Robert H. Farnsworth - my hero in urology

At the Gala Dinner of the Urological Society of Australia and New Zealand (USANZ) Annual Scientific Meeting on 13 April 2015, a special man was the recipient of the Society Medal (USANZ Medal). 

Robert Farnsworth's achievements are well known within my profession.  

The next few tweets sum up my thoughts

I was in my final year of urology training when I worked for Bob. Just some of the things that I recalled from my time with him included

1. treating everybody with equal kindness and respect, whether a janitor or internationally acclaimed professor
2. never ever making me feel bad when there was something that I could have done better
3. always having time for me, even for what in hindsight were trivial matters (even if this meant him going home later than planned)

When I returned from additional training abroad, I entered independent practice and there were a number of occasions that I would call him for clinical advice. Even though I was now his competitor, he continued to be so willing to share his wisdom.

It was a proud moment for all of us who have had the privelege of training under him to see him awarded the USANZ medal.  He's the closest you get to a Mr Holland (as per the movie Mr Holland's Opus) that would be possible in the Sydney urology scence. 

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)

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

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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)

Creating One's Own Luck

I’ve been inspired to write this blog piece after seeing the wonderful Prezi presentation constructed by Dr Marni Basto on Urology Social Media 101.  It really is a fantastic presentation that has gone viral throughout the international urological community.  Although she is yet to commence formal urological training (she deferred commencement by a year to work on her Masters of Surgery), she now has an international reputation for her skill and understanding in the area of social media and associated technology.  When you look at her presentation, it is obvious that she is an individual who has great clarity of thought and able to develop depth of understanding of a given topic – these types of skills are easily translated to any area of medicine.  One can only sense that she has a bright future ahead of her. 

I’ll now move onto what her Prezi has got me thinking about.  Over the years, I have observed a number of young urologists returning to Australia after completing post FRACS (surgical qualification) training.  I commonly see this expression of despair that they cannot find a coveted public teaching hospital position, which is always the best way to kick-start a new practice in surgery.  Here you have access to multidisciplinary care, senior collegial mentorship, teaching of surgical trainees and medical students as well as research opportunities.  These positions are in limited supply and only come about when they are to replace a surgeon who has either resigned or retired or if the waters have parted to create a new position. 

Some of these young surgeons feel a sense of entitlement that they should be able to just walk into such a position.  I recall one surgeon who complained that he was a subspecialized surgeon who had done his special post fellowship training and could not understand why no teaching hospital was making any particular effort to find space for him within their units.  Another said to me that he was technically a much better surgeon than some others who had received teaching hospital appointments. When I thought about their achievements, they had not made a single presentation at a major urological meeting, had not published a single paper whilst away and since returning home, had contributed little to the profession (eg could do volunteer work or perform committee work with the Royal Australasian College of Surgeons or Urological Society of Australian and New Zealand).   

And here lies the point that people can create their own luck.  I can usually make a prediction before one of our trainees goes overseas or interstate for post FRACS training, as to who will literally walk back into a teaching hospital position. When I look at trainees who have done research with me, the ones who reliably kept to deadlines and completed their assignments were the same who did such when abroad and the same ones who eventually found positions in teaching hospitals.  These were individuals prepared to go the extra mile and create their own luck.  The trainees where I had to repeatedly provide gentle reminders to complete tasks to help their own careers have more often struggled.   The ability to create luck had already been defined early in their careers.

Back to Marni.  She has already passed the hurdles to be selected for urological training and is yet to commence whilst she does her Masters of Surgery.  You know that Marni has already begun to create her own luck and I am excited that we will have a future urologist who will be more than just ordinary.

Addendum for Blog Post September 2012

Addendum 31 March 2013 to September 2012 Blog Piece


The main reason I have decided to put this up on my blog is that the issue of anonymous tweeting is running riot in doctor circles over recent GMC-UK recommendations. Rather considering this a new piece in isolation, I regard it more as an addendum to my blog post from September 2012.  If you read the earlier blog, this will make a lot more sense.


A doctor on twitter who had read this blog piece recently, sent me the following cropped mobile phone screenshot by email (easy to track down via either one of my publications or through the University of Sydney website - you see, I don't try to hide) that was taken of a tweet made about 10 days ago - comment was made that it was seen from a re-tweet as this person like myself, does not follow @otorhinolarydoc.  It wasn't sent to me anonymously but there is nothing to be gained by mentioning who that person was.  Interestingly, it is noted that he has since changed his user name and from this I gather that he is perhaps no longer a trainee and now a qualified ENT surgeon.  Whilst we can say it is a bit of harmless banter, it is essential that readers understand that M & M are an essential form of quality control and good clinical unit governance that must be taken seriously.  The purpose is not to chastise this tweeter but raise the question as to whether anonymous tweeting for entertainment purposes potentially undermines public confidence in the medical profession.  Whilst it might seem minor, you can give an inch and before you know it, you have a mile.  Once we lose public opinion, it is something unlikely to be regained.  Another issue is that of mentorship - registrars often copy the behaviour of their mentors - perhaps there is some shared responsibility between himself and his former mentors if these are the attitudes with which he has been raised as an ENT surgeon.  Let you be the judge on this.  

A Hypothetical Introduction to Research

Trainee: Hi Prof, I am interested in doing a research project now that I have my final exams out of the way.
Prof: No problem. Why don't you go talk to Doctor who has been working on a personal series of interventions for the last 10 years and needs somebody to write it up.
Trainee: Thank you.

Trainee: Hi Doctor, Prof said that you had your intervention series that you were keen to write up.
Doctor: Perfect timing. It is now mature enough to be written up.

Yada yada yada between Trainee and Doctor and a few months pass.

Doctor: Great job with the data analysis. We are close to the write up. Lets get the first draft together.
Trainee: Great stuff.

Prof: I heard that Trainee has done a great job so far. We should work out authorship. Trainee can go first and you second and I'll be last and senior author.
Doctor: Whilst I appreciate your referrals, this is my personal series and labour of love that I have worked on for 10 years and I should be senior and corresponding author.
Prof: But I was the one who introduced Trainee to you so I should be. It was my idea to push you along with getting the intervention written up.
Doctor: I was planning to have it written up in any case.

Yada yada yada between Doctor and other departmental colleagues who agree that Trainee should be first author and Doctor the senior and corresponding author.

Phone rings.

Prof: I have a solution to this impasse
Doctor: Great, I have been concerned about the friction this is causing in the department.
Prof: This will solve the problem. Why don't you go first author and take the credit for your hard work over 10 years and I go last and corresponding author.
Doctor: But what about Trainee?

Trainee: WTF???

Trainee loses interest.  The message is out that the paper is damned with misfortune and politics so no other takers to finish it off.  The paper does not progress any further.

DISCLAIMER: This is of course a completely fictional tale and I could not possibly imagine it ever occuring in real life.  Thanks for reading and follow me on Twitter  @DrHenryWoo