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“SEER-UROLOGY”

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“It’s a gold mine!” said someone to me once about the Surveillance, Epidemiology, and End Results (SEER).

Most of you are probably aware of the existence of this large observational population-based cohort of the National Cancer Institute in the United States. The quality of the SEER’s data collection and the immense pool of information on patient socio-demographics, morphology, therapeutic treatment and long-term follow-up for vital status (and more) are nothing short of extraordinary.

Officially, the SEER was developed to monitor cancer trends and data on cancer incidence, extent of disease, treatment and survival.

Unofficially, the SEER has become more or less a funhouse for research scientists, comprising urology investigators as well, probably because the advantages of the SEER database are so appealing:

– it is readily available (click and download);

– the number of patients, even after excluding a bunch of people, is colossal (“Wow! You did all those partial nephrectomies?” someone asked me at the American Urological Association two years ago);

– the findings are publishable (except at one famous journal, who rejects all SEER submissions without external review);

– It’s free! – unless you want to use the SEER Medicare-linked database, in which case, a few robotic-assisted prostatectomies performed by a co-investigator can easily cover the cost (thanks Quoc).

Yet, many individuals within the urological community remain skeptical, borderline aversive towards studies relying on population-based cohorts, such as the SEER database, or the

Nationwide Inpatient Sample (NIS), or the Florida Hospital Inpatient Datafile, to name a few.

At first I didn’t understand why. Because some of the highest quality, most well-designed, and widely cited studies that were published in high-end journals like the New England Journal of Medicine, the Journal of American Medical Association, and the Lancet actually originated from large population-based databases.

But then I realized that – put aside a few people who are just old and bitter – some of these aversions towards studies relying on observational cohorts could be because there is quite a bit of redundant, inconsistent, trivial junk out there that has been published using population-based cohorts like the SEER.

In a recent letter of correspondence in JAMA, Quoc and I wrote a little piece that could be considered as a potential remedy against the issue at hand.  Whereas some may think that the proposed principles appear excessively strict, we personally believe that it can help regulate the prevalent redundancy, reduce discrepancies, and improve the overall quality of the work within population-based reports. Well, at least that is what we think the population-based research community should aim for. Until then…the clock is ticking!

 

Maxine Sun is a urologic-oncological research scientist and co-director of the Cancer Prognostics and Health Outcomes Unit in Montreal. @maxinesun

 

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Humour and the doctor-patient interaction: thoughts from a urological perspective

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Marni Basto

The Urologist cursed with contempt at his finger in the air, discussing with me his practice of prostatic massage, “I’ve had to learn to use my left pointer, the right one developed osteoarthritis”. A moment of silence, then laughter!

From medical school I observed the different ‘phenotype’ of consultant between the specialties and noted the way certain personality types appeared attracted to particular fields. Whilst plastic surgeons displayed a dichotomy of perfectionism and relaxed demeanor, Urologists always struck me as the happy bunch. Witty, personable and sharp with the ability to laugh at themselves and the very nature of the specialty. The sensitive side of some urological conditions makes the doctor-patient interaction and rapport building all the more important. Humour has the ability to enhance communication, break down barriers, develop a therapeutic alliance and improve patient satisfaction. An Urologist’s judicious use of humour may provide the impetus to enter sensitive and personal areas of discussion.  However used without caution can be counterproductive and jeopardise the relationship. As a student and resident I recall some inspiring but also abysmal attempts at humour in the clinical encounter which made me think about how best we can utilise this powerful tool.

Interestingly, the etymology of humour is medically derived from Latin meaning ‘moisture’ or ‘fluid’. It was believed the proportion of four bodily fluids: Blood, phlegm, yellow bile and black bile each conferred unique personality traits and temperament. An imbalance of humours therefore made a person eccentric or odd. With time the word came to refer to those who provoked laughter at the oddities and incongruities of life. Clearly the ancient philosophers were not Urologically inclined –  Two shades of bile?!

Freud noted that the best humour often stems from taboo topics which is perhaps why Urology lends itself well to its use in a clinical encounter.   It’s a tool that can be used by both doctors and patients as a coping mechanism and to reduce the effect of stress.

Here this was exemplified, as I overheard an Urologist discussing with his British patient the TRUS Biopsy he was about to have,

Patient: ‘I am a little nervous, do you think I’ll feel it at all?’

Urologist: ‘No, no, you’ll be off to sleep. But if you did it looks and feels somewhat like the Gherkin in the London Skyline……. Hideously awkward!’

To which the patient almost fell off the bed in tears of laughter. Granted however the Urologist had known this patient for many years and was ‘au fait’ with his style of humour. Another important learning point. Lack of familiarity can cause humour to be ineffective particularly at first consult or in cross cultural encounters. Although we’d say most aspects of humour are broadly trans-societal, one can’t always assume. If unsure always err on the side of caution.

Patient-generated humour can be the most bonding of all in its ability to empower the patient and unite a medical team. ‘Nota bene dic doc’ a recent article published in the Canadian Urological Association Journal by Associate Professor Nathan Lawrentshuck describes a patient who strategically placed a poem in his underpants for the team to see prior to his prostatectomy. This is well worth accessing for the full read however ends along the lines of; “But my sex life is on the upwards curve, So hey there buddy can you spare a nerve?” This had the effect of uniting the team to achieve the best outcome for the patient, who was rapt with the positive response from the staff.

Developing this type of bond with your patients can be extremely rewarding for everyone involved and again Urology lends itself well to this interaction given patients are commonly followed up for years. It takes a while however to get to this point for example;

Patient to long term Urologist regarding recurrent bouts of renal colic: “Can’t you just prescribe me some cyanide?” 

Urologist: “I would except it’d be bad for business – I wouldn’t get any more follow-up visits out of you”. Both laugh!

In a world that is time poor and litigation crazy, humour also can be a tool to ameliorate risk. A US study looked at practice behaviours that helped to decrease the risk of a malpractice suit. It was found that physicians who’d never had a claim against them laughed more and used humour more often during visits. Perhaps this shows once and for all that laughter really is the best medicine!

So for this bunch of plumbers the opportunities for toilet humour are pretty damn concentrated, here’s a great reference! Some food for thought;

• Humour is a useful vector for developing a doctor-patient relationship and can lead to a more rewarding interaction for both parties.

• Humour is best developed with familiarity.

• Learn to use humour to create a healing environment.

• It may assist in entering sensitive areas of discussion.

• Judicious use of humour is appropriate always.

• Externally-focused humour (E.g. weather, parking) carries the least risk in miscommunication and is a good starting point.

• Beware of cross cultural barriers.

• Sole reliance on humour in an interaction can be perceived as flippant.

• Humour may assist in decreasing the risk of malpractice suits.

So even if you’re a medical student, like I was, whose only knowledge of Urology is the great catfish Candiru that swims up the urine stream against gravity and lodges in the urethra; feel free to share any comments, words of wisdom and your own funny experiences for everyone’s enjoyment below.

 

Marnique Basto is a Uro-Oncology Research Fellow at Peter MacCallum Cancer Centre, Melbourne, Australia.

@DrMarniqueB

 

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NOTES Procedure

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Natural orifice transluminal endoscopic surgery (NOTES): where are we going? A bibliometric assessment

Riccardo Autorino*†, Rachid Yakoubi*, Wesley M. White‡, Matthew Gettman§, Marco De Sio†, Carmelo Quattrone†, Carmine Di Palma†, Alessandro Izzo†, Jeorge Correia-Pinto¶, Jihad H. Kaouk* and Estevão Lima¶

*Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA, †Urology Unit, Second University of Naples, Naples, Italy, ‡Division of Urologic Surgery, University of Tennessee, Knoxville, TN, and §Department of Urology, Mayo Clinic, Rochester, MN, USA, and ¶Life and Health Sciences Research Institute, University of Minho, Braga, Portugal

The aim of this study was to analyse natural orifice transluminal endoscopic surgery (NOTES)-related publications over the last 5 years. A systematic literature search was done to retrieve publications related to NOTES from 2006 to 2011. The following variables were recorded: year of publication; article type; study design; setting; Journal Citation Reports® journal category; authors area of surgical speciality; geographic area of origin; surgical procedure; NOTES technique; NOTES access route; number of clinical cases. A time-trend analysis was performed by comparing early (2006–2008) and late (2009–2011) study periods. Overall, 644 publications were included in the analysis and most papers were found in general surgery journals (50.9%). Studies were most frequently clinical series (43.9%) and animal experimental (48%), with the articles focusing primarily on cholecystectomy, access creation and closure, and peritoneoscopy. Pure NOTES techniques were performed in most of the published reports (85%) with the remaining cases being hybrid NOTES (7.4%) and NOTES-assisted procedures (6.1%). The access routes included transgastric (52.5%), transcolonic (12.3%), transvesical (12.5%), transvaginal (10.5%), and combined (12.3%). From the early to the late period, there was a significant increase in the number of randomised controlled trials (5.6% vs 7.2%) or non-randomised but comparative studies (5.6% vs 22.9%) (P < 0.001) and there was also a significant increase in the number of colorectal procedures and nephrectomies (P = 0.002). Pure NOTES remained the most studied approach over the years but with increased investigation in the field of NOTES-assisted techniques (P = 0.001). There was also a significant increase in the adoption of transvesical access (7% vs 15.6%) (P = 0.007). NOTES is in a developmental stage and much work is still needed to refine techniques, verify safety and document efficacy. Since the first description of the concept of NOTES, >2000 clinical cases, irrespective of specialty, have been reported. NOTES remains a field of intense clinical and experimental research in various surgical specialities.

Autorino R, Yakoubi R, White WM, et al. Natural orifice transluminal endoscopic surgery (NOTES): where are we going? A bibliometric assessment. BJU Int 2013; 111: 11–16

Read the full article

“The most read surgical journal on the web”

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It is an enormous privilege becoming the new Editor-in-Chief of the BJUI. As an academic it has been my ultimate dream. Thank you for this exciting opportunity to serve our readers and authors. I also wanted to express my gratitude to our editorial board and reviewers without whom this journal would not exist.

Early one morning during the BAUS annual meeting 2012, I had the great pleasure of having breakfast with John Fitzpatrick. He has done wonders with the BJUI and I wish to thank and congratulate him for his excellent leadership, international collaboration and innovative approach, which has established the journal as a global landmark in urology. I asked him to describe his most important contribution to the BJUI in one word. The answer without hesitation was ‘colour’.

John immediately asked me the same question. With equal conviction I uttered the words that would describe the BJUI in the next 5 years –’the web’.

The other day I made my usual trip to the Guy’s Hospital, King’s College London, library. I love reading the new journals as well as archived copies that are stored on the first floor. I have done so regularly for the last 10 years. On this occasion I requested our friendly librarian to guide me towards the new editions of Science and the N Engl J Med. Rather to my astonishment, she said that the first floor had been shut and there were no paper journals there anymore! Instead she directed me to a computer terminal where I could browse every scientific journal with my college user name and password. It was then that I realised that my own library had stopped subscribing to paper journals. I have since learned that many other libraries have done the same. Libraries and not urologists are the largest subscribers of the BJUI. If they do not want paper journals they are just not going to buy them.

Welcome to the green revolution.

Over the next few years it will be my mission to make the BJUI the most read surgical journal on the web. We have not made the mistake of assuming that this is what all our readers want. Therefore, while we make the transition to the web, the paper version continues, but with a few differences. We will be reducing the number of paper issues to once a month. Our readers have told us that as soon as the first edition comes out of its plastic cover, the next one arrives. This is often rather overwhelming for a busy urologist who may find it challenging to find the important messages. A direct result of reducing the number of volumes is that fewer papers will ultimately be published and the acceptance rate will fall to ~15%. A triage system has been introduced whereby papers that are not felt to be suitable for the new journal are returned immediately to the authors. This is not a reflection of the quality of the papers but reduces wastage of valuable time and allows the articles to be submitted elsewhere without delay.

The BJUI website www.bjui.org has been entirely redesigned and, in keeping with our main mission statement, I have gathered a dedicated new team of enthusiastic innovators. You will notice that unlike other journals we have Associate Editors for innovation, impact, web, social media and design. These are young urologists with unique skills allowing us to deliver the BJUI on an exciting web-based platform that will evolve continuously. I hope you can join us on this journey.

The busy modern surgeon has a short attention span. If we cannot attract them to our key messages within 30 seconds of reaching our landing page, it is unlikely that they will stay there for 3 minutes rather than go elsewhere. Extensive studies and searches on web-based metrics have made these facts obvious to me. These are the realities of modern academic publishing. The web-based journal will have a much wider readership, not just amongst urologists but also other doctors, nurses, students and most importantly patients and their families.

With this in mind we have introduced the ‘article of the week’, almost like the headline news of The Times. If most urologists read just this on their iPads or smart phones, rather than ever even look at the paper version, we have successfully made our point. This month one such article is the updated Partin tables. As a predictive tool, they are important to urologists and patients alike and will allow our readers to counsel patients about the potential outcomes after treatment of their prostate cancer.

Another new feature is the BJUI blog for immediacy, HuffPost style; the days of writing a letter to the editor that gets published a year later are no more. Instead, your opinions will be moderated and appear real time on the website. The debate will be timely, educational and enjoyable.

Social media, especially Twitter, will play an important role in highlighting the most important content and allowing rapid interaction during international meetings. We have engaged the services of a group specialising in social media and I urge you to follow the BJUI on Facebook and Twitter. Who knows ‘tweetations’ might become as important as the impact factor, one day soon.

Finally, I wanted to especially thank Francesco Montorsi for inspiring me during dinner one autumn evening in Milan, where I had been invited to review a European Union grant application. The lesson I learnt from him was humility. As the Editor-in-Chief I always remember an important tale published by Hans Christian Andersen in 1837. ‘The Emperor’s New Clothes’ describes what happens when a vain king is paraded by two rogue weavers in his invisible new clothes through the streets of his own capital. I hope I will always manage to avoid the ‘emperor syndrome’. My job is to serve our readers and focus above all on the one thing that is of utmost importance to the BJUI – quality.

Prokar Dasgupta

Twitter: my #eurekamoment #pennydrops #babyvomit

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I remember distinctly when the penny dropped for me. It was about 2am on a warm summer’s night in early January 2012 (apologies to those of you shivering in the Northern Hemisphere). I had my one-week old son in one arm, swinging between sleeping and spewing, and an iPad in my other hand, providing distraction between nappy changes and feeds. The sleep-deprivation had dulled my senses considerably and my brain was capable of no more than light reading.

It was then I read a piece in the New York Times online about the power of Twitter in medical communication. Previously, I thought Twitter was the domain of Lady Gaga, Justin Bieber, Kim Kardashian (Kim who?) and various narcissistic cricket and football players. It seemed like puerile nonsense for a generation that I no longer belonged to. However, reading this opinion piece made me think again. It was clear that there is a whole generation of significant academic clinicians, researchers and publishers who have embraced social media and who use Twitter, in particular, to disseminate their work with a speed and reach that is simply unachievable through any other medium. I was struck by various examples of how key scientific publications are first flagged on Twitter and how within hours, responses are made by key opinion leaders and these responses are again disseminated rapidly around the Twittersphere. And although none of the examples were based around urology, it was clear to me that oncologists and surgeons were getting on board the social media rollercoaster.

So between nappy changes and having wiped some baby vomit off my iPad, I logged onto Twitter and created a username. I searched for prostate cancer and urology and quickly found my way to a few key resources and super-users who seemed to have a very active Twitter presence and who were tweeting content that immediately appeared of interest to me. Within a few minutes I had identified a few highly valuable Twitter users to follow and within their lists of followers and those who they were following, I quickly built up a useful stream of tweets dropping into my timeline. And then of course, a few of these Twitterers started following me back, which was mildly exciting. Within a few days and having posted a few tweaks, I began to feel part of the Twittersphere.

As the weeks went by, I continued to be astounded by just how fast information travels on Twitter. While I get emails with the table of contents for the various journals that I subscribe to, these only drop in my inbox every few weeks. Also, because there are a number of significant journals that I do not subscribe to (non-urological mostly), there are many papers published out there that do not come immediately to my attention. Depending on which Twitter sites you follow, all key papers related to your area of interest find their way into your timeline instantaneously as soon as they are published. Not just that, very interesting comment from others also gets to you very quickly. For example, key findings in prostate cancer tend to be picked up by the major US news sites who then invite comment from key leaders in major cancer centres. A typical example is that of the PSA screening recommendations made by the United States Preventive Services Taskforce in June 2012, which provoked huge controversy. Twitter came to life and key opinion leaders such as Matt Cooperberg (@cooperberg_ucsf) helped drive the conversation through Twitter and blogs (e.g.The Huffington Post blog) at lightning speed. These comments get tweeted out and responses to these comments also get blogged and within hours of a paper being published you have news of the paper, expert comment and wider reaction…… all in 140 characters or less!

And while none of us have much time in the day to add an extra task, I find that waiting for my coffee in the morning or while the resident puts an arterial line in my next patient, there are a few spare moments in the day where the Twitter app on my iPhone comes to life. Twitter is perfectly suited to the smart phone user and that is where the majority of tweets around the world are generated from. It is also perfectly suited for one of the other very exciting areas in which I have seen Twitter play a very useful role – that of conferencing. At the EAU in Paris, a small but energetic group of Twitter users started tweeting content from various sessions at this large meeting and started engaging with other Twitter users around the world. For me, I believe conferencing is about to be transformed by the power of social media but more about that soon.

For now, at the new BJUI, we want to grow the audience and get you all to join the conversation. Through Twitter, blogging, Facebook, YouTube and other social media platforms, we are building for the future of communication in urology. The next generation of trainees will be deeply embedded in all of these platforms and will expect to be engaged through them. We are entering a new generation of medical communication – come join the conversation.

Declan Murphy
@declangmurphy

 

Declan Murphy is Honorary Clinical Associate Professor at the Department of Surgery, University of Melbourne, St Vincent’s Hospital and Director of Robotic Surgery at the Peter MacCallum Cancer Centre. He had previously been consultant urological surgeon at Guys & St Thomas’ NHS Foundation Trust in London.

 

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