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.
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:
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.
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.
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:
The “bad” or “Pet Hates” list is interesting:
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:
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
This issue’s Article of the Month is a multicentre trial led by researchers in Cambridge, UK. The cover shows a typical Cambridge scene of bicycles leaning against a college wall.
Cambridge is home to the world-renowned University of Cambridge, which was founded in 1209. The city’s skyline is dominated by several college buildings, along with the spire of the Our Lady and the English Martyrs Church, the chimney of Addenbrooke’s Hospital and St John’s College Chapel tower.
© istock.com/oversnap
BJU International has a longstanding track record of promoting the principles of evidence-based clinical practice to an international audience of urologists. Recent initiatives include the “guidelines of guidelines” series which appraises and contrasts clinical practice guidelines from different professional organizations on the same topic, for example on microscopic hematuria and non-muscle-invasive bladder cancer. It also co-publishes high quality, urology-relevant guidance by the UK’s National Institute for Health and Care Excellence (NICE), for example on the preoperative testing for elective surgery (https://www.bjuinternational.com/learning-2/urology-guidelines/nice-guidance-routine-preoperative-tests-elective-surgery/).
In collaboration with the MAGIC research and innovation program (www.magicproject.org), BJU International has published its first Rapid Recommendation guidance document on the use of medical expulsive therapy (MET) with alpha-blockers that was triggered by the recent rigorous Cochrane review on the same topic. Its purpose is to provide trustworthy, timely and practical guidance on this topic based on the entire body of evidence, given several recently published trials with contradictory findings. To develop this trustworthy guidance, an international team that included patients with a personal history of ureteral stones, general practitioners (GPs), emergency clinicians, urologists familiar with treating renal colic, epidemiologists, and methodologists followed a rigorous and transparent GRADE-based process in accordance with The National Academy of Science, Engineering and Medicine (formerly: Institute of Medicine) (https://www.nationalacademies.org/hmd/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspx) standards for trustworthy guidelines. Panel member had no financial conflicts of interest and intellectual and professional conflicts of interests were described and carefully minimized. All meetings were conducted by web conference and the process was completed within 90 days of publication of the Cochrane review, which is co-published in BJU International in this same issue.
Initially pioneered in collaboration with the BMJ for questions of broader interest (https://www.bmj.com/rapid-recommendations) such as the use of corticosteroids for the treatment of a sore throat, this Rapid Recommendation breaks new ground for evidence-based guidance in urology, complementing the efforts by professional organizations such as the European Association of Urology (EAU) and American Urological Association (AUA). Rapid Recommendations stand out for their focus on patient-important outcomes, the use of an explicit and transparent process for moving from evidence to recommendations and its timely development process. Rapid Recommendations provide actionable guidance as well as information on the underlying evidence and supporting judgments that are summarized in an infographic that is easily understood by patients. The Rapid Recommendation on MET is intended to be the first of many to help inform patients, providers and policy-makers but also to seeks to provide a strong impetus for more trustworthy and useful guidelines in urology in general.
By Philipp Dahm1 2 and Per Olav Vandvik3 4 5
1 Minneapolis VA Medical Center, Urology Section, Minneapolis, MN, USA
2 University of Minnesota, Department of Urology, Minneapolis, MN, USA
3 Norwegian Institute of Public Health, Oslo, Norway
Disclosures:
Philipp Dahm serves as Coordinating Editor of Cochrane Urology, is member of the GRADE Working Group and served as a panel member of this Rapid Recommendation project
Per Olav Vandvik is member of the GRADE Working Group, is the leader of the MAGIC Foundation and BMJ Rapid Recommendations project and served as a panel member of this Rapid Recommendation project.
In the month that brings the BAUS annual meeting to Liverpool, the Article of the Month is a BAUS consensus document and so the cover features the sign for the Beatles Story museum in Liverpool.
The Museum contains recreations of The Casbah Coffee Club, The Cavern Club and Abbey Road Studios among other historical Beatles items, such as John Lennon‘s spectacles, George Harrison‘s first guitar and a detailed history about the British Invasion and the solo careers of every Beatle.
© istock.com/ilbusca
The NHS is the world’s largest, longest established, unified healthcare system and has been at the forefront of many pioneering medical innovations in its 70‐year history. These have included the intraocular lens, total hip replacement, the rod‐lens telescope, CT and MRI scanners, and the laryngeal mask. However, commercialisation of this technology has often been better achieved abroad.
Increasingly the latest greatest advances transforming our lives are originating directly from industry. Companies such as Amazon, Uber, Airbnb and Google are at the vanguard of this disruptive change. More and more, their innovative products and services are available directly to patients resulting in the disintermediation of doctors. This is heralding a new era – a personalised, empowered, democratised healthcare revolution.
Traditionally the NHS has supported clinicians who want to develop their career in academic, leadership or educational arenas but has not been as supportive of entrepreneurial clinicians.
If we are to deliver on the promise of the Five Year Forward View 1 and the patients of the NHS are to receive the first‐hand benefit of innovation, we need to equip our clinicians with the entrepreneurial skills, knowledge and experience that will enable them to understand and engage with this new world. We need to develop our clinicians, so that they have both entrepreneurial and intrapreneurial abilities.
This has already been recognised by trainee doctors. Increasingly juniors want to both deliver and improve healthcare. In the UK, >56% of trainees completing their Foundation Year 2 (FY2) do not continue straight into training posts and ~5% of trainees leave medicine each year to pursue other opportunities, many take up entrepreneurial positions. We are losing a generation of innovative, entrepreneurial clinicians with a skill set that would bring a new leadership capability to the NHS.
To address this NHS England in partnership with Health Education England has launched the Clinical Entrepreneur Programme 2. This national scale workforce development initiative allows clinicians to undertake entrepreneurial activity alongside their clinical work. It provides a coaching and mentoring scheme, less than full‐time training opportunities, advanced industry internships, customer matching, connections to funding and education, and networking events. In year one, 104 junior doctors were appointed, 50 start‐ups created, >£50 m in funding raised and a ‘brain drain’ was turned into a ‘brain gain’, with 34 doctors who had left medicine or were about to leave returning to work in the NHS. In year two, >220 clinicians have joined the programme. In future years we aim to include patients and citizens. By bringing all to the centre, as we re‐imagine and re‐design healthcare, will we have the best chance of getting it right.
The clinical entrepreneurs will ultimately number in the thousands and will act as ‘multilingual’ frontline agents for change, adoption, and spread of innovation throughout the NHS and beyond.
At the BAUS annual conference this year some of the current cohort will be pitching their start‐ups on the main stage. Why not join us and welcome the new generation of specialists in healthcare – the Clinical Entrepreneurs.
The 33rd annual congress of the European Association of Urology was held in Copenhagen. The weather outside was icy and further reason to stay inside and enjoy the modern and vast Bella Conference Center. The EAU conference offers more each year to engage with all its members and age groups. Science, innovation and research is presented in interesting and current ways including live surgery, great social media interaction, game changing sessions, “EAU press release” video interviews and expert-guided poster tours.
Prostate cancer
The pre-conference emails and newsletters this year promised updates on prostate cancer detection and several different groups presented data. Artificial intelligence use is growing around the world with medical systems starting to show promise to match trained doctors in the future. A chinese team led by Dr. Chengwei Zhang, presented an artificial intelligence system which can diagnose and identify cancerous prostate samples with above 99% accuracy.
The “Radiomic TRUS” system, uses an artificial intelligence system to target transrectal ultrasound biopsies, allowing only 6 cores to be taken. The artificial intelligence imaging system is calibrated from radical prostatectomy specimens and can detect lesions from US not visible to the human eye. Their recent randomised controlled trial also showed better detection rate compared to TRUS guided 12 core to systematic biopsies and mpMRI assisted 12 core systematic biopsy in their study. However systematic biopsies may soon be obsolete according to the “Game Changing” plenary session and one of the conference highlights, came from the “PRECISION” trial from UCL, presented by Veeru Kasivisvanathan.
The results showed 71 (28%) of the 252 men in the MRI arm of the study avoided the need for a subsequent biopsy. Of those who needed a biopsy, the researchers detected clinically significant cancer in 95 (38%) of the 252 men, compared with 64 (26%) of the 248 men who received only the TRUS biopsy. This shows the benefit of using a mpMRI for ALL men with suspicion of prostate cancer. Men with a normal MRI (and no red flags) can avoid a biopsy. Men with a suspicious lesion on mpMRI can have targeted biopsies only (not systematic). Therefore using this protocol avoids unnecessary biopsies and when biopsies are taken, fewer cores are required.
(Read more in the PRECISION BJUI blog by Declan Murphy:-
Upper Tract Urothelial Cancer (UTUC)
The winner of the first prize for oncology was for the results of the POUT trial, a phase III randomised trial of peri-operative chemotherapy versus surveillance in upper tract urothelial cancer (UTUC), by Birtle A.J et al. They compared surveillance and adjuvant chemotherapy with gemcitabine-cisplatin,
post nephro-ureterectomy giving histologically confirmed pT2-T4 N0-3 M0 UTUC.
The chemotherapy arm showed improved metastasis-free survival in UTUC. Recruitment to the POUT trial was terminated early because of efficacy favouring the chemotherapy arm; follow up for overall survival continues. POUT is the largest randomised trial in UTUC and its results support the use of adjuvant chemotherapy as a new standard of care.
Transgender
The first accurate data to confirm that male to female transgender surgery can lead to a better life. The study shows that 80% of male-to-female patients perceived themselves as women post-surgery. However, the quality of life of transgender individuals is still significantly lower than the general population. Dr. Jochen Hess and his team from Germany, followed 156 patients for a median of more than 6 years after surgery. They developed and validated the new Essen Transgender Quality of Life Inventory, which is the first methodology to specifically consider transgender QoL. They found that there was a high overall level of satisfaction with the outcomes of surgery.
Stones
Since the SUSPEND trial showed no benefit to stone passage with medical expulsive therapy (MET) many centres have ceased tamsulosin for ureteric stone passage. However this has not been as widely adopted as might be expected, with opinion especially from USA feeling that larger stones may benefit from MET. A Chinese multicenter, randomised, double-blind, placebo-controlled has now shown benefit to ureteric stone passage greater than 5 mm. With the MIMIC study (a multicenter, International ureteric stone study) showing no benefit in MET for stone passage, the debate is set to continue! However for now the latest EAU guidelines recommends MET may be used to aid spontaneous passage for ureteric stones greater than 5 mm.
Renal Cell Carcinoma
Diagnostic renal biopsy for presumed renal cancer may increase in the future, with data from the Royal Free Hospital, London, showing benign results in 21.5% of biopsies, of which 98% avoided surgical intervention.
Social media
Twitter use overall seems to be slightly less than the last two years, with fewer Tweets and tweets/participants, but there were more active Tweeps and more impressions.
The 6th annual BJUI social media awards was held at the Crowne Plaza Hotel, close to the conference center. This fun and lighthearted event celebrated tech leaders, with two awards going to the EAU communications department for best conference and innovation. Stephen Fry was also acknowledged for raising awareness by tweeting on his personal prostate cancer journey.
(Read more https://www.bjuinternational.com/bjui-blog/6th-bjui-social-media-awards-2018/)
EAU guidelines are finding effective dissemination though social media.
Finally the top conference tweet went to BJUI editor Prokar Dasgupta for his thought provoking talk on robotic surgery in the developing world.
This was a fantastically well organised conference with some great practice changing presentations, up next is EAU Barcelona in 2019. #EAU19 #Barcelona #SoMe
Nishant Bedi
Urology Registrar North London
@nishbedi
This issue’s Article of the Month, Dietary Intervention to Prevent Clinical Progression in Prostate Cancer, is from San Diego, USA.