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Face to interface

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Cast your mind back to college physics and recall that an interface is a boundary between two phases of matter, for example gas and liquid. The interface is where interaction occurs between the disparate parts, there may be an exchange of molecules, or a conversion of molecules from one state to the other such as evaporation. Information, such as light or sound is always upset when it reaches an interface and some of the message may be bounced off while some is transmitted across the interface to the other state. This is why we might see our reflection in a pond, as some of the incident light bounces of the liquid interface and back to our eyes. So far, so dry and irrelevant.

If we think about interfaces between people, the equivalent to phases of matter is two disparate minds attempting to transmit information across the interface of human communication. It seems logical that minds that are more familiar and perhaps similar due to experience and level of sophistication lose less information due to reflection (think of the ease of communication between close family members versus explaining theoretical physics to a three year old).

There is always an interface with communication, be it speech, gestures, semaphore, or Twitter. Our intention is to effectively get across sufficient information to understand and be understood. Each modality has pros and cons, for example a letter allows a distillation of thought and a poetry that is absent in a phone call, while Skype allows you to see a loved one in real time. Due to a lack of vocal inflection, facial expression, and physical gestures, many public figures have claimed a misunderstanding after making inflammatory statements on social media.

We certainly are getting used to communication through physical separation. The ability to keep in touch when you want to while geographically apart is undoubtedly a boon, and in the medical sphere isolated patients are benefiting from teleconferenced and video-linked consultations, along with podcasts, tweets, and YouTube videos that make medical advice more and more accessible.

But here is the problem. The interface between a doctor and a patient has a very high surface tension. That means that information struggles to breach the membrane from doctor to patient and vice versa. Without conscious effort, by default information thoughtlessly spouted will bounce off and be lost. The minds of the doctor and patient are usually disparate, with one an expert in their own experience of a disease, and the other an expert on pathophysiology and evidence based practice. Both are complex subjects, difficult to communicate to the non-expert in the conversation. With the addition of a screen, or phone line to the interface, we have to beware of the surface tension becoming impenetrable. As medicine becomes increasingly electronic, we need to remember that dispensing advice to the internet is different from communicating with a patient. Every communication interface has its weakness, and we need to be aware of avoiding pitfalls that compromise care. Humour often does not work as well in an email as it would in person, accompanied with a cheeky grin. Speech over an internet connection may be distorted, intermittent, and as a result, irritating to listen to, making us want to curtail conversations prematurely. To shamelessly direct you to my other work on the role of technology in medicine and life we need to add value as doctors above what a digital algorithm can provide to justify our work.

Why? The usual arguments (it is good business to keep the client happy, specially if you use Salesforce help, the prestige of being a preferred doctor, the opportunity to expand ones sphere of influence), but also I think most of us sacrificed our youth training in order to make people better, and we cannot do that if patients cannot hear us.

James Duthie is a Urological Surgeon/Robotic Surgeon. Interested in Human Factors Engineering, training & error, and making people better through electronic means. Melbourne, Australia @Jamesduthie1

 

What’s the diagnosis?

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Test yourself against our experts with our weekly quiz. You can type your answers here if you want to compare with our answers, or just click the ‘submit’ button below.

Image from Emara AM et al. BJU Int 2014; 113: 92–99. doi: 10.1111/bju.12252

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USI Blog: The inevitable call!

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We all would agree that once in a while, during the course of an operation, we feel uneasy because of that little monster of a device…your cell phone starts ringing. The urge to pick up and answer the call often becomes insurmountable. We have all committed this “cardinal sin” of answering a call during surgery. A recent survey conducted in India showed that a “whopping 90% nurses and 50% technicians interviewed for the survey admitted to answering calls during surgery”. 10% of the doctors admitted to checking text messages during surgery. 

I am sure that this number is an underestimate. I have seen almost everyone in my peer group taking calls during surgery.  And this is not just what’s happening in my part of the world, mind you. New York Times also ran an article highlighting this issue.

I would also like you to have a look at this interesting discussion at AAOS Now.

 

It’s been my observation that the introduction of robotics has also made us “much more available” to take calls during surgery.  What’s the take of the community on this issue? Is this an unnecessary fuss (considering that we tend to consider ourselves excellent at multitasking…) or is it an issue that needs to be addressed urgently?

Dr Tarun Jindal, MBBS, MS, MCh Urology
Consultant, AGHL, Kolkata, India

 

Editorial: How should we best manage obesity in urology?

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Abdul-Muhsin et al. [1] are to be congratulated on an excellent study involving >3000 patients undergoing robot-assisted radical prostatectomy over a 4-year period. In their study they demonstrate that the morbidly obese patient can be managed in a just about equal way to the non-morbidly obese patient for removal of the prostate. The complications and recovery characteristics in morbidly obese patients are reviewed and it is concluded that, in this single-operator single-centre study, the morbidly obese male with prostate cancer should not be overlooked as a candidate for radical surgery.

We are all faced with more obese patients presenting to our clinical care; in the UK 20% of the adult population are obese and >3% are morbidly obese. There are an increasing number of studies looking at the outcome of surgery in the obese and morbidly obese populations. These studies have drawn mixed conclusions, with some suggesting an increased risk and morbidity and others suggesting no difference when compared with a non-obese population. This is confusing: perhaps the use of body mass index alone to assess obesity is limited and misleading [2]. This is because the distribution of fat varies considerably among individuals, with the most at-risk patients being those with a centripetal fat distribution producing a large abdominal girth. In middle-aged men, a waist size of >102 cm is the best predictor of metabolic syndrome with all its concomitant risk factors [3]. It is these patients who represent the greatest risk for surgery and it is these same patients who urgently need to improve their lifestyle and shed weight in order to achieve a normal life expectancy both to aid surgery and thereafter. Factors such as hypoventilation, hypertension and the risk of thromboembolism are greatly increased in this group. Diabetes, abnormal lipids, bone and joint diseases and reflux are common. These factors will probably contribute to multiple potential peri-operative complications. Cardiopulmonary exercise testing is very useful in detecting the patients most at risk and likely to require most intensive care postoperatively. There are too few studies to date that include this test and that specifically looking at the morbidly obese population, but results are encouraging and will very probably detect those patients most likely to require critical care facilities [4].

While the surgical results in the Abdul-Muhsin et al. study are excellent, one would not wish to dilute the key message to our patients that preparation for major surgery with weight loss is vital. Addressing nutrition and exercise activity in the preoperative period is extremely beneficial and highly successful. Achieving a 10% weight loss within weeks before surgery is entirely achievable with significant benefits to the medical comorbidities and, in particular, breathing and muscle activity [5]. One great advantage of prostate cancer surgery is the often slow-growing nature of the tumour and we can, therefore, often take the opportunity to postpone major surgery for just a matter of weeks to improve fitness and nutrition. This window of opportunity is more than enough to transform a high-risk patient to one with a much lower risk profile.

If we inspire our patients to join in the aim of the whole surgical team to safely cure prostate cancer using weight reduction and improved fitness then long-term life benefits will surely follow in addition to the immediate gains for surgery and anaesthesia.

Peter Amoroso
The London Clinic, 20 Devonshire Place, London W1G 6BW

Read the full article

References

  1. Abdul-Muhsin H, Giedelman C, Samavedi S et al. Perioperative and early oncological outcomes after robot-assisted radical prostatectomy (RARP) in morbidly obese patients: a propensity score-matched study. BJU Int 2014; 113: 84–91
  2. Mullen JT, Moorman DW, Davenport DL. The obesity paradox body mass index and outcomes in patients undergoing non-bariatric general surgery. Ann Surg 2009; 250: 166–172
  3. Balentine CJ, RobInson CN, Marshall CR et al. Waist circumference predicts increased complications in rectal cancer surgery. J Gastrointest Surg 2010; 14: 1669–1679
  4. Hennis PJ, Meale PM, Hurst RA et al. Cardiopulmonary exercise testing predicts post operative outcome in patients undergoing gastric bypass surgery. Br J Anaesth 2012; 109: 566–571
  5. Benotti PN, Still CD, Wood GC et al. Preoperative weight loss before bariatric surgery. Arch Surg 2009; 44: 1150–1155

 

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

What’s the diagnosis?

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Test yourself against our experts with our weekly quiz. You can type your answers here if you want to compare with our answers, or just click the ‘submit’ button below.

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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.

 

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