Saturday, April 26, 2014

Sydney Punching Way Below Its Weight in Academic Urology - A Need For Change

A Canadian urologist who is one of the most prominent academics in the field has often been quoted as stating that the two cities in the world that really punch below their weight in terms of urological publishing and international academic recognition are Sydney and Rome.  Sadly, I must agree with him. I can’t really speak for Rome but I can speak for Sydney.

I recently had a letter published in the Australian and New Zealand Journal of Surgery that quantifies the academic publishing output of Level D and E ‘titled’ academics in Melbourne and Sydney.  This refers to those who hold a position of Associate Professor or Professor respectively.  For some, the position may be honorary and given in return for doing a bit of unpaid teaching to medical students – these honorary titles are usually prefixed by the term Adjunct, Conjoint or Clinical.  Academics who are employed by the universities usually have their title followed by a descriptor such as ‘of surgery’ or ‘of urology.’  The requirements for a paid position are usually significantly greater than for honorary titles but some holders of honorary titles should not be underestimated for their academic contributions which at times may well exceed those in paid positions.

So back to my letter.  What I did was to search and manually identify any academic writings indexed on Pubmed/Medline that could be attributed to authors who carried a Level D or E title and made comparisons between Melbourne and Sydney.  The results were not surprising but also disturbing.  There were a similar number of those with level D or E academic titles in both cities but the overall publication output from Melbourne was more than double that of Sydney overall and per annum.  In Sydney, there was only one urologist who was publishing on average in excess of 5 pieces of academic writing per annum over the past 5 years compared to Melbourne where there were at least 3 with this level of output.

How do we explain this?  Both cities have public hospitals funded by similar models and both have excellent universities with well regarded medical courses.  Both cities have urology departments that are equally poorly funded and poorly supported by the public hospital system and universities.

I do have some thoughts as to why this is the case and of course many will beg to differ.  Some may unkindly suggest that Sydney urologists are so consumed by private practice and making money and to the extent that any academic pursuit is well down the list for matters of importance.  Whilst there might be some truth in this, it is clearly not as simple as this.

Whilst the funding models for public hospitals in Sydney and Melbourne are globally similar, there are some differences in how things have become structured over the years.  As a result of funding cuts to support public outpatient departments in NSW hospitals, the vast majority of patients seeking urological care must see a urologist in their private rooms before being referred to a public hospital for treatment.  This drives work to the private rooms and the high cost of operating a private practice creates this imperative to work hard in the rooms to cover costs.  There is poor separation of private and public consultative practice compared to Melbourne.  In other words, urologists are spending time in their rooms trying to cover their costs are probably too busy to think about academic pursuits.

What of university funded positions? Some surgical specialties such as vascular surgery, colorectal surgery, breast/endocrine surgery and upper gastrointestinal tract surgery will have paid academics in almost all of the teaching hospitals at the expense of subspecialties.  But the situation is no different between Sydney and Melbourne. 

Is anything else different?  The most striking difference is the manner by which public hospital urology units have been established.  There is a common thread amongst all of the key academic centres in Melbourne.  In each of these, the Heads of the Urology Departments were all appointed when relatively young in their careers and these positions tied in with academic appointments.  These urologists were able to carve out academically strong departments in their own style.  To name a few, we have Professors Damien Bolton, Mark Frydenberg and Anthony Costello.  They all built departments from an almost embarrassing levels of infrastructure and nothing more or less than what any department in Sydney would have had when they began their academic tenure.  They have now mentored a fossil layer to whom they can hand over the baton and those mentored, already hold major positions within international organisations and urological journals and are already well established international key opinion leaders.  Can we say the same about Sydney?  Sadly not and hence the comments from our Canadian friend. Within an established academic environment as has been created in Melbourne, it is substantially easier to maintain the academic throughput but if there is none to begin with, as is the case in just about every urological unit in Sydney, what hope is there.

To effect change in Sydney, future academic leaders need to be identified and offered positions of department leadership with associated university positions while they are young energetic and full of bright ideas.  They will make mistakes and will grow as a result of them.  What they do create will outweigh any risk associated with placing a relatively inexperienced leader into the helm.  These leaders need to be supported to grow their departments in their own style and with a long term vision in mind.  To move forward, either current department heads should make way for new leaders or as they retire, appropriate succession planning for a strong academic head should be in place.  Over the years I have seen numerous Sydney trained urologists who could have been great leaders that could have steered Sydney public hospital units to the same level of international recognition as those in Melbourne but have been lost to battlefields of private practice. Following their post fellowship training, they return to public hospital units with no existing academic infrastructure or capacity to develop such infrastructure.

As far as academic urology in Sydney is concerned, we punch way below our weight.  The Melbourne situation demonstrates precisely where we should be and precisely what is possible if there is a will to effect change.

(Footnote - some grammatical corrections have been made since first published. I really should proof read a little better)

Sunday, April 6, 2014

Tips For Junior Surgical Registrars by Dr Kesley Pedler

This is the first ever guest blog piece on "Surgical Opinion."  It is written by Dr Kesley Pedler who has just completed the Surgical Education & Training (SET) in Urology.  We are on the brink of seeing her enter urological practice and in this piece she shares tips on the day to day work as a surgical trainee.  I think you will all quickly gather that Dr Pedler is going to be one of those individuals who will create their own luck. - Henry Woo


Tips for junior registrars (SET 1 to 3): things I wish I knew when I started my training

This week I completed my SET Urology training! It has been quite a journey and I have learnt a great deal from my many mentors over the last six years.  I have decided to share a few tips which I have figured out over the last few years which I have found helpful in performing my day to day job as a urology registrar. 

These tips will help you become an organised, competent, efficient and mature registrar which means your consultants will be more likely to increase your level of responsibility both inside and outside theatre which will allow you to learn more!

Be organised! ( especially for operating lists)

·       Know the cases beforehand:
o   This includes the indication for the procedure and results of relevant investigations .
o   This will help you understand the decision making process that has lead to your consultant bringing the patient to theatre.
o   Make sure you review the relevant imaging beforehand and display in the theatre (e.g. for a radical nephrectomy- make sure the CT is displayed demonstrating the tumour and also the vascular anatomy)

·       Know what major cases are coming up a few weeks in advance
o    Your consultants will expect you to know
o   This also gives you time to prepare for the case and read-up in advance. If you demonstrate understanding and knowledge of the operative steps, your consultant will feel a lot more comfortable letting you perform a significant part of the operation.
o   Befriend the administration staff in the bookings office in order to preview lists ahead of time.

·       Be punctual
o   Ensure you allow enough time to arrive on time (or even early) to theatres
o   This means scheduling enough time beforehand to complete ward rounds
o   Unless there has been an unforseen emergency elsewhere, avoid arriving at your theatre list after your consultant (and they will take note especially if this is a recurring occurrence).

Keep a notebook of details of operations
·       I have found it useful to keep a record of the particulars of certain procedures. This includes pre-op preparation, patient positioning, intra-operative details of each step including details such as particular sutures used and post operative management.
·       This can either be in the form of a notebook or keeping copies of select operation reports
·       This is invaluable since it will be a good reference to read before doing the particular case next time
o   Your consultant will be impressed you recall the details of the procedure and will be more likely to let you do more the next time.
o   You will often find that different consultants will perform the same procedure slightly differently and you will be expected to perform the procedure in their specific fashion.
·       This is also a useful resource in preparation for the operative viva in the fellowship examination.
·       It may also be useful when starting consultant practice- you can pick and choose which way you will perform a particular procedure according to what you have seen work well during your training.

Be organised outside the operating theatre
·       Keep a list of your inpatients close at hand
o   It is impossible to remember all details
o   I use this to record important information such as drain outputs, salient blood results and pending investigations.
o   I then refer to it when speaking to consultants about their patients (and jot down instructions and changes to the plan)

Think before calling your consultant
·       Have a definite purpose to your phone call
·       Think about how you will present your case before dialling.
·       Articulate your plan of management (even if you are not sure, suggest what you think is appropriate, it will help your learning even if you are incorrect)
·       Have a list of all your consultants patients plus any other issues you need to discuss so that all issues are dealt with in one phone call

Think beyond the acute hospital admission
·       This can take a little time to develop since as junior doctors we are only exposed to the acute hospital setting which is predominantly focused upon discharging patients
·       Think about what long term follow-up, investigations and future procedures are required. This will help you learn to manage the patient completely- a skill necessary in consultant practice and this will be assessed in the exam.

Look after yourself
·       Try to get enough sleep, eat and exercise when you can (although this is not always possible)
·       Have a proper holiday (i.e. going away and not thinking about study or work) at least once a year.

Remember that there is more to life than just urology!
·       Don’t neglect the significant people in your life (family, partners, friends). This is what is really important in life and it can be difficult to keep this a priority when your work and training often clash with other life events. 

·       The last thing you want is for the significant people in your life to feel of lesser importance than your work.

     (This piece was originally published in the USANZ Training Newsletter called "Bridges" in  February 2014. Dr Pedler has been kind enough to allow this piece to be reproduced here)