Standardising the Bi‐National Delivery of Breast Surgery Care: Reflections and Perspectives Regarding the <scp>BreastSurgANZ</scp> Post‐Fellowship Training

Breast Surgeons of Australia and New Zealand (BreastSurgANZ) was established in 2010 with the goals of standardising patient-centred care in breast surgery across the two countries through education, training, research, advocacy and audit [1]. The complexity of breast cancer care, the rapid advances in management options and developments in oncoplastic techniques have led to the recognition that an independent society is needed to ensure consistency of the quality of surgical practice and bi-national benchmarking within the field of breast surgery [1-5]. In the subsequent 15 years, BreastSurgANZ has flourished into an organization with over 400 members across Australia and New Zealand [1]. The post-fellowship training (PFT) program, first commenced in 2012, recognised the need for sub-specialty training to accommodate the management complexities and advancement in surgical techniques [1, 4, 6]. Successful completion requires trainees to achieve an appropriate case mix, participate in research and have sufficient experiences in patient-centred care both in the pre-diagnostic arena of Breast Screen as well as in the post-operative setting with multidisciplinary input. A centralised application process was introduced in 2015, resulting in over 30 applications for only 10 first-year positions in 2025 [7]. These numbers demonstrate the appeal of the PFT training pathway as well as the demand for breast surgery specialists. Similar subspecialty training fellowships internationally, such as the accredited breast surgery fellowships established in the UK and USA in 2002 and 2003 respectively, demonstrate comparable demands and requirements [3, 5, 8]. This is part of a growing trend with general surgeons obtaining post-fellowship subspecialty training in various fields, recognising that high volume centres with experience in complex oncological procedures offer better patient outcomes [4, 9-13]. In late 2023, BreastSurgANZ undertook a review of the PFT training program. Online surveys, which were reviewed and approved by the PFT training committee prior to being distributed, were developed to assess the PFT experience from the perspectives of current trainees, former trainees, and training supervisors. Participation was optional and all feedback was anonymous. Although BreastSurgANZ has been regularly conducting member and trainee surveys over the years, this was the first attempt to capture holistic feedback over all aspects of the PFT training program and from a broad range of perspectives. The online surveys were distributed via email to 27 current trainees, 127 former trainees and 25 training site supervisors at the end of 2023. Current trainees were identified as the PFT1 (first year) and PFT2 (second year) fellows in the year 2023. Former trainees were identified as all who have completed the 2-year PFT program, including those who completed one of their training years overseas. Training supervisors were the surgeons responsible for overseeing the PFT trainee in the accredited training positions. Feedback was received from 20 current trainees (74.1% response rate), 25 former trainees (19.7%) and 15 training supervisors (60.0%). Categorical data were reported as frequencies or relative frequencies. Continuous data were reported as means with standard deviations (SD). Qualitative results were collated and where appropriate, reported verbatim. Abbreviated responses were sometimes reworded to enable better comprehension. Similar responses are grouped together and paraphrased. Trainee demographics demonstrated relatively even distribution across aspects such as gender, age, and qualifications and experiences prior to the PFT program (Table 1). The mean age of current trainees was 39 years (SD ±3.5 years). Nineteen of the 45 trainees (42.2%) commenced the PFT program the year after obtaining their FRACS. From respondents who provided optional additional feedback, most fellowships that trainees completed prior to the PFT program were in the field of acute general surgery, with other responses including research or trauma fellowships. There was slightly more female than male trainees (58% and 42% respectively), with an even higher proportion of females within the current trainees sub-cohort (70%). While the proportion of women in surgery has steadily increased over the past few decades, the increase within individual specialties has been variable [14]. The specialty with the highest proportion of active female surgeons was paediatric surgery in 2021 at 31% followed by general surgery at 21% [14]. Within the BreastSurgANZ PFT program, on the other hand, the higher proportion of female to male fellows will subsequently result in a higher female representation as full members of BreastSurgANZ. Most respondents found information provided on the BreastSurgANZ website regarding the application process helpful, and the process itself clearly set out and easy to follow (Table 2). There was a rise in trainees' satisfaction from former trainees (72.0%) to current trainees (89.5%), perhaps reflecting the website upgrade in 2022. Overall, most respondents (94.7% of current trainees and 83.3% of former trainees) preferred a centralised selection process as opposed to individual applications to the training sites. Similarly, as demonstrated in Table S1, most of the 15 training supervisors who completed the survey reported they were satisfied (71.4%) or very satisfied (14.3%) with the centralised application process, though 78.6% of respondents would have liked to be more involved in the candidate selection process. While training supervisors have previously been invited to participate in the interview process, their involvement has increased in recent years. The overall feedback regarding the contents and requirements of the training program appeared to be positive (Tables S3 and S4), with highlights including the oncoplastic exposure and reconstructive experiences. While not all elements of the training program were rated equally high, it was still felt that the non-technical aspects such as communication and research were important to form a well-rounded breast surgeon. Most current trainees reported their PFT experience to be as expected (47.4%) or better than expected (42.1%). Positive feedback included an engaging specialty case mix, gaining the experience they expected from the PFT program, supportive units and formation of strong mentor-mentee relationships. Similarly, 90.5% of former trainees felt their training experience adequately prepared them for their future career, with most respondents (85.7%) crediting their completion of the PFT program for them finding employment. The importance of equipping trainees with comprehensive knowledge on all aspects of breast oncology as well as the operative skills of a modern oncoplastic surgeon has been highlighted not only locally in Australia and New Zealand, but also on a global scale [3, 5, 6, 8, 15]. Standardisation of training across hospital sites was a key area raised through the feedback received. Only 42.1% of current trainees found the training site descriptions on the website informative, voicing preference for more contemporaneous information on aspects such as the previous fellow's logbook, case mix, roster and salary. Similarly, former trainees had commented on the variability in their PFT experience and wished for more uniformity across training sites. This is an area that has been and is still being reviewed by the BreastSurgANZ PFT committee. Over the last 5 years, the PFT committee has strengthened the definitions of first- and second-year positions, resulting in either sites being reclassified in the PFT level posting or losing their PFT accreditation post. Similarly, the direct observation of procedural skills (DOPS) assessments have been more clearly defined as to which procedures were to be assessed at what training level. In conclusion, the importance of post-fellowship breast surgery subspecialty training has only increased since the inception of the BreastSurgANZ PFT program. It is generally regarded that fellows emerge at the completion of training as qualified breast surgeons with the necessary knowledge, skills, and experience. Future directions of the program may need to include ensuring standardised training experience across sites, addressing the changing needs of surgical trainees within a modern workforce, and futureproofing the subspecialty curriculum. Melanie Walker: conceptualization, writing – review and editing, supervision, methodology. Yuan Tian: investigation, writing – original draft, writing – review and editing, data curation, methodology, formal analysis. The authors would like to acknowledge the administrative help provided by the CEO of BreastSurgANZ, Sam Rawlings, in conducting the survey to the trainees and training supervisors and collating the results. The authors also acknowledge the contributions from the BreastSurgANZ Post-Fellowship Training (PFT) committee in assessing and approving the survey to be conducted. Finally, the authors would like to acknowledge the materials provided by Professor Andrew Spillane which shed light on the inception and early days of the BreastSurgANZ PFT program. The data that supports the findings of this study are available in the Supporting Information of this article. Table S1: Responses from Training Site Supervisors (N = 15). Table S2: Responses regarding the BreastSurgANZ Selection Process from Trainees. Table S3: Responses regarding the BreastSurgANZ Training Experience from Current Trainees (N = 19). Table S4: Responses regarding the BreastSurgANZ Training Experience from Former Trainees (N = 21). Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. 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