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Its happening and its happening fast. What the cardiothoracic surgeons in the UK have lived with for 8 years is coming to a specialty near you very soon. Individual urological surgeons results to be published openly, in the press in the UK from summer 2013.
It’s a massive change to the way we work and to the way surgical data is presented. No longer will the interesting elements of the urological literature be studies of the results of a few surgeons in a few centres of world renown but rather the performance of outliers. Reports will start to reflect what is achieved throughout the nation not in one or two centres in that nation. Warts and all if you like.
There are risks. Big risks. For surgeons and for patients.
Will surgeons who operate on high risk cases be smeared because they appear to be underperforming?
Will patients who are high risk be denied operations because surgeons subliminally start to make recommendations that are good for the surgeon but not for the patient?
Will surgeons continue to train junior surgeons or will juniors simply cut the stitches?
Why should surgeons carry the can for the performance of the whole team?
Will sample sizes be big enough to ensure that results could not be due to chance?
What outcomes should we be measuring in order to judge the quality of many operations?
Who should collect the data – the surgeons or independent reviewers?
Are surgeons going to be tabloid fodder?
Is it simply time to head for the hills with a cigar and a bottle of red…..
In cardiac surgery all these were live questions and they have worked it out. Standards have been shown to be astonishingly high. Will urology be the same? The specialities have been challenged to come up with a plan. Why not contribute to that process and add to the blog….
Tim O’Brien is a Consultant Urological Surgeon at Guy’s and St Thomas’s NHS Hospital, London. His views are his own.
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There is increasing concern that current UK trainees at the end of their training are less experienced than their previous counterparts and continue to require more education, skills and support when they assume their consultant posts in the form of mentoring.
It is generally accepted that the numbers of hours required to become an ‘expert’ is 10 000–30 000 and currently in the UK our trainees experience =6000 h of training. Much of this is due to the impact of the European Working Time Directive (EWTD) and the government ‘New Deal’ initiative on junior doctors contracts introduced in 2003. The UK conundrum shared with many other healthcare systems is how to provide effective training within the demands of service commitment and the EWTD. Skills training has therefore been seen as the mechanism to resolve the situation, encompassing the acquisition of both technical and non-technical skills. The challenge therefore is to devise innovative ways of training within the limit of fewer hours and training, not service, must become the priority for trainees and for those surgeons, departments and hospitals that train them.
Contemporary urology training is moving out of clinical practice and simulation is increasingly used to provide a safe and supportive learning environment for learning and maintaining skills. However, this needs the following criteria:
• An agreed curriculum
• Agreed set of standards
• A validated form of assessment
• The availability of local and national skills centres
• Educators and trainers
The problem is that traditionally the UK has few training centres, together with a lack of trained manpower and funding. However, controversy still remains over the efficacy of simulation for training and those who are able to fund such projects comment on the paucity of available data in relation to the predictability of future outcomes and patient safety.
Projects such as the Simulation and Technology enhanced Learning Initiative (STeLI) initiative documented in this paper are important contributors to the evidence base. The programme aims to establish the feasibility and acceptability of a centralised, simulation-based system incorporating both skills and non-technical skills aspects of training. The latter involving crisis resource management using the SimMan model to teach team-working, decision-making, and communication skills in various settings between senior and junior trainees. Not surprisingly senior trainees scored significantly better on virtual reality simulators, bench-top box trainers and the European wet-lab training facility, as well as in human patient simulation training in crisis resource management (CRM) using SimMan, than junior trainees. The interesting point raised in this paper is that the trainees’ behaviour shows the value of inclusion of the CRM training and the interplay between technical and non-technical skills. Non-technical skills have often been sidelined in courses focusing on technical skills acquisition and this paper highlights the importance and added-value of incorporating such a skill set into future course content and curricula.
Thus, there is no doubt that some surgical skills can be learned in the laboratory and although this will never be a substitute for operative experience, the first steps of training can be accelerated with potential reduction of risk to patients. Increasingly data from sources such as the STeLI project underline a better appreciation of the importance of the training in non-technical skills, which equip surgeons in working under stress and more importantly working as a team player. However, the ultimate test for simulation is whether the model and content is able to reduce surgical errors, improve patient safety and reduce operative time and costs. To try and answer these questions BAUS in conjunction with the Specialist Advisory Committee (SAC) in Urology have recognised that the technology is there but there is a need to identify trainers keen to train, with the nomination of a national lead for simulation to develop a national strategy to deliver a viable programme aligned to the curriculum to try and answer the important question: ‘Does simulation enhance real-life performance of a surgical technique?’.
Adrian D. Joyce
St James’ University Hospital, Leeds LS9 7TF, UK
It was weird, having spent a career looking after men with prostate problems, to discover that my own PSA was raised to 4.3ng/mL. A 3 Tesla MRI with gadolinium enhancement revealed a lesion in the right peripheral zone, which a biopsy confirmed as a Gleason 3+4=7 adenocarcinoma. The decision wasn’t difficult for me: I opted for a robot-assisted radical prostatectomy (RARP), to be performed by the Editor-in-Chief of this journal, Professor Prokar Dasgupta, ably assisted by Ben Challacombe and Krishna Patil. Details of my whole journey are available here for those who are interested.
The key point for discussion in this blog is the availability of the latest technology for the care of patients with prostate cancer who are less in the know than me. Shouldn’t we be lobbying for greater access for all to the latest pieces of high tech gear?
3 Tesla MRI imaging, together with the expertise to interpret the findings of diffusion-weighted images, for example, offers the possibility of a “prostate mammogram” which facilitates the targeting of the biopsy and holds the promise of avoiding biopsies in those in whom the MRI images appear blameless.
Da Vinci robotic technology undoubtedly facilitates the surgical procedure, especially the preservation of the neurovascular bundles and the very precise vesico-urethral anastomosis. It certainly was an interesting experience to sit and watch the DVD of my own operation at home, with a catheter still draining my bladder, wondering about my future continence and sexual function, as well as the histopathology report! After an operation like this anybody is going to need assistance to move around the house just to do basic activities like go to the bathroom or even change clothes. That’s why it is very important to check into a nursing home where they offer their professional service. In some cases these nurses don’t work professionally and often neglect their patients needs, so that is why it’s recommended to contact a nursing home neglect attorney for situations like this for legal help.
Am I discombobulated by this experience? Not especially, I genuinely found being on the receiving end of prostate surgery a truly educational experience and I now feel energised to help others get through their journey. In the upcoming issue of Trends in Urology three other of our urological colleagues share their own experiences of prostate cancer, as well as the lessons that can be learned from them. Check out the Trends in Urology website from mid-March onwards.
In the meantime we would be interested in your own thoughts on these issues. Do add a comment or question to this blog.
Roger Kirby
The Prostate Centre, London W1G 8GT
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Improving training in the United Kingdom may benefit from a more analytical assessment of natural abilities, individual learning curves and understanding and providing the necessary training methods to let trainees reach their potential. It used to be said that surgeons learnt from their mistakes, but surely this philosophy and approach is unacceptable in the 21st Century. To learn from a mistake when it could have been avoided in the first place, with the correct guidance, could be considered negligence. Of course to err is human and none of us are superhuman. However, what we must try to avoid is the “self-discovery” curve in surgery.
Vickers paper assessing fellowships to learn radical prostatectomy showed that a fellowship could shorten your learning curve. I have been on several fellowships abroad and what they had in common was of course numbers. Centres do not get a reputation or expertise by doing one case a year. However they also had in common a structured approach to training fellows that started with observation in theatre, then bedside assisting and finally doing defined steps of the procedure.
The combination of structured training and suitable experience is key to good surgical development. The individual who takes up golf and teaches himself or herself is unlikely to become a scratch golfer and may develop ugly habits that hold them back from reaching their potential. This can be seen in surgery. To complete the golfing analogy (and apologies to non-golfers): once a golfer has a reasonable swing and knows what he/she is doing, the single thing that will define how good he/she gets is how often they play.
Modern professional sportsmen are assessed for their technique using technology and we are starting to see this level of scrutiny in robotic training. Anyone who has used the Mimic technology in the Da Vinci robotic training, will recognise that it looks at several aspects of surgical technique, including economies of movement. In my own experience as an early trainee in open or endoscopic surgery I was rarely told how to hold an instrument properly or indeed about ergonomics and economies of movement. The focus was usually on the operative field, where to cut etc.
In professional sports much thought and investment has gone into creating the optimum environment to initially assess individuals for natural ability, then supporting and nurturing their talent, strengthening them both mentally and physically so that their “investment” is enabled to perform in the toughest situations as well as having longevity. Should we not aspire to do the same for our surgical trainees?
Justin Collins is a Consultant Urologist at Ashford and St Peters NHS Foundation Trust, UK and is a regular trainer on the faculty at IRCAD, Strasbourg, France. @4urology
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The other day we were listening to a podcast of a surgical technique; sadly, it sounded like a report from the BBC’s war correspondent in Afghanistan. The static was considerable and the recording of poor quality, as if transmitted by radiophone from a remote part of the world.
In keeping with our pledge to improve the quality of the BJUI, we present here a simple method of recording and submitting podcasts of the highest quality from your home or office. The results are obvious on bjui.org, where you can listen to a 60-second podcast on successful podcasting, in the BJUI Tube section. We encourage authors who have had their papers accepted to try this simple trick. We look forward to receiving your podcasts, which may enhance your articles in the right circumstances.
If you use an iPhone you should select the preinstalled ‘Voice Memo’ app. Similar apps are available for Android and other systems.
Simply tap ‘record’ when you are ready and start talking. Remember to breathe normally and speak in an even tone.
Once you are happy with your recording, simply use the share button to submit the file to us using our editorial office email address: [email protected]
In this issue, the Article of the Month is by Cooperberg et al. who present an analysis of the lifetime cost-utility of treatments for localised prostate cancer. This is a timely and controversial paper with an accompanying editorial from Pickard and Vale, who have been involved in a number of Health Technology Assessment. Cost-effectiveness ratios are now as important as clinical effectiveness although it does not necessarily mean that cheaper is always better. You can also enjoy a YouTube video provided by the authors to accompany their article in the BJUI Tube section of our website. To promote immediacy, we request you to add your comments to Blogs@BJUI. These will eventually replace the current section entitled Letter to the Editor. The debate needs to be topical and timely and not a year on when hardly anyone can remember what the original fuss was all about.
Prokar Dasgupta
Editor-in-Chief
Matthew Bultitude
Associate Editor, Web
Disclaimer: The BJUI does not support any particular smart phone. That choice is entirely up to our readers. Who knows, you may even decide not to have one, hence here is the paper version of our simple trick.
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Every year in February, 250 or so urologists make the pilgrimage to the Dallas airport to take the Urology Certifying Exam (a.k.a. the Oral Boards). This ranks as one of the strangest events in my life. I felt it appropriate to share my experience.
My trip to Dallas begins with a very sincere “good luck on your test daddy” from my 5-year old daughter. This makes me feel great, until I realize I am less than 24 hours from actually taking the exam. My stress level now starts to rise. As I board the plane in Portland, ME, I see one of my patients. I am pretty sure that I operated on her, but since my brain is crammed full of (now in hindsight) useless information, I cannot remember any details about her. I avoid all eye contact and quickly take my seat. By some miracle, I have the exit row all to myself. Is this a good omen? I feel slightly better until my second flight is delayed on the tarmac for an hour. Nervousness ensues.
I check into the hotel, which is conveniently located at the airport. My room isn’t ready yet, so I wander into the lobby, which is filled with other nervous urologists who are waiting for their rooms. They are all quizzing each other on case scenarios. This doesn’t help my anxiety, so I flee the area. Things become very “real” at registration where all of the other panicky urologists are crammed into a small ballroom. This exam is actually going to happen. I cannot back out now. To make myself feel better, I mock those wearing suits and ties. Who are they trying to impress? I am much cooler than them. Unfortunately, no one passes the boards for being cool. Maybe I should have put on a tie.
It is now t-minus 1 hour to exam time. My brain goes totally blank. I am convinced I have forgotten all of urology. I wonder if my hospital will hire me as a scrub tech. My stress level is now off the charts. I take my first exam – only took 45 minutes. Is this good or bad? I am convinced that I failed, but take solace in the fact that everyone else feels the same way. We are sequestered after the exam for 2 hours. There is nothing else to do, so we all end up talking about the exam. This doesn’t help my anxiety. For the rest of the day, I think about things I should have said during the exam. This again convinces me that I have failed.
As I walk down the long corridor (nicknamed the Green Mile by the staff) to my exam on the second day, all of the examiners are standing in the hallway with half smiles on their faces. What does this mean? Unfortunately, day #2 does not go better than day #1. I now realize why they are all smiling. I am now thoroughly convinced that I have failed. I wonder what I will do when I lose my job. I will need to modify my CV to apply for the scrub tech job. Not sure what else I am qualified to do.
Twenty-four hours later I am slowly relaxing. I try to put things in perspective. The numbers (90% pass rate) tell me that I probably haven’t failed. I am thankful for the colleagues that I saw this past weekend and for new connections that were made. Seeing all of them and sharing this experience confirms why I love urology and can’t see myself doing anything else. We are all blessed to be able to take care of patients and improve their lives. I am looking forward to returning to work tomorrow to get back to being a doctor. And I can’t wait to see my daughter and tell her that daddy did his best.
Matthew Hayn is an attending urologist at Maine Medical Center in Portland, ME and an Assistant Clinical Professor of Urology at Tufts University School of Medicine. His views are his own. @matthayn
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Governments of all nations struggle to work out how best to use the limited resources available for health care. One key area of uncertainty is long term conditions with multiple therapeutic options including no active treatment, where relative merits of different treatments are unclear and there is associated unexplained variation in use of often expensive interventions such as surgery. The management of localised prostate cancer typifies this situation. The problem is how to decide the relative worth of options especially as this judgement might differ between patients, clinicians, providers and funders. The best way is to perform well designed randomised trials between competing interventions with sufficient follow-up to identify any differences. For localised prostate cancer the ProTect trial is due to report in 2014. In the meantime, health care agencies commission Health Technology Assessments (HTA) to comparatively value interventions usually on the basis of the monetary cost of the added benefit they give in terms of better outcomes. This is commonly measured as the extra cost of each additional quality-adjusted life year (QALY) they give. The well laid out paper by Cooperberg et al. certainly adds to previous similar work that is available on relevant health agency websites (HTA 2003, CADTH 2011, HTA 2011, HTA 2012), but was interestingly funded by an industrial stakeholder, Intuitive Surgical. Given its perspective focusing predominantly on Medicare tariffs, it is perhaps most relevant to the US Government who pays these rates, but careful reading by all will at the very least give a flavour of the use of predictive statistical and economic modelling of the possible benefits to patients, and costs to funders of the treatments advised by clinicians.
It is important to highlight that the methods of meta-analysis of the existing literature used by Cooperberg et al. are unclear – this makes it hard to critique whether the best data have been used in the model. Furthermore, the data analyses are unusual. A more typical presentation would have been to explore the likelihood that each treatment would be considered cost-effective. The method used does not really illustrate whether the conclusion should be that there are no differences between treatments or whether there is insufficient evidence to determine whether there are differences. Furthermore, although baseline characteristics of patients included in the meta-analysis are not given it is likely that some would differ between men undergoing surgery or radiotherapy leading to bias in outcome. The linear Markov model used is also perhaps an inadequate reflection of reality since it does not appear to calculate QALYs for repeated transit through further cancer treatment/remission/recurrence states and between incontinent/continent and sexual dysfunction/no sexual dysfunction states which men would value specifically and independently. In terms of costs the have included costs of patient recovery time. Arguably recovery should be captured within the QALY measure and to include it again under costs might be an element of double counting. In addition they showed that the results were sensitive to certain assumptions that may be questioned such as the four year shorter time to metastasis after biochemical recurrence for radiotherapy.
Cooperberg et al. have certainly provided a useful example of how different treatments supervised by clinicians may be valued by those that pay the bills. A parting thought is if only clinicians of differing specialties could collaborate on large definitive RCTs we would not need to rely on predictive models based on imperfect data.
Robert Pickard is a Professor of Urology at the Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK. email: [email protected]
Luke Vale is Health Foundation Chair in Health Economics at the Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK. email: [email protected]
“To err is human, to cover up is unforgivable, to fail to learn is inexcusable”
Sir Liam Donaldson, Former Chief Medical Officer
As a specialist registrar, I recall operating on a large renal tumour along with my mentor Omer Karim (who is now my colleague). As the mobilization was difficult due to neovascularization, he took over and just as the kidney was about to be delivered out, the adrenal vein was avulsed and there was a gush of blood. A Satinsky clamp was placed and to my surprise, Omer asked me to come over and repair the tear, which was successfully done. I remember his wise words even today “Anyone can remove this kidney, what you need to learn is to fix the complications!”
The traditional apprenticeship model of training that exists even today involves the Boss taking over the case whenever there is a complication. This leads to a teaching model wherein the trainee fails to learn on ‘how to get out of the complication’. Indeed, a very wise piece of advice for a young surgeon in training is to work under a ‘not so good’ surgeon for a period of time, as you will then be exposed to many complications (some not mentioned in the books!), learn how to deal with them and try to avoid repeating those same mistakes. The very concept of learning from others’ errors goes into the heart of the very popular meeting held regularly by the Southern Laparoscopic Urology Group (SLUG). The group comprising of highly experienced laparoscopic urologists present their unusual complications and how they were dealt with and what others can learn from that particular complication.
Two recent blogs on bjui.org emphasize the importance of surgical simulation, especially training in the era of EWTD. However, most simulation exercises concentrate on how to perform a proper operation avoiding any errors. Although, this aspect is extremely important, less emphasis has been devoted to developing simulation modules on intra-operative complications and how to deal with them. This is where the concept of Error Training is fast becoming the buzzword among the education psychologists. A well-written article by DaRosa and Pugh on this interesting concept is well worth a read. The authors explore the reasons for the lack of integration of this important aspect into surgical training. There are only a few studies that have looked into the impact of error training on acquisition of skills. A study by Roger et al on the role for error training on surgical technical skill instruction and evaluation found that instruction about common errors, when combined with instruction about the correct performance enhanced the acquisition of the particular surgical skill. Their study suggested a role for the use of errors in surgical technical skill instruction. Similarly, in a study by Brannick et al, who evaluated an error-reduction training program for surgical residents, showed a reduction in the error during surgery. Natalie Bourgeois in her thesis on error training draws the attention for the need to develop error management training (EMT) as opposed to error avoidant training (EAT). EMT is a teaching method that promotes ‘trainee learning’ enabling them to make errors during their simulation exercises. EAT, however, dictates the trainee not to deviate from the prescribed steps and follow the instructions accurately avoiding any errors. Research has now shown that tasks, which involve making deliberate errors during the learning process, may decrease performance during that particular training session, but increases the performance in the ‘transfer environment’. Keith and Frese have shown that errors lead to more exploration during training, increased metacognition, increased emotional control and increased intrinsic motivation, which benefits transfer performance. Thus, there is emerging but limited scientific evidence about integrating error training into the surgical curriculum.
In the future, laparoscopic and robotic simulators should incorporate modules that would expose the trainee to scenarios of intra-operative complications and assess their ability to deal with it. Studies to validate the effectiveness of these modules would be difficult in a patient setting due to obvious ethical considerations. But there is no doubt that this kind of exposure would definitely prepare the trainee’s mind to manage any eventuality. I would end with the quote “First do no Harm. But if you do, have the knowledge to heal the harm”.
Amrith Rao is a Consultant Urological Surgeon at Wexham Park Hospital, Wexham, UK. @urorao
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