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The impact factor may be flawed but important

It has been a nice summer for the BJUI. Our impact factor has gone up to 4.387, the highest ever in the history of the Journal and we made the Altmetrics Top 50 for the first time ever with a score of 1166, Nature being the numero uno. I wanted to thank our editorial team, readers, authors and reviewers for their dedication and commitment, which made this possible.

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The question is how did we do this? For a journal without official society guidelines, it was not easy. So we had to focus on original articles rather than reviews and guidelines. There were three essential steps:

  1. Publishing the highest quality, citable papers irrespective of geographical location [1] – for example, this month we have highlighted the importance of personalised medicine in BPH from Taiwan [2], whereby the authors show that an endothelial nitric oxide synthase (eNOS) genetic polymorphism has a negative impact on response to α-blockers.
  2. Reducing the number of papers published while selecting clinically relevant, large prospective studies and trials – an example of this is the LAParoscopic Prostatectomy Robot Open (LAPPRO) study from Sweden [3], showing that even in very-low-risk prostate cancer, upgrading after radical prostatectomy occurs in over a third of patients and that the functional outcomes are not as good as expected.
  3. Amplifying our content through social media – this means that we believe in interaction with a wider audience, immediacy of response, and are not afraid of the occasional controversy and debate. An example is the comment on clostridium histolyticum collagenase followed by a brief editorial on what may increasingly be seen as an important treatment option for Peyronie’s disease [4].

Many consider the impact factor of a journal as a ‘gaming’ exercise, flawed by its very nature. I was very pleased to receive a WhatsApp from one of my colleagues saying how pleased he was that at the BJUI we have always played ‘with a straight bat’. An important consideration is that Universities often count original papers in the best journals for measuring academic output, which in turn drives income from various sources. In the UK this is given the term ‘returnable’ when considered within a system called the Research Excellence Framework. I am really pleased that the BJUI is now ‘returnable’ with its new impact factor and is seen as a serious player within a highly demanding system. I am aware that this also true for other international institutions, which is in keeping with our global presence as a journal without boundaries.

Prokar Dasgupta @prokarurol
Editor-in-Chief, BJUI 

References

1 Dasgupta P. Quality has no boundaries. BJU Int 2014; 113: 1

 

 

 

4 Poullis C, Shabbir M, Eardley I, Mulhall J, Minhas S. Clostridium histolyticum collagenase Is this revolutionary medical treatment for Peyronies disease? BJU Int 2016; 118: 18692

 

Urology in Zomba, Malawi. Reflecting on surgical care in a Resource-Limited country

Rajiv SingalAt the recent AUA meeting in San Diego as at all of our major meetings, a tremendous amount of data was presented and technology displayed to advance our specialty.   Walking through exhibit hall one sees an expensive bauble at every turn. The advancement of urology over the last 50 years has been remarkable.   We have a lot to be proud of.  I think we have the most interesting, exciting specially in all of medicine.  Urologist are generally technophiles and have always loved to push surgical procedures to new heights.   From robotics, lasers and endourology to advancing the molecular understanding of disease, urologists have always aimed to drive the bus.

As many of you know, I am on a short trip to Malawi Africa. I have written about this elsewhere. I am here on one hand as a board member for Dignitas International.  On the surgical side it is not a mission under the guise of anyone but rather my own personal attempt to understand what urology and surgery in a resource poor country might look like. I have been here in Zomba, Malawi and working at Zomba Central Hospital, which is one of four central hospitals in the country.

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A goal has been to try and assess what the basic urological needs might be in this part of the world and see how I could help bridge the gap, whether it would be with equipment, external manpower or ultimately by improving training and leaving something sustainable. I optimistically set out, confident in my abilities to eventually network and bring colleagues together and establish over time a reasonable urology program that at least resembles something familiar. I have the COSECSA guidelines on what it takes to establish a training program at my side. Perhaps nothing illustrates what a daunting task this will be like my days in surgery this week.

To start with, a typical OR at ZCH requires some refocusing compared to what I am used to. My DaVinci robot is nowhere to be seen

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I made ward rounds with my clinical officer yesterday and lined up several TUR type cases to try and do, with men bleeding from bladder tumours (all invariably Bilharzial disease) as well as men in retention. Some have had catheters for months, even years.

First there is the set up. No discussion about lasers and lifts or any other such fun. We don’t even have the 3L irrigation bags. For my irrigation set up, with a little water and some chlorine pucks we are ready to go.

 

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My first patient was a TURBT.  A very large, incompletely resected lesion, actively bleeding.  I clearly left disease behind but perhaps he won’t bleed for a while.  The tissue will not be sent to pathology.  Patients need to pay 16,000 MWK for it. The typical pay for many is 20,000-30000/month and 1$USD=700 MWK.  Managing him from any even rudimentary oncological perspective is a non-starter.

The second patient also had a bladder tumour.  It was palpable as a mass to just under the skin.  Again, the goal was to stop some bleeding, at least for a few weeks.    He almost certainly has metastatic disease but I have no way to image and know for sure. I did order a chest xray to look for obvious pulmonary nodules.  He will eventually just quietly die.

Before I could start a third case I found myself in the gynecology OR 2 weeks after a hysterectomy post-delivery for bleeding.  Following an injury, the left ureter was leaking.  I attempted the repair as best as I could with no proper light, no electrocautery no retractors and no ability to stent my freshly re-implanted ureter.   All of this on an HIV+ve new mother.   I hope it heals open.  I am not sure if it will.   I have come to understand that ureteral injuries are a not uncommon consequence of obstetrical care in Malawi.

My third patient had a TURP which was fairly straightforward.   He should hopefully void assuming reasonable residual bladder function.  He has had a catheter in place for months.

At least we did do some work Thursday.  On Tuesday my four patient list turned into one as my anesthetist did not attend.  Before surgical care can be improved, the critical shortage of anesthesia care has to also be addressed. I also wrote about that earlier.

I did bring a surgery checklist to ZCH on Tuesday.

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And Thursday in follow up, I gave a talk to the surgical team about checklists and so that is certainly good.

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They keep asking me to see men in the clinic with catheters.  With the inefficiencies of late start times, anesthesia shortages and only a week to go, most will get left behind.  It is really a depressing thought.

My OR team though is there to help and keen to learn.

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Daniel, Rex (T Rex) and Maryeuster

As I reflect on my experience in the operating room during week one I am struck by how discordant what I saw in San Diego was from the realities still faced in much of the world.  Basic endoscopic equipment does not exist. Serendipitously, a retired colleague of mine did bring some basic equipment a few months ago and this one set, washed and then resterilized (in a pail of chlorinated water) is all that we have.   I am still not clear what happens when the loops wear out.

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I do question when we pull millions of dollars and much intellectual capital into improving technology and chasing robots as to what are we really doing to benefit the care of our urological patients on a global scale. Do we have some obligation as champions of mens’ health and urologic care more broadly, to play a part?  I do wonder whether some of our intellectual energy and financial resources could be better spent simply bringing parts of this world even into the 1970s. If this was valued as worthy of academic support and promotion the way oncology, endourology and everything else is in our specialty is, then some of the bright young minds in our field might move this along further.  Whether we do a robot prostatectomy retroperitoneally or intraperitoneally, debate about a Rocco stitch or tweak this or do that, these changes are often incremental at best. Supine versus prone PCNL?  Who cares.  Other parts of the world I think deserve some of our high-level expertise to meet their complex challenges. I would invite the urological community to try and collectively address this problem. Should we keep pouring all of our massive resources only to steady, incremental benefit?  Clearly we always must advance the body of knowledge and the state of the art.  However, is there a role for reserving some resource and energy to advocate for simpler things that could affect a change on the order of several magnitudes?  Some of the easier things we might do is to at least act as advocates and lead some process change whether it be a surgical checklist, counting instruments and sutures pre and post operatively and ensure better preoperative screening and post-operative care.   Updating equipment and building surgical expertise necessarily follows.

Laser TURP?  Plasma button?  Urolift?   The men in Malawi and much of Africa would be happy just to get rid of their catheters.

We often joke about our ‘first world problems’.  It’s time to get serious.

Let’s do better.

Dr Rajiv Singal is a Urologist at Michael Garron Hospital and an Assistant Professor in the Department of Surgery at the University of Toronto

Follow him on Twitter at @DrRKSingal

To read more about Dr Singal’s experience in Malawi follow this link https://www.rajivsingal.com/blogCategories/view/malawi-june-2016/

 

 

 

Consensus guidelines for reporting prostate cancer Gleason Grade

Prokar_v2The International Society of Urologic Pathology (ISUP) has endorsed modifications to the Gleason grading system for prostate cancer [1]. Five Grade Groups have been defined with tumors of Grade Group 1 being the least aggressive and having the lowest likelihood of progression, whereas those of Grade Group 5 have the highest likelihood of early systemic spread. This new system provides clearer guidance for pathologists to classify cancers on the basis of gland morphology, and it aligns better with contemporary management including active surveillance.

The editors of the major uro-oncology journals believe this is a helpful change for clinicians, researchers, and patients alike and are eager to help this system establish itself in the reporting of pathologic grade. To that end we are now asking investigators to use the new system in the reporting of prostate cancers in their publications. As the Grade Groups correspond to current Gleason scores 6, 3+4, 4+3, 8, 9 and 10, the translation should be relatively simple. Over the next one to two years, side-by-side reporting of old and new histology may temporarily be necessary. We do recognize that some institutional and national databases are not set up to make the translation and exceptions will be granted in these cases.

Anthony Zietman, Editor-in-Chief*, Joseph Smith, EditorEric Klein , Editor-in-Chief, Michael Droller, Editor-in-Chief§Prokar Dasgupta, Editor-in-Chief¶ and James Catto, Editor-in-Chief**

 

*International Journal of Radiation Oncology Biology Physics, Journal of Urology, Urology, §Urologic OncologyBJUI and **European Urology

Reference

 

West Coast Urology: Highlights from the AUA 2016 in San Diego… Part 2

By Ben Challacombe (@benchallacombe) and Jonathan Makanjuola (@jonmakurology)

 

The AUA meeting was starting to hot up with the anticipation of the Crossfire sessions, PSA screening and the MET debate that appeared to rumble on.  We attended the MUSIC (Michigan Urological Surgery Improvement Collaborative) session. It is a fantastic physician led program including >200 urologists, which aims to improve the quality of care for men with urological diseases. It is a forum for urologists across Michigan, USA to come together to collect clinical data, share best practices and implement evidence based quality improvement activities. One of their projects is crowd reviewing of RALP by international experts for quality of the nerve spare in order to improve surgical outcomes.

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The MET debate continues to cause controversy. In the UK there has been almost uniform abandonment of the use of tamsulosin for ureteric stones following The Lancet SUSPEND RCT.

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The MET crossfire debate was eagerly awaited. The debate was led by James N’Dow (@NDowJames) arguing against and Philipp Dahm (@EBMUrology) in favour of MET. Many have criticised the SUSPEND paper for lack of CT confirmation of stone passage. Dr Matlaga (@BrianMatlaga) stated that comparing previous studies of MET to SUSPEND is like comparing apples to oranges due to different outcome measures. He recommended urologists continue MET until more data is published. More conflicting statements were made suggesting that MET is effective in all patients especially for large stones in the ureter. The AUA guidelines update was released and stated that MET can be offered for distal ureteric stones less than 10mm.

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In a packed Endourology video session there were many high quality video presentations. One such video was a demonstration of the robotic management for a missed JJ ureteric stent. Khurshid Ghani (@peepeeDoctor) presented a video demonstrating the pop-corning and pop-dusting technique with a 100w laser machine.

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One of the highlights of the Sunday was the panel discussion plenary session, Screening for Prostate Cancer: Past, Present and Future. In a packed auditorium Stacy Loeb (@LoebStacy), gave an excellent overview of PSA screening with present techniques including phi, 4K and targeted biopsies. Freddie Hamdy looked into the crystal ball and gave a talk on future directions of PSA testing and three important research questions that still needed to be answered. Dr. Catalona presented the data on PSA screening and the impact of the PLCO trial. He argued that due to inaccurate reporting, national organisations should restore PSA screening as he felt it saved lives.

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There was a twitter competition for residents and fellows requiring participants to  tweet an answer to a previously tweeted question including the hashtag #scopesmart and #aua16. The prize was Apple Watch. Some of the questions asked included; who performed the 1st fURS? And what is the depth of penetration of the Holmium laser?

UK trainees picked up the prizes on the first two days.

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The British Association of Urological Surgeons (BAUS) / BJU International (BJUI) / Urological Society of Australia and New Zealand (USANZ) session was a real highlight of day three of the AUA meeting. There were high quality talks from opinion leaders in their sub specialities. Freddie Hamdy from Oxford University outlined early thoughts from the protecT study and the likely direction of travel for management of clinically localised prostate cancer. Prof Emberton (@EmbertonMark) summarised the current evidence for the role of MRI in prostate cancer diagnosis including his thoughts on the on going PROMIS trial. Hashim Ahmed was asked if HIFU was ready for the primetime and bought us up to speed with the latest evidence.

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The eagerly awaited RCT comparing open prostatectomy vs RALP by the Brisbane group was summarised with regards to study design and inclusion criteria. It is due for publication on the 18th May 2016 so there was a restriction of presenting results.  Dr Coughlin left the audience wanting more despite Prof. Dasgupta’s best effort to get a sneak preview of the results!  We learnt from BAUS president Mark Speakman (@Parabolics) about the UK effort to improve the quality of national outcomes database for a number of index urological procedures.

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Oliver Wiseman (@OJWiseman) gave us a flavour of outcomes from the BAUS national PCNL database and how they are trying drive up standards to improve patient care. A paediatric surgery update was given by Dr Gundeti. The outcomes of another trial comparing open vs laparoscopic vs RALP was presented. There was no difference in outcomes between the treatment modalities but Prof. Fydenburg summarised by saying that the surgeon was more important determinant of outcome than the tool. Stacy Loeb closed the meeting with an excellent overview of the use of twitter in Urology, followed by a drinks reception.

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It was not all about stones and robots. The results of the Refractory Overactive Bladder: Sacral NEuromodulation vs. BoTulinum Toxin Assessment (ROSETTA) trial results were presented. Botox came out on top against neuromodulation in urgency urinary incontinence episodes over 6 months, as well as other lower urinary tract symptoms.

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The late breaking abstract session presented by Stacy Loeb highlighted a paper suggesting a 56% reduction in high-grade prostate cancer for men on long term testosterone. This was a controversial abstract and generated a lot of discussion on social media.

 

 

 

 

 

 

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It has been an excellent meeting in San Diego and we caught up with old and met new friends. It was nice to meet urologists from across the globe with differing priorities and pressures. There was a good British, Irish and Australian contingent flying the flag for their respective countries. It was another record-breaking year for the #AUA16 on twitter. It surpassed the stats for #AUA15 with over 30M impressions, 16,659 tweets 2,377 participants. See you all in Boston for AUA 2017.

 

West Coast Urology : Highlights from the AUA 2016 in San Diego… Part 1

By Ben Challacombe (@benchallacombe) and Jonathan Makanjuola (@jonmakurology)

 

The 2016 AUA returned to the beautiful city of San Diego set on the shores of the Pacific in an excellent conference centre located in the centre of the town adjacent to the Gaslamp district. For a change the wifi was excellent and allowed enhanced levels of social media interaction and urological discussion. Opening these interactions were 2 key sessions which provoked much debate. Firstly the announcement that after over 10 years of trying the FDA has approved HIFU treatment although it seemed to get there through a slightly “de novo” pathway. Apparently the FDA approved it as an ablation tools but not for prostate cancer.

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Although not directly approved for use in prostate cancer, that is exactly what it is going to be used for. A packed house saw a debate with evidence from both sides. Dr Nathan Lawrentschuk promoted the 4 Ds of HIFU. His key point was that 56/101 had a post treatment biopsy of which 51 where biopsy positive!

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The second big session focussed on the AUA/SAR consensus statement  document on prostate cancer diagnostics. This recommended a “High Quality” MRI should be strongly considered if patient has a rising PSA with a previous negative biopsy, has persistent clinical suspicion for prostate cancer or is undergoing a repeat biopsy. There was no mention of MRI for all at the pre-biopsy stage which many had hoped for and only 2 lines on trans-perineal biopsy as an option. This is of course related to health resources and the outpatient office-based nature of most USA urologists.

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A welcome innovation was the Crossfire Sessions which pitted 2 well known advocates of one treatment against 2 with the opposite views. It was hardly debating of the Oxbridge variety but none the less did provoke some useful discussions. Topics included radical prostatectomy vs radiotherapy, endoscopic vs nephro-ureterectomy management of upper tract TCC, and enucleation at partial nephrectomy vs formal resection. Standing room only at the back of the halls but no real audience interaction or voting which was a shame. 

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The session which really woke everyone up was Rene Sotalo’s wonderful complication horror show. Bleeding, bleeding and more bleeding in a variety of ways. How would you handle this he asked? Pray I thought! But this and similar sessions clearly show the benefits of recording all cases and reviewing these DVDs if something goes wrong. The cause of some complications were only identified by review of the intra-operative tapes. Some clinical titbits learn’t included  using only a horizontal incision for the camera port at RARP to reduce hernias and turning off pneumocompression stockings if there is a major venous injury to prevent excessive venous bleeding.

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From a SoME perspective there was both good and bad. One poster showed that 40% of graduating US residents had publicly accessible unprofessional content on social media. Food for thought at the consultant interview no doubt, but on the other side SoMe ranks third in the acquisition of urological knowledge (and climbing…). One hack produced this tweeting guideline for all to reflect on.

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Prof Prokar Dasgupta had the honour of presenting the widely anticipated session on emerging robotic technology . At last there appears to be some real competition to Intuitive’s dominance on the way. There are at least 3 credible robotic systems on the way. He finished with an intriguing slide on Dr Google being the most powerful doctor in the world!

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Despite Europe and Asia moving towards the use of PMSA PET , the USA is not moving in this direction due to reimbursement issues if the PMSA molecule.

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There was a lot of interest in a packed auditorium to see live surgery for a single use disposable fURS “Lithovue” with some reporting superior vision , optics and deflection.

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There were some sceptics amongst the stone community with the environmental impact and cost effectiveness a concern.

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With the popular Gaslamp district a stones throw away many delegates went after the conference for a meal and drinks. The local baseball team San Diego Padres was a popular destination with may watching baseball for the 1st time whist others had gone for a run along the harbour and even caught a sighting of some seals!

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May Editorial: The Current Hot Topics in Functional Urology

BJUI-May-2015-cover_smallFor some time, the challenge represented by managing the overactive bladder (OAB) has been dominant in functional urology research. The introduction of new therapies has galvanised the area, with mirabegron showing strong promise for many patients as a monotherapy. In addition, the potential for combined therapy using mirabegron with established antimuscarinics has recently been reported for urgency urinary incontinence [1]. Now that the place of onabotulinum-A injections in refractory cases is firmly established, management options have clearly taken a step forward in recent years. However, there remain people for whom even the more comprehensive current options are inadequate or intolerable. The need for basic science research remains a priority, in the hope of translation into clinical options. In this month’s BJUI, Aizawa et al. [2] report responses in an animal model to an inhibitor of fatty acid amide hydrolase, showing how exploiting the endocannabinoid pathway might be a translational focus for entirely new approaches in OAB. They consider an issue that is very important in developing clinical options, which is that the systems regulating bladder function are also fundamental in other organs, such as the CNS. As the compound they studied does not cross the blood–brain barrier, the potential generation of CNS adverse effects is reduced, which would be important for its potential as a new therapy.

OAB is a symptom syndrome based on storage-type LUTS [3]. Increasingly the field of functional urology is recognising the large number of people who present with voiding and post-micturition LUTS yet do not have BOO. Currently, there are no satisfactory treatment options for affected people and the symptoms can have considerable impact. Frustratingly, current diagnostic methods rely on urodynamic testing to establish whether the presence of detrusor underactivity explains voiding LUTS in an individual patient. Recently, the profession has established a move towards using symptoms to categorise the clinical need in patients [4]. Accordingly, the International Continence Society has established a working group to generate terminology for underactive bladder (UAB), which will report this year, including a symptom-based definition. A symptomatic diagnosis would be very helpful to enable therapy development to proceed without the need for urodynamic testing. Also, in this month’s BJUI, Kajbafzadeh et al. [5] report a clinical trial in UAB using transcutaneous interferential electrical stimulation in children. The treatment was delivered in the context of the rather laborious process currently required for managing this difficult problem, namely diet and fluid manipulation, scheduled voiding, toilet training, and pelvic floor and abdominal muscles relaxation training. The electrical stimulation was demonstrably beneficial, and included responses for the highly troublesome symptom of nocturnal enuresis. The comparatively straightforward nature of this therapeutic approach potentially makes it a valuable tool for dealing with a notoriously difficult problem.

Marcus J. Drake, Senior Lecturer
School of Clinical Sciences, University of Bristol, Bristol, UK

 

References

 

 

Trainee Jobs: Pot Luck or Picking Teams in Gym Class?


Fardod O Kelly FIIt is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is most adaptable to change…” (C. Darwin; ca.1857)

 

On Friday 18th March 2016, U.S. medical school students and graduates participated in the National Resident Matching Program (NRMP) with 42,370 registered applicants attempting to match into 30,750 PGY-1 and PGY-2 positions. This was preceded the same day by the Irish Higher Surgical Training (HST) Urology interview held in the RCSI in Dublin for a smaller number, but just as eager candidates endeavoring to secure their future in their own field. Thousands of candidates, in the pursuit of a career that they have so far, only dreamed about. Thousands of candidates, all with one thing in common: Not one of them knew where they were going to end up if they were somehow successful.

The British Medical Journal (BMJ) on their careers website explaining to core trainees how they might perform better in interviews, outline a roadmap of 12 key components from extra courses to leadership skills, but not once mention visiting the various deanery sites in order to assess whether the place represents a good fit for your own ambitions, learning objectives and style of management.

Prof. Adrian Joyce provided an editorial on the BJUI blogs site in 2013, highlighting the need to devise a better means of training “The UK conundrum shared with many other healthcare systems is how to provide effective training within the demands of service commitment and the EWTD… 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…”

Therefore, we have two health systems on these islands, with the UK National Health Service (NHS), and the Irish Health Service Executive (HSE), both acknowledging the mandatory requirements of the European Working Time Directive (EWTD) to shorten working hours, and the need to fulfill service commitments within the health sector, and the need to allow for postgraduate training to ensure a steady workforce into the future, but also to balance the requirements of the Specialist Advisory Committee (SAC) and the Joint Commission on Surgical Training (JCST) as well as the Royal Colleges to ensure that training is to a satisfactory level. In order to achieve this, hospitals and trusts are allocated a number of trainees who have gone through the above selection process and have accumulated years of experience, qualifications and debts to fill a very complex role within a volatile system.

However, when did a “one-size-fits-all” approach become acceptable to trainers and trainees who need to work alongside each other within these environments filled with stress, litigation, and variable relationships with managerial types within the system? We all see patients, break bad news, manage expectations, provide treatment options, and above all know that each patient is different. They handle information, make choices, adhere and respond to treatment in a myriad of ways depending on a huge number of variables and confounders (not to mention the relatives). We have developed nomograms to try to communicate outcomes and risks to patients for disease like prostate cancer, such that entering the keywords “prostate cancer” and “nomogram” into PubMed will in excess of 900 hits. So, the hospital environment is complicated, and patients are complicated, but what about the lowly figure of the surgical trainee who has successfully demonstrated the aptitude and the background to progress to higher training?

Sullivan et al. demonstrated in 2013 that despite the reduction in trainee hours in the USA, resident attitudes, and program location were most frequently associated with voluntary attrition, with “the personal cost of training” (p<0.001; HR2.89) playing a major role in leaving a program. Bell et al. elegantly demonstrated in 2012 that despite the abundance of information on particular candidates, many of the fundamental qualities that are associated with success for the surgical trainee cannot be identified by review of the applicants’ grades, scores, letters of recommendation, personal statement, or even from the interview process. Therefor only by meeting trainees, in order to identify unique behavioral, motivational and personal talents that applicants bring to the program, allowed the authors to determine applicants who were a good match for the structure and culture of that particular program.

The standard interview process, whilst objective, does not allow trainers and institutions the luxury of getting a feel for the candidate, and applying instinct and acumen as to whether and how the trainee will fit into the overall scheme of things. The exact statement can be played in reverse.

All the innate instinctual abilities and skills that we prize in being able to quickly assess measure patients have been denied to us in choosing some of our closest junior colleagues on whom we rely on so heavily.

From a trainee urologist’s perspective, and one that would apply to nearly any other profession, one of the greatest predictors of your happiness and productivity at work is your relationship with your senior colleague. This is therefore intuitively important when considering new post, on order to know how you’ll get along with your new boss. This can be hard to assess in an interview when one is attempting to masquerade an unbridled sympathetic response and trying to demonstrate one’s one appointability, but it’s crucial to evaluate the panel as well. What sorts of questions should you ask to understand their management style? Should one try to talk with other people who have previously rotated through the post? Are there red flags you should watch out for? Will it even matter?

There are a number of healthy checklists in the business world which lend themselves to translation in surgery:

  • Trust your instincts: Ask yourself whether this is the training post you want and the consultant you want to work for. Did you get a good feeling from the person? Is she someone you can imagine going to with problems? Or someone you could have a difficult conversation with? This is especially important when the stakes are high
  • Do your homework: One of the greatest faux pas one can make is to incompletely prepare. You should try to gather as much information on the unit/post as possible including the history of the department, publishing record of the consultants, theatre logbooks from other trainees, inter-personal relationships, red flags. Google each consultant and check out the social media presence of the unit (#SoMe) as a proxy of their willingness to engage with social technology and communication
  • Meet your colleagues: Spend time with future colleagues in the unit independent of the interview. Take some time to chat to nursing and clerical staff as well as other trainees. More information can be acquired about a unit over a cup of coffee with future colleagues than any other approach

In this time of flux within health service systems, trust, collegiality and communication as key. Things that sound apt are not always what they seem. The quotation attributed above to Darwin, is often one that is misquoted, and although seems appropriate, there is no evidence that he ever made that statement. In the same way, trainees can no longer be seen to be but from the same cloth. Their own lives and careers are unpredictable and multi-faceted, and the answers and applications relied on at interview do not guarantee a good correlation coefficient when plotted on a graph belonging to a particular unit i.e. not a “good fit”. Perhaps it is time to trust our own instincts when appointing a trainee to a particular unit by taking the time to meet candidates and assessing – in addition to applications and CVs – how they might slot into a department – so that when it comes to tackling overcrowding, waiting lists, theatre slots, emergencies, call, research, audit, management and teaching, at least they can be met with the strongest team possible.

 

“…it’s better in fact to be guilty of manslaughter than of fraud about what is fair and just…”  (Plato, The Republic and Other Works)

 

Fardod O’Kelly is a Specialist Registrar in Urology at AMNCH, Tallaght, Dublin 24, Ireland. Twitter @FardodOKelly

 

April #UROJC: The Surgeon Scorecard – Merits of Publicly Reported Surgical Outcomes

The April 2016 International Urology Journal Club on Twitter (#urojc) hosted a discussion on our paper, “Comparing Publicly Reported Surgical Outcomes with Quality Measures from a Statewide Improvement Collaborative”. Published in JAMA Surgery on March 16, 2016, the paper was authored by Gregory Auffenberg MD, David Miller MD, Khurshid Ghani, Zaojun Ye, Apoorv Dhir, Yoquing Gao. I contributed as a member of MUSIC.

It was an honor to have the paper selected for a #urojc discussion, and the authors would like to thank JAMA Surgery for providing open access during the discussion period. This post serves as an overview, and the entire #urojc transcript is available for reading courtesy of Symplur

For those not familiar, the #urojc Twitter chat is a 48-hour asynchronous conversation amongst urologists around the world on Twitter on a selected journal paper, taking place on the first Sunday/Monday of every month.

 

The ProPublica Surgeon Scorecard

The subject of our research centered on the online U.S. surgeon ratings compiled for ProPublica’s Surgeon Scorecard. ProPublica is an investigative journalism organization that was given exclusive access to U.S. Medicare data for the years 2009 to 2013.

“Reporters Olga Pierce and Marshall Allen studied almost 75 million hospital visits billed to Medicare looking for eight common, elective surgeries. They then looked to see whether the same person returned to the hospital for what appeared to be complications from the surgery. Their full methodology is spelled out here.

 

The Michigan Urological Surgery Improvement Collective

Specifically, our research paper looked at ProPublica’s ratings for only one procedure – results on radical prostatectomy (RP) for prostate cancer – and correlation to reporting by MUSIC, the Michigan Urological Surgery Improvement Collaborative. MUSIC is a state-specific quality initiative in the U.S. in which I am a participating surgeon. Participation in MUSIC is voluntary, over 85 percent of urologists in the State of Michigan participate in the collaborative.

 

 

April #UROJC

As our paper states, the recent release of the Surgeon Scorecard accelerated debate around the merits of publicly reporting surgical outcomes. Surgical outcomes assessment is not a new concept, even dating back to 1860 as this tweet by @mattbultitude surfaced.


What does our community of urologists think about public reporting? Does greater transparency correlate with better outcomes? What are the benefits of a collaborative method like MUSIC? What methods are used in other parts of the world?

 

The #urojc discussion found that many urologists outside the U.S. were not familiar with the ProPublica ratings or debate. Some were not surprised that we did not find a correlation between our MUSIC outcomes data and the ProPublica data, thereby validating the need for quality outcomes data.

 

 

If the Surgeon Scorecard is flawed, what needs to be done to create an acceptable public reporting system?

 

Is public reporting of surgical outcomes taking place in Australia, UK, Canada & elsewhere?

 

 

How are ‘outliers’ identified by this study handled by MUSIC?

 

Do ratings lead to cherry-picking of patients?

 

According to New York cardiologist, Sandeep Jauhar, MD via Medscape, 63 percent of cardiac surgeons acknowledged accepting only relatively healthy patients for heart bypass surgery owing to report cards in New York State.

 

Moving Surgical Outcomes Forward 

On behalf of the authors of the paper and the entire MUSIC collaborative, I would like to thank our #urojc colleagues around the world for their thoughts, insights, criticisms and questions about the paper.

The ProPublica Surgeon Scorecard has generated significant and serious discussion in the U.S. about the challenges and merits of the public reporting of surgical outcomes. In an increasingly connected world, it’s difficult to imagine how this can remain simply an American debate.

Urologists by their very nature are leaders. Personally, I see this debate as yet another opportunity for us to develop and implement systems and strategies that reassure the public and advance patient care.

MUSIC JAMA Paper

 

Publons: Giving Credit For Peer Review

NL Blog PicPeer reviewing of journal articles may be one of the most unheralded and feel at times as the least rewarded of continuing medical activities we do. People give time, expertise and judgement to make articles of a higher scientific standard and are crucial to the nature of medical publishing. As an Associate Editor of the BJUI, I am aware of the significant contribution reviewers make. I also review myself for many journals. For me it is one of the best forms of learning we have available to us. This was made even more apparent at the recent peer-reviewing workshop just prior to the EAU in Munich, where reviewers were delighted to learn of the possibility of a verifiable metric of reviewing.

Most journals provide recognition of peer-review work by publishing lists of reviewers, often collating CME credits and points or even the ability to provide a letter of reference when asked.

Third-party collation and recognition of peer-review work has until recently been lacking. This means to ‘prove’ one has indeed reviewed for a journal we would have few options apart from possibly saved emails thanking us for our good work. Publons has many aims but chief is to do just that – provide a platform where there is authenticity and recognition for peer review.

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How to do it?

  1. Go to www.publons.com
  2. Register (free)
  3. Upload a photo, short biography and your academic affiliations (Figure 1 and 2)
  4. Enter in your editorial board positions (the Journals you have reviewed for will be added by Publons once verified – Figure 3)
  5. Add reviews

IMG_8980The final point of adding reviews has been made relatively easy – it is automated and quick.

The official emails you have received over the years (which of course you carefully filed away…) stating “thank you for your review of the journal article entitled … Manuscript number …‘ just need to be forward to [email protected]

This will then, within a few days, be placed into the system. You will get an email notification. The partner publishing organizations (e.g. Nature publishing group) have their logo which makes it look all the more official (Figure 3)

 

IMG_8981Now for those of us who have not kept all of the ‘thank you’ emails, a second way is to go to each journal you have reviewed for, log in to the reviewers dashboard. Take screenshots and send as a JPEG (be careful to include your name as part of screenshot for verification). This may take a small fiddle to cut and paste to a word document if you have multiple shots. You can then send as PDF or photo etc. Again email the attachment to [email protected]. The website has provided rules on the types of proof or verification they will accept but they are pretty open to suggestions if there is an issue.

The review records are collated (Figure 4) and then a chance to upload your review. This type of open access is only in its infancy and not mandatory.

 

IMG_8982To make it more interesting there are award merits, which are a nice touch. Each review gets you three merits. Prizes are awarded quarterly and displayed on your profile page (Figure 1). They are categorical or may be within your country or university. Remember in this environment everyone doing peer review is represented so you are up against engineers, theologians and the like in some categories. The opening of reviews with ‘extra merit points’ available, although noble, is unlikely at this stage to have uptake. The peer-review process is fragile enough and this may need to be reworked. Perhaps “open review” bonus merit points could be separated out as it seems unfair to penalise reviewers as most are single or double blinded in any case and will not wish to open. Publons goals of promoting discussion and interaction are fine but after having spent time doing the reviews and not getting remuneration, it is somewhat counterintuitive to want to take more of your valuable time on a review – but it may suit some (read more on history of Publons here)

In time it is likely that Publons will become the Pubmed for peer reviewers. Relationships will form with publishers and hopefully it may become a network for peer reviewers and a tool for handling editors. Overall a wonderful initiative and a great step to recognize and hopefully enhance peer review, which is a sacrifice many of us make – but for the good of medicine!

 

Nathan Lawrentschuk, University of Melbourne, Australia

@Lawrentschuk

 

The 4th BJUI Social Media Awards

As you may know, we alternate the occasion of the BJUI Social Media Awards between the annual congresses of the American Urological Association (AUA) and of the European Association of Urology (EAU). Our first awards ceremony took place at the AUA in San Diego in 2013, followed by the EAU in Stockholm, and a really fun evening at AUA in New Orleans last year. This year, we descended on Munich, Germany to join the 13,000 or so other delegates attending the EAU Annual Meeting and to enjoy all the wonderful Bavarian hospitality on offer. More about that in our blog posts from #eau16.

1.1On therefore to the Awards. These took place on Sunday 13th March 2016 in the roof garden bar of the beautiful Bayerischer Hof hotel. Over 70 of the most prominent uro-twitterati from all over the world turned up to enjoy the hospitality of the BJUI and to hear who would be recognised in the 2016 BJUI Social Media Awards. Individuals and organisations were recognised across 46 categories including the top gong, The BJUI Social Media Award 2016; awarded to an individual, organization, innovation or initiative that has made an outstanding contribution to social media in urology in the preceding year. The 2013 Award was won by the outstanding Urology Match portal, followed in 2014 by Dr Stacy Loeb for her exceptional individual contributions, and in 2015 by the #UroJC twitter-based journal club. This year our Awards Committee consisted of members of the BJUI Editorial Board – Declan Murphy, Prokar Dasgupta, Matt Bultitude, Stacy Loeb, Mike Leveridge, and Henry Woo, as well as BJUI Managing Editor Scott Millar whose team in London drive the content across our social platforms. The Committee reviewed a huge range of materials and activity before reaching their final conclusions. As befits the fast-moving nature of social media, we decided to omit a couple of previous categories and add two new ones.

One of these was the “Best #EAU16 Selfie” competition which we launched on the eve of this year’s EAU Annual Meeting to encourage some fun among congress attendees.

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We had dozens of enthusiastic entries which betrayed the social side of urology conferences today – see examples on our Awards Prezi.

 

The full list of awardees, along with some examples of “best practice” in the urology social media sphere can be found in the Prezi. The winners are also listed here:

  • Most Read [email protected] – “The drugs don’t work”. Dr Matt Bultitude
  • Most Commented [email protected] – “The Urology Foundation Cycle India” – 87 comments. Accepted by Dr Ben Challacombe, on behalf of Prof Roger Kirby, London, UK
  • Most Social Paper (new category) – “Twitter response to the USPSTF recommendations against screening with PSA”. Published in BJUI 2015. Accepted by Stacy Loeb on behalf of Dan Makarov and other co-workers.
  • Best BJUI Tube Video – “Extended PLND – creating the spaces”. Accepted by Declan Murphy on behalf of John Davis, MD Anderson, USA.
  • Best Urology Conference for Social Media – #AUA15 – The American Urological Association Annual Meeting 2015. Accepted by Dr Stacy Loeb on behalf of the AUA.
  • Best Urology App – The “British Association of Urological Surgeons Emergency Urology App”. Accepted by BAUS President Mark Speakman on behalf of BAUS and Dr Nick Rukin
  • Innovation Award 2016 – “Urology Ontology Tag Project”. Accepted by Dr Jim Catto and Dr Henry Woo (Dr Alex Kutikov not present)
  • #UroJC Award – Dr Rustom Manecksha, Dublin, Ireland
  • Most Social Trainee (new category) – Kari Tikkinen
  • Best Selfie – Khurshid “Macgyver” Guru
  • Best Urology Journal for Social Media –Journal of Sexual Medicine. Accepted by Associate Editor for Social Media, Mikkel Fode
  • Best Urology Organisation – European Association of Urology. Accepted on behalf of EAU by European Urology Editor-in-Chief, Jim Catto.
  • Best #EAU16 Selfie (new category) – Maria Ribal with special mentions to Morgan Roupret and Inge van Oort
  • The BJUI Social Media Award 2016 – #ilookllikeaurologist. Accepted on behalf of female urologists all over the world by Dr Stacy Loeb, New York, USA

Most of the Award winners were present to collect their awards themselves, including Dr Stacy Loeb who received our top gong for her work in driving the #ilooklikeaurologist campaign. The Awards Committee had identified this wonderful social media campaign from early on as a stand-out example of how social media (Twitter in particular), can be deployed to drive a really important social message. The #ilooklikeasurgeon campaign had already caught the imagination of all of us who identified with the message that female surgeons were undervalued in our specialty, and the #ilooklikeaurologist campaign really brought a welcome focus on our female urology specialists and trainees. The tweet that first used the hashtag was sent by Stacy in August 2015 in reply to a tweet from Rustom Manecksha:

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Since that time, over 1000 tweets have been sent using this hashtag, most featuring great pictures of our female urologists at work or at play. See plenty of examples on our Prezi or just search the hashtag #ilooklikeaurologist.

A special thanks to our outstanding BJUI team at the Editorial Office in London, Scott Millar and Max Cobb, who manage our social media and website activity as well as the day-to-day running of our busy journal.

See you all in Boston for #AUA17 where we will present the 5th BJUI Social Media Awards ceremony!

Declan Murphy, Peter MacCallum Cancer Centre, Melbourne, Australia

Associate Editor – Social Media, BJUI

@declangmurphy

 

 

 

 

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