How I Almost Did Not Become a Urological Surgeon.

If anybody had suggested that I would become a urologist when I was a medical student or even as an intern, I would have told them that they were dreaming. My exposure to the field was fairly minimal during my time as a medical student and the thought of operating amidst urine just did not spark the slightest interest.  If anything at all, I was interested in becoming a plastic surgeon or a general surgeon. 

At the commencement of internship, we were all allocated to do at least one surgical term out of the 5 terms for the year. I was allocated urology for my surgical rotation. It was known to be horrendously busy and quite ironically, the two interns allocated to that rotation were probably lucky to ever have time to empty their bladders. I was horrified at the thought of doing the surgical specialty that was of least interest to me.  I quickly got in touch with a friend whose career interest was in psychiatry and he was completely unfazed about which surgical term he would do.  The swap was made and I got out of urology and did a plastic surgery rotation instead.  I just loved my time doing Plastics and by the end of the term, I was virtually unmovable in my desire to be in that specialty.  

For the second post graduate year (or resident medical officer year), it was again a fairly general year and to my horror, I was again allocated urology. I thought ‘hang on a sec, isn’t urology meant to be an intern rotation?’  Given that the term was so stressful for two interns, it was thought that it would be better to replace one of the interns with an RMO. Having that extra year of experience was going to make a huge difference.  I again hit the phones and on this occasion could not find anybody who was willing to do a swap. Begrudgingly, I accepted the fact that I would have to do this rotation. In spite of the adversity, I threw myself into the job and to my great surprise found the specialty extraordinarily interesting.  Urologists were both physicians and surgeons of the genitourinary tract and were not beholden to masters in any other specialty group in order to have a practice livelihood. On top of this, the urologists to whom I was to be exposed to, took great interest in my work ethic and general interest in surgery.  Their kindness and support for me had a profound impact on me although I was still steadfastly obsessed with having a career in Plastic Surgery.  

My primary career focus during my RMO year was to pass my surgical primary examination which at that time has a pass rate of around 25%. It was at that time, a clear barrier to restrict entry into the surgical profession. Fortunately I passed the examination on my first attempt which was pretty good going since my undergraduate academic record at university was fairly ordinary (after I discovered the medical revue, I never saw another credit or distinction grade for the remainder of my medical degree).  I now had to think carefully about where my next career move would be.  Something that I had noticed about the plastic surgery trainees at the time was the fact that they were all relatively old compared to other trainees.  At that time, those entering into plastic surgery training would first complete their general surgical training and then spend a year or more in non-accredited plastic surgery positions before commencing core training.  I came to realisation that the majority of those who were undertaking plastic surgery training were going to nudging 40 years of age by the time they were ready to commence independent surgical practice.  I thought that this was crazy and that I did have a life to live and made the tough decision to abandon the idea of training in plastic surgery.  My mind kept me returning to my time in urology and I soon became convinced that this was where my future lay.  

As is so often the case, it can be the mentors that you meet in the field rather than the field itself that can initially draw you towards it. 

To this day, I have no regrets.

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.

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

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

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)

Urolift-off. The rewards associated with Doctors working together with Engineers.

Since 2005, I have in my spare time, been working on a project that I was invited to join by a start up company called Neotract Inc which is based in the Bay area of San Francisco.  The company was initially made up of a small group of engineers who had a great idea of how a minimally invasive device could be created to treat male lower urinary tract symptoms (LUTS).  Over the years, minimally invasive devices to treat LUTS as a consequence of benign prostatic hyperplasia involved destroying prostate tissue whether it be by freezing, cooking, steaming, lasering or even microwaving. Whilst less invasive than procedures that physically removed prostate tissue at the time of surgery, these still required a period of recovery and there was often a delay in deriving full benefit due to the need for tissues to recover after destructive energy or one sort or another had been applied to the prostate. The idea was to use a mechanical implant that would pull open the prostate urethra. 

(Screenshot taken from www.neotract.com)

Through my involvement with Neotract, I was able to provide clinical input as well as being part of the clinical trials. This has lead to a number of publications that can easily be found by searching under my name and the search term either prostate or urolift.  This month, we have seen this technology finally achieved US FDA approval. I wrote a piece about the benefits of clinicians and engineers working together for the BJUI Blogs.  I was deeply moved to receive the following letter from Josh Makower, Chair of the Board of Neotract, Inc.  I felt compelled to share this letter (with permission) which was addressed to myself and my co-investigator Dr Peter Chin.

Dear Henry and Peter –

This morning I opened my email and found this...  http://www.bjuinternational.com/bjui-blog/urolift-takes-off-from-down-under-the-potential-rewards-when-engineers-bring-you-into-their-inner-circle/

I must say, Henry’s words brought a small tear to my eye.   After 9 years of amazing struggle against many obstacles, our small team of passionate dedicated people have finally made it through a most significant hurdle towards bringing this technology to patients in the US.  It’s a milestone that for many years seemed almost un-attainable and there were many dark days,.. but perseverance, trust and a vision held us together. 

Henry and Peter – you were the first.  There are always those who go first and history thankfully will mark them as innovators and leaders. You went where no one had gone before and gave us your time, your ideas and your talent towards a dream.  That dream is one step closer to being realized and we would not be here if it were not for the two of you.  When procedures and technologies become mainstream medicine, people often forget what it took to get there.  They  forget, or do not even know, how much a toll such a process takes on our relationships as we invest our lives in bringing something like this to fruition.  But for those of us who were all in the trenches together; for those of us who hunkered down, re-grouped, re-engaged, re-energized and stood up again to regain ground when all appeared lost, we will never forget you and never forget the team that brought us here.

On behalf of all us, Henry and Peter, thank you for your leadership and your partnership.  Henry – you articulated something special that must be shared – the partnership between engineers, entrepreneurs and physicians needed to advance medical technology is an essential one that we must never lose.  Without it, medical innovation would not happen.  Thank you for sharing your thoughts and putting them to paper in such a special way.  I hope thoughts like these help preserve that special balance of talents, interests and shared goals that truly have the power to change the world and make it a better place.

From all of us at ExploraMed and NeoTract, and for all the patients who will benefit from all our collective efforts – thank you.

Sincerely -

Josh