feature you will find more common in the field of surgical oncology. Most surgical oncologists that go through the fellowship will have done it another two years of their general surgery residency on top of that in the lab.
John spent two years at the NCI (National Cancer Institute), strictly focused on basic science research outside of his five years of general surgery. That’s absolutely crucial in a disease like cancer where new discoveries every day are coming out so you have to be up to speed on your patients.“Not everyone has a lab. But aside from being able to communicate and collaborate with a multidisciplinary healthcare team, you also have to be able to collaborate with the Ph.D. folks.”Click To Tweet
[12:42] Taking Calls
John and his partner take a week at a time for calls and they cover consults. We see general surgery consults for patients within the sarcoma program, but also the extremity and soft tissue infection consults. They also have a GI oncology team that sees more of the bowel obstruction and cholecystitis sorts of consults. So splitting it up is the way they’ve organized their center.
Another aspect is the transfer. A lot of patients are initially seen at another hospital, where they will refer those patients as an inpatient for a transfer. And so during that week he has to take calls, he also covers transfers from throughout the state that transfer those patients for a higher level of care at their institution.
Operating in the middle of the night and other emergencies are not as common as it was when he was a resident at a general hospital. But now that he’s at a cancer hospital, things are more elective. That’s not to say that there aren’t emergencies that happen at night and on the weekends.“Cancer patients certainly have all of the usual urgent general surgery concerns like diverticulitis and cholecystitis as well as infected sebaceous cysts and things like that.“Click To Tweet
Then you also have to put that on in the background of folks that are getting systemic chemotherapy for other causes. They have a huge bone marrow transplant (BMT) program at their hospital. And those BMT patients have those normal surgical emergencies that can happen. Those cases can be a little more complex, but those are the sorts of things that they would see on-call that would be more of urgent intervention.
[14:35] Do They Also Give General Surgery Care to Their Patients?
When their patients are receiving therapy, let’s say a patient that’s moved on to radiation or moved on to chemotherapy, or may have recurred with metastatic disease, then yes, they absolutely have to provide general surgery care.
But for most of their patients who live a good 2-4-hour-distance away, they rely on their local community physician and/or community hospital. These are for those more urgent concerns where they can’t travel for hours.
Then in those cases where they may have a history of cancer and they have no evidence of disease (NED), and then four years later, they have, say, cholecystitis, that’s something that’s honestly best cared for at their local community hospital. Because they’re close to their family and they’re close to their support system.“Having them drive for hours to have their gallbladder out when they could easily have it done 20 minutes from home doesn't make a lot of sense.”Click To Tweet
But certainly, while they’re on active cancer therapy, they can serve as their patient’s general surgeon. So John still gets to practice some of that acute care surgery he learned in his training.
[16:07] Work-Life Balance'We need to think more about work-life integration than work-life balance.'Click To Tweet
In any specialty, you are always a little bit at work. As a physician, you cannot turn it off. You just can’t, and you shouldn’t.
So you have to think about how you can integrate work into your life. For example, you may have to leave the office a little earlier because you need to get your kids to bed early. That’s an example of integrating rather than staying in the office late and not seeing your kids right.
You have to think of ways to integrate and get your work done, but still see your family and hold up those other responsibilities that you have outside of medicine.
[17:28] The Training Path
After medical school, you get into a general surgery residency which is five years in most academic programs. There are also a lot of community general surgery programs now that are increasingly funded by for-profit hospital systems.'General surgery residency is really quite prevalent.'Click To Tweet
Most folks that apply to a surgical oncology fellowship will have done a period of dedicated research time. In John’s case, he spent two years of bench research. But there are also those that will take two years and do some fantastic outcomes, large database, data analysis sort of fellowships.
But most people take some time away from their general surgery residency to get off a niche in terms of research effort. Then afterward, you do a two-year surgical oncology fellowship.
Then there’s a board exam at the end of your general surgery residency, both written and oral board as well as at the end of your Surgery Oncology fellowship (written and oral board).
Ultimately, you’re looking at five years plus two years in the lab plus another two years – so it’s a nine-year training endeavor. Then you’re double board-certified in both of those specialties.
[19:10] How to Be a Competitive Applicant
The surgical oncology fellowships are increasing year to year. It’s actually one of the more dynamic specialties in terms of programs being added. About five to six years ago, it became a separate boarded specialty, which was through the ACGME.
Now in order to sit for the boards, you have to complete an ACGME fellowship, like any other residency, and so the fellowships are being added. There’s now somewhere in the neighborhood of about 40 programs, and around 100 fellows a year that graduate.
Applicants that apply to those are super focused, and not like a large applicant pool. That being said, it’s one of the more competitive fellowships. A lot of them will have done that time in research and have a fair number of publications and good board scores.
And then in surgery, it’s the American Board of Surgery (ABS) In-Training exam so those ABS scores are usually pretty crucial to matching into a fellowship.
One thing that the American Board of surgery did a few years ago was they changed their process. Where it used to be, you would recertify every 10 years, and now it’s every two years. It’s a more continuous certification now. It’s a shorter test, actually an open-book, shorter test so it’s less onerous. John thinks it’s a good move in the right direction from the ABS.“Medicine changes a lot in 10 years. And so the old model of recertifying every 10 years just doesn't seem quite as appropriate these days.”Click To Tweet
When folks are hiring or looking for a new partner, they have some area of the practice that needs to be developed. Most people focus their practice based on the need of the groups that they join. Some groups may be hiring someone who needs to really focus on the breast or someone may have folks that are doing hepatic biliary and we need someone who can focus on the colon cancer or rectal cancer.
When fellows who graduate are looking for jobs, everyone has things that interest them and things that don’t. And part of the job search is looking at what disease and where you’re going to focus on the job that you go to.
[23:16] Message to Osteopathic Students
When applying, take two years to do some sort of dedicated research time, and it absolutely does not have to be pipetting in a hood. It just needs to define yourself as some early level of an expert in some niche and that’s crucial for anyone.“Whether it's allopathic or osteopathic graduating from your general surgery residency, you have to demonstrate that you have a handle on the basic principles of general surgery.”Click To Tweet
Be able to demonstrable why you are interested in surgical oncology. And your dedicated research time allows you to demonstrate that.
As program leadership, what you’re looking for when you’re matching folks into a fellowship is folks who are going to come to your training program, learn what you have to teach them, but then go out and be a leader themselves. That’s the most enticing to a fellowship director.
[25:00] Message to Future Primary Care Physicians'Not all soft tissue bumps are lipoma.'Click To Tweet
John says that they see a lot of patients that were referred to them with a soft tissue lump in their thigh that someone thought was a lipoma. And they took it out. And lo and behold it was a high-grade sarcoma. In which case, that’s not good for them.
Having it on your radar in terms of your differential diagnosis for soft tissue masses, certainly from a sarcoma standpoint is crucial.
Additionally, having a low threshold to get that MRI or pause and get a biopsy before you send them to a general surgeon are things that really can change the trajectory of a patient’s outcome.
All of the things we learned in medical school, good physical exam skills, good history-taking, these are crucial things as a primary care physician. You just don’t realize how much you impact the trajectory of that patient’s outcome by that very first clinic visit. So having that on your radar as well as having a good contact list of people you can consult with or refer to can really impact the outcomes for your patients.
Soft tissue sarcomas are rare. For every 50 lipomas, you’re going to have one sarcoma. But it’s that one sarcoma patient that you’re really going to impact their outcome to a detrimental degree.
A lipoma is a soft, small lesion, subcutaneous tissue. But if it’s a firm, fixed mass in the proximal thigh, then it’s probably not a lipoma. So you really have to have good physical exam skills, and really understanding that taking it out is not the approach that should be taken.
[28:00] Other Specialties Surgical Oncologists Work the Closest With
They’re working closely with medical oncologists and radiation oncologists. The three of them are sort of the crux of the treatment plan for a cancer patient. But outside of that the pathologist and the radiologist are equally as crucial. If they don’t get the right diagnosis, it doesn’t matter how great of an operation they do, or what kind of chemo their medical oncologist colleague gives. If they don’t get the right diagnosis through their pathologists then that’s a real problem.
They also work closely with their ancillary folks like the anesthesiologists who are also crucial in terms of providing great outcomes to their surgical patients.“Medicine is a team sport. But surgery is absolutely a team sport.”Click To Tweet
You have to recognize what each member on the team brings, what their strengths are, and look for those colleagues that can help you get the best outcomes for your patients.
[29:15] Message to Younger Self
There were times when John would doubt his own trajectory. But he was always someone who has always focused on the next years of his life, thinking about where he’s going to be in the next two years. Thinking 5-10 years ahead is great but many times, you just get lost in all of the possibilities.
Thinking constantly ahead and not focusing necessarily on where you’re at is key. Always thinking about your next step keeps you going. And it keeps you focused on why you’re doing what you’re doing at that moment.“A lot of people apply to medical school not knowing exactly what's on the other side.”Click To Tweet
Maybe it’s family pressure or social pressure that you’re going to medical school. But if you can imagine yourself literally doing anything else, then do it.
[32:28] The Most and Least Liked Things
Every day is different. Every patient is different. John has a general sense of what his schedule is for the day. But things are always on the move and dynamic. And that’s something that keeps him interested every day.
On the flip side, what he likes least besides charting and insurance companies is the non-patient focused items.
We all go into medicine because we want to help people. We want to take care of patients. John says he could write patient notes all day long. And it’s fine, as long as he is doing it with the intent of helping his colleagues understand why he’s taking care of this patient, which is the point of the medical record. But when you’re having to document the history and a physical exam based on some sort of coding requirements, that’s where John draws the line.'We gripe about the administrative burden, but it's not really the administrative burden. It's the administrative burden that isn't patient-centered.'Click To Tweet
That’s why John stresses that we need folks in medicine that aren’t on the physician side of things. We need them on the administrative side thinking about how do we make healthcare work for patients better and not checkboxes.
And that’s where the burnout comes from. John would rather work 12 hours taking care of patients, than two hours of doing something that has nothing to do with patient care. And a lot of physicians feel the same way.
[34:52] Major Changes Coming Into the Field
The biggest is the whole exploding field of immuno-oncology or immunotherapy. Historically, cancer was treated with surgery, chemo, or radiation, and that was it. And now, understanding how our immune system relates to cancer in the next 10 years is going to be unbelievable, especially in solid tumors.
If you look at patients with lymphoma, there are absolute cures of patients with high-grade lymphomas, that 2-3 years ago were not cured. And that’s amazing! And that’s just entirely based on cellular immunotherapy.
So the field of cellular immunotherapy in solid tumors is at the early stages of this. So that’s one of the most exciting things when treating patients by modifying their immune system to some degree.
[35:48] Final Words of Wisdom
John could not imagine doing anything else. He loves working with all of his colleagues in different specialties.'You can't have a whole team of Tom Brady's. That isn't going to work. But every team needs one Tom Brady.'Click To Tweet
So you need to understand what your strengths are. People who get into some area for reasons not of their own volition that they ended up in that specialty, that’s where you’re going to burn out. Because you don’t enjoy it, and you just went into it for the wrong reasons.
Finally, keep your options open. Don’t pigeonhole yourself too early. Have a sense of your strengths, know what you’re good at, and then look for a specialty that fits those characteristics. That’s how you’re going to be happy.
If you want more information on the specialty of complex general surgical oncology, go check out absurgery.org.
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