Baking, Breasts and the Beginning of Surgery

Two weeks ago, I wouldn't have thought that I'd enjoy surgery this much.

Alright, so that's not completely true. I knew I would probably enjoy going into theatre, observing and assisting. But I still had an innate fear of getting things wrong, of accidentally cutting something irreparable or causing a tear. I think that's one of the reasons why I respect surgeons so much. There are people who say that surgeons are egotistical, stick their noses up to others; however, it's understandable - it takes a lot of knowledge, courage and self confidence to be able to cut into another living, breathing, human being and trust in your own abilities to do the right thing and perform the surgery as stated during consent, irregardless of possible complications.

During these last two weeks with the breast team, I've learned a lot - clinically and personally. The sense of community and the camaraderie - of the consultants, Mr. Johri and Mr. Bonomi; the speciality doctors in surgery, Ms. Kalra and Mr. Rapisarda; the junior doctor I met while I was in my gastro rotation for Internal Medicine, Dr. Train; and all of the breast care nurses and radiologists - is amazing. Everyone on the team made me feel welcome from the beginning, taking me under their wing and teaching me.

Monday of last week, I watched my first lipomodelling. Last Wednesday, I scrubbed in for the very first time and assisted. And the following day, I got to do subcuticular stitches on a patient for the first time. It was rewarding, and educational. As I said before, I have had a longstanding fear of the fragility of human tissue - mainly stemming from my own encounters with accidents, especially the time I got run over by a bike in Davis. But that day, I got over my fear of accidentally tearing the skin while retracting. It still amazes me how resilient the human body is. No matter how much trauma is inflicted upon the tissues and organs, with time, a good blood supply and sufficient nutrients, the body heals itself.

The difference between a cadaver and living person is so unreal - one would imagine that the basic fundamentals of anatomy would be the same, and they are. But at the same time, very different. Our very first semester of medical school, anatomy was fun, exciting, a chance to see inside the body and explore things for ourselves. I must admit, we weren't the best of surgeons at the time, but we took chances and tried our best. In the end, I think we came out the better for it. We learned the basics of anatomy, insertions and origins, vascular supply and nerve endings while respecting our very first patient, the person who had donated their body to our education. Now that I have observed surgical procedures, I wonder how the very first surgeon got accustomed to warm bleeding flesh and obtained the nerve to continue with incisions knowing that the patient's life was literally in their hands. (Hmm... that was a bit of a graphic query wasn't it? I shall try to refrain for the rest of this post.)

In any case, back to learning.

I am absolutely certain now that patient interaction is a must. Despite having met some very knowledgeable and engaging pathologists, I know that I could never stay in a lab with the minimum of patient contact. Pediatrics taught me that I love talking to people (alright, so I didn't really learn that then). It showed me that I could piece together a jumbled story from a parent with patience and present the child's story with precision and confidence to my senior. It taught me that the simple act of talking, of engaging and offering reassurance goes a long way towards establishing rapport with both patients and family members.

This afternoon, I almost started crying in the middle of clinic.

Last week, I had dubbed it Bad News Friday, mainly because the multidisciplinary meetings (MDTs) between the surgeons, radiologist, pathologists and nurses occurred on Wednesdays thus leaving Friday for the presenting of results and final decisions to patients. Friday is the day we tell patients the results of scans and tests. Granted, it's not all bad news. Some are cysts (fluid filled sacs encased in epithelial tissue) or fibroadenomas (fibrous stromal/epithelial tissue that is rearranged into a well demarcated mass) - both benign findings which occur normally in breast tissue. But then there are the patients who must be told they have cancer. DCIS, LCIS, invasive, adenocarcinoma, Paget's. The names and acronyms are relevant to us but to the patient, the most significant thing is that they have malignant cells - cancer. To some, it is a shock. To others, they have wondered and prepared. But nothing truly prepares a person until the event occurs.

That is exactly what happened today. It was not unexpected. The patient knew the results and had a discussion previous to today regarding treatment options but nothing could have predicted the emotional storm I was swept into. Prior to this appointment, I had blinked furiously, sniffled a few times during consultations, but the moment I heard the fear and uncertainty in the patient's voice and saw the tears welling up, I had to forcibly control my own outburst. It was hard. Normally, with a friend or acquaintance, tears are acceptable from either party. But professionally, I knew that with the surgeon, breast care specialist nurse and breast team nurse in attendance, I had to put on a strong front for the patient, to show them that we were there for them, that we were in control of the situation and allow the patient to lean on us for support. And at the end of the appointment, a few more tears were shed but we reached a consensus on treatment, worked on a timeline and gave the patient the reassurance she needed and the knowledge that she was in good hands.

After the patient left, I couldn't bring myself to admit that I had been on the verge of crying. But it was true - I could have just as easily started sobbing alongside the patient. One of the things I have learned over the years - teaching at Ida B. Wells Continuation High School, volunteering at UCSF/UCD Medical Centers, listening to my friends and offering my advice - is that I cannot help but empathize with whomever I encounter. I know that it will serve me well in the future, that it will make me a better person and doctor - I have heard many a time that I am a compassionate person, but in the end, it's not the words and phrases that mean anything, it's my actions that will stand through time. In not shedding tears and offering tissues when required, I spoke wordlessly with the patient, telling them I was there, that they had my support and that I understood and was not judging them for their actions.

So that's some of the things I've learned outside of the books in the past two weeks, the next post might have more useful factoids. But to end this segment, here's the chocolate cake I baked twice in two days; once for a slice of happiness in the midst of Bad News Friday and once for the joy of feeding the people I love.

Hershey's Chocolate Cake
(I halved the original recipe)

1 cup sugar
7/8 cup flour (or 3/4 cup and 2 tblsp)
6 tbls cocoa
3/4 tsp baking powder
3/4 tsp baking soda
1/2 tsp salt
1 egg
1/2 cup milk
1/4 cup vegetable oil (I have also used olive oil)
1 tsp vanilla
1/2 cup boiling water

In a large bowl, combine all the dry ingredients and mix together. In a separate container, mix all the wet ingredients except for the water. Add the wet ingredients to the dry and mix until well incorporated. Add the boiling water to the batter. It will look very separated but stir well until the consistency of the batter is uniform. It will be very thin but don't be alarmed. Pour into an 8 inch round pan and bake at 350 (180 C) for 35-40 minutes or until a knife stuck in the center comes out clean.

Making it in the hospital accommodation, I've been baking things for a significantly increased time, so if you know your oven, adjust baking times and temperatures accordingly.

For both cakes, I made chocolate ganache to pour over the top. Just the basic recipe I use tweaked for a smaller amount.

Chocolate Ganache
1/4 cup whipping cream
100 grams (3.5 oz) dark chocolate
1 tsp vanilla/Irish Whiskey/the flavoring of your choice

In a pan or microwave safe bowl, heat the cream but not to boiling. Place the chocolate pieces into the cream and let sit for a few minutes before stirring. When all the chocolate is melted and incorporated smoothly, add the flavoring of your choice. Pour the ganache over the cake and place in fridge to set. Or... just consume. :D