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Learning curve vs discovery curve: Training urological surgeons, what can we learn from sport?

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Improving training in the United Kingdom may benefit from a more analytical assessment of natural abilities, individual learning curves and understanding and providing the necessary training methods to let trainees reach their potential. It used to be said that surgeons learnt from their mistakes, but surely this philosophy and approach is unacceptable in the 21st Century. To learn from a mistake when it could have been avoided in the first place, with the correct guidance, could be considered negligence. Of course to err is human and none of us are superhuman. However, what we must try to avoid is the “self-discovery” curve in surgery.

Vickers paper assessing fellowships to learn radical prostatectomy showed that a fellowship could shorten your learning curve. I have been on several fellowships abroad and what they had in common was of course numbers. Centres do not get a reputation or expertise by doing one case a year. However they also had in common a structured approach to training fellows that started with observation in theatre, then bedside assisting and finally doing defined steps of the procedure.

The combination of structured training and suitable experience is key to good surgical development. The individual who takes up golf and teaches himself or herself is unlikely to become a scratch golfer and may develop ugly habits that hold them back from reaching their potential. This can be seen in surgery. To complete the golfing analogy (and apologies to non-golfers): once a golfer has a reasonable swing and knows what he/she is doing, the single thing that will define how good he/she gets is how often they play.

Modern professional sportsmen are assessed for their technique using technology and we are starting to see this level of scrutiny in robotic training. Anyone who has used the Mimic technology in the Da Vinci robotic training, will recognise that it looks at several aspects of surgical technique, including economies of movement. In my own experience as an early trainee in open or endoscopic surgery I was rarely told how to hold an instrument properly or indeed about ergonomics and economies of movement. The focus was usually on the operative field, where to cut etc.

In professional sports much thought and investment has gone into creating the optimum environment to initially assess individuals for natural ability, then supporting and nurturing their talent, strengthening them both mentally and physically so that their “investment” is enabled to perform in the toughest situations as well as having longevity. Should we not aspire to do the same for our surgical trainees?

Justin Collins is a Consultant Urologist at Ashford and St Peters NHS Foundation Trust, UK and is a regular trainer on the faculty at IRCAD, Strasbourg, France. @4urology

 

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Reflections from “The Boards”

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Every year in February, 250 or so urologists make the pilgrimage to the Dallas airport to take the Urology Certifying Exam (a.k.a. the Oral Boards). This ranks as one of the strangest events in my life. I felt it appropriate to share my experience.

My trip to Dallas begins with a very sincere “good luck on your test daddy” from my 5-year old daughter. This makes me feel great, until I realize I am less than 24 hours from actually taking the exam. My stress level now starts to rise. As I board the plane in Portland, ME, I see one of my patients. I am pretty sure that I operated on her, but since my brain is crammed full of (now in hindsight) useless information, I cannot remember any details about her. I avoid all eye contact and quickly take my seat. By some miracle, I have the exit row all to myself. Is this a good omen? I feel slightly better until my second flight is delayed on the tarmac for an hour. Nervousness ensues.

I check into the hotel, which is conveniently located at the airport. My room isn’t ready yet, so I wander into the lobby, which is filled with other nervous urologists who are waiting for their rooms. They are all quizzing each other on case scenarios. This doesn’t help my anxiety, so I flee the area. Things become very “real” at registration where all of the other panicky urologists are crammed into a small ballroom. This exam is actually going to happen. I cannot back out now. To make myself feel better, I mock those wearing suits and ties. Who are they trying to impress? I am much cooler than them. Unfortunately, no one passes the boards for being cool. Maybe I should have put on a tie.

It is now t-minus 1 hour to exam time. My brain goes totally blank. I am convinced I have forgotten all of urology. I wonder if my hospital will hire me as a scrub tech. My stress level is now off the charts. I take my first exam – only took 45 minutes. Is this good or bad? I am convinced that I failed, but take solace in the fact that everyone else feels the same way. We are sequestered after the exam for 2 hours. There is nothing else to do, so we all end up talking about the exam. This doesn’t help my anxiety. For the rest of the day, I think about things I should have said during the exam. This again convinces me that I have failed.

As I walk down the long corridor (nicknamed the Green Mile by the staff) to my exam on the second day, all of the examiners are standing in the hallway with half smiles on their faces. What does this mean? Unfortunately, day #2 does not go better than day #1. I now realize why they are all smiling. I am now thoroughly convinced that I have failed. I wonder what I will do when I lose my job. I will need to modify my CV to apply for the scrub tech job. Not sure what else I am qualified to do.

Twenty-four hours later I am slowly relaxing. I try to put things in perspective. The numbers (90% pass rate) tell me that I probably haven’t failed. I am thankful for the colleagues that I saw this past weekend and for new connections that were made. Seeing all of them and sharing this experience confirms why I love urology and can’t see myself doing anything else. We are all blessed to be able to take care of patients and improve their lives. I am looking forward to returning to work tomorrow to get back to being a doctor. And I can’t wait to see my daughter and tell her that daddy did his best.

 

Matthew Hayn is an attending urologist at Maine Medical Center in Portland, ME and an Assistant Clinical Professor of Urology at Tufts University School of Medicine. His views are his own. @matthayn

 

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Article of the week: Reality check: simulators are effective training tools for robotic surgery

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Every week the Editor-in-Chief selects the 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.

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

Current status of validation for robotic surgery simulators – a systematic review

Hamid Abboudi, Mohammed S. Khan, Omar Aboumarzouk*, Khurshid A. Guru†, Ben Challacombe, Prokar Dasgupta and Kamran Ahmed

MRC Centre for Transplantation, King’s College London, King’s Health Partners, Department of Urology, Guy’s Hospital, London, *Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK, and †Department of Urology, Roswell Park Center for Robotic Surgery, Roswell Park Cancer Institute, Buffalo, New York, USA

Read the full article

To analyse studies validating the effectiveness of robotic surgery simulators. The MEDLINE®, EMBASE® and PsycINFO® databases were systematically searched until September 2011. References from retrieved articles were reviewed to broaden the search. The simulator name, training tasks, participant level, training duration and evaluation scoring were extracted from each study. We also extracted data on feasibility, validity, cost-effectiveness, reliability and educational impact. We identified 19 studies investigating simulation options in robotic surgery. There are five different robotic surgery simulation platforms available on the market. In all, 11 studies sought opinion and compared performance between two different groups; ‘expert’ and ‘novice’. Experts ranged in experience from 21–2200 robotic cases. The novice groups consisted of participants with no prior experience on a robotic platform and were often medical students or junior doctors. The Mimic dV-Trainer®, ProMIS®, SimSurgery Educational Platform® (SEP) and Intuitive systems have shown face, content and construct validity. The Robotic Surgical SimulatorTM system has only been face and content validated. All of the simulators except SEP have shown educational impact. Feasibility and cost-effectiveness of simulation systems was not evaluated in any trial.Virtual reality simulators were shown to be effective training tools for junior trainees. Simulation training holds the greatest potential to be used as an adjunct to traditional training methods to equip the next generation of robotic surgeons with the skills required to operate safely. However, current simulation models have only been validated in small studies. There is no evidence to suggest one type of simulator provides more effective training than any other. More research is needed to validate simulated environments further and investigate the effectiveness of animal and cadaveric training in robotic surgery.

 

 

 

 

 

 

 

 

 

Read Previous Articles of the Week

Editorial: VR simulators can improve patient safety

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You wouldn’t expect the pilot of the aeroplane in which you fly to the EAU or AUA meeting to be a novice who was training on the aeroplane that you were being transported in! Similarly, patients undergoing robot-assisted surgery do not expect to be the “guinea pigs” upon which trainee surgeons move up the learning curve of surgical experience. Sometimes, however, they are.

Surgical simulators offer the means for surgeons to gain experience before moving to operating on actual patients. However, the publication from Guy’s and St Thomas’s illustrates how little research has been done yet to confirm that outcomes are improved by such a move.

Patient safety is a “buzz word” at present, especially after the report of Robert Francis QC on the Mid-Staffordshire NHS Trust disaster. It seems probable that virtual reality (VR) simulators can improve safety, not only by improving technical skills, but also by enhancing non-technical “human factor” responses.

Much work needs to be done to provide the VR training facilities and ensure access to them for all urology trainees. Once they are in place studies will be needed to confirm their value. In a world where doctors and Trusts are facing a tidal wave of litigation there seems little doubt that this is the way ahead.

Roger Kirby
The Prostate Centre, London W1G 8GT

Read the full article

Twitter Chat Tools for International Urology Journal Club

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Twitter is a great social channel for professionals to exchange ideas. I regularly use Twitter to connect with urologists, health care professionals, patients and thought leaders around the world. I also use Twitter to share my blog posts.

 

Participating in Twitter Chats

One of the many other ways I find value on the platform is by participating in Twitter Chats. Twitter chats are a great way to get people with a common interest into a community. A Twitter Chat can be a one-time event; however, most take place on a regular basis – weekly or monthly – and are organized around a designated hashtag.

Weekly healthcare chats that I regularly enjoy include: #hcsmanz (Healthcare and Social Media in Australia and New Zealand) and #hcsm (Healthcare Communications and Social Media) both on Sundays, #hcldr (Healthcare Leader) on Tuesdays, and #HITsm (Health IT Social Media) on Fridays.

My favorite Twitter chat, however, is the monthly #UROJC chat, International Urology Journal Club on Twitter. #UROJC takes place on the first Sunday of every month, starting at 3 pm Eastern time, and continues over a 48-hour period, rather than one hour. During this time, I can review and discuss current research in urology and engage with academic and community urologists around the world. The origins of #UROJC have previously been described by Dr. Henry Woo, @DrHWoo, in a BJUI blog post.

 

Twitter Chat Tools to Know

When you participate in #UROJC, or any other Twitter Chat, there are a few tools and tips that can be used to enhance your experience.

1. Tweetchat

A great application for Twitter Chats and conferences is Tweetchat.com. You can tweet directly from Tweetchat, and your tweets will automatically be appended with the hashtag. All participants using the hashtag can be viewed in a real-time stream.

How to use Tweetchat:

  • Go to Tweetchat.com.
  • Log in with your Twitter account.
  • Add the hashtag for the chat, i.e., #UROJC, in the “room” text box.
  • Now you will see all the people participating in the chat displayed in the stream in real time.
  • You can tweet directly from the platform through the tweet box provided. Tweetchat.com will automatically add the hashtag, and you are visible in the stream. You can click on buttons next to a tweet to reply or retweet another user.
  • You can also click to follow colleagues in the chat via Tweetchat. This is a great way to expand your network.

 

2. Twitterfall

Twitterfall is similar to Tweetchat, but has some customizable features. For example, you can edit out retweets, and control the speed of the Twitter stream. Twitterfall also has a place to create lists of people you want to engage with.

To get started on Twitterfall:

  • Go to Twitterfall.com.
  • Log in with your Twitter account to tweet directly from the platform.
  • Enter the hashtag #UROJC into the “search” text box.
  • View the discussion and participants in the stream.
  • Set your selections for a variety of other options including creating a list of participants.


3. Symplur

You can get a transcript of the tweets from each monthly #UROJC chat courtesy of Symplur. This is valuable if you want to review a chat or if you happened to miss a chat altogether.

In addition to chats, Symplur’s Healthcare Hashtag project is a rich resource for discovering and mining healthcare conversations on Twitter around specialties, disease states, patient communities, and healthcare conferences.

It is also interesting, at the end of a chat, to view Symplur’s analytics that show the participants who have the most mentions, tweets and impressions. Symplur can also a great place to identify new people to follow.

 

4. World Clock:

Because #UROJC is a global discussion over a two-day period, it can be confusing to keep track of starting times across multiple time zones. A great tool to find the time in your part of the world is the World Clock time zone converter.

 

I hope that you find these Twitter Chat tools and tips helpful, and I look forward to seeing you in the stream of our next monthly #UROJC. You can keep updated on what is up and coming on #UROJC by following the official Twitter account for the chat at @iurojc. You can always connect with me on Twitter @storkbrian.

 

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EWTD: Quantity or Quality?

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The European Working Time Directive (EWTD) was due to be in full implementation from August 2009 limiting junior doctors to a 48-hour week averaged over a 6-month period. The reality of this is somewhat different from the legislation. In truth, the questions needed to be asked were – was it ever feasible? What was the training impact in a craft-based speciality going to be? Where are we now?

The detrimental effects to training in a reduced working environment has been documented in both hemispheres. Canter, in a review of the EWTD in the United Kingdom and Ireland reported ~90% non-compliance of the restricted working week. ‘Time for Training’ reviewed the implications of the EWTD and Professor Temple felt ‘high quality training can be delivered in 48 hours’; however, this is precluded where trainees have a ‘major role in out of hours services’. As most trainees, in all health systems, will attest to junior doctors do play a ‘major role’ in on-call services.

As a current urological trainee, the pressures to develop skills to operate in an ever-changing and exciting field are evident. A limited working week, twinned with health service cut backs and limited hospitals beds is without doubt a concern when filling in our logbooks. ‘Could a passage to India be the way to get more surgical experience?’, a feature in the BMJ in 2012, Elliot sends trainees abroad to gain the invaluable exposure to numbers we are limited by here.

There are two sides to the impact that a limited working week will have to an aspiring surgeon’s experience, the quantity and quality of time spent in the hospital. The debate remains regarding the length of surgical training the current structures are changing in Ireland, led by the RCSI, in an effort to shorten the length of surgical training in line with other jurisdictions. We need to strive to efficiently and effectively train surgeons within an appropriate timeframe within the restraints of legislation without a drop in the standard of skills required.

As time has passed, it remains to be seen if the EWTD will ever be implementable in keeping with the continuity of patient care to the highest standard they deserve and that we aspire to offer them. The EWTD is currently being debated at a European Commission level in order to negotiate a revised directive more in line with the challenges of healthcare professionals in a 21st century health service. Revisions to the directive may allow for longer hours in certain disciplines such as the skill based surgical specialities.

Gregory J. Nason, MRCSI, is currently Registrar in Urology, St Vincent’s University Hospital, Dublin.

 

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Urologist as the Go-to Adrenal Surgeon?

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What do Galen, da Vinci, and Vesalius have in common? All three, in all their detailed description of human anatomy, failed to note the existence of the adrenal glands. In fact, it was Bartholomeus Eustachius (yes, the one of the “tube”) who in 1563 was the first to document the glands’ existence. Meanwhile, it took another three centuries for Thomas Addison to recognize the physiologic importance of the adrenals. Soon thereafter, Charles Brown-Sequard, who appears to have toyed not only with spinal cords, removed both adrenals from a dog, thus proving that the glands were critical to life.

Notwithstanding the adrenals being a source of major human ailments, the glands and their pathology to this day often remain unnoticed. For instance, a study in the Harvard Vanguard healthcare system revealed that >80% of adrenal lesions do not receive adequate evaluation. Meanwhile, nearly 20% of adrenal incidentalomas potentially represent surgical lesions. Indeed, perhaps due to their understated anatomic prominence or more likely due to the embryologic origins that are distinct from the urinary or gastrointestinal tracts, the adrenal glands largely remain “orphans” in the surgical arena. Yes urologists, surgical oncologists, and more recently subspecialists known as endocrine surgeons manage and operate on the adrenal glands; nevertheless, referral patterns and expertise vary, and, arguably, no surgical specialty has consistently “parented” these organs.

In this lies a great opportunity.  Today’s urologists are ideally positioned to take the reigns on the surgical management of the adrenals. With the urologist’s advanced minimally invasive surgical skills, comfort with both retroperitoneal anatomy and surgical approaches to retroperitoneal organs, it is only natural that the evaluation and surgical management of adrenal disorders evolve and remain in the domain of urologic surgeons.

Nevertheless, a technical skillset in removing an adrenal should not be mistaken for adequate expertise in management of its pathology. In order for urologists to position ourselves as surgical leaders in the adrenal space, fluent knowledge of adrenal pathophysiology and appropriate evaluation is paramount. Nevertheless, “know-how” of adrenal management is infrequently mastered during urologic training. In my experience, many trainees and practicing urologists are somewhat overwhelmed by the complexity of adrenal pathophysiology and are often unsure how to distill the large volume of information they’ve learned for standardized examinations into practical knowledge. For instance, expertise on how to appropriately evaluate a referral for a newly diagnosed adrenal lesion is often lacking. Such lack of expertise potentially leads to overtreatment of some patients and undertreatment of others.

As the field moves forward, we must better educate our trainees and practicing urologists on the practical nuances of surgical management of the adrenals. The AUA Core Curriculum effort is a great start. However, a brief course at the AUA and/or EUA for practicing urologists is urgently needed.

As such, the close anatomic and physiologic relationship of the adrenals to the kidney positions urologists as the most appropriate surgical specialists for treatment of surgical adrenal disorders. However, leadership in the surgical adrenal space must be founded not only on technical skills, but also on clinical fluency in appropriately evaluating, selecting, and medically managing patients with adrenal neoplasms and disease. Tremendous opportunities on bridging the knowledge gap in management of surgical adrenal disorders exist and, potentially, can be solved by formal courses at national meetings.

 

Dr Alexander Kutikov, MD is an Associate Professor of Urologic Oncology at Fox Chase Cancer Center, Philadelphia, USA. @uretericbud

 

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BJUI and The Urology Foundation at 10 Downing Street

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Last night, I was delighted, along with other members of the BJUI Editorial Board, to attend a reception for The Urology Foundation at Number 10 Downing Street, hosted by the UK’s “First Lady” Samantha Cameron.

The reception was attended by many eminent urologists as well as a number of well-known personalities.

The primary aim of the reception was to raise awareness for the Foundation and its work and all of us at the BJUI are happy to help in that aim.

Prokar Dasgupta, Editor-in-chief

 

 

 

The Urology Foundation issued the following Press Release:

TUF Downing Street Reception hosted by Samantha Cameron

On Tuesday 22nd January 2013, Samantha Cameron kindly hosted a reception at No 10 Downing Street, for The Urology Foundation.

The Urology Foundation is the only UK charity that covers all urological diseases. It aims to improve the diagnosis, choice and care of patients with urological diseases by supporting pioneering research and providing specialist training to improve the skills and effectiveness of UK health professionals working in urology.

Around 120 dedicated supporters and friends gathered together in the Terracotta and Pillared Rooms, to celebrate The Foundation and the exceptional work it undertakes. Speeches were given by Samantha Cameron as well as the Hon Secretary of The Foundation, the esteemed Professor Roger Kirby, who announced an exciting new Bladder Cancer Awareness campaign for 2013.

Kindly showing their support were, amongst others, Ronnie Corbett CBE who is embarking upon a radio campaign for The Foundation, Private Eye editor Ian Hislop and actors, Jemma Redgrave, Vanessa Kirby and Douglas Booth.

 

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No Heat in the Desert

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I am blogging again my friends. Blogging is freedom in the 21st Century; the modern equivalent of standing on a soapbox in Speakers’ Corner in London. Still, only old people write formal blogs now, young people microblog. They use Twitter, Reddit, Tumblr, or Instagram. Blogging is no more modern than an open radical prostatectomy is sexy; actually its old-fashioned and beneath me. Still, I like it. And more importantly, it gives me an easy outpost to write about urology in an informal manner. So off we go – I am going to give blogging its sexy back.

For the past 20 years, my department at the University of Pittsburgh has sponsored and developed a course to aid board-eligible urologists tackle the oral urology boards (or part 2). We locate the course in Scottsdale, Arizona in Maricopa County. Maricopa county was recently in the news for having a controversial sheriff cited by the Department of Justice for “engaging in a pattern or practice of unconstitutional policing” and had “a chronic culture of disregard for basic legal and constitutional obligations.” I use this to scare the candidates into submission. If they misbehave I simply release them into the streets and lock the hotel door. Good luck out there!

 

 

 

I have been the supreme leader – or king as my followers call me – of the course for the past 3 years. The onus is on me to develop, curate, prod, shape, and refine the protocols for the exam. Naturally, I do a great job. This year we had an active hashtag following the course #GUMOCK13.

The urotwitterati were in heavy attendance from Dr. Loeb (@LoebStacy) gracing us with her fashionista presence, and the braintrust of Drs. Morgan and Kutikov (@wandering_gu and @uretericbud) were also there. Even my colleague Dr. Averch (@tdave) made a good twitter presence (a breakthrough). The break dancing and karaoke crooner Prof. Cooperberg (@cooperberg_ucsf) also had a defining presence.

The highlight for me was the profound talk from our guest motivational speaker Wayne Sotile. Just calling yourself a motivational speaker makes me yearn for a shotgun. As a non-believer I was thoroughly entertained and – more importantly – actually learned a great deal about the work/family balance. Some highlights with (tongue-in-cheek) twitter reactions as hyperlinks:

  1. It is not the absolute hours you work that impacts your family life it’s the mood you bring home with you. Tweets here….
  2. We work in a high-demand and low-control environment – that is the ultimate stressful situation. Tweets here…here
  3. Levels of intimacy plummet until the 10 year mark in your marriage then they increase markedly. Tweets….here

The course ended with overall good reviews. The candidates appeared well-prepared, fine young doctors and I was impressed. Still – with a fail rate hovering at 11% the stress levels are high for these physicians. It did not help that the hotel seemed unable to provide the comfort we all desire after working all day and drinking all night – a hot shower. Over 50% of the attending participants had to contend with a cold or tepid shower because of a failed water pump that the hotel scampered to fix. I didn’t mind the dishevelled hippie hair look and – luckily – it appeared to keep the Sheriff’s department at bay.

 

 

Benjamin Davies is Assistant Professor of Urology at the University of Pittsburgh; Program Director, Urologic Oncology Fellowship and Chief, Division of Urology Shadyside Hospital. His views are his own. @daviesbj

 

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“SEER-UROLOGY”

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

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

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

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

– it is readily available (click and download);

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

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

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

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

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

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

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

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

 

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

 

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