Surgical Opinion

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

I am deeply concerned about the rising incidence of so called ‘superbug’ infections associated with prostate biopsy. These bacteria are resistant to the great majority of antibiotics we have available for use and the only ones that work generally have to be given through the veins. These bacteria have become particularly prevalent in Asia where the indiscriminant use of antibiotics in agriculture has lead to the breeding of antibiotic resistant bacteria in the community. When you are well, they are of no risk and they live harmoniously within your body. Should you be placed in circumstances where your own bacteria turn against you and you happen to have the ‘superbug’, this can lead to serious infection as conventional antibiotics are not effective. For those who wish to get technical, with the term ‘superbug’, I am referring to the so called extended spectrum beta lactamase producing bacteria (ESBL). With increasing travel to Asia, growing numbers of Australians will carry these bacteria within their intestines. Any procedure that carries ANY risk of infection, which happens to include prostate biopsies, will carry a risk of serious infection.

The article published in the The Age today is entitled “Prostate biopsy blamed for preventable superbug deaths”. This headline will understandably place fear in every man who is about to be scheduled to undergo a prostate biopsy should they read this piece. However, there needs to be some perspective on the calls for urgent rectification of the problem of superbugs by having all public hospitals purchase the equipment that will enable the risk of any prostate biopsy related infection to be eliminated. The typical cost of such equipment is $150,000 and multiply this by the number of public hospitals, it poses a massive infrastructure cost and represents monies that have to be taken from somewhere else in the health budget.

Transperineal prostate biopsy (TPB) creates significant burdens on resource utilization. TPB require a general anaesthetic and day surgery admission to hospital as well as utilization of precious operating theatre time. Almost all Transrectal ultrasound prostate biopsies (TRUSPB) are performed in an outpatient setting and typically take 15 to 30 minutes including turnover time. A TPB can typically utilize as much as 45 to 60 minutes of operating time including turnover time. More than 20,000 prostate biopsies are performed in Australia each year and if every one of these were to be immediately pushed into the hospital system, urological surgical resources would be pressed to cope. Waiting lists would likely significantly increase and it is highly unlikely that there would be increased allocations of operating theatre sessions for urological procedures.

Figure 1. Transperineal biopsies performed in the operating theatre setting

Even if a reliable mechanism was found to perform the procedure under local anaesthetic, the procedure would still need to be performed in the hospital setting as appropriate infrastructure such as physical floor space and the operating table which enables coupling to the transperineal biopsy equipment is simply not readily available in the outpatient setting.

The majority of men would need to take the day off for the procedure and often the following day given that they have had a general anaesthetic. If the procedure is performed as a TRUSPB under local anaesthesia, most are able to return to normal activities either the same or following day.

There are certainly issues with infections associated with TRUSPB. These men can become very sick and a small number of cases may require admission to Intensive Care Units. Men should however, be reassured that their risk of dying from a prostate biopsy infection is extremely small. The Victorian data demonstrates a reported incidence of 2 deaths over the past five years. With over 7000 biopsies being performed in Victoria each year, this equates to an incidence of 2 out of over 35,000 prostate biopsy procedures (<0.006%) and in the article published in the Age today, these are attributed to the ‘superbugs’. When we look at the mortality rates associated with infections, a recent paper found that the incidence of community acquired ESBL sepsis was around 10%. In a mix of patients with healthcare related and community acquired ESBL sepsis, the mortality rate was as high as 20%. The patients most likely to die were elderly or had significant medical co-morbidity and exactly the type of patient who perhaps prostate biopsy ought not be undertaken.

There are relatively few invasive procedures that do not carry a risk of infection although transperineal prostate biopsy is one where the risk is negligible if not zero. This data has been repeatedly confirmed and provide a compelling argument to switch completely from TRUSPB to TPB. But are there any medical reasons why we should reflect on this assertion? A recent Australian studypublished this year, the risk of acute urinary retention was 4.2% whereas following TRUSPB, it is a very rare event.

Rather than see panic stations with public outcry and a call for all hospitals to be immediately armed with the expensive equipment, other processes should be enter into practice with a greater level of urgency. We have to be pragmatic and recognize that hospitals are not about to be funded for this equipment in the immediate future and other strategies need to be sought in the meantime.

With the recognition that too many men diagnosed with prostate cancer die with the disease rather than from it, we need to better select the men in whom prostate biopsies are recommended. We also need better risk assess which men are more likely to carry the ESBL ‘superbug’ and a history of recent travel to Asia should be explored. We also need to get smarter about either using or searching for simple strategies to minimize the risk of ESBL infection such as performing rectal microbial swabs in advance of the prostate biopsy, use of antiseptics such as betadine suppositories in the rectum or dipping the biopsy needle in chemicals such as formaldehyde before each pass. These strategies need more work but represent that the profession recognizes more needs to be done. With growth in the use of MRI scans prior to prostate biopsy, it is also possible that fewer biopsies will need to be taken and there is the potential that fewer numbers of biopsies taken may ultimately be proven to be associated with less risk of infection. We can also potentially improve the recovery from infection by having men appropriately counseled to attend for assistance immediately with the onset of infection rather than ‘sitting on it overnight and attending in the morning’ – when bacteria are capable of double in numbers as fast as 20 minutes for some, early presentation can make a huge difference to recovery.

In conclusion, ‘superbug’ infections are a serious problem and we need to do more to minimize the risk to our patients on many fronts. I believe that transperineal prostate biopsies are one way forward, but the practicalities and priority needs to be considered in the context of other health priorities.

Disclosure - A/Prof Henry Woo has access to TPB equipment at his hospital and does perform this procedure in selected men. The vast majority of his patients undergo TRUSPB under a local anaesthetic prostate block in an ambulatory outpatient setting.

Usually when there are complaints to be made about travel, it will be to do with a provider whether it is a tour operator, tourist venue, airline or hotel. Some of you may have seen my periodic twitter rants on travel complaints – instead, mine is directed at fellow air passengers. In order, here are the five of the things I particularly find annoying.

1. Bare feet – as far as I am aware, no airlines that I have flown with have a policy on bare feet during flight. They do however, mandate that foot wear must be worn for boarding or disembarking (not ‘de-planing’ – if this was to be an appropriate term, then getting on a plane would be called ‘planing’ - which joker came up with that moronic term! – apologies for the extra little rant on the side here.) Imagine you have just reclined back in your seat and have just closed your eyes – all of a sudden you become aware of the pungent smell of foot odour. Just because they have boarded from exotic places such as Bangkok or Singapore does not make the fruitiness of the flavor any more tolerable! You then look down and see the distorted looking nails from chronic fungal infection, not to mention the peeling skin from tinea. Apart from the assault on our visual and olfactory senses, you see these people put their foot up on their knee and see it touching the seat in front and side of the cabin smearing the foot love on the internal plane surfaces. You then see the love metastasise as they climb over the two seats to reach the aisle to go to the toilet.

Lovely tinea of the feet

Lovely fungal nails

2. Legs apart syndrome. Yes, this is the man with the hydrocele. These men have pathologic scrotal swelling that necessitate them to sit with their legs apart so that they invade your personal space. There is an unwritten rule that the airspace immediately in front of your seat is for your personal use. Of course there could not be any other reason why somebody would sit with their legs so widely, would there? To remedy this, it sometimes takes an applied equal and opposite force but eventually your fight to reclaim your airspace will prevail – as gross as it is to have such a large surface area of contact with a total stranger, just close your eyes and chant “Newton”

Hydocele is a good reason to have to sit with legs apart

3. The super halogen light effect – the cabin lights have been dimmed and all the windows have been closed except for the jerk across the seat row next to the window who decides to open it so he or she can read. It’s like a super powerful halogen light that is shone on to a stunned kangaroo and is about to be shot. During a night flight when trying to get some sleep, you can forget it. Flight attendants can ask them to close the window but if passengers do not wish to, they will not go as far as instructing them to do so as it is not against the rules (airline dependent of course).

4. People who won’t shut (shout) up. When you have trouble hearing, there is that natural tendency to speak louder. When they natter for hours like they’re speaking into a mobile phone with poor reception.

Almost enough to make you re-think your support of gun control

5. People hogging the flight attendant. You are trying to get the attention of the flight attendant who has been quarantined by passengers who don’t want to stop telling him or her about every detail of their holiday.

***

When there are no specific rules to say that something cannot be done, I have found flight attendants to often be reluctant to take action. As much as you do not wish to have conflict, so do they. For a growing number of airlines, they really don’t give a damn about your comfort, they just want to get to the end of their shift – another flight down before they reach their retirement work entitlements.

Generally, I can put up with crap from airlines, tour operators and hotels. For the most part they either genuinely try to fix any problems that arise or are totally disingenuous about concern for your inconvenience and don’t give a damn (if you fly a budget airline, what do you expect?). For selfish fellow passengers, I think it is time to make a stand and ask them to correct their behavior with the threat to shame them through social media – lets not put up with this crap anymore.

What annoys you about fellow passengers?

***

Since posting this blog piece less than 24 hours ago, I received this tweeted comment which I just had to share with you. It makes you sick thinking that some poor punter will pick up this magazine that has had a foot smeared all over it.

I normally do not read inflight magazines from airlines as they find them quite boring. They are generally full of articles about travelling to exotic places or buying expensive products that only those who have so much money (that they do not know what to do with it) will have any interest. This week, I was flying on the luxury carrier Emirates for the very first time and during the process of checking out all that they had to offer on my very long haul flight from Sydney to London via Dubai, I flicked through their inflight magazine.

I was taken by surprise to see a very prominent advertisement by a urological surgeon offering his surgical services for the treatment of prostate cancer. Given that I practice in this same subspecialized area of surgery, this naturally caught my attention.

Prior to seeing this advertisement, I had become aware of Dr David Samadi for all the wrong reasons. I had become aware of his name through overhearing discussions amongst US urologists over a number of years when attending the Annual Meeting of the American Urological Association. I would frequently hear urologists discussing him with the gist of the discussion being summed up with the frequent rolling of the eyeballs or groan every time his name was mentioned. Whilst urologists were careful not to verbally state anything negative about him, it was clear that they did not think favorably of him. At the time and as an outsider, I really didn’t take that much notice as any gripes US colleagues had about him were not particularly relevant to me.

So when I saw this advertisement in the Emirates inflight magazine, I immediately recognized his name and remember it being associated with groans and eyeball rolling. As I read the advertisement, I now found myself rolling my eyes and groaning in disbelief. It was almost like US urologists saying to a previously disinterested me, ‘told you so’.

Mobile phone captured image from the January 2014 Emirates inflight magazine

The statement that really got my attention was his claim of a “97% prostate cancer cure rate”. When we talk about cure of cancer, we generally mean total and permanent eradication of the disease. Whilst one could argue through dictionary meanings that cure can mean recovery from disease or restoration of health, I think that the average person would interpret cure of cancer being total and permanent eradication of cancer. My personal view is that prostate cancer doctor can come close to providing a 97% cure of prostate cancer and data shows that this is probably impossibility unless the subjects were all men with such low volume indolent disease that they did not need surgery in the first place. Why is this an issue? The statement can give cancer sufferers unrealistic expectations. The statement is unquestionably a draw card to consider his services as it gives hope and promise of an exceptional chance of success but I am sure that. I did call him out on Twitter to clarify his claim of 97% cure rates and was not surprised that he chosen not to respond.

I did call him out on Twitter to clarify his claim of 97% cure rates and was not surprised that he had chosen not to respond.

The statement “96% of patients regain continence” is not defined. Continence as far as I am concerned means a man who does not leak urine at all. If we look at the prevalence of incontinence in ageing men, a 96% continence rate is higher than for men who have not undergone prostate cancer surgery. It would be very easy to make a ridiculous suggestion that the surgery seems to give better urinary control rates than if you did not have surgery and one should therefore line up to have surgery with cancer being a mere technicality. – again I emphasise that this is a ridiculous suggestion but it does raise the question as what is meant by this claim. What is meant my continence? Does it include the men who are wearing one pad per day or doesn’t wear a pad but drips urine everytime he has a cough or sneeze. Undefined, the figure is very impressive and all those attracted by such figures should seek to clarify exactly what is meant be this. The population of men in whom you operate can make a difference as well – older men are more likely to have incontinence than younger men as one example.

Same applies to erectile function recovery. I personally think that statement that “85% men regain sexual function” is very vague but nonetheless will be interpreted by most readers that it refers to erections. My own overall figures do not come close to this. However, if I were to narrow it down to my younger men in whom the cancer was considered to be well localized and they were candidates for nerve sparing (nerves that spare erectile function) surgery, then this might be a more realistic figure. 'Regain' implies recovery to where they were prior to surgery – that’s how I interpret it but I know that some may argue otherwise. I have quite a number of men who have lost erections following prostate cancer surgery, particularly when I have had to sacrifice the erectile nerves in order to clear the cancer but they remain sexually active in that with their partners they achieve a pleasurable orgasm with a flaccid penis. I have men who are sexually active with the assistance of medications such as Viagra and Cialis or even with the use of medications that they inject into their penis in order to stimulate an erection (eg Caverject, trimix) but should that constitute ‘regain’ of sexual function?.

For both continence and sexual function, definitions are everything and without them, I am concerned that presentation of such exceptional results will create unrealistic expectations. I am sure that the man with locally advanced cancer will be appropriately counseled that he would not fit in the group with such good results but the advert would have done its job of pulling him in through the consultation door so that he can then told what he really can expect. Should there be a asterixed disclaimer as in every good advertising offer that 'conditions apply'.

The statement “When you’re the best in the world” also raises questions. What evidence does he have that he is a superior surgeon clinically and technically than anybody else in the world? How does he benchmark this? Is it fair to claim that just because you have had patients from 40 different countries that this must mean that you're are the best? Is this international spread of patients have any relationship to international based marketing strategies?

I am currently registered as a medical practitioner with the Australian Health Practitioners Regulatory Authority. AHPRA has strict advertising guidelines. There is also a code of conduct published by the Royal Australasian College of Surgeons (and endorsed by the Urological Society of Australia and New Zealand) that dictates my appropriate behavior as a surgeon. If I were to have written such an advertisement, I would unquestionably be investigated by AHPRA and run risk of punitive actions and I would also stand a significant chance of being stripped of my surgical diploma from the RACS for breaches to our code of conduct. Dr Samadi is not required to adhere to Australian licencing regulations or code of conduct but in my opinion, there appears to be a lower bar for this behaviour in the United States. In Australia, any statements that have a likelihood of being misinterpreted as well as not being able to be substantiated are taken seriously and run a high risk of punitive sanctions and reputational loss. Having previously been registered with the General Medical Council of the UK (when I worked there years ago), I can also say that their guidances on these matters are equally, if not more, restrictive. It is important to state that these restrictions are not to make life harder for doctors to promote their practices, but to protect the public from misleading or unsubstantiated claims.

As a urological surgeon, I personally feel embarrassed to see such a colleague resort to advertisements in international inflight magazines to market their surgical practice. Maybe I'm just a bit old fashioned with my attitude to medical advertising. I was further embarrassed as a surgeon to see Dr Samadi refer to his twitter followers as fans. I hope that does not include his patients.

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.

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.

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.

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)

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 and 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 and in my opinion to a different magnitude.

I do have some thoughts as to why this is the case and of course many will beg to disagree. 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 academic 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 in 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.

What else is different? The most striking difference is the manner in 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 level of infrastructure and nothing more or less than what a department in Sydney would have when they began their academic tenure. They have now mentored a fossil layer in whom to 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 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.

I thought that I would share the story of how a group of people attending an Annual Meeting of the American Urological Association managed to score an entry into a Prince concert.

We had been enjoying a wonderful meal at a San Diego restaurant and mention was made that Prince was in town. A couple of our group were from Minnesota which of course is the home town for Prince. As such we were cajoled into walking back to our hotel via the Hard Rock Cafe Hotel for the sake of a possible glimpse of fame. As we reached the Hard Rock Cafe Hotel, there was a long line on the footpath. When asked as to why they were lining up, we were told that they were waiting to get into the Prince concert which was starting at around 10pm. One person in the line mentioned that there might still be tickets at the sales desk in the hotel lobby.

Upon reaching the ticket sales desk in the hotel lobby, we were advised that no more tickets could be sold because just at that very moment, their printer had completely malfunctioned. A well dressed man with a much younger lady who was literally hanging off him, was not happy. He carried the attitude of “do you know who I am?” and it was suggested to him by one of the bouncers to try using the hotel’s business center to see if tickets could be purchased on line and printed out from there. We decided to follow this couple to the business center to check out whether tickets were available and how much they were going to cost. Once ‘on line,’ it quickly became evident that ticket sales for this show had been discontinued as it was too close to the time of the show’s commencement. In any case, this was a small and fairly intimate gig with ticket prices being in the vicinity of $250 each. The pricing pretty much turned us off from pursuing this any further.

The man I mentioned earlier was really unhappy and complained bitterly to bouncer. The bouncer then suggested that he go to the head bouncer at the entrance door to the venue to try to resolve the situation. My thoughts were that we should tag along in case we could benefit from being in the slipstream and I signalled to the others with my hand to follow. At the entrance, the story was explained to the head bouncer that an attempt was made to buy tickets in good faith but because of the printer malfunction, attendance to the gig was not going to be possible. The head bouncer went into a huddle with his colleagues and then announced that if $250 cash per person was paid, then entry would be permitted. The couple that we followed coughed up the cash and were granted entry. We jokingly said how about $250 for the five of us but that was a no go. As we were walking away from the entrance, we bumped into the first bouncer who had been directing us in the hotel lobby.

He asked, ‘how did you go?’ I explained the story of how we had 5 Australians and 2 from loyal Prince fans from Minnesota who had tried in good faith to buy tickets but were not able to as a result of the printer malfunction and then with the closure of the on line ticketing website for sales to this gig. I explained how as visitors to this town, we simply did not walk around with hundreds of dollars in our pockets and relied on our credit cards. The bouncer then says. "F**k, I hate when this happens. Look, come with me."

He leads us down the footpath and around the corner where it was dark. He pulls our entry wristbands and says to us "just give me what you have in cash and I’ll make sure it goes to Prince’s favourite charity" Most of us only had about $20 in our wallets and even though it was all that I had left in my wallet, I was happy to part with it. We put on our wristbands and he then lead us through a back way through the hotel into the venue. The next moment we were inside and the doors behind us closed and the bouncer was gone. It was major high five and it is pretty obvious that it was a fantastic gig.

You never know what is going on in town when you attend an AUA meeting. In the previous year in Atlanta, we were treated to an outdoor concert featuring the Flaming Lips, This year, the only performers of note were Modest Mouse. Tickets were available although scarce but at over 5 times the original cost so decided to give it a miss.

Roger Dmochowski is highly regarded international academic urologist. His name on a presentation or publication carries weight and implies quality of content. This is precisely why one of these so called predatory journals would stoop so low to essential steal his credability.

Lately, I have been receiving numerous emails from an online publisher called Photon Journal. They have created a journal in my field called the Journal for Urology. This journal name is rather similar to the established Journal of Urology which is a prestigious journal owned by the American Urological Association. The header of the email has the Dr Dmochowski’s name with the intent to grab our attention. They know that his name implies that there is content that is worth taking notice of.

The links in the email take you to a amateur site with no academic content. Just numerous self grandiose ideas of how professional, established and reputable they are as a publishing group.

I wrote to Dr Dmochowski to determine if he was aware of these emails. It was clear from his response that he was. He mentioned that legal recourse has not swayed them at all. I also forwarded it to the Publications Committee of the AUA who also indicated that they were aware and it was clear that they were frustrated. To quote

"We have received numerous emails regarding this group and Dr. Dmochowski has even tried to contact them personally about the use of his name but to no avail. However, thanks for notifying us."

The emails have continued and there was in fact a mini run of them where 4 were sent in the space of about 4 hours, perhaps just in case I did not read the first few.

We have seen a number of these predatory on line journals stoop to pretty low tactics but I think Photon Journals take the prize for the worst offender I have seen to date. It is one thing to financially rip off scientists and medical researchers but stealing their identity has gone too far.

Let me know if you have had any experience with the Photon Journal group.

Make sure you check out my earlier piece about OMICS

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.

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..

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

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.

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.

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)

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

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What annoys you about fellow passengers?

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Medical doctors in academia are gullible. They are so gullible that they are amongst a number of groups, the perfect target for predatory publishing groups. The definition for a predatory journal or publishing group can be found on this link. They appear to be growing in numbers at a seemingly exponential rate. It is obviously worth the effort for the creators of these on line publishing companies who try every tactic to trick academics into paying excessive fees to publish. In other words, there are always enough gullible individuals to make if worth the effort. This is all well documented and whilst there is growing awareness of these scams, it is disappointing to see how academics are quick to give up their credibility by becoming a part of the problem. They allow themselves to become the bait to attract other academics to submit their manuscripts to the journal.

I get these emails all the time. These are invitations to join the editorial boards of these junk journals. This one gives the impression of being US based but when you visit the website, it is obvious that the authors of the website are not native English speakers and most people would be able to work out that it is really based in India.

The emails often butter up the recipient with glorified praise about their eminence in the field. That aside, being invited to be a member of an editorial board is generally considered to be something of value and the more editorial boards one can boast the better. Without much thought, academics respond in the affirmative and their picture and bio soon appears on the ‘journal’ website. These predatory journals have also been in the habit of placing academics on their editorial boards without permission but from my own investigations, it appears that the vast majority has actually consented to the process without having given a thought to where they have gifted their good name as well as the good name of their university.

We are all keen to see these journals run out of business but it is not only the gullible academics who support them by submitting their manuscripts but also our gullible academics who give provide some resemblance of credibility to these journals. We are very much part of the problem.

Disclosure - Henry Woo is on the editorial boards of Prostate Cancer Prostatic Diseases, Prostate International and World Journal of Men's Health which are all Pubmed/Medline indexed. He is also the Editor in Chief of BJUI Knowledge, a new CME portal of the reputable BJUI Company.

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