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The rise of the clinical entrepreneur

The NHS is the world’s largest, longest established, unified healthcare system and has been at the forefront of many pioneering medical innovations in its 70‐year history. These have included the intraocular lens, total hip replacement, the rod‐lens telescope, CT and MRI scanners, and the laryngeal mask. However, commercialisation of this technology has often been better achieved abroad.

Increasingly the latest greatest advances transforming our lives are originating directly from industry. Companies such as Amazon, Uber, Airbnb and Google are at the vanguard of this disruptive change. More and more, their innovative products and services are available directly to patients resulting in the disintermediation of doctors. This is heralding a new era – a personalised, empowered, democratised healthcare revolution.

Traditionally the NHS has supported clinicians who want to develop their career in academic, leadership or educational arenas but has not been as supportive of entrepreneurial clinicians.

If we are to deliver on the promise of the Five Year Forward View 1 and the patients of the NHS are to receive the first‐hand benefit of innovation, we need to equip our clinicians with the entrepreneurial skills, knowledge and experience that will enable them to understand and engage with this new world. We need to develop our clinicians, so that they have both entrepreneurial and intrapreneurial abilities.

This has already been recognised by trainee doctors. Increasingly juniors want to both deliver and improve healthcare. In the UK, >56% of trainees completing their Foundation Year 2 (FY2) do not continue straight into training posts and ~5% of trainees leave medicine each year to pursue other opportunities, many take up entrepreneurial positions. We are losing a generation of innovative, entrepreneurial clinicians with a skill set that would bring a new leadership capability to the NHS.

To address this NHS England in partnership with Health Education England has launched the Clinical Entrepreneur Programme 2. This national scale workforce development initiative allows clinicians to undertake entrepreneurial activity alongside their clinical work. It provides a coaching and mentoring scheme, less than full‐time training opportunities, advanced industry internships, customer matching, connections to funding and education, and networking events. In year one, 104 junior doctors were appointed, 50 start‐ups created, >£50 m in funding raised and a ‘brain drain’ was turned into a ‘brain gain’, with 34 doctors who had left medicine or were about to leave returning to work in the NHS. In year two, >220 clinicians have joined the programme. In future years we aim to include patients and citizens. By bringing all to the centre, as we re‐imagine and re‐design healthcare, will we have the best chance of getting it right.

The clinical entrepreneurs will ultimately number in the thousands and will act as ‘multilingual’ frontline agents for change, adoption, and spread of innovation throughout the NHS and beyond.

At the BAUS annual conference this year some of the current cohort will be pitching their start‐ups on the main stage. Why not join us and welcome the new generation of specialists in healthcare – the Clinical Entrepreneurs.

 

Tony Young
Innovation NHS England, Southend University HospitalInnovation Mid and South Essex STP, and School of Medicine, Anglia Ruskin University, Cambridge, UK

 

References

 

 

Public Pronouncements and Individual Responsibility

jonathan-glassThe articles beneath headlines in the media relating to medicine rarely contain anything truly revolutionary or even anything particularly new despite what the headlines might have suggested.  We have all seen headlines promising a new cure for cancer, condemning an individuals practice and suggesting they are a charlatan and articles suggesting doctors are under-treating patients and depriving them of life changing care or over-treating patients and wasting and misusing limited resources.  More often than not the hyperbole of the headlines fail to truly represent the truth.  What is claimed to be new turns out to be old news, cures for cancer never show the results that were promised, and the extremes of over or under treatment are never quite as extreme as suggested.

headline1

A week or two ago we have seen the newspapers filled with headlines about a list of 40 treatments or tests that form part of current practice that are deemed unnecessary.  This list was originated from the ChoosingWisely group, an American group now established in the UK.  This organisation encourages both patients and clinicians to question what they are doing and whether certain processes or interventions are wise, necessary and appropriate resource efficient.

Much of the recommendations on these lists in these sites are undoubtedly true and worth looking at to make sure your practice is mainstream although much of the advice is old and well established.  The AUA has 10 recommendations on the US based Choosingwisely.org website the vast majority of which are simply current practice (don’t do a bone scan in men with low risk prostate cancer), however one or two make me feel uncomfortable and one or two differ on the UK and US websites.

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The recent headlines were predictable –  ‘40 common treatments and tests that doctors say aren’t necessary‘ & ‘Senior doctors condemn 40 treatments and tests as being of little or no use‘. Among the advice that reached the headlines obtained from the UK site (choosingwisely.co.uk) was the statement ‘Unless a patient is at risk of prostate cancer because of race or family history, PSA based screening does not lead to a longer life’.  The UK site has also commented on the use of chemotherapy in ‘advanced’ cancer saying it may not be appropriate – also evidently true.  The US site includes the recommendation that creatinine is not measured in men with benign prostate disease and minor lower urinary tract symptoms. 
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One particular problem with these public health, committee lead recommendations and advice is that treating populations is easy.  Populations don’t sue public organisations, individual patients sue individual practitioners and therein lies the nub.  What may be right as an idea – not measuring creatinine in men with low grade LUTS – is fine until the chap who has significant renal impairment walks in to your clinic and asks you why you didn’t measure his creatinine when he saw you a year ago.   Not measuring a PSA seems fine until the patient with missed prostate cancer reappears and suggests he asked you about testing his PSA, but as he had no family history and wasn’t black you told him it wasn’t necessary;  you showed him a website and explained to him we’d be wasting resources if you tested his PSA.   He may not understand that the delay may not have impacted on his survival.  Patients don’t hear that if they perceive there has been a delay in establishing a diagnosis.

Treating individuals, caring for the person across the table from you is very different from making pronouncements about populations.   It’s easy to recommend that chemotherapy is not used, until you are the one being offered a chance, if only small, of being offered some hope and a chance of survival.

I recognise that resources are not endless and that it is right for clinicians and healthcare workers in all sectors to think about how resources are used. The problem however is that the user of healthcare resource – the patient – wants their care to be lowest risk, independent of cost, and increasingly they are resorting to using legal channels if they perceive that care has been anything other than perfect.

Of the men on those panels not recommending use of PSA, I wonder how many of them would refuse to have it checked, or indeed would refuse chemotherapy if it was their only, if slim, hope?

 

Jonathan Glass

Consultant Urologist

Guy’s & St Thomas Hospital

 

Article of the Week: Evaluating health resource use and secondary care costs for RP and partial nephrectomy

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Mr. Jim Adshead, discussing his paper.

If you only have time to read one article this week, it should be this one.

Health resource use after robot-assisted surgery vs open and conventional laparoscopic techniques in oncology: analysis of English secondary care data for radical prostatectomy and partial nephrectomy

David Hughes*, Charlotte Camp*, Jamie OHara*† and Jim Adshead

 

*HCD Economics, Daresbury, Faculty of Health and Social Care, University of Chester, Chester, and Hertfordshire and South Bedfordshire Urological Cancer Centre, Department of Urology, Lister Hospital, Stevenage, UK

 

Read the full article

Objectives

To evaluate postoperative health resource utilisation and secondary care costs for radical prostatectomy and partial nephrectomy in National Health Service (NHS) hospitals in England, via a comparison of robot-assisted, conventional laparoscopic and open surgical approaches.

Patients and Methods

We retrospectively analysed the secondary care records of 23 735 patients who underwent robot-assisted (RARP, n = 8 016), laparoscopic (LRP, n = 6 776) or open radical prostatectomy (ORP, n = 8 943). We further analysed 2 173 patients who underwent robot-assisted (RAPN,n = 365), laparoscopic (LPN, n = 792) or open partial nephrectomy (OPN, n = 1 016). Postoperative inpatient admissions, hospital bed-days, excess bed-days and outpatient appointments at 360 and 1 080 days after surgery were reviewed.

JUnAOTW2FI

Results

Patients in the RARP group required significantly fewer inpatient admissions, hospital bed-days and excess bed-days at 360 and 1 080 days than patients undergoing ORP. Patients undergoing ORP had a significantly higher number of outpatient appointments at 1 080 days. The corresponding total costs were significantly lower for patients in the RARP group at 360 days (£1679 vs £2031 for ORP; P < 0.001) and at 1 080 days (£3461 vs £4208 for ORP; P < 0.001). In partial nephrectomy, Patients in the RAPN group required significantly fewer inpatient admissions and hospital bed-days at 360 days compared with those in the OPN group; no significant differences were observed in outcomes at 1 080 days. The corresponding total costs were lower for patients in the RAPN group at 360 days (£779 vs £1242 for OPN,P = 0.843) and at 1 080 days (£2122 vs £2889 for ORP; P = 0.570). For both procedure types, resource utilisation and costs for laparoscopic surgeries lay at the approximate midpoint of those for robot-assisted and open surgeries.

Conclusion

Our analysis provides compelling evidence to suggest that RARP leads to reduced long-term health resource utilisation and downstream cost savings compared with traditional open and laparoscopic approaches. Furthermore, despite the limitations that arise from the inclusion of a small sample, these results also suggest that robot-assisted surgery may represent a cost-saving alternative to existing surgical options in partial nephrectomy. Further exploration of clinical cost drivers, as well as an extension of the analysis into subsequent years, could lend support to the wider commissioning of robot-assisted surgery within the NHS.

Read more articles of the week

Editorial: Cost-effectiveness of robotic surgery; what do we know?

The introduction of the daVinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA) has led to a continuous discussion about the cost-effectiveness of its use. The capital costs and extra costs per procedure for robot-assisted procedures are well known, but there are limited data on healthcare consumption in the longer term. In this issue of BJUI, a retrospective study investigated the NHS-registered, relevant care activities up to three years after surgery comparing robot-assisted, conventional laparoscopic, and open surgical approaches to radical prostatectomy and partial nephrectomy [1].

The robotic system is particularly useful in difficult to perform laparoscopic surgeries, which are easier to perform with the daVinci system due to improved three-dimensional vision, ergonomics, and additional dexterity of the instruments. Because the use of the robotic system is more costly, to justify its use the outcomes for patients should be improved. Therefore, more detailed information about the clinical and oncological outcomes, as well as the incidence of complications after surgery with the daVinci system, is needed.

Lower rates of positive surgical margins for robot-assisted radical prostatectomy (RARP) vs open and laparoscopic RP have been reported [2]. There also is evidence of an earlier recovery of functional outcomes, such as continence. RARP is associated with improved surgical margin status compared with open RP and reduced use of androgen-deprivation therapy and radiotherapy after RP, which has important implications for quality of life and costs. Ramsay et al. [3] reported that RARP could be cost-effective in the UK with a minimum volume of 100–150 cases per year per robotic system.

Centralisation of complex procedures will not only result in better outcomes, but also facilitate optimal economical usage of expensive medical devices. Furthermore, the skills learned to perform the RARP procedure can be used during other procedures, such as robot-assisted partial nephrectomy (RAPN) and radical cystectomy (RARC). The recent report by Buse et al. [4] confirms that RAPN is cost-effective in preventing perioperative complications in a high-volume centre, when compared with the open procedure. Minimally invasive techniques for complex procedures, such as a RC, take more time to perform, but result in less blood loss. A systematic review by Novara et al. [5] showed a longer operation time for RARC, but fewer transfusions and fewer complications compared with open surgery. However, there is no solid evidence about the cost-effectiveness of this technique to date. The RAZOR trial (randomised trial of open versus robot assisted radical cystectomy, DOI: 10.1111/bju.12699) is likely to provide some answers about differences in cost, complications, and quality of life when the results of the study become available later this year.

Additionally, the robotic system has been shown to shorten the learning curve of complex laparoscopic procedures in simulation models [6]. Recently, a newly structured curriculum to teach RARP has been validated by the European Association of Urology-Robotic Urology Section [7]. The effect of the shorter learning curve on the cost of the procedures has not yet been well studied for cost-effectiveness. However, due to the shorter learning curves, patients have lower risks of complications, which from the patients’ perspective is more important than any increased costs.

The study reported in this issue [1]; however, does not include the ‘out of pocket’ expenses of patients, it does not report on the differences in patient and tumour characteristics, and outcomes such as complications and oncological safety. These issues are all challenges to be addressed in a thorough prospective (randomised) trial on the cost-effectiveness of the use of robot-assisted surgery, including quality-of-life measurements and complications of the surgical procedures. In the Netherlands the RACE trial (comparative effectiveness study open RC vs RARC, www.racestudie.nl) started in 2015 and the results are expected in 2018–2019.

Read the full article
Carl J. Wijburg
Department of Urology, Robotic Surgery , Rijnstate HospitalArnhem, The Netherlands

 

References

 

 

2 HuJC, Gandaglia G, Karakiewicz PI et al. Comparative effectiveness of robot-assisted versus open radical prostatectomy. Eur Urol 2014; 66: 66672

 

 

4 Buse S, Hach CE, Klumpen P et al. Cost-effectiveness of robot-assisted partial nephrectomy for the prevention of perioperative complications. World J Urol 2015; [Epub ahead of print]. DOI:10.1007/s00345-015-1742-x

 

 

6 Moore LJ, Wilson MR, Waine E, Masters RS, McGrath JS, Vine SJRobotic technology results in faster and more robust surgical skill acquisition than traditional laparoscopy. J Robot Surg 2015; 9: 6773

 

 

Video: Health resource use after robot-assisted surgery vs open and conventional laparoscopic techniques

Health resource use after robot-assisted surgery vs open and conventional laparoscopic techniques in oncology: analysis of English secondary care data for radical prostatectomy and partial nephrectomy

David Hughes*† ,Charlotte Camp*, Jamie OHara*† and Jim Adshead

 

*HCD Economics, Daresbury, Faculty of Health and Social Care, University of Chester, Chester, and Hertfordshire and South Bedfordshire Urological Cancer Centre, Department of Urology, Lister Hospital, Stevenage, UK

 

Read the full article

Objectives

To evaluate postoperative health resource utilisation and secondary care costs for radical prostatectomy and partial nephrectomy in National Health Service (NHS) hospitals in England, via a comparison of robot-assisted, conventional laparoscopic and open surgical approaches.

Patients and Methods

We retrospectively analysed the secondary care records of 23 735 patients who underwent robot-assisted (RARP, n = 8 016), laparoscopic (LRP, n = 6 776) or open radical prostatectomy (ORP, n = 8 943). We further analysed 2 173 patients who underwent robot-assisted (RAPN,n = 365), laparoscopic (LPN, n = 792) or open partial nephrectomy (OPN, n = 1 016). Postoperative inpatient admissions, hospital bed-days, excess bed-days and outpatient appointments at 360 and 1 080 days after surgery were reviewed.

JUnAOTW2FI

Results

Patients in the RARP group required significantly fewer inpatient admissions, hospital bed-days and excess bed-days at 360 and 1 080 days than patients undergoing ORP. Patients undergoing ORP had a significantly higher number of outpatient appointments at 1 080 days. The corresponding total costs were significantly lower for patients in the RARP group at 360 days (£1679 vs £2031 for ORP; P < 0.001) and at 1 080 days (£3461 vs £4208 for ORP; P < 0.001). In partial nephrectomy, Patients in the RAPN group required significantly fewer inpatient admissions and hospital bed-days at 360 days compared with those in the OPN group; no significant differences were observed in outcomes at 1 080 days. The corresponding total costs were lower for patients in the RAPN group at 360 days (£779 vs £1242 for OPN,P = 0.843) and at 1 080 days (£2122 vs £2889 for ORP; P = 0.570). For both procedure types, resource utilisation and costs for laparoscopic surgeries lay at the approximate midpoint of those for robot-assisted and open surgeries.

Conclusion

Our analysis provides compelling evidence to suggest that RARP leads to reduced long-term health resource utilisation and downstream cost savings compared with traditional open and laparoscopic approaches. Furthermore, despite the limitations that arise from the inclusion of a small sample, these results also suggest that robot-assisted surgery may represent a cost-saving alternative to existing surgical options in partial nephrectomy. Further exploration of clinical cost drivers, as well as an extension of the analysis into subsequent years, could lend support to the wider commissioning of robot-assisted surgery within the NHS.

Read more articles of the week

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

 

Avoiding treatment in prostate cancer: time and money, please?

It seems impossible to say anything regarding prostate cancer without inciting emotionally charged controversy, even when based on high-level evidence. The updated prostate cancer guidelines from the National Institute of Clinical Health and Excellence (NICE) this week sparked media attention that focused on the role of active surveillance for low and intermediate risk groups.

 

The newspaper headlines state that patients with prostate cancer have been told to avoid immediate treatment. Whether patients are to go against advice given by their doctor or whether this is an attempt by the government to save money is unclear if the online comments are anything to go by. On a local level, patients who are awaiting treatment are questioning their choices.

The sensational implication is that active surveillance is a novel management strategy that was previously not considered. In fact, the equally controversial guidelines from 2008 promoted this alternative: the phrase “suitable for all options including active surveillance” is expressed frequently throughout the country when discussing individual cases at multidisciplinary team meetings.

There is no doubt that a proportion of men who undergo radical treatments may not benefit. The challenges arise in determining who these men are within the constraints of NHS pathways. A standard pathway for a UK man is to request a PSA blood test from his GP, commonly sparked by concerned relatives or friends and endorsed by high-profile survivors and campaigners. A raised result then triggers a “two-week” urgent suspected cancer referral and a clock ticks with diagnosis, staging and treatment to be completed within a 62-day target.

Inevitably, the urgency of referral will influence patient beliefs regarding the seriousness of their condition. A quick online search of comments on recent mainstream articles will throw up anecdotes from men who have sadly failed “wait and see” policies by progressing and finding themselves with incurable disease. A well informed patient will know that a standard transrectal biopsy will have under-estimated his risk in a third of cases. In this emotional state and limited time-frame, our patients are expected to make a rational decision regarding complex management choices – definitive treatment with associated side effects but the knowledge that every effort has been made to “cure” the disease, or what may be a lifetime of repeated, potentially dangerous, biopsies, blood tests and prostate examinations with risk of failure and “living with cancer”. Active surveillance is hardly an attractive option when considered in these terms.

What’s the answer? Detailed evaluation of prostate disease can be achieved with improved imaging with multiparametric MRI in conjunction with a modern transperineal biopsy technique that evaluates the prostate more thoroughly. Suitable patients for active surveillance (and radical treatment) can then be potentially better selected and counseled with higher confidence. Of course, resources are required for this, but shouldn’t this be what we should be campaigning for? And time to deliver this.

Benjamin Disraeli said, “He who gains time gains everything” and perhaps this is the greatest gift we can give to our patients. The lack of time pressure in terms of clinical urgency in low risk prostate cancer gives ample opportunity to get it right in these patients.

I can’t agree that the NICE guidelines are designed to cut NHS costs (active surveillance may cost the same as surgery) but I do fear that without better resources and the reduction in target pressures for low risk prostate cancer, active surveillance will remain an under-utilized management option for many who would benefit from it.

Peter Acher

Prostate cancer survivorship: a new way forward

Over 2 million people in England have a diagnosis of cancer. This is such a large problem, the Department of Health is spending £750 million on improving earlier diagnosis and prevention of cancer, yet at the same time, £20 billion of efficiency savings must be made. One arm of post-cancer care is survivorship. Survivorship care was initially developed in the USA 20 years ago, starting with breast cancer patients. Prostate cancer survivorship care has been lagging far behind.

Survivorship care involves risk profiling of patients, supported by community based teams and developing shared care/decision making. More often than not, they are fit and well, requiring PSA follow-up only. Yet no guidance relates to survivorship management.  

 

Cancer survivorship encompasses the “physical, psychosocial, and economic issues of cancer from diagnosis until the end of life.” There are significant concerns that current follow-up methods are unsuitable. Concerns regarding permanent physical, psychosocial, and economic effects of cancer treatment have been highlighted and give us good landmarks for survivorship care. These include monitoring for recurrence, metastases, side effects and coordination between secondary and primary care and impact on quality of life. If we examine what patients expect, this includes a full assessment of needs, discussion on side effects of treatment and a personalised care plan post-treatment. Patients also report not knowing who to contact for their care out of hours. Five key phases to survivorship care were identified: care via primary treatment from diagnosis, enable as rapid and full a recovery as possible, ensure recovery is sustained, manage side effects of treatment and monitor for recurrence or disease progression. As part of a National Cancer Survivorship Initiative, a recovery package was developed. This includes a holistic needs assessment and care planning at key points of the care pathway, a treatment summary, a cancer care review, a patient education and support event.

Based on these facts, we have developed a new survivorship model – this was set up as a National Cancer Survivorship Initiative. This programme was initially devised when it was identified specific areas of care were lacking in this cohort, when followed up on a clinic basis. It aims to address the holistic need of the survivorship cohort, and at the same time, allow monitoring for acute recurrence and follow-up care as well as community based follow-up and patient support.

Our Survivorship programme is for patients post-curative therapy for organ confined disease (surgery, external beam radiotherapy or brachytherapy). Patients are offered the option of entering into the survivorship programme and discharged from clinic (Figure 1). Inclusion criteria specify patients must be two years post-radical prostatectomy with an unrecordable PSA, or three years post-radiotherapy or brachytherapy with a stable PSA. We currently have over five hundred patients on this programme. The patients’ demographic, disease and treatment details are entered onto a password protected web based database. The IT programme allows patients to be monitored for recurrence via automatic extraction of PSA results from the hospital database. It is a bespoke database. Alerts are automatically generated if the PSA is above a previously set range. The clinical nurse specialist (CNS) running the programme will contact the responsible consultant once an alert is generated with the patient reviewed in clinic, if required. The CNS will also go through a ‘Distress Thermometer’ with patients on admission to the programme, to identify areas where the patient needs support, psychological, social etc. The specialist nurse would act as the patients’ keyworker, should they develop any side effects of treatment, or any recurrence.

At its initial inception, a focus group of patients was conducted, as part of participatory action research, to find out what they wanted as part of this programme – a user led system. Specifically, they mentioned a conference where they have access to health care professionals and specific topics covered including diet and exercise, nutrition, psychosexual counselling. This conference is held annually, with a range of healthcare professionals advising on identified patient issues e.g. psychological care, health promotion, research, and welfare. The conference allows patients to draw on their strengths and share experiences with each other. Topics such as identification of recurrence, long-term complications, rehabilitation services, quality-of-life issues, pain and symptom management and treatment of recurrent cancer are examples of areas covered. 

There are over 600 patients currently on the programme, a mixture of post-surgery, radiotherapy and brachytherapy. Of these patients, 29 have been referred back to clinic. When asked at the pilot conference if it was worth attending, 100% said yes. As a result of the initial focus group, comments have been made in support this programme.

Whilst this programme is currently only for patients post curative treatment, the next steps forward are to see if patients undergoing active surveillance or hormone therapy can be followed-up using this programme.

Further information:

National Cancer Survivorship Initiative

Worcestershire Prostate Cancer Survivorship Conference

Worcestershire Prostate Cancer Survivorship Programme

 

Goonewardene SS*, Persad R,Nanton V, Young A, Makar A
*Homerton University Hospital, London, North Bristol NHS Trust, Warwick University, Worcestershire Acute Hospitals

Headline news: “Doctors and nurses may face jail for neglect”?

It has been an important few weeks in for doctors in the United Kingdom, sensationalist headlines have been on the front pages of many of the national newspapers: “Doctors and nurses may face jail for neglect

This has all stemmed for the publication of the Francis report and Berwick review into patient safety. They detail recommendations on how the National Health Service (NHS) can learn and improve the standard of patient safety. The Berwick report was led by Professor Don Berwick, an international expert and former adviser to US president Barack Obama, in patient safety. He was asked by the British Prime Minister David Cameron to carry out the review following the publication of the Francis Report into the breakdown of care at a Mid Staffordshire NHS Foundation Trust Hospital.

Stafford Hospital is an NHS hospital in the West Midlands area of England where hundreds of hospital patients died as a result of substandard care and staff failings between January 2005 and March 2009. The Mid Staffordshire Trust failed to provide safe care in the wards, people lay starving, thirsty and in soiled bedclothes. Decisions about which patients to treat were left to receptionists, inexperienced junior doctors were put in charge of critically-ill patients, and nurses switched off equipment because they did not know how to use it. The culture of the hospital Trust was one of secrecy and defensiveness. The inquiry highlights a whole system failure.

Both reports highlight the main problems affecting patient safety in some hospitals in the NHS and makes recommendations on how to address them. It says that the health system must, amongst many things, recognise the need for wide systemic change by abandoning blame as a tool and trust the goodwill and good intentions of the staff. The use of quantitative targets must be approached with caution and they should never displace the primary goal of better care.

The main headline grabbing item was the recommendation that the UK Government should create a new general offence of willful or reckless neglect or mistreatment applicable both to organisations and individuals.

Organisational sanctions might involve removal of the organisation’s leaders and their disqualification from future leadership roles, public reprimand of the organisation and, in extremis, financial sanctions but only where that will not compromise patient care.

Individual sanctions should be on a par with those in Section 44 of the Mental Health Capacity Act 2005 in UK law, which states that a person can be found guilty of an offence if he ill-treats or willfully neglects a person who lacks capacity and if convicted could be sentenced to imprisonment for a term not exceeding 5 years or a fine or both.

So does this affect us as urologists?

As doctors our first duty of care is towards our patients and patient safety should be our number one priority. However, in light of the report there is the possibility of a custodial sentence to individual(s) where the standard of care falls far short of expectations and blatant neglect is proven. In the age of clinical teams, proving that one individual was at fault is very difficult.

There has been a recent case in the UK press in which a surgeon has been jailed for two and a half years for manslaughter for gross negligence of a patient.

In another case in Australia a 63-year-old American surgeon working in a hospital in Queensland faced complaints from hospital staff that he had botched operations, misdiagnosed patients and used poor surgical techniques. He was arrested in the US in 2008 and extradited to Australia to stand trial. He was jailed for seven years in 2010 after being convicted of criminal negligence leading to the deaths of three patients.

These are two isolated cases but both demonstrate that the days when problematic surgeons were quietly retired are over. Our actions will be scrutinised by an ever demanding public with complications not just being discussed in mortality and morbidity meetings locally but in some cases publicly and in extreme situations in the courts.

My question to the readers is: what happens to clinical staff in your individual countries when clinical negligence and neglect is accused? Is jail time a possibility if proven?

 

Jonathan Makanjuola is a Urology Trainee, Innovator and techie based at King’s College Hospital, London, United Kingdom. @jonmakUrology

Think Twice About Operating on Fridays and Weekends and Stick to Golf Instead

I recall participating many elective major procedures on Friday nights and Saturday mornings during my residency training, thinking to myself that not only should I be home, but this just can’t be good for the patient…can it? Well, apparently not.

A new population-based study by Aylin et al. published in the British Medical Journal suggests that patients undergoing surgery on Fridays and weekends have significantly higher of both 2-day perioperative mortality as well as 30-day mortality. Utilizing the robust information provided by the English National Health Service (NHS), the authors analyzed over 4 million elective cases performed in England from 2008-2011 and found a crude mortality rate of 6.7 per 1000 cases. While overall mortality seems low, after adjusting for confounding variables the authors found a stunning 44% and 82% statistically significant increase in 30-day mortality if an elective procedure was performed on a Friday or weekend compared to Monday, respectively. When analyzing 2-day mortality, the authors found a whopping 167% increase in mortality on a weekend compared with Monday.

A “weekend effect” has been proposed in prior studies, however these studies for the most part analyzed emergency admissions and included emergency surgeries on patients that were likely to be much sicker than the average patient. What makes this paper different, and thus more significant, is that it only analyzed elective procedures and is the first paper to suggest that with each successive weekday, patients are at increased risk of mortality, culminating with the highest risk on Fridays.

Data on urologic cases within this study remain unknown, as urologic procedures were not selected for sub-analysis. However, overall analysis included all elective procedures, which must have included high-risk urologic procedures such as cystectomy, nephrectomy, partial nephrectomy, prostatectomy, RPLND, and endourologic procedures on infected stones. Therefore, this data should still have relevance for urologists performing such high-risk procedures.

Why is this happening? We know that major complications from elective surgeries happen within the first 48 hours postoperatively (Cavaliere F, et al.). Therefore, patients that have surgery on Friday or over the weekend are at their most vulnerable when the hospital is most short staffed. Additionally, there has been concern that the more junior faculty and trainees bear the majority of weekend coverage, and are therefore most often the primary points of care over weekends, leading to potential failure to rescue due to inexperience. Finally, there is the issue of cross coverage and dialogue between hospital staff during the week and the weekends. How much can a covering physician truly learn about a potentially complicated patient from a simple sign-out?

More importantly, what can we do? Ideally, major cases should be scheduled earlier in the week to allow the patients to have care while all hospital staff are available during the remaining week or so of recovery. Endoscopic and same-day procedures should be scheduled later in the week. However, is this realistically possible? OR time can often come at a premium and is difficult to come by in some busy hospitals, especially for junior faculty. Therefore, such a change would have to come from the top hospital administrators and likely would meet resistance from more senior faculty.

When asked by The Guardian regarding these results, Sir Bruce Keogh, cardiac surgeon and director of the NHS, downplayed the results, stating that when he performed open heart surgeries he would often intentionally operate on patients later in the week to get more time in the ICU over the weekend. With all due respect to Sir Keogh, I just do not see the logic in this approach, and feel we should take these results more seriously rather than downplay them. The data presented by Aylin et al. seems pretty convincing to me: while overall mortality is low, patients getting surgery later in the week and on weekends are getting inferior care leading to inferior outcomes. We need to acknowledge this data, not ignore it or diminish it, and come up with some kind of reasonable and fair solution to the problem.

What say you, Urology community? If any field can come up with a solution, it’s us. Somehow, we need a system that allows all surgeons, young and old, to perform higher risk surgeries earlier in the week to prevent potential complications happening under the watch of an undermanned, inexperienced hospital staff over the weekend. In the meantime, I will try to use my free weekends for spending time with my wife, golf, and watching sports while trying my hardest to perform major surgery earlier in the week. Not only will this please my wife, it will likely improve the care of my patients.

Keith J. Kowalczyk, MD
Department of Urology, Medstar Georgetown University Hospital, Washington, DC, USA@KeithKow

 

 

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