Getting a Second Opinion for Cancer Surgery

Second opinions for medical advice is nothing new and an accepted part of modern day medical practice. Practically all doctors are happy to provide second opinions for patients who seek them.  It goes without saying. My own surgical practice has a significant proportion of patients who come through such channels.  I usually ask them how they came to see me and in the vast majority of circumstances it was due to a recommendation from a friend or acquaintance who had been treated by me for the same condition.

Procedural specialties have particularly taken to having an on line presence for marketing of their services.  It makes a great deal of sense.  The more patients you can attract so as to be able to perform procedures, the more income that is generated.  Increasingly we are seeing offers of seeing patients for second opinions appearing on the websites of surgeons. Often there will be a form to complete where you type in your basic demographics and some basic information about one's condition which in turn invites the surgeon or designated staff member to make contact and subsequently encourage the patient to make an appointment.

What concerns me is that the second opinion marketing is mainly directed to newly diagnosed cancer sufferers.  These patients are vulnerable and on the steep learning curve with the acquisition of knowledge about their condition whilst trying to cope with the unknowns that lie before them. The second opinion websites often boast the achievements of the cancer surgeon being promoted but with very little possibility of the reader being able to verify the statements.  

We see statements such as 

“I was the first…” 

“I have done the most…..” 

“I pioneered the introduction of ……..”

Not uncommonly these statements bear zero relationship to the consultative or clinical or technical skills of the surgeon.

Rather than allow these websites seed one's mind about that the current care being received is inadequate, readers should instead consider why is it that such great efforts are being made to promote the availability of a second opinion service.  It is nothing more than a mechanism to goad patients into switching doctors when at their most vulnerable time. There should not be a need to promote that second opinion services are available as this goes without saying. If a surgeon had such a good reputation, why would they need to market for those second opinion cases. Do they have a deficiency of work that necessitates such action?  

There is nothing wrong with seeking out information on suitable surgeons to see for a second opinion but perhaps one could do better than a cold call to a website.  Consider other sources for recommendations. Start with the family doctor and additionally, staff who work at the hospital you would like to attend, if you know any.  Look the overall digital footprint of the provider and in particular independent sources of information.  When searching provider websites, be wary when there is over the top self promotion and whether you feel that a second opinion form is being thrust into your face. If it was from anything other than a medical provider website, you would probably consider it differently.  Remember that marketing is marketing and I'm afraid to say that even doctors partake in provision of information under the guise of marketing.

As a junior specialist, I recall being advised by a senior colleague that my patients would be my best ‘advertisement’.  All I had to do was to treat them with respect and compassion and to do what I would wish to have done for myself or my close relative. This was sound advice and I continue to uphold this principle.  I am grateful that my practice is sufficiently busy to never feel a need to market for second opinions - but why should I need to market for them when it is after all, a normal part of medical service provision.

Note- this piece is written in the context of Australian medical practice

Do You Know Who I Am.

It also happens in the hospital system but maybe not in the celebrity sense.

I never forget the moment when I was a junior doctor working in a major teaching hospital.  I was in a staff lift and the only other person in the lift and as far away as he could be from me was this cardiac surgeon.  There was no eye contact and I did not dare say a word or even a nod in acknowledgement.  Back then, these cardiac surgeons were the gods of hospital and quite frankly, I was scared of them. The lift opened on the next floor and wardsman trips over the slight step between the floor and the lift and bumped into him - yes, he dared to touch him (even though by accident).  Apart from a bit of a fright, definitely no physical harm done.  I remember clearly to this day how the cardiac surgeon then commenced a barrage of abuse of how dare he push him and does he know who he is.  The wardsman apologised multiple times to no avail with it only coming to an end when the surgeon had to get off at the next floor.  This would not likely happen in an Australian hospital these days - apart from being unacceptable behaviour, cardiac surgeons can no longer have the reputation of being a total jerk given that their livelihood is now so dependent upon the good will of cardiologists - what a contrast to my days as a junior doctor where I observed cardiologists literally begging surgeons to take on their cases for coronary bypass surgery. Stents have changed the dynamics of the cardiologist/cardiac surgeon relationship completely as well the behaviour of cardiothoracic surgeons.

I thought of the above story as a "Do You Know Who I Am incident".  It came to mind because of a more recent event involving myself.  I was coming in to operate after-hours and I was entering the theatre complex at the same time as another staff member. She was wearing her hospital ID card with her name fully visible and the picture on it clearly matching her face. I wasn’t wearing my ID card because I was wearing a T shirt and jeans and there was nowhere to clip it to.  I had it in my pocket.  The staff member asked me politely if I knew where I was and if I needed assistance or in other words, she was asking if I had a purpose to being in this restricted area.  I have been a surgeon at this hospital for almost 20 years and could have thought that the majority of people would know me.  I was initially surprised to be asked but instinctively, I took out my ID badge and showed it to her and explained that I was coming in to do a operative case. Given that she worked after hours shifts, she would not see me on a regular basis and sporting a scruffy Mo for the month of Movember probably did not help.  She did the right thing.

These thoughts lead to another thought about DYKWIM in hospital systems and the answer is often “No”.  Staff members are increasingly hiding their names on their ID badges - easily done under the guise of the badge having to attached to other essential badges or being turned the wrong way around. When you call a ward, how often does the staff member indicate who is on the phone. So much for Garling Report recommendations on staff identification.

(Typical hiding of the name on a ID badge of a hospital worker.  I took this sneak picture in a hospital lift)

Rolling Stones in Sydney on 12 November 2014 at Allphones Arena. Another brilliant performance spectacular.

Mick Jagger announced to the audience that the Rolling Stones had been coming to Sydney for 50 years and that tonight’s performance was the 20th occasion that they had performed in this city. The last occasion that they had performed in Sydney was in 2006 at the massive Olympic stadium next door. We could all have been forgiven in thinking that the 2006 tour may well have been the last to Australia, as they were regarded as being somewhat older (make that a great deal older) than what we usually refer to as a veteran rock stars. With all of them 8 years older, would they still have it in them.  

Mick Jagger aged 71, Keith Richards 70, Charlie Watts 73 and the youngest one Ronnie Wood 67 demonstrated to an also ageing audience that there has been no diminution in their ability to perform, entertain and please a crowd. For many, hip and knee joints were pre-marinated in Celebrex and glucosamine in preparation for an evening that had been especially anticipated after the cancellation and rescheduling from the original March date due to the untimely death of Mick Jagger’s partner earlier in the year. There was also the concern that Mick’s voice would not 'make it' after earlier last minute cancellations of dates in the Australian tour due what was described as a serious throat infection. 

The Sydney audience had nothing to fear. When the Rolling Stones bounced onto stage and launched into Jumping Jack Flash, the entire audience were up on their feet and there was no turning back. All fears about throat infections evaporated as Mick belted out the chorus to the song with crowd singing in unison. Behind the stage, there was a huge monitor that provided image resolution almost unheard of at such a large venue.  Facial expressions were crystal clear and yes, the Rolling Stones indeed had the look that they had been performing for over half a century.

The screen also provided the opportunity for a cheeky animation during the equally cheeky “Honky Tonk Woman”.  The animation featured a giant bikini clad woman walking the streets of a city and then climb a building, very much in the spirit of King Kong. Planes flown by cunning gorillas began their attack once she had climbed to the top of the building.  Guns aimed at her bikini straps soon saw to exposure of her breasts and with a slap of one of the planes, it went out of control and as the song moved into the final bars, it went crashing into her breasts.

As has become a common feature of Rolling Stones concerts, Keith Richards was given an opportunity to headline a couple of songs.  In spite of his fall out of a coconut tree and subsequent head injury, it was clear that his sense of humour had not diminished when he announced 

“great to see you ….(pause)…great to see anything” much to the crowd’s approval.

The focus of the play list was very much on the classics. Other bands that enter into self indulgent sets to satisfy their own egos rather than the wishes of their fans have much to learn from the Rolling Stones. We could argue all day on essential classics that had to be played but for me, they hit the spot.  Some of these included, Sympathy for the Devil, Paint It Black, You Can’t Always Get What You Want, It’s Only Rock and Roll.

Sydney 12 November Play List

Jumping Jack Flash (single, 1968)

It’s Only Rock ‘N’ Roll (But I Like It) (from It’s Only Rock N Roll, 1974)

Respectable (from Some Girls, 1978)

Tumbling Dice (from Exile On Main Street, 1972)

Sweet Virginia (from Exile On Main Street, 1972) (Request)

Bitch (from Sticky Fingers, 1971)

Paint It Black (from Aftermath, 1968)

Honky Tonk Woman (single, 1968)

You Got The Silver (from Let It Bleed, 1969)

Before They Make Me Run (with Keith on lead vocals)(from Some Girls, 1978)

Happy (with Keith on lead vocals) (from Exile On Main Street, 1972)

Midnight Rambler (with Mick Taylor on guitar) (from Let It Bleed, 1969)

Miss You (from Some Girls, 1978)

Gimme Shelter (from Let It Bleed, 1969)

Start Me Up (from Tattoo You, 1981)

Sympathy For The Devil (from Beggars Banquet, 1968)

Brown Sugar (from Sticky Fingers, 1971)

ENCORE

You Can’t Always Get What You Want (from Let It Bleed, 1969)

(I Can’t Get No) Satisfaction (from Out Of Our Heads, 1965)

Following the completion of the show, it was difficult to not feel Satisfaction.  Once again,  the Rolling Stones had lived up to their reputation as arguably the greatest performing rock band in history. This may well have been the last time that we will see them but if there were to be another time, there would be no shortage of willing ticket buyers, even at record prices of $577 per ticket.

Rodriguez Touring Down Under for Possibly the Last Time - Review of Sydney Opera House Concert Hall performance 23 October 2014

Rodriguez enjoyed considerable success as an artist in Australia, New Zealand and South Africa.  It is interesting how there was such little interest in his work in his home country of the USA.  Maybe things would have been different if his time was in the internet era rather than in the 1970’s when radio airplay and record/cassette tape distribution was 100% at the mercy of record company executives.

After limited success in 1970’s, he returned to a reclusive existence in Detroit until in the late 1990’s, when a dedicated team of fans from South Africa began their search for the “Sugar Man”.  This re-discovery is what has brought him back into our lives.  He is now about 72 years of age and regularly tours the strongholds of his fan base.

When his latest concert series for Australia and New Zealand was announced, fans were quick onto their keyboards to acquire tickets.  The general feeling was that this was likely to be his last tour down under. Initially two performances at the Sydney Opera House Concert Hall were announced and when tickets went on sale, they were sold out in about 15 minutes.  There was the usual anger associated with ticket scalping when tickets were almost immediately and readily available on Ebay Australia at approximately 4 times the original ticket selling price.  An additional three performance dates at the somewhat less salubrious Enmore Theatre were subsequently announced.

Our small group of curious Rodriguez fans attended his performance on Thursday 23 October 2014.  On a Thursday evening, the late start performance time of 9 pm meant that getting into town was less stressful than would normally be the case after a full day at work.  It was advertised that there was to be no supporting act and that was fine with us.

To our surprise, there was a single song support act from a person unknown and never identified to us.  She quietly entered the stage and sat on a stool with an acoustic guitar.  She looked as though she might be related.  We politely applauded after a short and slightly off key performance.  Just as quietly, she left the stage and now, anticipation was at an all time evening high.  Our bucket list check box next to Rodriguez’s name was about to be ticked with another lifetime achievement confirmed. 

Slowly, a dark figure plodded through the shadows supported by two of crew members.  The crowd erupted in cheers and screams as the legendary Rodriguez was lead out onto centre stage.  It was obvious that his eyesight is at least as limited as has been reported.  Although we were only in the fifth row from the front and in the middle of the row , we could barely see his face.  He was wearing a large sun visor that protruded some 15-20cm beyond his hairline, which cast a Mordor like shadow over any facial features. 

Considering that he used to play with his back to an audience, we will take his on-stage shyness as having come a long way.

He said nothing but gave a half wave of acknowledgement to the audience before launching into songs from a back catalogue of two shortish albums.  A couple of filler cover songs helped take his total on stage performance time to around 75 to 80 minutes.  He played what the audience wanted to hear, which was essentially every track on the album Cold Fact. This album had a place in every self respecting record collection of the 1970’s.  He barely said a word to the audience although at one stage, he did mumble the names of his supporting band members.   He did leave the stage after about 70 minutes of performing for the obligatory request that the audience beg for an encore.  Just before the second song of the encore, he mumbled into the microphone ‘this is going to be our last song’ and these were possibly the first intelligible words that I could make out the whole evening.  He and his crew then bowed to the appreciative audience.

I enjoyed this concert and had no regrets about being there that evening.  The reality was that there was an elderly man on stage in the concert hall of the world famous Sydney Opera House who called himself Rodriguez playing a series of ‘okay’ covers of this demi-god of a man who called himself Rodriguez back in the 1970’s.  His follow up album to “Cold Fact” was actually called “Coming From Reality” but I’m going to put all that aside and remember him with the same romanticism and adulation as the fans who have quite possibly have seen him perform for the very last time in Australia.

First Changes of Suprapubic Catheters. A Need to Change a Stupid Policy

A suprapubic catheter is a tube that is placed through the lower abdomen into the urinary bladder as a way of managing problems associated with the storage of urine or emptying of the bladder.  Placement is a minor surgical procedure and essentially involves filling the bladder to capacity and then literally stabbing the lower abdomen with a sharp pencil like device (trocar) through which the catheter can then be introduced.  A syringe port allows us to inflate a balloon located towards the tip of the catheter with water and this helps hold it in place.

(Image from http://www.registerednursern.com)

Within days, a scar tissue type reaction forms around the tube and within a couple of weeks, there is  channel lined with scar tissue which we refer to as a tract.  This channel or tract acts a conduit through which the tube can be easily changed. Patients who have these suprapubic catheters (SPC) ideally should have them changed every 4 to 6 weeks.  Changing these catheters is a simple task and expertly performed by nurses.  In hospitals where there resources do not have such nursing expertise, the task is often relegated to the most junior and least experienced of medical officers, interns.

A policy regarding the first change of a SPC came into being a number of decades ago and the exact origins of this policy are unlikely to ever be determined.  The policy is that the first change of the SPC should be performed in a hospital. And thereafter, SPC changes could then be done in the community. It is one of those unwritten policies that entered healthcare folklore in the total absence of evidence.  It is a folklore tightly held by a number of administrative or officious types who want nothing of a challenge to this dogma.

I recently had a twitter rant over this as a result of an elderly patient of mine being literally forced to return to hospital for a simple change of SPC that could have been done in the community.  I could not care less about the wastage of the precious hospital resources but what I did care about was the enormous disruption associated with having to get the patient prepared and transported to hospital to have a simple procedure that takes about 10 minutes to perform.  We tried reasoning with the person in charge of the local community nurse services to only receive a blunt response that it was POLICY that the first change of SPC be carried out in the hospital.  I asked for where this policy is written but we all know the reason why this request was not responded to  - obviously there is NO SUCH WRITTEN POLICY. 

Okay, are we subjecting the patient to risk by doing the first SPC change in the community or are we placing the community nurse under untenable litigation risk?  Of course not.  What is the worse that arise from a bungled SPC change?  The catheter may not be able to be replaced because the tract was too tortuous or the catheter balloon might be blown up in the middle of the tract instead of in the lumen of the bladder.  This happens rarely and something that could just as likely occur in the hospital.  If a problem occurs, is it a dire medical emergency? No. A urethral catheter can generally be placed until a replacement SPC procedure can be arranged or they can be sent to the hospital.  The long term sequelae from such an event – remote if anything could be thought of. 

Outside hospitals, it is the community nurses who perform regular catheter changes week in week out.  They are highly skilled and to state that they lacked the capability to do a first change of catheter is nothing short of insulting.  I am sure that both you and I would much rather have a skilled community nurse perform a catheter change at home rather than trudging our way to hospital to have a less experience intern medical officer do the change.  Interestingly, many of the community nurses that I have interacted with are in themselves quite happy to do the first change but are not permitted by their superiors who remain opposed to change. 

Lets get back to evidence.  A highly talented urology nurse consultant, Colleen McDonald from Westmead Hospital, performed a study onirst changes of SPC in the community versus that performed in the hospital environment. I really do not need to go into the detail of what the study showed.  The title of the paper says it all.

McDonald.C & McFarland,M. (1999).  First Suprapubic Catheter Change...from Hospital to Community....A Clinical Practice Change.  Journal of Stomal Therapy Australia, 20(3), 14-15

Dr Glatter and Dr Samadi - Together in Forbes!

Dr Robert Glatter is a medical doctor who is a regular contributor to Forbes, a huge global print and on line portal for news and opinion.  

He started writing for Forbes in February 2012 and has been contributing on almost a weekly basis.  It was not until December 2013 that he wrote his first piece on prostate cancer entitled "Inflammation Noted In Repeat Prostate Biopsies Linked To Reduced Future Prostate Cancer Risk".  This was actually quite a well written informative piece.

He next wrote about prostate cancer on 7 March 2014.  All of a sudden, prostate cancer has become the flavour of the month with further articles on 6 April 2014, 10 April 2014, 21 April 2014, 4 June 2014 and the most recent piece on 20 September 2014.  

It seems rather odd that there is this sudden interest in prostate cancer.  He does write a lot of articles on other subject matters but the frequency of prostate cancer topics has been disproportionately higher during the course of this year.  This made me wonder as to whether there was some explanation for this.  The most glaringly obvious common binding feature about all of his articles on prostate cancer this year has been the mention of Dr David Samadi.  

Briefly, Dr Samadi is a celebrity urological surgeon who has a program on the Fox Channel called Housecall.  He cites amazing figures for prostate cancer surgery outcomes that defy the academic literature, particularly with his claims of providing a 97% cure rate from prostate cancer. He also earns a great deal of money and was the highest earning doctor in 2012 according to a New York Post investigation stating "The city’s top earner was urologist and prostate-cancer specialist Dr. David ­Samadi, whose 2012 compensation came to $7.6 million."

Okay, back to Dr Glatter.  Who is he?  I have never met him and only discovered him through reading articles on the Forbes website where my friend and colleague Dr Benjamin Davies is also a contributer. The easiest way to start is Google.  The first hit is his work at Forbes.  The second hit is his twitter account.  His bio states the following:- "Emergency Medicine Physician-Lenox Hill Hospital /Media Spokesperson/Forbes Contributor/WebMD Editor/DR 911 housecall practice" and also provides a link to a website.  

Hang on a second - Lenox Hill Hospital?  Isn't this where Dr Samadi does his work?  I don't know the relationship between Dr Glatter and Dr Samadi but if there is any conflict of interest, it should be declared on the Forbes website.  In particular, the fact that Dr Glatter works at Lennox Hill Hospital is not listed anywhere that I can find on the Forbes website. It may be all innocent but in the context of this sudden increase this year in prostate cancer articles, all of which lavishly cite Dr Samadi, raises questions on transparency.

On a final note, the most recent article from 20 September 2014 is a far cry from Dr Glatter's excellent first article on prostate cancer in December 2013 (incidentally, he does not actually mention Dr Samadi at all in this first article).  Not only does he promote the hashtag #samadichallenge but also makes ridiculous comments such as "In case of a positive diagnosis, urge men to seek Treatment immediately" - this demonstrates a lack of insight of the biology and natural history of prostate cancer.  It goes totally against the direction taken by leading urologists which is to be less aggressive in treating clinically significant prostate cancer.

Statements like "Symptoms of prostate cancer may include changes in urinary function including a burning sensation, blood in the urine or semen, frequent urination, as well as a weak or interrupted flow" only create fear and alarm amongst men with urinary symptoms.  It is uncommon for prostate cancer to cause urinary symptoms when clinically localised - any clinician would know that it is the non-cancerous condition of the prostate called benign prostatic hyperplasia (BPH) that causes the symptoms.  It is these symptoms that lead men to get checked by their doctors who then serendipitously diagnose their cancers.  It is not a cause effect relationship.

The hashtag #samadichallenge with a doctors name in it? Is the aim to achieve awareness about the doctor or about prostate cancer? I am happy to be instructed on this. 

And Dr Glatter, is there any relationship of any sort between yourself and Dr Samadi? If so, be transparent and declare.  If not, state that to be the case.  It is hard otherwise to not be suspicious about the sudden interest in prostate cancer articles where Dr Samadi comes across to me as being featured expert in each of them..

Some Tips on Successful Conference Tweeting

Recently, I have heard disappointed comments about the lack of conference tweet activity for given healthcare conferences. On each occasion, it seemed fairly obvious as to why this was the case.  Having participated in quite a number of conferences by the way of Twitter, I have made a number of observations of what seems to make the difference.

1. Must Be Good WiFi

This is perhaps the greatest impediment to the success of conference tweeting. Frequently, the systems are tested when the conference centre is empty and of course everything works fine.  As soon as the conference commences and people are using the system, it comes to a grinding halt.  Once again, there is no greater impediment to conference tweeting than the lack of adequate WiFi.

2. Conference Twitter Account

This account would help define to observers what the conference is and what official conference hashtag has been assigned. This account should tweet out updates, announcements as well as interact with key twitter accounts through replies, favourites and retweeting.  This account can also act as a catalyst for activity if the twitter stream is quiet.  With this comes the assigning of a person to look after this account during the course of the conference.

3. Appropriate Hashtag

The hashtag should appear relevant to the conference and should use the minimum number of characters.  Ideally the number of characters should be no more than 6 or 7 characters.  Any more detracts from the precious 140 character count and would limit the information that can be shared to the hashtag audience.  Only one hashtag should be assigned.  Sub-hashtags only lead to confusion and in combination with the main hashtag, chew up valuable characters.

An example of a misleading hashtag was when the #uro12 was assigned to the American Urological Association meeting when the hashtag of #AUA12 would have made much more sense.  An example of wasted characters is the Royal Australasian College of Surgeons using #RACS2014 when #RACS14 would have been more appropriate.  With the RACS meeting this year, there were no fewer than 4 hashtags being used by various conference tweeters and the twitter stream from this meeting was a disaused the hashtag #CFAConf14.  A long hashtag hampers expression and detracts from participation. Including the space, #CFAConf14 chewed up 10 characters when a simpler #CFA14 would have been appropriate. With the 2014 RACS meeting mentioned above, there were no fewer than 4 different hashtags being used by various conference tweeters and the twitter stream from this meeting was a total mess.  

4. Engage KOL Twitter Users

Conference organisers should seek out the key opinion leaders who are active on twitter in advance of the meeting.  Organisers could consider requesting specific accounts to be assigned to tweet proceedings from specific sessions.  Having predetermined users involved creates a core group of participants.  People are reluctant to be a sole or one of only few tweeters for a conference. 

5. Twitter Boards

Strategically placed monitors showing the twitter feed are often a magnet for the attention of conference attendees.  The most organized meetings will have such monitors outside every meeting room as well as in the registration and trade exhibition areas.

6. Twitter Instruction

At the American Urological Association annual meeting this year, opportunities for small group or one-on-one instruction on twitter basics and how to conference tweet.  Alternatively having a course or conference session on social media as was the case at the European Association of Urology congress (#EAU14) and Urological Society of Australia and New Zealand ASM (#USANZ14) respectively was particular done well. These sessions were not only well attended but also created an explosion of activity on the conference hashtags during these sessions.

7. Publicity

The role of social media at the conference needs to be publicized and prominently implied.  The hashtag should appear on all background slides that appear at the beginning of conference sessions as well as all publications such as the conference proceedings and conference badges as examples.  Such publicity adds negligible if at all any cost to the conference but is returned many times over by increasing the engagement of those attending as well as reaching a much larger global audience in virtual attendance.

8. Register on Symplur

Registering a health conference hashtag with the Symplur Healthcare Hashtag Project is free.  This provides access to basic twitter statistics.  Tweeting these during the conference often generated interest when enormity reach of the conference tweets is realized.

There are probably other ideas that would enhance conference twitter activity that I have forgotten about so please feel free to add your comments.  One example is to allow participants to ask questions via twitter - on occasions I have actually offered this to the audience when I have chaired sessions. A few questions do come in although this is not a deal breaker for twitter engagement at a conference. I look forward to your comments.