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Digital Doctor Conference 2013

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Digital consumerism is progressing relentlessly and whilst the advantages of new technology are evident in our personal lives, there is a palpable air of concern amongst the medical profession. “The Digital Doctor” team are positively embracing the benefits of moving healthcare into a new era and hope to direct the use of new technology in a constructive manner that will benefit both healthcare professionals and patients. To achieve these aims the “Digital Doctor Conference 2013”, was held for its second year last November, again kindly sponsored by the British Computer Society and held at their excellent headquarters in Covent Garden, London. The conference was attended by IT professionals, doctors, medical students and patients; thus group sessions contained some perspective on every aspect of healthcare technology. The organisers are also an eclectic mix of doctors and IT professionals, united by their interest in improving Health IT.

The conference included plenary talks, interactive group sessions and workshops. Eminent plenary speakers included Martin Murphy, Clinical Director at NHS Wales Information Service.

Martin challenged us to redefine our relationship with our patients in a new era where clinical information will be in control of patients and access to healthcare professionals can be as easy as a click away. Currently, services like those at rocketdoctor.ca are now properly stablished and operating everyday. Adapting to this change works the same way as medicine has always done. Implementing new technologies to improve medicine is and always has been a top priority, looking only to more effectively save or better lives.

Software mediated care – implications for our patients and ourselves from Digital Doctor on Vimeo.

Popular teaching sessions at the conference were daily life IT tools, including the “Inbox Zero” philosophy, how to collaborate online, keeping up to date with RSS readers and Stevan Wing gave an introduction to the open-source “R project” for statistics. Other sessions focused on how to develop IT systems. This insight is useful both to allow healthcare professionals to construct their own IT solutions but also to help translate ideas to IT professionals. One such example being Sarah Amani, who used her experience as a mental health nurse to develop a mental health app for young people, called “My Journey”. In her inspiring plenary, co-presented with Annabelle Davis who developed the Mind of my Own app, she makes the point that the vast majority of young people rely on email, social media and online services therefore this is the best place to reach them. A session giving the methods and practicalities of developing IT systems was given by Rob Dyke, Product Development Manager of Tactix4. To help delegates get their ideas to reality Ed Wallitt, one of the organisers and the founder of Podmedics, built on earlier sessions about how to code, how a website works and information design, explaining how to use wireframes and prototypes, to achieve professional design of websites and apps.

Existing NHS IT systems were explained using the example of an emergency patient admission. Tracking the patient journey from home to hospital, via A+E, then transfer to ward, rehab back home, with GP clinic the final destination. At each stage a different IT system is employed such as the emergency 999 network and the N3 private network. Concepts such as the NHS spine were introduced and explained. A complex web of systems were shown to be in use, with numerous safety mechanisms; providing some explanation as to the difficulties faced by employees in the NHS.

Delegates were able to implement this teaching in the “App factory”, to solve problems they face in daily life or work. Three app ideas were created and presented by separate teams. These were a teaching log for doctors to record teaching sessions and simultaneously get feedback from students, a productivity app to provide useful information for new doctors to know about any hospital, however the winning idea was a patient facing app for use in hospital, to track updates in ongoing care.

In another session Matthew Bultitude, an Associate Editor of BJUI, was invited by Nishant Bedi (another organiser) for his vision of the future of medical journals. Journals are key in shaping the way medical practice is conducted and the dissemination of information is as important as ever in the digital age. Paperless journals may be the future however traditional business models rely on paper journals for revenue and many journals have yet to feel confident in moving all of their content exclusively online. Yet there are signs of change with European Urology adopting a paperless format for members from Jan 2014, now surely others will follow?

Under new leadership, the BJUI has recently focused on revolutionising its online presence, starting with a complete website overhaul. Amongst many changes to its design, the website now hosts an article of week, user poll, blogs and picture quiz. Numerous metrics for the website now show significant improvement in website visitors, duration of visit (1 to 3 min) and “bounce” rate. The increasing importance of social media for health professionals is demonstrated by the fact that more than ¼ of website traffic now arrives from Twitter and Facebook, having previously been dominated by search engines. Matthew finished by discussing alternatives to impact factor, such as the journal’s “Klout” score or “individual article” metrics, which are likely to be increasingly important as medical journals develop more web and social media presence. Extremely accurate individual “article level metrics” are calculated by checking number of views, tweets and re-tweets, and mentions in review sites (such as F1000 Prime). It is clear to see how powerful this could be, for example when discussing viewing numbers and duration of reading, Matthew can inform us that currently BJUI Blog articles are each read for a total of 5 min, with even the 15th most popular article receiving almost 500 views.

This talk was paired with one from the futuristic journal “F1000 Prime”. This journal provides an extra layer of expert peer review, using scientific articles that are already published in other journals. Thus articles selected by F1000 Prime direct users to the most significant developments in their chosen field, the expert reviews of the articles include an article rating, relevance to practice and whether there are any new findings. Research has shown that selection of an article by F1000 Prime, is an accurate indicator of future impact factor. Users may also receive email alerts of recommended relevant papers and they are able to nominate articles, follow the recommendations of an expert reviewer. Also refreshingly, any submissions to the journal, receive a completely transparent peer review process, openly available to any user.

Conference attendees were given the patients’ perspective of Health IT, by a panel chaired by Anne-Marie Cunningham (another organiser). These real life stories, gave insight into the mindset of people suffering from demanding chronic disease, both at home and in the hospital. Importance is given to people taking ownership of their health; both rare and common diseases were mentioned including Addison’s disease, asthma and mental health issues, where 24 hour support is an unfulfilled requirement and there is a need for a more integrated approach. Positive examples were given with one patient gaining reassurance by regular home peak-flow monitoring that can be reviewed remotely by her respiratory consultant. This helps to determine optimal timing for clinic review, with other similar examples seen in home blood pressure or blood sugar monitoring. Importantly social media and support groups can provide 24 hour advice and connect patients with expert doctors or similar sufferers all over the world. It was clear that the lack of hospital WiFi disconnects some patients from their online support networks, when they are actually most vulnerable. Other complaints centred around the underuse of email appointments and text alerts, which could empower patients to chase their own appointments or scans. 

Delegate feedback suggests this conference is unique and covers a rapidly expanding area of Medicine. We look forward to the next conference in 2014. The Digital Doctor 2013 conference program and highlights are available from the website or directly on our vimeo chanel. For updates and upcoming events follow us on Twitter @thedigidoc and the podcast is available from iTunes or our website. 

Mr. Nishant Bedi
Core Surgical Trainee (Urology), West Midlands Deanery

Dr Stevan Wing
Academic Neurology Registrar, East of England and The University of Cambridge 

 

Annabelle Davis

Out with the old; In with the new. Stats and metrics: The BJUI website 2013

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Is it already over twelve months since the new Editor took over and the new BJUI web journal was launched? The old one had served its purpose well but the editorial board had decided the change of leadership dictated a clean new website would be launched in January 2013. Decisions were hard. Out went non-journal content such as case reports and in its place we created four main content areas with the aim of maintaining fresh, regularly changing content. These (article of the week; BJUI blogs; picture quiz of the week; BJUI poll) you will by now be familiar with, but how has the new web journal performed? Let’s look at the metrics over the last year.


The BJUI website prior to 2013

Firstly, most of the figures referred to in this article are for the www.bjui.org site only. They do not include direct access to the journal articles in the Wiley Online Library where the issues are stored. Thus analysing overall visitor numbers is not that valid and doesn’t allow for meaningful comparison. However, it appears there has been an increase in web visits of at least 10%. When we drill deeper, this is where we really notice a change. Readers now spend on average over 3 minutes on the site per visit. This is a dramatic change from previously – in 2012 the mean visit duration was just 87 seconds!

More and more people today decide to get involved with an online business, due to the fact that having a business operated through the internet offers a lot of advantages over doing it the traditional way. Online business means that you can do business right at the comforts of your own home. Thus, there is no need for you to get dress and step out of your house to earn a living. However, there are many important things that you need to learn more about in getting your online business off the ground. One of which is the creation of your own website, and the need to obtain hosting, in order to get it launched onto the World Wide Web. With so many employees working from home it’s understandable that so many businesses are now using software to monitor online activity as this means that staff can be easily managed.

Knownhost web hosting can be obtained through a company who have its own servers, where websites are hosted. In other words, a hosting service is one of the necessities in getting your own website visible through the internet. For sure, there are many ways that you can have your own web page today, such as creating a free blog or a free website. However, in most cases, these types of services are limited and having one of those pages does not mean that you entirely own them, since another website is actually hosting it.

In a nutshell, website hosting is very important because you simply could not launch your own website without having it. The hosting service provider is the one that will provide you with the space where you can upload your files that are related to your site, and they are also the ones who will ensure that your website is visible to people when they type your site’s address on their favorite web browsers.

Since there are a lot of web hosting service providers available in the market today, selection is very important in order to get associated with a reliable one. When you are able to obtain a hosting account from a reliable provider, you will be able to avoid loss of sales caused by downtimes. There are actually hosting service providers, which do not have reliable servers. In other words, they encounter a lot of downtimes, and because of that, your business would lose a lot of sales opportunities. This is because server downtimes mean that your website would not be visible on the net during those times. Thus, people who are suppose to make certain purchases, may decide to buy the items from your competitors.

In relation to that, aside from the importance of hosting for your online business, you should also become more aware of the importance of selecting a reliable web host; and one of the best ways to do that is by learning about the features of the hosting account that they can offer to you.

Geographically, the top country by visit is the United States with 22% of all visits, closely followed with the UK (21.6%) with Australia third. In total there were visits from 189 countries with both India and Japan making the top 10 (numbers of visitors) emphasising the journal’s global reach. This is truly an international journal.

 
Global subscriptions to BJUI represented as a “heat map”

Another major difference we have noticed is in bounce rate. This refers to the percentage of people who leave immediately after visiting the page they landed on i.e. if everyone only looks at the first page they come to then the bounce rate would be 100%. In 2012 the bounce rate was 66% – and this has improved significantly to 50% in 2013. This rate is never going to be very low – people come directly to a blog, quiz or just go straight onto the author guidelines or an article on Wiley Online Library. But to see such a reduction is encouraging and vindicates the approach we have taken with the web.

When we look at traffic sources, again we see another big change. This is how the visitor came to the site i.e. do they type in the web address, use a search engine or get driven to the site by social media. As you might expect, the largest single source of traffic (45%) is from Google – these visitors also spend over 3 minutes on the site with a bounce rate of 40% – so the site is not being found by accident and readers move onto other pages. 24% of traffic is direct but what is new behaviour is that 12% is from Twitter and 6% from Facebook – so social media is now driving nearly 20% of all website traffic. Facebook visitors also spend over 4 minutes on the site – they come for a reason! Of course there are the quirks – a men’s health magazine drove 1% of visits to a specific article on penis extenders! Those readers aren’t urologists as they only spend 16 seconds on the site with a bounce rate of 99.4% – this, however, does give credibility to the use of these statistics.

Apart from the homepage, the majority of social media-driven traffic is to the blogs. This has been highly successful with regular topical blogs and comments. Blog traffic has been high with the most popular (Melbourne Consensus Statement) receiving over 6500 views and 58 comments. Whilst this is clearly the highest, the top 8 blogs all have over 1000 views. Time spent on these blogs is high with several being read for an average of over 6 minutes. In January 2014 we added widgets to our blogs that allow you to see the number of reads each blog has received, and also  to allow tweeting and Facebook liking directly from the blog. Blogs posted prior to this time also have these features but the number of reads prior to January 2014 are not displayed. With this section being so popular are Letters to the Editor dead?

In a recent poll, we asked you what single feature you had liked best. Exactly equal with 34% were the blogs and the free Articles of the Week (which have also been popular in the web metrics with over 13,000 views). Picture quizzes have been successful with over 10,000 views. These demonstrate a shorter time on the page as one would expect (100 secs) but also a lower bounce rate (48%) – these readers often go elsewhere on the site. The video section has also been popular with over 2000 views although obtaining good quality videos is challenging and we encourage authors to submit video with their articles to further drive this section.

 

How does this translate to actual journal article downloads? Interestingly our approach has led to an increase of over 35% in full text downloads from Wiley Online Library compared with 2012. This is exciting and shows the web journal has been very successful not only in driving website activity as described above but also in promoting core journal content.

So for 2014 we have a new App to view the journal. Currently only on the Apple platform (80% of mobile devices used in 2013 to view the website were Apple), this is free to download although requires a log-in to view full content (available via your institutional subscription, from Wiley or from your society). It works really well on the iPhone as well as the iPad and allows access to not only the monthly journal but ‘Early View’ articles as well. This is already my preferred method for reading the journal and I highly recommend trying it.

With high-quality web and mobile interfaces, the question has to be are we ready to go paperless? As the Web Editor I should of course say yes. We discussed this at length at our first board meeting in November 2012. Due to our diverse international readership it was felt to be too early for such innovation. This will inevitably happen and another major urology journal has taken this step in 2014 (€60 supplement for the print version of European Urology). It is surely only a matter of time until digital is the standard platform. Hopefully you, the readers, will tell us when the time is right.

Matthew Bultitude
Associate Editor, Web

Report from the RSM Winter Urology Meeting

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The Winter meeting of the RSM may in the past, have had a reputation, more for its skiing than for its scientific profile. This was my second meeting 24 years after the first and I was seriously impressed with the scientific content, quality of the presentations and the first class debate that took place after the presentations.

Certainly starting with a world class motivational presentation from Sir Clive Woodward set the meeting off really well and RSM Section President John Parry subsequently chaired a good debate on how the successful messages of ‘teamship’ from World Cup Rugby and the 2012 Olympics success, could be transferred into British Urology and the NHS in general, was very motivating.

Fifty presentations over 5 days from urologists, oncologists, renal physicians, anaesthetists and GPs was always going to have something for everyone.

Stand out highlights for me were the juxtaposition of Mark Frydenberg from Melbourne and Bruce Montgomery presenting state of the art lectures on Active Surveillance and the place of multiparametric MRI and 4 linked presentations on all aspects of the management of small renal tumours and the management of tumours in single kidneys including auto-transplantation from the Universities of Western Australia (Mike Wallace), Oxford (David Cranston and Mark Sullivan) and Melbourne (Mark Frydenberg).

Whilst not particularly urological, separating the quality science with first class presentations on the Great Losses of the Great War by John Reynard and Medical Issues of Climate change by Juliet Boyd (retired anaesthetist) was yet another sign of the first class programming from Dominic Hodgson and Rik Bryan. Whilst on the subject of Rik, his presentation on bladder cancer pathways created more debate than possibly any other topic. Here was a cancer that killed over 5000 patients per year and where clinical outcomes had not significantly improved over the last 30 years. There was a desperate need for a new bladder cancer initiative to raise funds for research whilst pulling together all the bodies interested in this neglected malignant condition.

Commissioning is not everyone’s ideal topic but clear presentations on this subject clarified the muddled terminology and may position us to get involved in the ongoing debate.

There were 3 world-class oncologists present and Nick James and Peter Harper covered drugs for prostate, bladder and renal cancers and once again Steve Harland entertained and educated us in his classic understated style whilst challenging the majority surgeons in the room by asking them when surgery was appropriate in testicular cancer.

Coincidentally the organisation was first class the venue outstanding and after 20 hours of lectures and presentations the skiing was of the highest order (well at least from some of the younger delegates)!

 

Mark J Speakman
Consultant Urologist, Taunton & Somerset FNHST and Vice President BAUS
Twitter: @Parabolics

 

Editorial: The age old question: who benefits from prostate cancer treatment?

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Widespread PSA-based screening has dramatically altered the profile of newly diagnosed prostate cancer in many countries. Although screening effectively decreases the rates of metastatic disease and prostate cancer death [1], the increasing proportion of low-risk disease necessitates a critical assessment of the need for aggressive therapy.

Active surveillance and watchful waiting are potential alternatives to delay or avoid the need for treatment in carefully selected patients. The key issue is determining which patients are appropriate for conservative management. Although these approaches are often targeted toward elderly men, such men are more likely to be diagnosed with high-risk disease. A recent study by Scosyrev et al. [2] raised concern about excess prostate cancer mortality attributable to under-treatment in the elderly.

Overall, there is very little Level 1 evidence to guide prostate cancer treatment selection. One such trial, the Swedish Prostate Cancer Group 4 (SPCG-4), showed that radical prostatectomy significantly improved survival compared with watchful waiting [3]; however, that study examined a primarily clinically detected population from the 1990s. Subsequently, the Prostate Cancer Intervention versus Observation Trial (PIVOT) randomized US male veterans diagnosed with prostate cancer from 1994 to 2002 to radical prostatectomy vs observation [4]. At 10 years, they reported no significant difference in overall survival between the two arms in the intent-to-treat analysis (hazard ratio 0.88; 95% CI 0.71–1.08, P = 0.22). However, that study was smaller than anticipated owing to difficulty with recruitment and there was a high rate of crossovers between the intervention and observation arms. Per-protocol analysis was not reported for PIVOT and the prostate cancer landscape has continued to change in the past decade, raising unanswered questions over what the results would be if we compared contemporary men who were actually treated to those who were not.

This is the knowledge gap addressed by Aizer et al. [5] who used Surveillance, Epidemiology and End Results (SEER) data for 27 969 US men diagnosed with low-risk prostate cancer from 2004 to 2007. Overall, 67.1% of these men received radical prostatectomy or radiation therapy, while >30% underwent active surveillance or watchful waiting. Using competing risks regression, they showed that both age and non-curative treatment were associated with a significantly higher short-term prostate cancer-specific mortality. These results should be interpreted with caution, however, since they comprise observational data with great potential for confounding. Interestingly, at a short median follow-up of only 2.75 years, 5.4% of these men with presumed low-risk disease died from prostate cancer. Recently, there has been debate over whether Gleason 6 disease should really be considered a cancer [6], but these data highlight the limitations of current clinical staging, such that even presumed low-risk disease may be understaged. The authors suggest that use of a more extended biopsy scheme before active surveillance might reduce the risk of early progression due to undersampling. MRI represents another potential non-invasive treatment method to improve clinical staging and patient selection for active surveillance in the future [7].

Stacy Loeb
Department of Urology, New York University, New York, NY, USA

Read the full article

References

  1. Schroder FH, Hugosson J, Roobol MJ et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med 2012; 366: 981–990
  2. Scosyrev E, Messing EM, Mohile S et al. Prostate cancer in the elderly: frequency of advanced disease at presentation and disease-specific mortality. Cancer 2012; 118: 3062–3070
  3. Bill-Axelson A, Holmberg L, Ruutu M et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 2011; 364: 1708–1717
  4. Wilt TJ, Brawer MK, Jones KM et al. Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med 2012;367: 203–212
  5. Aizer AA, Chen MH, Hattangadi J, D’Amico AV. Initial management of prostate-specific-antigen-detected, low-risk prostate cancer and the risk of death from prostate cancer. BJU Int 2014; 113: 43–50
  6. Carter HB, Partin AW, Walsh PC et al. Gleason score 6 adenocarcinoma: should it be labeled as cancer? J Clin Oncol 2012; 30:4294–4296
  7. Vargas HA, Akin O, Afaq A et al. Magnetic Resonance Imaging for Predicting Prostate Biopsy Findings in Patients Considered for Active Surveillance of Clinically Low Risk Prostate Cancer. J Urol 2012; 188: 1732–1738

 

Another new year, but evidently no new overall survivability for patients presenting with metastatic prostate cancer

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The first International Journal Club of 2014 pulled momentum from December’s discussion on treatment of metastatic prostate cancer. The study reported retrospective review of the California Cancer Registry (CCR) from 1988 to 2009 and found no significant improvement in overall or disease-specific survival in men presenting with metastatic prostate cancer. [1] Senior author Marc Dall’Era (@mdallera) led the Twitter #urojc chat.

 

 

 

 

Fresh into a new year, the crowd was giddy.

… and turned toward more important current events, like the U.S. Preventative Services Task Force’s prostate cancer screening recommendations from 2012.

Ultimately, Dall’Era reigned in the masses. His study sought to investigate whether improvement in patients with metastatic prostate cancer have contributed to the overall decline in prostate cancer mortality since the introduction prostate-specific antigen (PSA). The authors identified 19,336 men through the CCR who presented with de novo metastatic prostate cancer between 1988 and 2009. Over the entire study time period, median age of diagnosis decreased significantly from 73 years to 71 years.

The authors separated the men into chronologic cohorts:  1988-1992, 1993-1997, 1998-2003, and 2004-2009. Men in the recent era showed no significant overall survival (OS) or disease-specific survival (DSS) improvements versus earlier cohorts after 1988. Interestingly, on multivariate analysis controlling for baseline patient characteristics, OS was better for men in the 1988, 1993, and 1998 cohorts versus the 2004 cohort. DSS did improve with time when comparing the 2004 cohort with patients presenting in all earlier years.

If there have been no changes in overall survival in patients with de novo metastatic prostate cancer, might this support the effect of PSA screening?

Tweeters discussed prostate cancer screening selecting out a more biologically aggressive metastatic disease. Dall’Era explained the theory.

The overwhelming question chat participants asked is whether the lack of survival benefit over time is truly accurate, a false reflection of treatment advancements made in recent years, or an artifact created from limitations of the study.

Future studies should attempt to control for the different metastatic disease profiles, namely those patients diagnosed after clinical symptom workup versus those who are asymptomatic on presentation. Examining and comparing tumor biology is another future step.

Ultimately, it’s important not to lose sight of the two dramatic trends over the past decade: the decline in prostate cancer-specific mortality and incidence of metastatic disease. The next steps are solidifying which low-risk patients to treat and developing advanced methods to treat the most aggressive diseases.

The Best Tweet prize for January goes to Parth Modi from New Brunswick, NJ, which goes to show that even Urology residents are in with a chance to win.  The January prize has been kindly been donated by European Urology.

Thank you, Marc Dall’Era, for joining the chat. Your interaction made the January chat particularly lively and insightful. Thank you, European Urology for generously providing the Best Tweet prize.

Finally, here are the Symplur.com analytics for the chat.

[1] Wu JN, Fish KM, Evans CP, deVere White RW, Dall’Era MA. No improvement noted in overall or cause-specific survival for men presenting with metastatic prostate cancer over a 20-year period. Cancer 2013. In Press. doi: 10.1002/cncr.28485

Christopher Bayne is a PGY-3 urology resident at The George Washington University Hospital in Washington, DC and tweets @cbaynemd.

 

Urological Fellowships – the unwritten but almost essential step to a future specialist consultant practice?

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Preamble:
Training in urology in the UK, and indeed globally has seen significant changes in the last decade. This has mirrored the changing face of health care provision within and outside the NHS. For award of a Certificate of Completion of Training (CCT), the Joint Committee on Surgical Training (JCST) has recommended specific guideline criteria for different specialties, including urology. The current structure of urological training in the UK has evolved to prepare a trainee by the completion of training at bare minimum for a general urologist. However, depending on the training environment, trainers and trainee enthusiasm with an early focus of interest, many trainees achieve more than just this bare minimum by way of modular training, especially in their final years of training. Some will carry on with acquisition of specialist skills as junior consultants, but increasingly trainees are opting to go for fellowships in their area of specialist interest. This is almost becoming an unwritten essential step for getting a plum specialist post.

When to start?
Those trainees with a special interest in a particular area (and wish to pursue this after CCT) should start the thought process by the end of second year, and their initial groundwork to identify suitable fellowships by third year. Why the rush? Simple reason: the application time to the start of some fellowships typically lags by a year or more. For example, many North American institutional fellowships have application submission deadlines in January, followed by interviews in February-May, for a fellowship that will start in July the following year (18 month lag!). This rush is even more important if the fellowship is intended to be undertaken prior to end of training as an ‘out of programme experience’ or ‘out of programme training’, as the rules have recently changed as of April 2013 where some Local Education and Training Boards (LETBs), previously called ‘Deaneries’, under the Health Education England will not allow OOPE or OOPT in the final year of training. Refer to www.gmc-uk.org and www.hee.nhs.uk for more details on OOPT and OOPE.

When to go on fellowship?
The options are either doing your fellowship before completing training as an OOPE / OOPT or going on a post-CCT fellowship. When to go depends on your individual interest, personal circumstances, fellowship criteria, your choice and importantly the support of your programme director and local surgical training committee. The advantage of an OOPE/OOPT fellowship before CCT is that when you come back, you have your registrar job and salary to come back to. You also don’t lose your grace period at the end of CCT. The disadvantage is that you may come back specialised and ready for a consultant job, but since you haven’t yet completed your full training, you could miss some good job opportunities while you go back to being a registrar for a year. The advantage of a post-CCT fellowship is that you can start looking for jobs during your fellowship and ideally walk into a consultant (or locum consultant) job, but this requires diligently keeping in touch while you are away. The disadvantage is that you may not have anything to come back to, and you lose your grace period. Either way, it’s a gamble.

Where to go?
Traditionally, the two most popular destinations for fellowships are USA and Australia. Emerging spots include Canada, Europe and home-based UK fellowships. Each place has its pros and cons. Australian fellowships, usually for a year, are supposedly good hands-on experience with a fantastic salary package, proportional to frequency of calls. However they grossly lack research and formal learning opportunities. American and Canadian fellowships are usually 2 years with a year of research and a year of clinical/operative work. The research exposure as well as publishing, critical appraisal and exposure to knowledge is fantastic. For US fellowships, trainees have to sit the USMLE and be ECFMG certified. Canadian fellowships are becoming popular with British trainees as holding the FRCS (Urol) suffices, and there is no need to sit any other exams. They also offer a fine mix of research opportunities and hands-on operative experience. For oncology fellowships, visit www.suonet.org. Good financial planning is crucial, especially for North American fellowships.

 

Jaimin Bhatt
University of Toronto Health Network, Princess Margaret Hospital, Toronto, Canada
Post-CCT SUO Fellow in Urologic Oncology. Completed his urological training in the Oxford deanery (now called Health Education Thames Valley)

 

Editorial: Does performing LND at nephrectomy give a survival benefit or not?

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We read with interest the article by Sun et al. [1] in this issue of the BJU International. We were pleased to see another research group interested in this important aspect of the management of patients with lymph-node-positive non-metastatic RCC. The question of the benefits of lymphadenectomy in such patients could not be answered by the European Organization for Research and Treatment of Cancer randomized trial [2], as only 4% of clinically node-negative patients had micrometastatic disease.

Given some of the complexities involved in the analysis of Surveillance, Epidemiology and End Results data and the particular statistical analysis we used in showing a benefit to increasing nodal yield in patients with positive nodes [3], we were reassured that Sun et al. were able to validate our findings when replicating our data extraction and analysis. They performed two additional analyses and the four results are shown in Table 1.

 

While Sun et al. concluded that multiple imputation introduces bias into the findings, inspection of the estimates of the impact of lymph node dissection (the hazard ratio) appear identical. If bias is a deviation of an estimate from the truth [4], we would argue that Sun et al. found no evidence of bias introduced by the multiple imputation method. This is not to say that all four analyses are free from potential bias – the reported hazard ratios may in fact still be biased results – but that there is no more bias in the multiple imputation model than in the others. In addition, we were somewhat surprised to see the use of a missing indicator approach proposed as less likely than multiple imputation to introduce bias as studies have shown the opposite [5].

Furthermore, the CIs show that the benefit to extent of lymphadenectomy may be as great as a 34% reduction in cancer-related death, with exclusion of all but a 5% increase in death associated with the procedure. CIs provide extremely valuable information, particularly in the setting of marginally significant or nonsignificant P values. Sun et al. could have strengthened their paper on statistical considerations by discussing this further. In fact, we would argue that their additional analyses lend further support to the potential benefit of the extent of lymphadenectomy.

The most notable difference across the analyses is a drift in the P value. We would argue that this mirrors the loss in power associated with the censoring of almost 3000 patients (28%) with missing grades. In addition, grade does not appear to be missing at random, as patients with missing tumour grades were associated with larger tumours, higher local stage, increased probability of nodal involvement and increased risk of kidney cancer death. The censoring of such patients may in and of itself introduce bias, although again the hazard ratios do not seem to reflect this. The devaluation of the P value continues to be an active area of biostatistical research, although in general journals have not foregone its inclusion in favour of an entirely Bayesian approach [6]. We believe that, in this case, Sun et al. have taken a far too traditional approach to interpretation of small differences in P values, particularly in the setting of changing sample sizes.

We agree with Sun et al. that consideration of another randomized trial focused on patients at high risk of nodal involvement or with clinically apparent nodes on CT is warranted based upon our combined results.

Jared M. Whitson and Maxwell Meng
Department of Urology, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA

Read the full article

References

  1. Sun M, Trinh Q-D, Bianchi M et al. Extent of lymphadenectomy does not improve survival of patients with renal cell carcinoma and nodal metastases: biases associated with handling of missing data. BJU Int 2014; 113: 36–42
  2. Blom JH, van Poppel H, Marechal JM et al. Radical nephrectomy with and without lymph-node dissection: final results of European Organization for Research and Treatment of Cancer (EORTC) randomized phase 3 trial 30881. Eur Urol 2009; 55: 28–34
  3. Whitson JM, Harris CR, Reese AC, Meng MV. Lymphadenectomy improves survival of patients with renal cell carcinoma and nodal metastases. J Urol 2011; 185: 1615–1620
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Avoiding treatment in prostate cancer: time and money, please?

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It seems impossible to say anything regarding prostate cancer without inciting emotionally charged controversy, even when based on high-level evidence. The updated prostate cancer guidelines from the National Institute of Clinical Health and Excellence (NICE) this week sparked media attention that focused on the role of active surveillance for low and intermediate risk groups.

 

The newspaper headlines state that patients with prostate cancer have been told to avoid immediate treatment. Whether patients are to go against advice given by their doctor or whether this is an attempt by the government to save money is unclear if the online comments are anything to go by. On a local level, patients who are awaiting treatment are questioning their choices.

The sensational implication is that active surveillance is a novel management strategy that was previously not considered. In fact, the equally controversial guidelines from 2008 promoted this alternative: the phrase “suitable for all options including active surveillance” is expressed frequently throughout the country when discussing individual cases at multidisciplinary team meetings.

There is no doubt that a proportion of men who undergo radical treatments may not benefit. The challenges arise in determining who these men are within the constraints of NHS pathways. A standard pathway for a UK man is to request a PSA blood test from his GP, commonly sparked by concerned relatives or friends and endorsed by high-profile survivors and campaigners. A raised result then triggers a “two-week” urgent suspected cancer referral and a clock ticks with diagnosis, staging and treatment to be completed within a 62-day target.

Inevitably, the urgency of referral will influence patient beliefs regarding the seriousness of their condition. A quick online search of comments on recent mainstream articles will throw up anecdotes from men who have sadly failed “wait and see” policies by progressing and finding themselves with incurable disease. A well informed patient will know that a standard transrectal biopsy will have under-estimated his risk in a third of cases. In this emotional state and limited time-frame, our patients are expected to make a rational decision regarding complex management choices – definitive treatment with associated side effects but the knowledge that every effort has been made to “cure” the disease, or what may be a lifetime of repeated, potentially dangerous, biopsies, blood tests and prostate examinations with risk of failure and “living with cancer”. Active surveillance is hardly an attractive option when considered in these terms.

What’s the answer? Detailed evaluation of prostate disease can be achieved with improved imaging with multiparametric MRI in conjunction with a modern transperineal biopsy technique that evaluates the prostate more thoroughly. Suitable patients for active surveillance (and radical treatment) can then be potentially better selected and counseled with higher confidence. Of course, resources are required for this, but shouldn’t this be what we should be campaigning for? And time to deliver this.

Benjamin Disraeli said, “He who gains time gains everything” and perhaps this is the greatest gift we can give to our patients. The lack of time pressure in terms of clinical urgency in low risk prostate cancer gives ample opportunity to get it right in these patients.

I can’t agree that the NICE guidelines are designed to cut NHS costs (active surveillance may cost the same as surgery) but I do fear that without better resources and the reduction in target pressures for low risk prostate cancer, active surveillance will remain an under-utilized management option for many who would benefit from it.

Peter Acher

Should we beware of the patient bearing gifts?

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Whilst I was observing a doctor in an oncology clinic, the doctor mentioned to me a gift she had received the previous week from a patient after giving her the wonderful news that she was cured of her lung cancer. This gift was a pair of concert tickets, which clearly cost a lot of money, and made me think about the ethical issues of, and the regulations behind, receiving a gift from a patient. However, thieves and con-artists don’t give up easy, so here are the tactics you can expect them to use. You can expect them to represent themselves using domain names that sound like government agencies. Names such as Obama Modification, or Obama Housing Plan, and similar names. They will buy.org domains to present themselves as non-profit agencies. For instance, there are bankruptcy Long Island Personal Injury Law Firm, family law and divorce lawyers, tax lawyers, etc. There is no area of practice known as loan modification. Many attorneys can provide help with a loan modification. But, it’s important to understand, that the only party that can modify your mortgage is the lender. Well you can read some tips here for mortgage investment. Check out Mortgage consultants in Queensland for the best service. The attorney can only help facilitate it. It’s fine, even a good idea to retain an experienced attorney to help you when you are faced with a financial hardship and the possibility of losing your home.  A law firm is a law firm and has no need to qualify itself as back, based, or driven. If you are facing these issues, most law firms offer free consultations to discuss your case. Take that opportunity to meet with an attorney and find out how they can help you. It will cost you nothing and may save you not just thousands of dollars, but very likely will save your home as well. David Miller is a freelance writer and marketing consultant. He has written extensively about bankruptcy, debt settlement, debt consolidation, credit and credit cards, collection agency abuse, consumer law, credit card defense, FDCPA guidelines and complaints, loan modification scams, and foreclosure.

Injury cases can be very complex for an average person to deal with, especially if that person is injured and under a lot of stress. If you are injured, then the last thing you should be focusing on is paperwork and legal semantics. This is just one reason why hiring a personal injury attorney may be best for you. These attorneys will automate the entire legal process for you, so you won’t have to worry about filing any paperwork. Another reason why hiring a personal injury attorney would be a good idea is to receive reparations for any property damage that may have occurred during the incident in which you were injured. Often times property damage and injuries go hand and hand. Aside from receiving financial health aid, it would be best to ensure the safety and well being of your property as well, and a personal injury attorney can help you with that. You can read this article for more information about the Chicago Personal Injury Lawyer.

 It is human nature to show gratitude for a deed done. This is why after a doctor has treated a patient they are sometimes presented with a gift from the patient or a relative. This becomes particularly apparent at Christmas time with long-term patients whom doctors see on a regular basis. This gift is usually simply a token of their gratitude towards the doctor and is meant in good will. Of course, the gift may not be given in gratitude, but meant as a bribe or used as a way of manipulating the physician into a particular treatment decision. Thus, receiving and accepting this gift raises a few ethical dilemmas. The acceptance of the gift can be suggestive of bribery and favouritism when it comes to treating the patient on a subsequent occasion or even influencing the doctor’s treatment decision if received part way through treatment. The GMC guidance in ‘Good Medical Practice’ (GMC, 2013) states in their ‘Honesty in Financial Dealings section’:

“You must not ask for or accept – from patients, colleagues or others – any inducement, gift or hospitality that may affect or be seen to affect the way you prescribe for, treat or refer patients or commission services for patients. You must not offer such inducements.”

Under the Bribery Act (2010), bribery is defined as “inducement for an action which is illegal, unethical or a breach of trust” with inducements being in the form of “gifts, loans, fees, rewards or other privileges”. Thus clearly this is a relevant piece of legislation to the ethics of receiving a gift from a patient.

Gifts can often range from tickets to a concert or show, money, high street shop vouchers, wine, or just a box of chocolates. The value of the gift, in terms of monetary value, is more important than what the gift actually is. Where these gifts are easy to share, for example a box of chocolates, then most healthcare professionals would place these in the staffroom or nurses’ office for everybody to share. The current General Medical Services (GMS) contract states that any gift worth over £100 must be declared and the details must be kept in a register at the hospital or surgery (MPS, 2013). Of note, individual hospital trusts will have their own rules, so it is worth finding out what your local policy is. For example, one hospital trust clearly states that while small gifts e.g. chocolates are ok up to a value of £25, larger gifts e.g. wine or food hampers are not and should be refused and entered onto the hospitals gift register.

If local rules are not followed, not only would it constitute a breach of employment with the ultimate sanction being dismissal, the doctor who received the gift may even be accountable on the Bribery Act charge, which has the maximum penalty of 10 years in prison and an unlimited fine. The advice given is that if you do accept a gift, you must declare it, be able to prove that it did not influence your treatment decisions regarding that patient and to make sure that the patient is aware of the implications.

The size of the gift is also important when considering how substantial it is and whether the patient can afford this gift within their means. If you believe this gift is too extravagant for the patient to afford then the best thing to do would be to politely refuse it. The refusing of the gift is one of the main ethical issues, where the act of refusal may offend the person giving the gift and even disrupt the doctor-patient relationship which has clearly reached a certain level of respect and kindness. An excellent and important example of this can be learnt from the high profile case of psychiatrist Dr Peter Rowan who accepted monetary gifts of £50,000, £100,000 and a £1.2 million beneficiary from a woman under his care in London (MDDUS, 2010). When he tried to refuse these gifts she became angry and he felt obligated to take them. Due to the large amount of money, he made sure this was within her financial means by consulting her solicitor. Dr Peter Rowan has since been struck off due to the unclear reason why his patient left him £1.2 million in her will.

The concert tickets gift received by the doctor in the oncology clinic mentioned above clearly cost more than £100 and thus had to be declared. The doctor, not wanting to offend the patient, accepted the tickets and feeling it was not right to accept the tickets for her own use, organised a raffle for everybody in the oncology department to win the tickets. This, to me, seems like an appropriate and perfectly acceptable decision, which solves the ethical dilemmas of accepting the gift and not offending the patient, but not being accountable for using the gift as a bribe or to influence patient treatment by raffling the tickets for the whole department.

Kathryn Miller
3rd year Medical Student, KCL, London, UK
@Kathryn4365058

Prostate cancer survivorship: a new way forward

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Over 2 million people in England have a diagnosis of cancer. This is such a large problem, the Department of Health is spending £750 million on improving earlier diagnosis and prevention of cancer, yet at the same time, £20 billion of efficiency savings must be made. One arm of post-cancer care is survivorship. Survivorship care was initially developed in the USA 20 years ago, starting with breast cancer patients. Prostate cancer survivorship care has been lagging far behind.

Survivorship care involves risk profiling of patients, supported by community based teams and developing shared care/decision making. More often than not, they are fit and well, requiring PSA follow-up only. Yet no guidance relates to survivorship management.  

 

Cancer survivorship encompasses the “physical, psychosocial, and economic issues of cancer from diagnosis until the end of life.” There are significant concerns that current follow-up methods are unsuitable. Concerns regarding permanent physical, psychosocial, and economic effects of cancer treatment have been highlighted and give us good landmarks for survivorship care. These include monitoring for recurrence, metastases, side effects and coordination between secondary and primary care and impact on quality of life. If we examine what patients expect, this includes a full assessment of needs, discussion on side effects of treatment and a personalised care plan post-treatment. Patients also report not knowing who to contact for their care out of hours. Five key phases to survivorship care were identified: care via primary treatment from diagnosis, enable as rapid and full a recovery as possible, ensure recovery is sustained, manage side effects of treatment and monitor for recurrence or disease progression. As part of a National Cancer Survivorship Initiative, a recovery package was developed. This includes a holistic needs assessment and care planning at key points of the care pathway, a treatment summary, a cancer care review, a patient education and support event.

Based on these facts, we have developed a new survivorship model – this was set up as a National Cancer Survivorship Initiative. This programme was initially devised when it was identified specific areas of care were lacking in this cohort, when followed up on a clinic basis. It aims to address the holistic need of the survivorship cohort, and at the same time, allow monitoring for acute recurrence and follow-up care as well as community based follow-up and patient support.

Our Survivorship programme is for patients post-curative therapy for organ confined disease (surgery, external beam radiotherapy or brachytherapy). Patients are offered the option of entering into the survivorship programme and discharged from clinic (Figure 1). Inclusion criteria specify patients must be two years post-radical prostatectomy with an unrecordable PSA, or three years post-radiotherapy or brachytherapy with a stable PSA. We currently have over five hundred patients on this programme. The patients’ demographic, disease and treatment details are entered onto a password protected web based database. The IT programme allows patients to be monitored for recurrence via automatic extraction of PSA results from the hospital database. It is a bespoke database. Alerts are automatically generated if the PSA is above a previously set range. The clinical nurse specialist (CNS) running the programme will contact the responsible consultant once an alert is generated with the patient reviewed in clinic, if required. The CNS will also go through a ‘Distress Thermometer’ with patients on admission to the programme, to identify areas where the patient needs support, psychological, social etc. The specialist nurse would act as the patients’ keyworker, should they develop any side effects of treatment, or any recurrence.

At its initial inception, a focus group of patients was conducted, as part of participatory action research, to find out what they wanted as part of this programme – a user led system. Specifically, they mentioned a conference where they have access to health care professionals and specific topics covered including diet and exercise, nutrition, psychosexual counselling. This conference is held annually, with a range of healthcare professionals advising on identified patient issues e.g. psychological care, health promotion, research, and welfare. The conference allows patients to draw on their strengths and share experiences with each other. Topics such as identification of recurrence, long-term complications, rehabilitation services, quality-of-life issues, pain and symptom management and treatment of recurrent cancer are examples of areas covered. 

There are over 600 patients currently on the programme, a mixture of post-surgery, radiotherapy and brachytherapy. Of these patients, 29 have been referred back to clinic. When asked at the pilot conference if it was worth attending, 100% said yes. As a result of the initial focus group, comments have been made in support this programme.

Whilst this programme is currently only for patients post curative treatment, the next steps forward are to see if patients undergoing active surveillance or hormone therapy can be followed-up using this programme.

Further information:

National Cancer Survivorship Initiative

Worcestershire Prostate Cancer Survivorship Conference

Worcestershire Prostate Cancer Survivorship Programme

 

Goonewardene SS*, Persad R†,Nanton V‡, Young A‡, Makar A
*Homerton University Hospital, London, †North Bristol NHS Trust, ‡Warwick University, Worcestershire Acute Hospitals

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