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West Coast Urology: Highlights from the AUA 2016 in San Diego… Part 2

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By Ben Challacombe (@benchallacombe) and Jonathan Makanjuola (@jonmakurology)

 

The AUA meeting was starting to hot up with the anticipation of the Crossfire sessions, PSA screening and the MET debate that appeared to rumble on.  We attended the MUSIC (Michigan Urological Surgery Improvement Collaborative) session. It is a fantastic physician led program including >200 urologists, which aims to improve the quality of care for men with urological diseases. It is a forum for urologists across Michigan, USA to come together to collect clinical data, share best practices and implement evidence based quality improvement activities. One of their projects is crowd reviewing of RALP by international experts for quality of the nerve spare in order to improve surgical outcomes.

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The MET debate continues to cause controversy. In the UK there has been almost uniform abandonment of the use of tamsulosin for ureteric stones following The Lancet SUSPEND RCT.

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The MET crossfire debate was eagerly awaited. The debate was led by James N’Dow (@NDowJames) arguing against and Philipp Dahm (@EBMUrology) in favour of MET. Many have criticised the SUSPEND paper for lack of CT confirmation of stone passage. Dr Matlaga (@BrianMatlaga) stated that comparing previous studies of MET to SUSPEND is like comparing apples to oranges due to different outcome measures. He recommended urologists continue MET until more data is published. More conflicting statements were made suggesting that MET is effective in all patients especially for large stones in the ureter. The AUA guidelines update was released and stated that MET can be offered for distal ureteric stones less than 10mm.

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In a packed Endourology video session there were many high quality video presentations. One such video was a demonstration of the robotic management for a missed JJ ureteric stent. Khurshid Ghani (@peepeeDoctor) presented a video demonstrating the pop-corning and pop-dusting technique with a 100w laser machine.

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One of the highlights of the Sunday was the panel discussion plenary session, Screening for Prostate Cancer: Past, Present and Future. In a packed auditorium Stacy Loeb (@LoebStacy), gave an excellent overview of PSA screening with present techniques including phi, 4K and targeted biopsies. Freddie Hamdy looked into the crystal ball and gave a talk on future directions of PSA testing and three important research questions that still needed to be answered. Dr. Catalona presented the data on PSA screening and the impact of the PLCO trial. He argued that due to inaccurate reporting, national organisations should restore PSA screening as he felt it saved lives.

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There was a twitter competition for residents and fellows requiring participants to  tweet an answer to a previously tweeted question including the hashtag #scopesmart and #aua16. The prize was Apple Watch. Some of the questions asked included; who performed the 1st fURS? And what is the depth of penetration of the Holmium laser?

UK trainees picked up the prizes on the first two days.

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The British Association of Urological Surgeons (BAUS) / BJU International (BJUI) / Urological Society of Australia and New Zealand (USANZ) session was a real highlight of day three of the AUA meeting. There were high quality talks from opinion leaders in their sub specialities. Freddie Hamdy from Oxford University outlined early thoughts from the protecT study and the likely direction of travel for management of clinically localised prostate cancer. Prof Emberton (@EmbertonMark) summarised the current evidence for the role of MRI in prostate cancer diagnosis including his thoughts on the on going PROMIS trial. Hashim Ahmed was asked if HIFU was ready for the primetime and bought us up to speed with the latest evidence.

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The eagerly awaited RCT comparing open prostatectomy vs RALP by the Brisbane group was summarised with regards to study design and inclusion criteria. It is due for publication on the 18th May 2016 so there was a restriction of presenting results.  Dr Coughlin left the audience wanting more despite Prof. Dasgupta’s best effort to get a sneak preview of the results!  We learnt from BAUS president Mark Speakman (@Parabolics) about the UK effort to improve the quality of national outcomes database for a number of index urological procedures.

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Oliver Wiseman (@OJWiseman) gave us a flavour of outcomes from the BAUS national PCNL database and how they are trying drive up standards to improve patient care. A paediatric surgery update was given by Dr Gundeti. The outcomes of another trial comparing open vs laparoscopic vs RALP was presented. There was no difference in outcomes between the treatment modalities but Prof. Fydenburg summarised by saying that the surgeon was more important determinant of outcome than the tool. Stacy Loeb closed the meeting with an excellent overview of the use of twitter in Urology, followed by a drinks reception.

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It was not all about stones and robots. The results of the Refractory Overactive Bladder: Sacral NEuromodulation vs. BoTulinum Toxin Assessment (ROSETTA) trial results were presented. Botox came out on top against neuromodulation in urgency urinary incontinence episodes over 6 months, as well as other lower urinary tract symptoms.

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The late breaking abstract session presented by Stacy Loeb highlighted a paper suggesting a 56% reduction in high-grade prostate cancer for men on long term testosterone. This was a controversial abstract and generated a lot of discussion on social media.

 

 

 

 

 

 

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It has been an excellent meeting in San Diego and we caught up with old and met new friends. It was nice to meet urologists from across the globe with differing priorities and pressures. There was a good British, Irish and Australian contingent flying the flag for their respective countries. It was another record-breaking year for the #AUA16 on twitter. It surpassed the stats for #AUA15 with over 30M impressions, 16,659 tweets 2,377 participants. See you all in Boston for AUA 2017.

 

West Coast Urology : Highlights from the AUA 2016 in San Diego… Part 1

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By Ben Challacombe (@benchallacombe) and Jonathan Makanjuola (@jonmakurology)

 

The 2016 AUA returned to the beautiful city of San Diego set on the shores of the Pacific in an excellent conference centre located in the centre of the town adjacent to the Gaslamp district. For a change the wifi was excellent and allowed enhanced levels of social media interaction and urological discussion. Opening these interactions were 2 key sessions which provoked much debate. Firstly the announcement that after over 10 years of trying the FDA has approved HIFU treatment although it seemed to get there through a slightly “de novo” pathway. Apparently the FDA approved it as an ablation tools but not for prostate cancer.

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Although not directly approved for use in prostate cancer, that is exactly what it is going to be used for. A packed house saw a debate with evidence from both sides. Dr Nathan Lawrentschuk promoted the 4 Ds of HIFU. His key point was that 56/101 had a post treatment biopsy of which 51 where biopsy positive!

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The second big session focussed on the AUA/SAR consensus statement  document on prostate cancer diagnostics. This recommended a “High Quality” MRI should be strongly considered if patient has a rising PSA with a previous negative biopsy, has persistent clinical suspicion for prostate cancer or is undergoing a repeat biopsy. There was no mention of MRI for all at the pre-biopsy stage which many had hoped for and only 2 lines on trans-perineal biopsy as an option. This is of course related to health resources and the outpatient office-based nature of most USA urologists.

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A welcome innovation was the Crossfire Sessions which pitted 2 well known advocates of one treatment against 2 with the opposite views. It was hardly debating of the Oxbridge variety but none the less did provoke some useful discussions. Topics included radical prostatectomy vs radiotherapy, endoscopic vs nephro-ureterectomy management of upper tract TCC, and enucleation at partial nephrectomy vs formal resection. Standing room only at the back of the halls but no real audience interaction or voting which was a shame. 

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The session which really woke everyone up was Rene Sotalo’s wonderful complication horror show. Bleeding, bleeding and more bleeding in a variety of ways. How would you handle this he asked? Pray I thought! But this and similar sessions clearly show the benefits of recording all cases and reviewing these DVDs if something goes wrong. The cause of some complications were only identified by review of the intra-operative tapes. Some clinical titbits learn’t included  using only a horizontal incision for the camera port at RARP to reduce hernias and turning off pneumocompression stockings if there is a major venous injury to prevent excessive venous bleeding.

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From a SoME perspective there was both good and bad. One poster showed that 40% of graduating US residents had publicly accessible unprofessional content on social media. Food for thought at the consultant interview no doubt, but on the other side SoMe ranks third in the acquisition of urological knowledge (and climbing…). One hack produced this tweeting guideline for all to reflect on.

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Prof Prokar Dasgupta had the honour of presenting the widely anticipated session on emerging robotic technology . At last there appears to be some real competition to Intuitive’s dominance on the way. There are at least 3 credible robotic systems on the way. He finished with an intriguing slide on Dr Google being the most powerful doctor in the world!

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Despite Europe and Asia moving towards the use of PMSA PET , the USA is not moving in this direction due to reimbursement issues if the PMSA molecule.

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There was a lot of interest in a packed auditorium to see live surgery for a single use disposable fURS “Lithovue” with some reporting superior vision , optics and deflection.

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There were some sceptics amongst the stone community with the environmental impact and cost effectiveness a concern.

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With the popular Gaslamp district a stones throw away many delegates went after the conference for a meal and drinks. The local baseball team San Diego Padres was a popular destination with may watching baseball for the 1st time whist others had gone for a run along the harbour and even caught a sighting of some seals!

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Bringing Out the Best: 69th USANZ ASM Highlights

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The 69th Annual Scientific Meeting (ASM) of the Urological Society of Australia and New Zealand (USANZ) took place at a venue, well-known for its sun and surf – Gold Coast, Queensland. With some of Australia’s best beaches and coast line, the theme of the meeting was fitting: “Bringing out the Best”. Prem Rashid (@premrashid) and Peter Chin (@docpete888) convened a meeting boasting an impressive international and local faculty. Attendees were provided with a healthy balance of scientific update and social interaction to truly ‘bring out the best’ in each of us.

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The meeting got off to a flying start with Dr. Mukesh Haikerwal AO (@DrMukeshH) delivering the Harry Harris Oration. His words were a timely reminder that the healthcare team has only one purpose: to care for the patient in need. The inspiring narrative of his time as a patient following a violent assault was told with humour and humility. The vastly underestimated issue of mental health was also brought to the fore. Despite a few technical malfunctions (Apple and Android!), the tone of the meeting was well and truly set. Attendees were then led out of the auditorium by a vibrant, rhythmic ensemble – a USANZ ASM first! Delegates at the welcome reception were joined by the SandMan, who created an artistic sand sculpture of the conference surfboard logo whilst delegates greeted one another over drinks and canapés.

drummingensemble_smA drumming ensemble lead delegates to the Welcome Reception

The plenary sessions were varied and engaging. Mornings were filled with world-class presentations by local and international faculty. Michael Cookson (@uromc) discussed management of advanced prostate cancer, Margit Fisch discussed urinary diversion options, and Armando Lorenzo discussed issues in transitional care, an area very dear to his heart. James N’Dow (@NDowJames) was especially engaging. He spoke on the importance of the EAU Guidelines and the recent ratification of the same by USANZ. The cross-continental collaborative spirit was further demonstrated by an announcement from Christopher Chapple that USANZ had been accepted as a member of the EAU. On a softer note, James N’Dow captured listeners’ hearts with tales of his philanthropic work in Sub-Saharan Africa and Scotland. His starkly honest account challenged all present to consider engaging in charitable works for those in need both local and abroad.

jamesndow_smJames N’Dow was particularly engaging, telling of his philanthropic work

Australia’s own Jeremy Grummet (@JGrummet) presented latest data on transperineal biopsy for the detection of prostate cancer. It was hard to argue with such impressive statistics: zero incidence of sepsis after more than 1000 biopsies and counting. He also reported early experiences with the Biobot Mona Lisa – a robotic technology for obtaining transperineal biopsies. Jeremy is to be congratulated for being recently appointed as an associate to the EAU Guidelines Committee.

Prokar Dasgupta @prokarurol presented the BJUI Global Prize to @maheshatw and Sean Huang.


Live debates provided robust discussion regarding hot topics. Kathleen Kobashi (@KKseattle) (described by the conference convenor as “the definition of intellectual elegance”!) and Kurt McCammon (@mccammonka) provided very topical debate regarding the merits and outcomes of native tissue versus synthetic slings. Focal therapy for prostate cancer was debated between our local expert Phil Stricker and international guest Jonathan Epstein, both of whom had very compelling arguments.

All this was conducted by the plenary session chairs, who looked particularly dapper behind the surf board faculty table! Only in Australia.

surfboard@DrRLC: “Only in Australia would a urological discussion around a surfboard be considered quite normal…”

Concurrent sessions were well attended throughout the meeting. Highlights include Thomas Knoll’s (@rockknoll) update on stone disease including his approach to difficult stones. He managed to enlighten and entertain even with topics such as “Metabolic Evaluation of Stones”! Mini-PCNL was in the spotlight with David Webb deserving of special mention. Run Wang discussed a practical approach to management of Peyronie’s disease, and Christian Gratzke (@cgratzke) discussed management of male LUTS and presented outcomes of prostatic urethral lift.

The program included non-scientific sessions titled “Getting My Message Across” (Henry Woo [@DrHWoo] & Declan Murphy [@declangmurphy]) and a fantastic education session (Stuart Philip & Melvyn Kuan [@MelvynKuan]). Trainees and consultants were updated on controlling their online presence in the internet age, publishing tips and pitfalls to avoid, and professionalism. Claus Roehrborn (@clausroehrborn) was especially illuminating on how to read a journal article. Equally, David Hillis (@dhillis1957) and Stephen Tobin (@deansurg) shared thoughts on professionalism that all surgeons would do well to heed. Speakers at the global health session inspired many to consider making an impact abroad.

The customary trainee breakfast grilling session was chaired by Nathan Lawrentschuk (@lawrentschuk) and his partner in crime, Louis Kovoussi (@DrKavoussi). Trainees were interrogated on all topics and benefited immensely from Louis’ expertise. Kurt McCammon (@mccammonka) taught the trainees on posterior urethral reconstruction, but also inspired their minds with career and life advice – a charge to be happy, do what you love, and prioritise family. His parting words “Don’t leave any potential on the table”, certainly urged trainees to, Bring out the Best from within.

Socially, the meeting was an absolute delight. Faculty dinners, industry dinners, dinners between friends and colleagues, were dotted around various restaurants all over the Gold Coast. The social highlight of the Meeting was the annual Gala Dinner, held at Australia’s Movie World, hosted by Batman and Marilyn Monroe! Alfresco style, the night was fresh and lively, with food, chatter, singing and dancing. The convenors @premrashid and @docpete888 were congratulated for a successful meeting. Prize winners were announced and congratulated: Ahmed Saeed Goolam (@asgoolam) for the BAUS Trophy, Matthew Winter (@matthewwinter01) for the Keith Kirkland prize, David Wetherell (@DrDRW) for the Villis Marshall prize, and Ailsa Wilson (@Willyedwards) for the inaugural Low-Arnold Prize in Female and Functional Urology.

galadinner_smGuests siphoning into Australia’s Movie World for the Gala Dinner

galadinner2_smThe Gala Dinner – the social highlight of the USANZ ASM

The Meeting flew by at phenomenal pace and soon it was time to pack our bags and say goodbye (or go for another surf!). Time sure flies when you’re having fun, and learning constantly! The 69th USANZ ASM surely brought out the best.

We’d like to extend our gratitude to the international and local experts who attended the meeting and generously shared of their expertise and collegiality. International guests include: Christopher Chapple, Michael Cookson, Jonathan Epstein, Prokar Dasgupta @prokarurol, Shin Egawa, Margit Fisch, Pat Fulgham (@patfulgham), Mantu Gupta, Christian Gratzke (@cgratzke), Louis Kavoussi, Thomas Knoll, Kathleen Kobashi (@kkseattle), Daniel Lin (@DanLinMD), Armando Lorenzo, Kurt McCammon, James N’Dow, Claus Roehrborn, Mark Speakman (@Parabolics), Anil Varshney and Run Wang. On behalf of ANZ Urologists and Trainees (@USANZurology), we thank you for your time, expertise, and friendship. We hope you are either enjoying some much deserved recreational time Down Under, or else have arrived safely home.

We would also like to thank the Meeting’s sponsors, in particular, platinum sponsor Abbvie for supporting the Meeting.

We are also grateful to everyone who participated in #usanz16 on social media, making #usanz16 the most active USANZ ASM on Twitter ever! With over 5 million impressions, the conference fun and science was more far-reaching than we could ever know. Thank you for helping to Bring out the Best.

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A special mention for Ruth Collins (@DrRLC) for her witty tweets and Photoshop talent throughout the meeting.

shark@DrRLC: “Henry Woo & David Winkle ponder the risks of hanging out on a surf board all morning #usanz16”

We look forward to the 70th USANZ ASM which will be held in Canberra, the nation’s capital (24-27th February 2017). Although the 69th USANZ ASM will be a hard act to follow, no doubt, convenors Nathan Lawrentschuk @lawrentschuk and Shomik Sengupta @shomik_s, will have some great tricks up their sleeves and we look forward to the program they have compiled. Till next time!

 

 

Amanda Chung is a Urological Surgeon and PhD candidate in Sydney, NSW and Isaac Thangasamy  @USANZUrology trainee in Queensland, Australia

 

 

AUA 2016

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2.00 pm – 2.05 pm

Welcome Remarks
2.05 pm – 2.25 pm Freddie HamdyFreddie C. Hamdy, MD

Treatment Effectiveness in Prostate Cancer -Early Thoughts from the Protect Study
2.25 pm – 2.45 pm Mark EmbertonMark Emberton, MD

What We Know and What We Don’t Know About the Role of MRI in the Prostate Cancer Diagnostic Pathway
2.45 pm – 3.05 pm Hashim AhmedHashim U. Ahmed, MD

Focal Therapy – Ready for Prime Time?
3.05 pm – 3.20 pm Geoff CoughlinGeoff Coughlin, MD

A Randomised Controlled Trial of Robotic vs. Open Radical Prostatectomy
3.20 pm – 3.40 pm Mark FrydenbergMark Frydenberg, MD

Prospective Non –randomised Longitudinal Comparative Study of Outcomes After Primary Surgical Treatment for Localized Prostate Cancer
3.40 pm – 3.50 pm

Tea Break

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3.50 pm – 4.10 pm MG2Mohan Gundeti, MD

Recent Advances in Pediatric Robotic Surgery
4.10 pm – 4:30 pm Mark SpeakmanMark J. Speakman, MD

The Publication of Urologist identifiable surgical outcome data – an English Experience
4.30 pm – 4.50 pm Oliver WisemanOliver Wiseman, MD

How Might the BAUS National PCNL Database Improve Outcomes?
4.50 pm – 5.10 pm Stacy LoebSpeaker: Stacy Loeb, MD

Social Media in Urology

 

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May Editorial: The Current Hot Topics in Functional Urology

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BJUI-May-2015-cover_smallFor some time, the challenge represented by managing the overactive bladder (OAB) has been dominant in functional urology research. The introduction of new therapies has galvanised the area, with mirabegron showing strong promise for many patients as a monotherapy. In addition, the potential for combined therapy using mirabegron with established antimuscarinics has recently been reported for urgency urinary incontinence [1]. Now that the place of onabotulinum-A injections in refractory cases is firmly established, management options have clearly taken a step forward in recent years. However, there remain people for whom even the more comprehensive current options are inadequate or intolerable. The need for basic science research remains a priority, in the hope of translation into clinical options. In this month’s BJUI, Aizawa et al. [2] report responses in an animal model to an inhibitor of fatty acid amide hydrolase, showing how exploiting the endocannabinoid pathway might be a translational focus for entirely new approaches in OAB. They consider an issue that is very important in developing clinical options, which is that the systems regulating bladder function are also fundamental in other organs, such as the CNS. As the compound they studied does not cross the blood–brain barrier, the potential generation of CNS adverse effects is reduced, which would be important for its potential as a new therapy.

OAB is a symptom syndrome based on storage-type LUTS [3]. Increasingly the field of functional urology is recognising the large number of people who present with voiding and post-micturition LUTS yet do not have BOO. Currently, there are no satisfactory treatment options for affected people and the symptoms can have considerable impact. Frustratingly, current diagnostic methods rely on urodynamic testing to establish whether the presence of detrusor underactivity explains voiding LUTS in an individual patient. Recently, the profession has established a move towards using symptoms to categorise the clinical need in patients [4]. Accordingly, the International Continence Society has established a working group to generate terminology for underactive bladder (UAB), which will report this year, including a symptom-based definition. A symptomatic diagnosis would be very helpful to enable therapy development to proceed without the need for urodynamic testing. Also, in this month’s BJUI, Kajbafzadeh et al. [5] report a clinical trial in UAB using transcutaneous interferential electrical stimulation in children. The treatment was delivered in the context of the rather laborious process currently required for managing this difficult problem, namely diet and fluid manipulation, scheduled voiding, toilet training, and pelvic floor and abdominal muscles relaxation training. The electrical stimulation was demonstrably beneficial, and included responses for the highly troublesome symptom of nocturnal enuresis. The comparatively straightforward nature of this therapeutic approach potentially makes it a valuable tool for dealing with a notoriously difficult problem.

Marcus J. Drake, Senior Lecturer
School of Clinical Sciences, University of Bristol, Bristol, UK

 

References

 

1 Drake MJ, Chapple C, Esen AA et al. Efficacy and safety of mirabegron add-on therapy to solifenacin in incontinent overactive bladder patients with an inadequate response to initial 4-week solifenacin monotherapy: a randomised double-blind multicentre phase 3B study (BESIDE). Eur Urol 2016; [Epub ahead of print]. DOI: 10.1016/j.eururo.2016.02.030

 

2 Aizawa N, Gandaglia G, Hedlund P et al. URB937, a peripherally restricted inhibitor for fatty acid amide hydrolase, reduces prostaglandin E2-induced bladder overactivity and hyperactivity of bladder mechano-afferent nerve fibres in rats. BJU Int 2016; 117: 821–8

 

3 Abrams P, Cardozo L, Fall M et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub- committee of the International Continence Society. Neurourol Urodyn 2002; 21: 167–78

 

4 Chapple CR, Osman NI , Birder L et al. The underactive bladder: a new clinical concept? Eur Urol 2015; 68: 351–3

 

5 Kajbafzadeh AM, Sharifi-Rad L, Ladi-Seyedian SS, Mozafarpour S. Transcutaneous interferential electrical stimulation for the management of non-neuropathic underactive bladder in children: a randomised clinical trial. BJU Int 2016; 117: 793–800

 

Trainee Jobs: Pot Luck or Picking Teams in Gym Class?

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Fardod O Kelly FI“It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is most adaptable to change…” (C. Darwin; ca.1857)

 

On Friday 18th March 2016, U.S. medical school students and graduates participated in the National Resident Matching Program (NRMP) with 42,370 registered applicants attempting to match into 30,750 PGY-1 and PGY-2 positions. This was preceded the same day by the Irish Higher Surgical Training (HST) Urology interview held in the RCSI in Dublin for a smaller number, but just as eager candidates endeavoring to secure their future in their own field. Thousands of candidates, in the pursuit of a career that they have so far, only dreamed about. Thousands of candidates, all with one thing in common: Not one of them knew where they were going to end up if they were somehow successful.

The British Medical Journal (BMJ) on their careers website explaining to core trainees how they might perform better in interviews, outline a roadmap of 12 key components from extra courses to leadership skills, but not once mention visiting the various deanery sites in order to assess whether the place represents a good fit for your own ambitions, learning objectives and style of management.

Prof. Adrian Joyce provided an editorial on the BJUI blogs site in 2013, highlighting the need to devise a better means of training “The UK conundrum shared with many other healthcare systems is how to provide effective training within the demands of service commitment and the EWTD… The challenge therefore is to devise innovative ways of training within the limit of fewer hours and training, not service, must become the priority for trainees and for those surgeons, departments and hospitals that train them…”

Therefore, we have two health systems on these islands, with the UK National Health Service (NHS), and the Irish Health Service Executive (HSE), both acknowledging the mandatory requirements of the European Working Time Directive (EWTD) to shorten working hours, and the need to fulfill service commitments within the health sector, and the need to allow for postgraduate training to ensure a steady workforce into the future, but also to balance the requirements of the Specialist Advisory Committee (SAC) and the Joint Commission on Surgical Training (JCST) as well as the Royal Colleges to ensure that training is to a satisfactory level. In order to achieve this, hospitals and trusts are allocated a number of trainees who have gone through the above selection process and have accumulated years of experience, qualifications and debts to fill a very complex role within a volatile system.

However, when did a “one-size-fits-all” approach become acceptable to trainers and trainees who need to work alongside each other within these environments filled with stress, litigation, and variable relationships with managerial types within the system? We all see patients, break bad news, manage expectations, provide treatment options, and above all know that each patient is different. They handle information, make choices, adhere and respond to treatment in a myriad of ways depending on a huge number of variables and confounders (not to mention the relatives). We have developed nomograms to try to communicate outcomes and risks to patients for disease like prostate cancer, such that entering the keywords “prostate cancer” and “nomogram” into PubMed will in excess of 900 hits. So, the hospital environment is complicated, and patients are complicated, but what about the lowly figure of the surgical trainee who has successfully demonstrated the aptitude and the background to progress to higher training?

Sullivan et al. demonstrated in 2013 that despite the reduction in trainee hours in the USA, resident attitudes, and program location were most frequently associated with voluntary attrition, with “the personal cost of training” (p<0.001; HR2.89) playing a major role in leaving a program. Bell et al. elegantly demonstrated in 2012 that despite the abundance of information on particular candidates, many of the fundamental qualities that are associated with success for the surgical trainee cannot be identified by review of the applicants’ grades, scores, letters of recommendation, personal statement, or even from the interview process. Therefor only by meeting trainees, in order to identify unique behavioral, motivational and personal talents that applicants bring to the program, allowed the authors to determine applicants who were a good match for the structure and culture of that particular program.

The standard interview process, whilst objective, does not allow trainers and institutions the luxury of getting a feel for the candidate, and applying instinct and acumen as to whether and how the trainee will fit into the overall scheme of things. The exact statement can be played in reverse.

All the innate instinctual abilities and skills that we prize in being able to quickly assess measure patients have been denied to us in choosing some of our closest junior colleagues on whom we rely on so heavily.

From a trainee urologist’s perspective, and one that would apply to nearly any other profession, one of the greatest predictors of your happiness and productivity at work is your relationship with your senior colleague. This is therefore intuitively important when considering new post, on order to know how you’ll get along with your new boss. This can be hard to assess in an interview when one is attempting to masquerade an unbridled sympathetic response and trying to demonstrate one’s one appointability, but it’s crucial to evaluate the panel as well. What sorts of questions should you ask to understand their management style? Should one try to talk with other people who have previously rotated through the post? Are there red flags you should watch out for? Will it even matter?

There are a number of healthy checklists in the business world which lend themselves to translation in surgery:

  • Trust your instincts: Ask yourself whether this is the training post you want and the consultant you want to work for. Did you get a good feeling from the person? Is she someone you can imagine going to with problems? Or someone you could have a difficult conversation with? This is especially important when the stakes are high
  • Do your homework: One of the greatest faux pas one can make is to incompletely prepare. You should try to gather as much information on the unit/post as possible including the history of the department, publishing record of the consultants, theatre logbooks from other trainees, inter-personal relationships, red flags. Google each consultant and check out the social media presence of the unit (#SoMe) as a proxy of their willingness to engage with social technology and communication
  • Meet your colleagues: Spend time with future colleagues in the unit independent of the interview. Take some time to chat to nursing and clerical staff as well as other trainees. More information can be acquired about a unit over a cup of coffee with future colleagues than any other approach

In this time of flux within health service systems, trust, collegiality and communication as key. Things that sound apt are not always what they seem. The quotation attributed above to Darwin, is often one that is misquoted, and although seems appropriate, there is no evidence that he ever made that statement. In the same way, trainees can no longer be seen to be but from the same cloth. Their own lives and careers are unpredictable and multi-faceted, and the answers and applications relied on at interview do not guarantee a good correlation coefficient when plotted on a graph belonging to a particular unit i.e. not a “good fit”. Perhaps it is time to trust our own instincts when appointing a trainee to a particular unit by taking the time to meet candidates and assessing – in addition to applications and CVs – how they might slot into a department – so that when it comes to tackling overcrowding, waiting lists, theatre slots, emergencies, call, research, audit, management and teaching, at least they can be met with the strongest team possible.

 

“…it’s better in fact to be guilty of manslaughter than of fraud about what is fair and just…”  (Plato, The Republic and Other Works)

 

Fardod O’Kelly is a Specialist Registrar in Urology at AMNCH, Tallaght, Dublin 24, Ireland. Twitter @FardodOKelly

 

April #UROJC: The Surgeon Scorecard – Merits of Publicly Reported Surgical Outcomes

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The April 2016 International Urology Journal Club on Twitter (#urojc) hosted a discussion on our paper, “Comparing Publicly Reported Surgical Outcomes with Quality Measures from a Statewide Improvement Collaborative”. Published in JAMA Surgery on March 16, 2016, the paper was authored by Gregory Auffenberg MD, David Miller MD, Khurshid Ghani, Zaojun Ye, Apoorv Dhir, Yoquing Gao. I contributed as a member of MUSIC.

It was an honor to have the paper selected for a #urojc discussion, and the authors would like to thank JAMA Surgery for providing open access during the discussion period. This post serves as an overview, and the entire #urojc transcript is available for reading courtesy of Symplur

For those not familiar, the #urojc Twitter chat is a 48-hour asynchronous conversation amongst urologists around the world on Twitter on a selected journal paper, taking place on the first Sunday/Monday of every month.

 

The ProPublica Surgeon Scorecard

The subject of our research centered on the online U.S. surgeon ratings compiled for ProPublica’s Surgeon Scorecard. ProPublica is an investigative journalism organization that was given exclusive access to U.S. Medicare data for the years 2009 to 2013.

“Reporters Olga Pierce and Marshall Allen studied almost 75 million hospital visits billed to Medicare looking for eight common, elective surgeries. They then looked to see whether the same person returned to the hospital for what appeared to be complications from the surgery. Their full methodology is spelled out here.”

 

The Michigan Urological Surgery Improvement Collective

Specifically, our research paper looked at ProPublica’s ratings for only one procedure – results on radical prostatectomy (RP) for prostate cancer – and correlation to reporting by MUSIC, the Michigan Urological Surgery Improvement Collaborative. MUSIC is a state-specific quality initiative in the U.S. in which I am a participating surgeon. Participation in MUSIC is voluntary, over 85 percent of urologists in the State of Michigan participate in the collaborative.

 

 

April #UROJC

As our paper states, the recent release of the Surgeon Scorecard accelerated debate around the merits of publicly reporting surgical outcomes. Surgical outcomes assessment is not a new concept, even dating back to 1860 as this tweet by @mattbultitude surfaced.


What does our community of urologists think about public reporting? Does greater transparency correlate with better outcomes? What are the benefits of a collaborative method like MUSIC? What methods are used in other parts of the world?

 

The #urojc discussion found that many urologists outside the U.S. were not familiar with the ProPublica ratings or debate. Some were not surprised that we did not find a correlation between our MUSIC outcomes data and the ProPublica data, thereby validating the need for quality outcomes data.

 

 

If the Surgeon Scorecard is flawed, what needs to be done to create an acceptable public reporting system?

 

Is public reporting of surgical outcomes taking place in Australia, UK, Canada & elsewhere?

 

 

How are ‘outliers’ identified by this study handled by MUSIC?

 

Do ratings lead to cherry-picking of patients?

 

According to New York cardiologist, Sandeep Jauhar, MD via Medscape, 63 percent of cardiac surgeons acknowledged accepting only relatively healthy patients for heart bypass surgery owing to report cards in New York State.

 

Moving Surgical Outcomes Forward 

On behalf of the authors of the paper and the entire MUSIC collaborative, I would like to thank our #urojc colleagues around the world for their thoughts, insights, criticisms and questions about the paper.

The ProPublica Surgeon Scorecard has generated significant and serious discussion in the U.S. about the challenges and merits of the public reporting of surgical outcomes. In an increasingly connected world, it’s difficult to imagine how this can remain simply an American debate.

Urologists by their very nature are leaders. Personally, I see this debate as yet another opportunity for us to develop and implement systems and strategies that reassure the public and advance patient care.

MUSIC JAMA Paper

 

Publons: Giving Credit For Peer Review

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NL Blog PicPeer reviewing of journal articles may be one of the most unheralded and feel at times as the least rewarded of continuing medical activities we do. People give time, expertise and judgement to make articles of a higher scientific standard and are crucial to the nature of medical publishing. As an Associate Editor of the BJUI, I am aware of the significant contribution reviewers make. I also review myself for many journals. For me it is one of the best forms of learning we have available to us. This was made even more apparent at the recent peer-reviewing workshop just prior to the EAU in Munich, where reviewers were delighted to learn of the possibility of a verifiable metric of reviewing.

Most journals provide recognition of peer-review work by publishing lists of reviewers, often collating CME credits and points or even the ability to provide a letter of reference when asked.

Third-party collation and recognition of peer-review work has until recently been lacking. This means to ‘prove’ one has indeed reviewed for a journal we would have few options apart from possibly saved emails thanking us for our good work. Publons has many aims but chief is to do just that – provide a platform where there is authenticity and recognition for peer review.

IMG_8979

How to do it?

  1. Go to www.publons.com
  2. Register (free)
  3. Upload a photo, short biography and your academic affiliations (Figure 1 and 2)
  4. Enter in your editorial board positions (the Journals you have reviewed for will be added by Publons once verified – Figure 3)
  5. Add reviews

IMG_8980The final point of adding reviews has been made relatively easy – it is automated and quick.

The official emails you have received over the years (which of course you carefully filed away…) stating “thank you for your review of the journal article entitled … Manuscript number …‘ just need to be forward to [email protected]

This will then, within a few days, be placed into the system. You will get an email notification. The partner publishing organizations (e.g. Nature publishing group) have their logo which makes it look all the more official (Figure 3)

 

IMG_8981Now for those of us who have not kept all of the ‘thank you’ emails, a second way is to go to each journal you have reviewed for, log in to the reviewers dashboard. Take screenshots and send as a JPEG (be careful to include your name as part of screenshot for verification). This may take a small fiddle to cut and paste to a word document if you have multiple shots. You can then send as PDF or photo etc. Again email the attachment to [email protected]. The website has provided rules on the types of proof or verification they will accept but they are pretty open to suggestions if there is an issue.

The review records are collated (Figure 4) and then a chance to upload your review. This type of open access is only in its infancy and not mandatory.

 

IMG_8982To make it more interesting there are award merits, which are a nice touch. Each review gets you three merits. Prizes are awarded quarterly and displayed on your profile page (Figure 1). They are categorical or may be within your country or university. Remember in this environment everyone doing peer review is represented so you are up against engineers, theologians and the like in some categories. The opening of reviews with ‘extra merit points’ available, although noble, is unlikely at this stage to have uptake. The peer-review process is fragile enough and this may need to be reworked. Perhaps “open review” bonus merit points could be separated out as it seems unfair to penalise reviewers as most are single or double blinded in any case and will not wish to open. Publons goals of promoting discussion and interaction are fine but after having spent time doing the reviews and not getting remuneration, it is somewhat counterintuitive to want to take more of your valuable time on a review – but it may suit some (read more on history of Publons here)

In time it is likely that Publons will become the Pubmed for peer reviewers. Relationships will form with publishers and hopefully it may become a network for peer reviewers and a tool for handling editors. Overall a wonderful initiative and a great step to recognize and hopefully enhance peer review, which is a sacrifice many of us make – but for the good of medicine!

 

Nathan Lawrentschuk, University of Melbourne, Australia

@Lawrentschuk

 

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