No Justice For Those Who Have Suffered Bullying, Discrimination and Sexual Harassment with Increased Surgical College Subscription Payments.

As Fellows of the Royal Australasian College of Surgeons, we pay annual subscriptions.  There is not a whole lot of practical choice but for us to pay these subscriptions if one wishes to be a practicing surgeon in Australia.  It has just been announced that the subscriptions for 2016 are going up and by a lot.  

Whilst the Consumer Price Index is sitting around 1.5%, it has just been announced that it will be going up by 6% to cover the cost of implementing recommendations of the Expert Advisory Group (EAG). 

As a reminder, the EAG had documented the serious extent to which bullying, discrimination and sexual harassment (BDSH) has existed within the male Anglo-Saxon dominated surgical establishment. 

Text from the RACS email advising of the fee increase

This increase represents a gross injustice for those who have suffered from bullying, discrimination and sexual harassment during their formative years in building a career in surgery.  Having been subjected to such treatment, they now must pay more for having had the privilege to have had such an experience.  

Meanwhile, the main perpetrators of such behavior remain unpunished and will not as they should, bear the brunt of the additional costs for the RACS to make good on their past behavior.  

These are fees that I paid in 2015 for the privilege of being a Fellow.

But the reality is that implementing EAG Recommendations is going to be a costly exercise and it is money that cannot be covered from its financial reserves.  Apart from these costs, the RACS remains at significant risk of litigation and financial settlements in the event individuals find the courage to commence legal proceedings.  The RACS doesn’t really have a choice but to fund the implementation of EAG Recommendations through a significant increase in Fellowship subscriptions and to apply this across the board.  

The fact that the RACS is understandably unable to adjust for who should or should not pay a greater or smaller contribution to cover these costs does not change the fact that it lacks justice.  It will undoubtedly leave a bitter taste for many Fellows who will begrudgingly pay their subscriptions for 2016.

I do have one axe to grind over the manner by which this increase is being applied. Rather than a general revenue surcharge buried into our overall subscription, I strongly believe the increase above CPI should be listed as a separate line entry to send a clear message to all Fellows that they are paying for the indiscretions of past and present surgeons engaging in BDSH.  Without this, the reason for the 'bumped up' subscriptions will be quickly forgotten.  The issue of BDSH and it being addressed by the EAG represents a very significant watershed moment in the history of the RACS.  It should not be devalued by being buried into general business.  I appeal to the RACS to make it a separate line entry.  Call it an "EAG Levy" or "EAG contribution" or whatever.

It is just important to make it transparent. Make it visible.  Do not allow it to be forgotten.  

Maybe it is all just about trying to make a good impression – I’m sure you will agree that the RACS needs to do everything it can do to improve the impression it gives to the general public and its Fellows.  It will cost the RACS nothing to implement this. The cost of giving a negative impression......... 

Related blog pieces

Actions must speak louder than words - RACS and the EAG

Bullying culture in surgery

Cardiac surgeons were the worst perpetrators of bullying behaviour

RACS Elections and Candidate Review

Election results shows that there is appetite for change in the RACS

Action Must Speak Louder Than Words

Medical Oncologist, Dr Ranjana Srivastava wrote on the subject of “how doctors treat doctors may be medicine's secret shame “ in the Guardian newspaper back in February 2015. About a month later, vascular surgeon Dr Gabrielle McMullin used a book launch speech to expose the problems of sexual harassment in the surgical profession.  She highlighted a story of where a neurosurgical trainee had refused sexual advances and subsequent to launching a formal complaint, her career was ruined. Her statement that  “she would have been much better to have given him a blow job” made national headlines in Australia.  This opened a can of worms and numerous stories suggesting a toxic culture of bullying, harassment and sexual discrimination (BDSH) were aired.  Under pressure, the Royal Australian College of Surgeons acted swiftly and appointed an independent Expert Advisory Group to investigate and to make recommendations.  Six months later, the draft report of the EAG  was published and results were “quite frankly shocking” as in the words of the President of the RACS.  The report was released in conjunction with a formal humbling RACS apology that has been uploaded to YouTube.

Prior to the release of the report, I had noticed a lot of discussion on social media and in real life on how the prevalence of bullying, harassment and sexual discrimination was overblown and stated to be no more so than in any other profession. Whilst the EAG Report makes clear that these assertions are absolutely wrong and that there is a special case for surgery that requires serious reflection and action.

On this basis, I then tweeted the following:- 

I followed the above tweet with the following:-

The tweet above generated interest and that evening was aired on the Lateline news program on ABC television.  This tweet does not suggest in any way that individuals with all of these attributes are part of the bullying and harrassment culture but think about it; they are the ones who are least likely to be subjected to it or to see it. If they chose to, they had the best opportunity to be untouchable.

As expected there is some criticism of the EAG Report as well as to my own comments.  The following tweets are more than likely to represent the tip of an iceberg for those who share similar thoughts. It is obvious that the vast majority in this camp have gone to ground since the release of the report but they will be observing closely and we can only hope that time will bring about attitudinal change.  I commend these commentators for publicly sharing their thoughts as it informs those of us who embrace the report as to the battles that lie ahead.

Some of the worst perpetrators of BDSH continue to be in roles of significant power.  We all know who they are and even subsequent to the EAG report, there will be reluctance to report or expose them.  How the RACS intends to deal with these perpetrators and exactly how they propose to change the toxic culture that exists within surgery is the major challenge ahead?  Whilst the RACS has worn the brunt of criticism for BDSH in surgery, hospital administrators have got away scot free.  They are equally, if not more, responsible for the reasons we have come to where we are now.  We eagerly await the final report of the EAG and detail of the proposed path forward.

_______________________________



Those of you who have read this piece may also be interested on this subsequent piece about elections to the RACS Council.

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)

Men with High Gleason Score Prostate Cancer should be given honest appraisals and expectations of outcomes from treatment

Men with a Gleason score 8-10 cancers have a significant chance of not being cured by radical prostatectomy.  Only in very exceptional circumstances would a man with a Gleason score 8-10 cancer be offered surgery if extent of disease scans (typically scans such as a bone scan and CT scan of the abdomen and pelvis) show evidence of spread to other organs.  

The vast majority of men with Gleason score 8-10 prostate cancer are offered surgery because there is no objective sign of cancer spread on scans and provided other factors such as age and concurrent medical problems are not likely to be an issue.  The big BUT is that if such scans fail to show signs of spread, it does not mean that spread has not occurred.  We know for a significant number (at least 30-50%) will have already had microscopic spread that is simply beyond the resolution of the scans to detect.  In other words, let’s say that some cancer cells from the prostate gland have managed to enter into blood vessels or lymphatic vessels and travel all the way to either the bones or lymph glands respectively. Remember that tiny deposits less than a millimetre is size would have no chance of being seen by a scan.  Before operating on such men, we need to be honest with them about this possibility.  They need to recognise that even if we are to successfully remove the prostate and have the prostate specimen margins free of cancer, it does not mean that they have necessarily been cured.  It is simply one of a number of hurdles that have been jumped over.

Having a Gleason score 8-10 prostate cancer is bad enought but if we look at men who have Gleason score 10 cancer in particular, we would regard these men as having a very high (not just high) risk of existing microscopic spread.  When these men undergo radical prostatectomy, a typical expectation is that less than 40% will be alive in 10 years without having signs of detectable spread of the cancer.  Even fewer will be alive with signs of cancer having returned as evidenced by their PSA blood test levels. In other words, most men with Gleason score 10 cancer will not be able to be cured.  This of course does not mean that these men should not be offered treatment with curative intent but it is an indication that appropriate counselling be offered and that men not be given false expectations about their prognosis.  It would be brave to suggest to such men that after surgery for a Gleason score 10 cancer, that they had ‘beaten it’ just because the surgical specimen showed that the excision margins did not have cancer at the edges (also known as positive surgical margins).  Another consideration is that these men who have arguable the worst prognosis, should be offered the opportunity to participate in clinical trials give them access to additional promising treatments that could offer them the best hope of overcoming these cancers. In my opinion, this is less likely to be offered in the setting of treatment by commercially driven surgeons.

There is more to treatment decision making processes than what the Gleason score is found to be on prostate biopsies. This blog piece attempts to show just one aspect of how we consider how we embark upon offering the best for our patients. 

The intention was not to make this blog piece sound like an argument against offering men with the most aggressive prostate cancers any treatment.  I regularly offer men with clinically localised 'high risk' prostate cancer treatment with curative intent.  In spite of our recognition that many will experience signs of failure to cure the disease, treatment offers these men their best chance.  Recent randomised control trial data shows that there is increasing evidence that treatment for this particular group of men makes a clinically relevant impact upon their survival.   

On a final note, I draw attention to a tweet from Dr David Samadi who is a 'celebrity' urologist who claims cure rates of 97% from prostate cancer surgery - he indicates that he has a patient who had just recently undergone surgery who had now ‘beaten the disease’ and is celebrating. You make up your own mind whether the patient has been given realist expectations on what the future holds for his cancer.  When the PSA starts rising, will Dr Samadi look after him now that the surgery is done, or simply refer him to another specialist (medical or radiation oncologist) to manage something that is no longer for him to look after? I do not know the answers to these questions but leave it in your mind to decide.

First Data Published from a Twitter Based Journal Club

It is pleasing to report the ongoing success of the International Urology Journal Club on Twitter.  The first 12 months experience has culminated in the publication of a manuscript in the journal European Urology.  This is the highest impact journal in the field of urology at 10.476.   

Link to the article is at:-

http://www.sciencedirect.com/science/article/pii/S0302283814001134

The manuscript is expected to be indexed on Pubmed any day from now.

The 48-hour asynchronous format has worked well for time poor surgeons who find it difficult to commit to a designated on line meeting time.  The format has also enabled global involvement given that time zones are no longer an issue.  This is not to cast criticism at the fixed time journal clubs.  As a relatively small surgical specialty, global involvement is necessary to have sufficient participation to make it viable.  Larger specialty interest groups enable regional fixed time journal clubs to flourish.

Following on from our model is the commencement of a respiratory and sleep medicine journal club (#rsjc) and one from the general surgeons (#igsjc). We are eager to see that they succeed.

We will see more online journal clubs and hopefully more data to quantify participation and value as a CME learning tool.