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Reaching for the stars – rating the quality of systematic reviews with the Assessment of Multiple Systematic Reviews (AMSTAR) 2

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The number of published systematic reviews and meta‐analyses in the urological literature has dramatically increased in recent years [1]. This is good news given their importance in guiding clinical decision‐making, guideline development and health policy. However, many of these studies are of low quality, raising concerns about the trustworthiness of their results. As with other research studies, it is therefore important for readers to have a framework for determining the quality of a given systematic review. Therefore, in 2017 BJU International launched a scoring system for systematic reviews that provides readers with a summary assessment as to whether established methodological safeguards against bias for systematic reviews have been met [2]. This is based on the Assessment of Multiple Systematic Reviews (AMSTAR), a validated instrument that assesses methodological quality on an 11‐point scale (0–11), with higher scores reflecting greater methodological rigor and all criteria being given the same relative weight [3].

Recently, an updated version of this instrument has become available, offering a better assessment of systematic reviews [4]. The revised instrument (AMSTAR 2) includes 10 of the original domains; it has 16 items in total (compared with 11 in the original), simpler response categories to the original AMSTAR, and provides an overall rating that is largely based on seven critical domains that should all be met. These relate to: (i) documentation of an a priori registered protocol in Prospective Register of Systematic Reviews (PROSPERO) or through Cochrane, (ii) a comprehensive literature search, (iii) explicit justification for excluding studies, (iv) a risk of bias assessment of included studies, (v) appropriate use of meta‐analytical methods, (vi) consideration of risk of bias when interpreting the results of the review, and (vii) assessment of presence and likely impact of publication bias. Other, non‐critical domains include a clear description of the study question in Population, Intervention, Comparison, Outcome (PICO) format, study selection and data extraction in duplicate, and identification of sources of funding of the studies included in the review and the review itself. This results in a four‐tiered rating (high, moderate, low, and critically low) that reflects the confidence that a reader may place in the results. Notably, a high‐quality rating requires no critical weakness and allows for only one non‐critical weakness. More than one non‐critical weakness drops the rating down to moderate, and just one critical weakness (such as lack of an a priori protocol) drops the rating down to low. Any review that has more than one critical weakness will be rated as critically low.

BJU International editors will routinely apply this AMSTAR 2‐based scoring system to screen for methodological quality in order to raise the awareness of this issue and promote reviews of higher quality (Fig. 1)[1]. Needless to say, BJU International is not the place for systematic reviews of sub‐optimal methodological quality in which the readers cannot place their trust. Meanwhile, we also fully understand that methodological rigor is not everything but has to be paired with clinical relevance and newsworthiness. Much has been written about the dramatic redundancy of systematic reviews on the same topic; in certain areas of medicine, the number of systematic reviews exceeds that of eligible studies that these reviews included [5]. Therefore, when systematic reviews already exist, there needs to be a clear rationale for any ‘encore’ performance. BJU International also encourages the development of systematic reviews by author teams that are financially unconflicted and have thoughtfully managed any intellectual conflict of interest.

Figure 1: New BJUI rating system of systematic reviews based on AMSTAR 2. The number of coloured stars in the inner and outer layers of the system represents completeness of an individual critical domain and overall confidence rating of the systematic review, respectively. The number in the middle of the system refers to the summary AMSTAR 2 score based on the overall confidence rating of the systematic review (high: 4, moderate: 3, low: 2, critically low: 1).

Through this initiative, BJU International not only intends to become the premier journal for high‐quality systematic reviews as they relate to urology, but also to move the field forward, reducing redundancy and waste. As we embrace the higher standards of AMSTAR 2, we present the first review to be scored using this method in this issue [6] and we encourage all systematic review authors to accept this challenge and reach with us for the stars.

References

  1. Han JL, Gandhi S, Bockoven CG, Narayan VM, Dahm P. The landscape of systematic reviews in urology (1998 to 2015): an assessment of methodological quality. BJU Int 2017; 119: 638–49
  2. Dahm P. Raising the bar for systematic reviews with Assessment of Multiple Systematic Reviews (AMSTAR). BJU Int 2017; 119: 193
  3. Shea BJ, Grimshaw JM, Wells GA et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007; 7: 10

 

About the authors:

Dr Philipp Dahm is Professor of Urology and Vice Chair of Veterans Affairs at the University of Minnesota. He also serves as Director of Research and Education for Surgical Services at the Minneapolis Veterans Administration Medical Center (@EBMUrology).

 

Dr Jae Hung Jung is from the Department of Urology, Wonju College of Medicine, Yonsei University, Korea.

 

 

 

November 2018 – about the cover

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BJUI November 2018

©istock.com/f11photo

The article of the month for November 2018 is on work carried out at the University of Pittsburgh Medical Center (UPMC), Pennsylvania, USA: The United States opioid epidemic: a review of the surgeon’s contribution to it and health policy initiatives.

The city is located at the confluence of the rivers Allegheny, Monongahela and Ohio and is known both as the “city of bridges” due to its 446 bridges and the “steel city” as it was formerly home to over 300 steel-related businesses.

The old industrial areas have been restored and redeveloped into museums, heritage centers, parks, libraries and medical centers. UPMC is now one of the biggest employers in Pennsylvania, and has been vital in treating the country’s most recent shooting victims. It has also been a pioneer in transplant surgeries with many world firsts in multiple organ transplants.

 

October 2018 – about the cover

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This issue’s Article of the Month is The effect of timing of an immediate instillation of mitomycin C after transurethral resection in 941 patients with non‐muscle‐invasive bladder cancer, carried out by a team from Amsterdam, The Netherlands.

The cover shows the skyline of Amsterdam, the capital of the Netherlands, although it is not the seat of government, which is The Hague. Amsterdam is well-known for its canals, its Art (particularly Rembrandt and Van Gogh) and its infamous coffee shops. In 2013 there were more bicycles than people in Amsterdam.

©istock.com/fotolupa

 

Urofair 2018

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Urofair Congress Highlights – Singapore 2018

From 12-14 July, the Singapore Urological Association (SUA) welcomed 450 delegates from across Asia and further afield to sunny Singapore for Urofair 2018.

The theme was Integrating Scientific Knowledge, Technology and Clinical Urology, and the excellent scientific program crafted by the organizing chairman John Yuen and scientific chairmen Joe Lee and Terence Lim, certainly reflected this.

Continuing a fine tradition, the BJUI once again has supported this meeting with all accepted abstracts to be published in a special supplements issue.

Learn about healthy supplements at Amazon.com.

Pre-Urofair activities

Preceding the Urofair, was the Urology Residents Course (URC) and the European Basic Laparoscopic Urological Skills (E-BLUS). The revision of key concepts at URC followed by grounding of basic laparoscopic skills by great minimally invasive surgeons Christian Schwenter and Evanguelos Xylinas was truly beneficial for the residents, and primed them well for the latest updates they received at Urofair.

Urology Residents Course Class of 2018

Simulation and tutoring – Evanguelos Xylinas supervising a trainee on laparoscopic trainer at E-BLUS

Urofair 2018 started with a bang, with the ever popular live and semi-live surgery sessions at Tan Tock Seng Hospital. One of the highlights of the session was the masterful demonstration of retroperitoneal robotic assisted partial nephrectomy by James Porter (@JamesPorterMD). One of the attractions of live surgery is the anticipation of intraoperative problems and the thrill of watching experts manage them. This session was no exception, as Allen Sim of Singapore General Hospital showed calmness under pressure, as he showed how to deal with an inadvertent breach of the peritoneum and control of bleeding during a difficult retroperitoneal nephroureterectomy. The semilive demonstrations were no less educational, with Christopher Evans showing how he manages unusual anatomic variants during robotic radical prostatectomy.

One of the main highlights of this year’s Urofair was the launch of the inaugural KT Foo Lecture by the Father of Singapore Urology, Professor Foo, Keong Tatt who presented his life-long research work on the management of BPH. At the end of this tour de force, he was presented with the well-deserved SUA Life-time Achievement Award.

Lim Kok Bin (left), President of the SUA presenting the SUA Lifetime Achievement Award to Prof KT Foo (right)

 One of the goals of the SUA is to serve as a bridge between regional and international urological associations. Urofair 2018 reflected this goal with multiple joint sessions with our friends from the Malaysian Urological Association (MUA), European Urological Association (EAU), Urological Associations of Asia (UAA), Federation of Asean Urological Associations (FAUA) and Hannam Urological Association. Dr Tan Hui Meng delivered the MUA lecture on testosterone replacement therapy (TRT). He refuted some of the controversies regarding TRT, and cited the supporting data to defend its use. On a practical note, he shared his checklist for counselling and consent-taking before starting TRT in clinical practice. We were deeply honoured that the Secretary General of the EAU Professor Christopher Chapple(@ProfCRChapple) himself, delivered the EAU plenary on Substitution Urethroplasty. The management of urethral strictures is challenging due to the vast variability between patients, stricture aetiology, location and available tissue reconstruction. One key tip was that urethroscopy was useful to identify early stricture recurrence, which otherwise can be missed on uroflowmetry.

Hong Seok Shin from the Hannam Urological Association presented his unique presentation on Plastic surgery in collaboration with phẫu thuật gọt hàm, highlighting the importance of patient selection and counselling. The FAUA session was held concurrently with attendance of key office-holders of the various ASEAN urological associations. The theme of the session was on the development of MIS in Urology in the ASEAN countries discussion on “Cross-boundary Disease Management” with interesting clinical cases presented from different countries was lively. Koon Ho Rha delivered the UAA lecture on “The Role of Cytoreductive Prostatectomy in Advanced Prostate Cancer”, and showed in his series, that well selected patients with locally advanced disease, benefited from prostatectomy, which can be safely done robotically.

Multiple masterclasses ran concurrently on a range of subjects, including MRI-TRUS Fusion biopsies, Renal Transplantion, Andrology and Reconstructive Urology. The Robotic Surgery Masterclass chaired by Png Keng Siang was attended by a full house! The five expert robotic surgeons (Chris Evans, Koon Ho Rha, James Porter, Declan Murphy and Steve Chang) spoke on a range of topics from retroperitoneoscopic RAPN, to nerve-sparing techniques and complications of RARP to the use of different versions of robots (Si vs Xi) in robotic nephroureterectomy. The session ended with lively discussions between the panel and the audience in an interactive video session on trouble shooting challenging surgical aspects of RAPN and RARP.

The closing plenary was a “Glimpse into the Future”, covering topics from Precision Oncology and the role of Clinical Genetics for Urologic cancers, to the “The New Robots on the Block”.

Koon Ho Rha gave us a tour of the development of the ubiquitous Da Vinci, followed by the up and coming competitors, including one which has licensed and commercially available in Korea. Competition in this field can only make robotics in urology better and hopefully more cost effective.

Declan Murphy(@declanmurphy), Social Media Director of the BJUI shared his insights on the role of Social Media in Urology Practice. He highlighted the shift in the publishing paradigm, with videos and blogs of new findings peer reviewed on social media, before “traditional publication” by a journal, followed by amplification of the publication on social media.

Nurses are an integral part of the urological care, and they were certainly active at Urofair. The 180 strong audience at the Nursing Symposium were rapt with attention as Ms Helen Crowe shared her vast experience as Australia’s first Urology Nurse Practitioner on Prostate Cancer Nursing as well as expanding the role of Urology Nurses.

The Nursing Masterclass on the management of urinary incontinence was fully subscribed, and the practical hands on nature of the class was a big hit with the participants.

Physiotherapists conducting pelvic floor exercises with the Urology Nurses

 Our GP partners were not forgotten, and the 120 GPs who attended were treated to a great program. In this era of fake news, the standout lecture must have been “Google is not your friend”, where Lee Fang Jern shared the perils of medical fake news, and how medical practitioners can guide our patients to navigate the internet in search of reliable medical information.

The Gala Dinner was a fitting end to a fruitful Urofair, where everyone had a chance to strengthen and renew friendships over good food and wine.

Organising Chairman John Yuen is all smiles after the successful conclusion of Urofair

 The highlight of the Gala, was the rarely seen Bian Lian (变脸) performance. Bian Lian is an ancient Chinese dramatic art, where performers wear brightly colored costumes and vividly colored masks, typically depicting well known characters from the opera, which they change from one face to another almost instantaneously with the swipe of a fan, a movement of the head, or wave of the hand.

Bian Lian (变脸) performer

On a personal note, Urofair was a great opportunity to reconnect with Declan Murphy, who was my supervisor during my fellowship at the Royal Melbourne Hospital. I was honoured to have him and his son @cianblakemurphy (who is probably the youngest person to drive the Da Vinci) visit the National University Hospital where I work. Declan shared to a multispecialty group of robotic surgeons, his journey of expanding the adoption of robotics across multiple surgical disciplines at the Peter MacCallum Cancer Centre, and that the Da Vinci’s role in education, research and talent retention was key in surmounting concerns regarding cost.

On behalf of the SUA, we would like to thank all our international and local faculty for their efforts, and the delegates from near and far, for making Urofair 2018 a resounding success.

Finally, we are excited to announce Urofair 2019 will be held on 4-6 April 2019. Please save the date, and we look forward to welcoming you to Singapore.

Lincoln Tan

Consultant Urologist and Director of Urologic Oncology, National University Hospital, Singapore

Twitter: @LincolnRoboDoc

August 2018 – About the Cover

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This issue’s Article of the Month is the UK-ROPE study, a multicentre study with several authors from Southampton. The cover shows Southampton’s Calshot Castle, an artillery fort constructed by Henry VIII.

The development of Calshot castle as well as Cowes, Hurst and Netley castles along Southampton Water and the Solent, by Henry VIII in about 1540, meant that Southampton was no longer so dependent upon its fortifications.

 

© istock.com/kodachrome25

 

BAUS 2018 Highlights Day Three

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BAUS Day 3—Going home images and snippets…

On the final night of BAUS, I had the honor of giving a dinner talk to the IBUS group—International British Urology Society.  With BAUS contracting from 4 to 3 days, some of the previous joint sessions fell by the wayside, but IBUS president Subu Subramonian put together a nice evening program for the group.

The Day 3 morning session started with what is likely an original debate topic: “Consenting to Death.”  The pro/con centered around whether or not every circumcision operation should be consented for the possibility of death.  The idea was nominated by Jonathan Glass who also did a Twitter poll on the subject, which was similar to this audience poll—around 90% saying no.

The general flow of the debate was whether or not the rare incidence of a complication should be left off, so as not to alarm/concern the patient with minutia.  On the other had, severe complications and death should potentially be consented even if rare.

 

Note the risk of everyday life compared to surgery: soccer was 1: 50,000.  Mr. Glass had a nice display on how choices of driving routes to the hospital could affect the risk of dying.  Turns out the bus is safest.

At the end of the debate, the voting shifted slightly to around 30% saying they would consent for death for a circumcision.

As Mr. O’Brien asked—do you also have to show the patient some horrific picture of gangrene so they are truly informed as to the risk of serious infection?

My favorite phrase on the serious but rare event is “its low risk, but never zero…perhaps a lightning strike.” Never say “routine surgery,” as that is always what the newspaper says: “ He died after routine surgery.”  Routine sounds like zero risk.  I must say also that the risk of “bleeding, infection, cardiac event, stroke, and death” is on almost every U.S. hospital template consent.  So I think patients are used to it and will not freak out.  Also vis-a-vie the Day 2 Blog on Dr. Wachter’s talk, an unintended consequence of the EPIC EMR is that we rarely print consents for patient review—rather we shows them on a screen and they digitally sign.  But I bet they read the details less often than before.  Oddly, they are not able to view their consents with their personal accounts, yet they can read clinic notes, diagnostics, imaging, path ,etc.  Need a solution here.

Always good to have some humor in the slides.

Next, we heard a lecture from a truly unique individual. Mr. David Sellu gave us his personal account of how he was brought before a criminal court for manslaughter when a patient had a bowel perforation after a knee operation—he was in call coverage.  He served time but won his appeals to drop charges and clear his name.  I’m sure there were errors in the case, but in the U.S. this would likely have been a malpractice/civil court case and the hospital would have been co-defendant (system errors). Roger Kirby has tweeted the progress of this case for years, so it was interesting to hear from him personally.

Look at the multiple layers of jeopardy his case took him through over a 6 year period.

Here is a link to a previous blog on the case:

https://blogs.bmj.com/bmj/2018/03/20/the-case-of-david-sellu-a-criminal-court-is-not-the-right-place-to-determine-blame-in-complex-clinical-cases/

The Urology Foundation sponsored a session.  They recognized a recent research scholarship awarded to Mr. David Eldred-Evans “The PROSTAGRAM trial: a prospective cross-sectional study assessing the feasibility of novel imaging techniques to screen for prostate cancer.

Roger Kirby then gave a guest lecture on his personal journal with prostate cancer as a surgeon and patient.  He highlighted his actual biopsy specimens and RP path.  He is 5 years disease free.  He also showed some great nostalgia as he was being interviewed  >20 years ago at the launch of Proscar to the market.  He had 2 interviewers trying to gang up on him on conflict of interest and trying to make the drug sound toxic.  I wonder how he would have handled those two in this era.

Some highlights of his slides on advice to surgeons.  Thanks for all you do Roger.

 

 

 

 

 

 

Finally, there was an interesting session on the Global practice of urology with emphasis on training pathways and what has changed over the decade.   Alan Partin presented his department’s approach to urology training at Johns Hopkins and the US perspective.  James N’Dow outlined how diverse urologic training and credentialing is organize across Europe.  Sanjay Kulkarni gave in Indian perspective—noteworthy that the urologist does not have such constraining credentialing pathways, and often will have private practice across multiple hospitals.  He has attended over 60 and now owns one for his urethroplasty cases.  Times are changing globally for urologic training, and Dr. Partin summed it up well by pointing out that the process of training is highly scrutinized now and seemingly higher priority than the final trained product.  Does anyone think that a urology graduate in 2018 is better trained than 1998?

Ok—time to get back to work in Houston.

John W. Davis, MD, FACS

Associate Editor, BJUI.

 

BAUS 2018 Highlights Day Two: The 2018 BJUI Guest Lecture

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Achieving the Promise of Digital Health: Are we There Yet? If Not, When…and How? Dr. Robert Wachter

Day 2: The 2018 BJUI Guest Lecture: Dr. Robert Wachter.  Achieving the Promise of Digital Health: Are we There Yet? If Not, When…and How?

Image 1: Q&A with Dr. Robert Wachter, moderated by BJUI Trustee Chair, Prof. Krishna Sethia.

For Day 2 of BAUS18, the BJUI team invited a very unique expert to the podium. Dr. Robert Wachter is chief of medicine at the University of California San Francisco. He is more than an international guest flown across the pond for a keynote speech. Rather he is an expert in the digitization of health care and has consulted with the NHS in the past and extensively toured UK facilities. In a prior era of his career, he is credited with inventing the term “hospitalist” as internal medicine trained doctors who only service hospital-based points of care rather than the traditional outpatient clinic.

As a preface, he showed U.S. statistics that in ten years, we transformed from a < 10% to > 90% rate of electronic medical record (EMR) adoption—much of it spurred by financial incentives from the federal government. We all assume EMRs are more accurate and cut down on medical errors—queue the picture of the poor penmanship resulting in wrong drug/wrong patient/wrong dose. Yet he showed a post digitization era mistake where a drug was given 39 times rather than once due to mg vs mg/kg confusion—somehow the error made it through the whole system of EMR check points, robotic pharmacy dispensing, bar coders, and administration. The patient somehow survived. The take home point is the unintended consequences of the EMR.

What drives the EMR? Familiar themes of safety, accuracy, and low cost. At my hospital, we went through the famous EPIC EMR transformation in 2016. We lost so much money in the transition, it was fodder for articles in our national press and it certainly had an impact of several administrators’ careers. But even > 2 years later, I can say that I can make EPIC work at the level I worked before. But am I any faster? Definitely not. And the InBasket feature is a never-ending taskmaster of clinic results and messages and notifications.

Dr. Watcher showed a nice children’s drawing of a visit to her pediatrician. Everyone in the family is drawn, and she is on the exam table. The doctor? Back turned to the patient and clicking away at the EMR. So true and I’m as guilty as anyone. The only mistake made by the 7-year-old artist was that the doctor is smiling while clicking away on the computer! You can see the image yourself (copyrighted) in the article by Toll E, JAMA 2012 PMID 22797449. He pointed out that in most industries, digitization and automation would normally contract the work force and reduce or transfer out job positions. But not in health care—the popular solution to the physician’s back to the patient is to hire a “medical scribe” to do all of the EMR work while the doctor returns to the face to face role. In another talk on Global trends in health care and education, Dr. Allan Partin pointed out that it is increasingly popular in the USA for undergraduate students to take a “gap” year after graduation and before medical school, where they often do research, travel, work in the field, etc. Both trends are now part of my household—my older daughter graduated Baylor University with Health Sciences Studies degree and is both taking a gap year and taking a job as a medical scribe while applying to medical school.

Next is really the key point to where we are now in health care—yes we have converted to the EMR, and yes we have a few tricks like voice recognition software, medical scribes, and *** template phrases to speed up or at least maintain the pace of the pre-EMR era. However, what lies ahead is how to unlock the mystery of how to increase productivity. As far as we know, no one is more productive with an EMR across the board. In some cases, it can still be the opposite—the EMR became such a temptation for hospitals to “tack on” more tasks while they have us in there: not just an H&P but lets add TMN cancer staging, and a problem list, and reconcile meds, and an enormous review of systems, and review outside problems, and do all of the coding and billing. And at least in the EPIC version of the EMR, if any members of your extended team (nursing, trainees, advanced practice providers, etc.) make a mistake in their documentation, you usually can neither correct the error yourself nor close the encounter. So you have to chase them down by email to finish the work. At our center they now want encounters done by 7 days and promise to fine us starting day 14.
So that might be the future—improvements to EMRs or use of artificial intelligence to make our work better and more efficient. A quick example was an endocrine service where the chief could use the EMR to screen hospitalized patients at risk for hyperglycemic complications. He could send alerts to the nursing team on how to further assess and avoid problems. He can scan the whole hospital to flag 20 cases, and send 10 messages—all in the course of an hour. If any one of those 20 cases became a consult, it would probably be an hour each—so that’s the efficiency multiplier.
Overall it was an excellent and thought-provoking lecture. It fits thematically with the prior 2 blogs in the sense of looking at the effects of “mandating” quality improvement projects or “mandating” MDT discussion of all cancer cases—what are the unintended consequences and where is the next paradigm shift.

As I sign off, I think everyone of a certain age’s favorite example of unintended consequences was the story of the radiology film room attending who commonly sat in a dark office in the basement of the hospital. You would go down there with your team of residents, students, and attending and looks through the films and discuss face to face who has pneumonia and who was fluid overloaded, etc. Once we went digital, that whole interaction disappeared for better or worse. As a funny recollection, the other key staff down there when I was a resident were the guys organizing the film library—once a day you had to give them a list of cases to pull from the stacks. They were your friends and could make you look good at conference time. As I recall, once we went digital that job when away quickly. Seems like many of them found employment at our local airport as TSA security agents. I guess the experience with x-rays was a good prerequisite.

 

John W. Davis, MD, FACS
Associate Editor, BJUI

Image 2: Key Slide. The latter point of digitization of health care is the next point of emphasis, following pressure to deliver high value care.

 

 

Residents’ Podcast: CUA 2018 review

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Jesse Ory and Andrea Kokorovic
Department of Urology, Dalhousie University, Halifax, NS, Canada

Dalhousie residents Jesse Ory and Andrea Kokorovic sum up the highlights of day 1 at the 2018 Canadian Urological Association annual meeting in Halifax

Song credits
Don’t fear the reaper: Blue oyster cult
Mute city: F Zero
Mortal Kombat Theme: The Immortals
Funky Suspense – Bensound.com

BJUI Podcasts now available on iTunes, subscribe here https://itunes.apple.com/gb/podcast/bju-international/id1309570262

 

 

BAUS 2018 Highlights Day Two

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BAUS Day 2. The Multidisciplinary Team Debate. Which way are you headed?

BAUS is certainly a UK-centric meeting. But we all share most of the same challenges in healthcare, and as an international urologist in attendance, the learning experience is often gaining insight into how different health systems tackle common problems with solutions and evolutions.

During day 2 prime time, the agenda tackled the current and future situation with MDTs in cancer treatment—multidisciplinary team meetings. For the USA, we might use the term Tumor Board. At MD Anderson we just say, “Urological Multidisciplinary Case Conference.” So yes, MDT is much more efficient.

The goals are straightforward in principle: 1) increase the quality and standardization of care, 2) improve access to expert imaging/pathology, 3) provide a “group” decision which may be more experienced than any 1 person. In the United States, each center is left on its own how to organize and conduct MDTs, although there may be requirements for inclusion as an NIH designated comprehensive cancer center. In the UK, it appears that MDTs are more of a compulsory element. Another key decision is what patients will be presented—all or selected. In the UK, it appears the goal has been to present everyone.

The first speaker was Hashim Ahmed who showed how the “present everything” model has increasingly become impossible, as half of all cases are presented/discussed in < 2 minutes and few go beyond 3 minutes. A national strategy is being discussed and likely piloted in prostate cancer whereby “routine” cases might be listed as a statistic but not discussed; and time reserved for more complicated cases where discussion might be more fruitful. This model will require the MDT chair to spend more pre-meeting time triaging the meeting agenda.

Jo Cresswell expanded the topic by compiling the UK real world experience with MDTs in terms of what has worked well and where it has been lacking.

The “good” might include:

  • Building working relationships with colleagues
  • Mentorship interactions
  • Challenging old practices—evolving from eminence based to evidence based decisions
  • Calling out bad practice/minimize rouge decision making
  • Comforting patients that their case has been heard by a group—sort of a free 2nd opinion

The “bad” or “Pet Hates” list is interesting:

  • The cost of running the MDTs—actual and effort
  • Reduced ownership of the patient—notes where the plan just reads “refer to MDT”
  • Waiting on the MDT
  • MDT Tennis—i.e. referring back and forth between different MDTs
  • Fatigue—going through 120 cases in a session—is anyone awake at the end? Some providers have to attend multiple MDTs per week
  • Loud voices can overrule others (queue the photo of Trump)
  • Agenda effect—if you always present in the same order then whoever goes last on the agenda probably gets less quality discussion.

What is the best middle ground? Again,the concept of discussion reserved for complex cases, and routine cases are under the MDT but not given time.

The final speaker was Bill Dunsmuir. He started by challenging the assumption that the MDT make up of 10-20 experts in oncology will produce wiser decisions than any single provider. Case and point was the 1996 climbing expedition to Mount Everest where the group decision making of expert climbers led to the deaths of the many. Maybe group thinking is not so wise? Problems might include group thought with the same ideas, hierarchy that minimizes dissent, and false debates.

From the Emperor of All Maladies book, he channeled the similar questions, “What is Cancer, why does cancer kill?” One trainee responded in a survey “A cancer killed because they were unfortunate enough to have their cases discussed at an MDT.”   So why do we have MDTs?

His proposal was to consider MDTs as not only dedicated to group decisions, which may or may not always be right. Rather consider them as multidisciplinary professional education. As an example, if the group encounters a specific problem, there would be a pool of short video clips to review the evidence and guidelines—and then discussion could flow off of these standardized points. Ambitious for sure and would need funding and buy in.

In conclusion, this was a well-done session, and highlights the natural history, so to speak, of compulsory MDTs including all patients.   At MD Anderson, we went the other way: select presentations. Each case takes 10-20 minutes, so we usually only get through 3-5 in an hour session. Attendance is optional and there tends to emerge faculty personalities who like MDT interaction, and some who never go. Cases are nominated by a fellow or faculty and you would probably be criticized for presenting a patient where we already have a treatment protocol in placed, i.e. “put them on the protocol, next case.” As a fellow in 2001-2002 I observed there are 3 popular categories of MDT case presentation that are always worthwhile:

  1. I dare you to operate on this patient (co-morbidity, prior surgery, obesity etc.)
  2. How to manage multiple cancers
  3. Look what they screwed up on the outside. Now what?

Please use our comment section—where do you stand on MDTs at your center and what is in the future?

 

John W. Davis, MD, FACS

Associated Editor, BJUI

 

Figures: Slide highlights on current and future of MDTs

 

BAUS 2018 Highlights Day One

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Day one at BAUS gets started with society meetings and the John Blandy Prize and Lecture delivered by Editor Prokar Dasgupta.  The winner was from Pisano et al from Turin, Italy on “The role of re-transurethral resection in the management of high risk NMIBC (PMID 26469362).

But I had to miss this event as I was having my first patient encounter with the NHS.  I have 4 days of severe pain in my left foot after a lot of walking/running around as a tourist on a Baltic Sea cruise.  I went to the nearby NHS walk in clinic—there for an hour and saw the nurse practitioner and left with new scripts for NSAIDs, pain, etc.  And no bill?  Not in the USA!

So now that I can walk (sort of—but only with my running shoes—looks great with a suit) I made it to the teaching course on quality improvement (QI).  I am interested in the topic as I am a Quality Officer for Urology at MD Anderson Cancer Center.  One of our new directives has been to help with fellows organizing a new mandatory “quality improvement” initiative as part of their training.  From the course, I learned that the UK has similar programs but also similar challenges in implementation and standardization.  In the UK, it sounds like medical students are being taught quality improvement in the curriculum.  But if you are like me and finished school > 20 years ago, you likely missed this content.  A consensus opinion was that educational materials on quality improvement science will be created and hopefully will land on the BJUI Knowledge website.  This will help trainees but also trainers catch up on terminology, goals, and how to coach trainees on project development.

The next strong consensus was that quality improvement projects be listed on a website—likely BAUS—so that they could be indexed and searched.  Similar to clinicaltrials.gov or the PROSPERO website that catalog clinical trials and meta-analyses, respectively, the BAUS site could be searchable for projects that were successful as well as those that failed for some reason (perhaps with lessons learned).  Indexing could help with project selection as some QI ideas are unique to urology versus all specialties, and QI projects may emphasize different practice environments such as clinic, operating theatre, or diagnostic departments.

Overall, QI is an emerging field and we are struggling with the same barriers on both sides of the Atlantic.  Principle questions include 1) how to differentiate a clinical study from QI, 2) the role of statistics, evidence-based medicine principles, and ethics committees in QI, 3) how QI should be taught in medical school and post graduate programs, and 4) how QI projects can be published.  On the latter point the Journal of Clinical Urology has expressed interest in publishing QI projects.

The course was directed by Mr. James Green from Barts Health, and also taught by Prof. Nick Sevdalis.  Congrats to both on a job well done.  From my perspective, this field will continue to grow and for some young academic minded urologists will develop into a legitimate academic niche to go along with established pathways such as laboratory investigations, health services research, and surgical education.

Figure: My favorite slide—so may sources of inspiration for a Quality Improvement Projects

John W. Davis, Associate Editor.

 

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