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Every year in February, 250 or so urologists make the pilgrimage to the Dallas airport to take the Urology Certifying Exam (a.k.a. the Oral Boards). This ranks as one of the strangest events in my life. I felt it appropriate to share my experience.
My trip to Dallas begins with a very sincere “good luck on your test daddy” from my 5-year old daughter. This makes me feel great, until I realize I am less than 24 hours from actually taking the exam. My stress level now starts to rise. As I board the plane in Portland, ME, I see one of my patients. I am pretty sure that I operated on her, but since my brain is crammed full of (now in hindsight) useless information, I cannot remember any details about her. I avoid all eye contact and quickly take my seat. By some miracle, I have the exit row all to myself. Is this a good omen? I feel slightly better until my second flight is delayed on the tarmac for an hour. Nervousness ensues.
I check into the hotel, which is conveniently located at the airport. My room isn’t ready yet, so I wander into the lobby, which is filled with other nervous urologists who are waiting for their rooms. They are all quizzing each other on case scenarios. This doesn’t help my anxiety, so I flee the area. Things become very “real” at registration where all of the other panicky urologists are crammed into a small ballroom. This exam is actually going to happen. I cannot back out now. To make myself feel better, I mock those wearing suits and ties. Who are they trying to impress? I am much cooler than them. Unfortunately, no one passes the boards for being cool. Maybe I should have put on a tie.
It is now t-minus 1 hour to exam time. My brain goes totally blank. I am convinced I have forgotten all of urology. I wonder if my hospital will hire me as a scrub tech. My stress level is now off the charts. I take my first exam – only took 45 minutes. Is this good or bad? I am convinced that I failed, but take solace in the fact that everyone else feels the same way. We are sequestered after the exam for 2 hours. There is nothing else to do, so we all end up talking about the exam. This doesn’t help my anxiety. For the rest of the day, I think about things I should have said during the exam. This again convinces me that I have failed.
As I walk down the long corridor (nicknamed the Green Mile by the staff) to my exam on the second day, all of the examiners are standing in the hallway with half smiles on their faces. What does this mean? Unfortunately, day #2 does not go better than day #1. I now realize why they are all smiling. I am now thoroughly convinced that I have failed. I wonder what I will do when I lose my job. I will need to modify my CV to apply for the scrub tech job. Not sure what else I am qualified to do.
Twenty-four hours later I am slowly relaxing. I try to put things in perspective. The numbers (90% pass rate) tell me that I probably haven’t failed. I am thankful for the colleagues that I saw this past weekend and for new connections that were made. Seeing all of them and sharing this experience confirms why I love urology and can’t see myself doing anything else. We are all blessed to be able to take care of patients and improve their lives. I am looking forward to returning to work tomorrow to get back to being a doctor. And I can’t wait to see my daughter and tell her that daddy did his best.
Matthew Hayn is an attending urologist at Maine Medical Center in Portland, ME and an Assistant Clinical Professor of Urology at Tufts University School of Medicine. His views are his own. @matthayn
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Governments of all nations struggle to work out how best to use the limited resources available for health care. One key area of uncertainty is long term conditions with multiple therapeutic options including no active treatment, where relative merits of different treatments are unclear and there is associated unexplained variation in use of often expensive interventions such as surgery. The management of localised prostate cancer typifies this situation. The problem is how to decide the relative worth of options especially as this judgement might differ between patients, clinicians, providers and funders. The best way is to perform well designed randomised trials between competing interventions with sufficient follow-up to identify any differences. For localised prostate cancer the ProTect trial is due to report in 2014. In the meantime, health care agencies commission Health Technology Assessments (HTA) to comparatively value interventions usually on the basis of the monetary cost of the added benefit they give in terms of better outcomes. This is commonly measured as the extra cost of each additional quality-adjusted life year (QALY) they give. The well laid out paper by Cooperberg et al. certainly adds to previous similar work that is available on relevant health agency websites (HTA 2003, CADTH 2011, HTA 2011, HTA 2012), but was interestingly funded by an industrial stakeholder, Intuitive Surgical. Given its perspective focusing predominantly on Medicare tariffs, it is perhaps most relevant to the US Government who pays these rates, but careful reading by all will at the very least give a flavour of the use of predictive statistical and economic modelling of the possible benefits to patients, and costs to funders of the treatments advised by clinicians.
It is important to highlight that the methods of meta-analysis of the existing literature used by Cooperberg et al. are unclear – this makes it hard to critique whether the best data have been used in the model. Furthermore, the data analyses are unusual. A more typical presentation would have been to explore the likelihood that each treatment would be considered cost-effective. The method used does not really illustrate whether the conclusion should be that there are no differences between treatments or whether there is insufficient evidence to determine whether there are differences. Furthermore, although baseline characteristics of patients included in the meta-analysis are not given it is likely that some would differ between men undergoing surgery or radiotherapy leading to bias in outcome. The linear Markov model used is also perhaps an inadequate reflection of reality since it does not appear to calculate QALYs for repeated transit through further cancer treatment/remission/recurrence states and between incontinent/continent and sexual dysfunction/no sexual dysfunction states which men would value specifically and independently. In terms of costs the have included costs of patient recovery time. Arguably recovery should be captured within the QALY measure and to include it again under costs might be an element of double counting. In addition they showed that the results were sensitive to certain assumptions that may be questioned such as the four year shorter time to metastasis after biochemical recurrence for radiotherapy.
Cooperberg et al. have certainly provided a useful example of how different treatments supervised by clinicians may be valued by those that pay the bills. A parting thought is if only clinicians of differing specialties could collaborate on large definitive RCTs we would not need to rely on predictive models based on imperfect data.
Robert Pickard is a Professor of Urology at the Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK. email: [email protected]
Luke Vale is Health Foundation Chair in Health Economics at the Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK. email: [email protected]
“To err is human, to cover up is unforgivable, to fail to learn is inexcusable”
Sir Liam Donaldson, Former Chief Medical Officer
As a specialist registrar, I recall operating on a large renal tumour along with my mentor Omer Karim (who is now my colleague). As the mobilization was difficult due to neovascularization, he took over and just as the kidney was about to be delivered out, the adrenal vein was avulsed and there was a gush of blood. A Satinsky clamp was placed and to my surprise, Omer asked me to come over and repair the tear, which was successfully done. I remember his wise words even today “Anyone can remove this kidney, what you need to learn is to fix the complications!”
The traditional apprenticeship model of training that exists even today involves the Boss taking over the case whenever there is a complication. This leads to a teaching model wherein the trainee fails to learn on ‘how to get out of the complication’. Indeed, a very wise piece of advice for a young surgeon in training is to work under a ‘not so good’ surgeon for a period of time, as you will then be exposed to many complications (some not mentioned in the books!), learn how to deal with them and try to avoid repeating those same mistakes. The very concept of learning from others’ errors goes into the heart of the very popular meeting held regularly by the Southern Laparoscopic Urology Group (SLUG). The group comprising of highly experienced laparoscopic urologists present their unusual complications and how they were dealt with and what others can learn from that particular complication.
Two recent blogs on bjui.org emphasize the importance of surgical simulation, especially training in the era of EWTD. However, most simulation exercises concentrate on how to perform a proper operation avoiding any errors. Although, this aspect is extremely important, less emphasis has been devoted to developing simulation modules on intra-operative complications and how to deal with them. This is where the concept of Error Training is fast becoming the buzzword among the education psychologists. A well-written article by DaRosa and Pugh on this interesting concept is well worth a read. The authors explore the reasons for the lack of integration of this important aspect into surgical training. There are only a few studies that have looked into the impact of error training on acquisition of skills. A study by Roger et al on the role for error training on surgical technical skill instruction and evaluation found that instruction about common errors, when combined with instruction about the correct performance enhanced the acquisition of the particular surgical skill. Their study suggested a role for the use of errors in surgical technical skill instruction. Similarly, in a study by Brannick et al, who evaluated an error-reduction training program for surgical residents, showed a reduction in the error during surgery. Natalie Bourgeois in her thesis on error training draws the attention for the need to develop error management training (EMT) as opposed to error avoidant training (EAT). EMT is a teaching method that promotes ‘trainee learning’ enabling them to make errors during their simulation exercises. EAT, however, dictates the trainee not to deviate from the prescribed steps and follow the instructions accurately avoiding any errors. Research has now shown that tasks, which involve making deliberate errors during the learning process, may decrease performance during that particular training session, but increases the performance in the ‘transfer environment’. Keith and Frese have shown that errors lead to more exploration during training, increased metacognition, increased emotional control and increased intrinsic motivation, which benefits transfer performance. Thus, there is emerging but limited scientific evidence about integrating error training into the surgical curriculum.
In the future, laparoscopic and robotic simulators should incorporate modules that would expose the trainee to scenarios of intra-operative complications and assess their ability to deal with it. Studies to validate the effectiveness of these modules would be difficult in a patient setting due to obvious ethical considerations. But there is no doubt that this kind of exposure would definitely prepare the trainee’s mind to manage any eventuality. I would end with the quote “First do no Harm. But if you do, have the knowledge to heal the harm”.
Amrith Rao is a Consultant Urological Surgeon at Wexham Park Hospital, Wexham, UK. @urorao
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The man was unconscious on the operating table, in lithotomy position and fully prepped for the major extirpative surgery which he was about to undergo. Four of us from different surgical specialities stood around his nether regions with arms folded, having all done a very thorough bimanual examination. We were discussing whether his recurrent colorectal cancer felt mobile enough to get away with a posterior exenteration, or if all the pelvic organs had to go. As we considered the physical exam findings it occurred to me that this was not a normal situation. I looked at the patient and said to the head of Colo-Rectal surgery, “you know, in some workplaces people discuss things around the watercooler”. All of a sudden the stark reality of this bizarre situation was apparent as it might be to the casual observer.
Surgery is not normal, and neither are surgeons.
Surgical training is not normal. Much has been written about the unique legal status that medical trainees have, whereby they may dismember dead human bodies with impunity in the course of their education. As training progresses we are not only allowed, but expected to assault people with an array of sterilized weapons, so long as we expect that they will be better off for it. Only a fool would promise this will definitely be the case of course. Less has been written about the fact that it is not normal to be occasionally scolded in your workplace like a school kid and given “homework” in your thirties. It only seems normal because our colleagues seem to accept it.
That surgeons are not normal, I believe, is both self-selection and indoctrination.
Even the kindest, most humane surgeons have steel beneath the surface in my experience. At best, this is only revealed when advocating for a patient, such as demanding theatre access for an urgent after-hours case, but at worst…we have all met that surgeon. Almost all of us have surely had to grit our teeth late one night performing a procedure at the limit of our ability, unable or unwilling to call for help. Timid people do not self-select for surgery. In most countries the process requires an at least somewhat forceful personality to get through selection interviews. A certain drive is required to jump through the necessary hoops and survive the long hours and emotional trauma of the training. Once training begins, as is the case in the military, the majority of waking hours are spent with colleagues in the same environment, but sometimes in different locations. No-one on the outside truly understands the unique demands on the individual. Survival tips are shared, but competition is fierce even when unspoken. Even closest friends can be an obstacle to getting enough experience.
My non-medical father called me one evening some years ago and asked how busy I was. I told him “not bad”, I just had to knock out an appendix and I was almost done. He was taken aback by what seemed a cavalier attitude to what must be a frightened 18 year old about to undergo an anaesthetic for the first time and have his belly cut into. If you are a surgeon, it is understood that no-one has the emotional resources to care this much for every one of the endless multitude of people we treat. I care very much about doing my job as well as I can, but out of necessity I do not routinely involve myself in their personal drama. This would impact my ability to make them better.
Is that normal?
James Duthie is a Uro-Oncology Trainee (Robot Surgery) at Peter MacCallum Cancer Centre, Melbourne. He is interested in Human Factors Engineering, & making people better through electronic means. @Jamesduthie1
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You wouldn’t expect the pilot of the aeroplane in which you fly to the EAU or AUA meeting to be a novice who was training on the aeroplane that you were being transported in! Similarly, patients undergoing robot-assisted surgery do not expect to be the “guinea pigs” upon which trainee surgeons move up the learning curve of surgical experience. Sometimes, however, they are.
Surgical simulators offer the means for surgeons to gain experience before moving to operating on actual patients. However, the publication from Guy’s and St Thomas’s illustrates how little research has been done yet to confirm that outcomes are improved by such a move.
Patient safety is a “buzz word” at present, especially after the report of Robert Francis QC on the Mid-Staffordshire NHS Trust disaster. It seems probable that virtual reality (VR) simulators can improve safety, not only by improving technical skills, but also by enhancing non-technical “human factor” responses.
Much work needs to be done to provide the VR training facilities and ensure access to them for all urology trainees. Once they are in place studies will be needed to confirm their value. In a world where doctors and Trusts are facing a tidal wave of litigation there seems little doubt that this is the way ahead.
Roger Kirby
The Prostate Centre, London W1G 8GT
Twitter is a great social channel for professionals to exchange ideas. I regularly use Twitter to connect with urologists, health care professionals, patients and thought leaders around the world. I also use Twitter to share my blog posts.
Participating in Twitter Chats
One of the many other ways I find value on the platform is by participating in Twitter Chats. Twitter chats are a great way to get people with a common interest into a community. A Twitter Chat can be a one-time event; however, most take place on a regular basis – weekly or monthly – and are organized around a designated hashtag.
Weekly healthcare chats that I regularly enjoy include: #hcsmanz (Healthcare and Social Media in Australia and New Zealand) and #hcsm (Healthcare Communications and Social Media) both on Sundays, #hcldr (Healthcare Leader) on Tuesdays, and #HITsm (Health IT Social Media) on Fridays.
My favorite Twitter chat, however, is the monthly #UROJC chat, International Urology Journal Club on Twitter. #UROJC takes place on the first Sunday of every month, starting at 3 pm Eastern time, and continues over a 48-hour period, rather than one hour. During this time, I can review and discuss current research in urology and engage with academic and community urologists around the world. The origins of #UROJC have previously been described by Dr. Henry Woo, @DrHWoo, in a BJUI blog post.
Twitter Chat Tools to Know
When you participate in #UROJC, or any other Twitter Chat, there are a few tools and tips that can be used to enhance your experience.
1. Tweetchat
A great application for Twitter Chats and conferences is Tweetchat.com. You can tweet directly from Tweetchat, and your tweets will automatically be appended with the hashtag. All participants using the hashtag can be viewed in a real-time stream.
How to use Tweetchat:
2. Twitterfall
Twitterfall is similar to Tweetchat, but has some customizable features. For example, you can edit out retweets, and control the speed of the Twitter stream. Twitterfall also has a place to create lists of people you want to engage with.
To get started on Twitterfall:
3. Symplur
You can get a transcript of the tweets from each monthly #UROJC chat courtesy of Symplur. This is valuable if you want to review a chat or if you happened to miss a chat altogether.
In addition to chats, Symplur’s Healthcare Hashtag project is a rich resource for discovering and mining healthcare conversations on Twitter around specialties, disease states, patient communities, and healthcare conferences.
It is also interesting, at the end of a chat, to view Symplur’s analytics that show the participants who have the most mentions, tweets and impressions. Symplur can also a great place to identify new people to follow.
4. World Clock:
Because #UROJC is a global discussion over a two-day period, it can be confusing to keep track of starting times across multiple time zones. A great tool to find the time in your part of the world is the World Clock time zone converter.
I hope that you find these Twitter Chat tools and tips helpful, and I look forward to seeing you in the stream of our next monthly #UROJC. You can keep updated on what is up and coming on #UROJC by following the official Twitter account for the chat at @iurojc. You can always connect with me on Twitter @storkbrian.
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When I was a medical oncology trainee in 2001 looking for an area to specialise in my mentors told me prostate cancer was going to be the next big thing. I must admit I was dubious but now more than 10 years later this is amongst the best advice I have ever received. On a par with support Manchester United and buy property in London! Systemic treatment for prostate cancer has well and truly arrived and we are in a position where at times we are spoilt for choice.
So how did we get here and why did it take so long. To answer the second part first we need to go back to 1941 and Huggins and Hodges ground-breaking work showing the profound effect of castration on metastatic prostate cancer. Both the original paper and the Nobel lecture are fascinating reading. Castration remains a cornerstone of the treatment of prostate cancer. The androgen receptor is one of, if not the, most dominant biological pathway in solid tumour oncology. Apart from chemotherapy for testicular cancer, another urological success, I cannot think of another systemic treatment that has such profound activity both in terms of clinical response and disease control rates. For instance androgen deprivation far surpasses the activity seen with tamoxifen in ER +ve breast cancer. So prostate cancer got off to a flier and perhaps was the hare to the tortoise when compared to other cancers, which have slowly but surely overtaken.
There was a long lull with very little positive data for metastatic prostate cancer. Why was this? Perhaps the activity of androgen deprivation set too high a bar for subsequent treatments and a sense of nihilism for those that followed. This is shown by the negative reaction to the data on docetaxel first published in 2004. The 50% PSA response rate (a decline in PSA of 50% or greater) is impressive particularly in this highly pre-treated population. More importantly docetaxel improves quality of life and provides a small but significant survival advantage against an active comparator. We now have a second chemotherapy, cabazitaxel, which again shows a significant survival advantage. Whilst chemotherapy in prostate cancer remains controversial, and worthy of a future blog, there is no doubt for a significant number of patients it provides real benefit.
Prostate cancer is leading the way for other areas of systemic therapy. Sipuleucel-T is one of the only immunotherapies to show a survival benefit in solid tumour oncology. Whilst Sipuleucel-T is controversial and has many detractors, it does have level 1 evidence to support it. During my fellowship with Phil Kantoff’s group in Boston, I saw several patients who I am convinced benefited from this treatment. Alpharadin is the first radionucleotide to show a survival advantage and is likely to become an integral part of systemic therapy for CRPC.
The drugs that have provided most excitement and the greatest benefit in day-to-day practise are abiraterone and enzalutamide. These drugs build on the work of Huggins and Hodges and show that 70 years of targeting the androgen receptor is still relevant even with castration. These drugs have changed how we describe the disease moving from ‘hormone-refractory’ to ‘castration-refractory’. Abiraterone is now licensed in the pre- and post-chemotherapy setting and it is likely that enzalutamide will follow in the not too distant future. In my own practise these drugs are game changers. Ones that provide real benefits relieving symptoms, controlling disease and allowing some men with prostate cancer to live much longer.
Who should be responsible for all these new drugs? Medical oncologists? Urologists? Nurse specialists? For me this shouldn’t be territorial. I want men with prostate cancer looked after by those with a real interest in this area. The days of people dabbling should be in the past and testicular cancer has shown us that patients do better when looked after in high volume centres. In reality men with metastatic prostate cancer have complex medical needs and only with the input from the whole multidisciplinary team are we able to give them the best care.
So systemic treatment for prostate cancer is suddenly fashionable and my mentors (Ellis and Harper) were proved right! ‘Told you so Chowdhury!’ This is only going to be the beginning with prostate cancer, which is now at the forefront of cancer research. Our understanding of the biology of prostate cancer is likely to grow exponentially and with it our ability to improve treatment. So watch this blog – to be continued…
Simon Chowdhury is Consultant Medical Oncologist at Guy’s, King’s and St Thomas’ Hospitals, London. He is actively involved in clinical trial research into urological cancers.
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