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BAUS 2018 Highlights Day Three

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

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 2018 Highlights Day Two

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

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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