"I'm on an island": A qualitative study of underperforming surgical trainee perspectives on remediation.

BACKGROUND: There is a significant gap in the literature regarding trainees' perceptions of remediation. This study aims to explore surgical trainees' experiences and perspectives of remediation. METHODS: This qualitative study used semi-structured interviews with 11 doctors who have experienced formal remediation as a surgical trainee. Reflexive thematic analysis was used for data analysis. RESULTS: In this study, trainees perceived remediation as a harrowing and isolating experience, with long-lasting emotions. There was a perceived lack of clarity regarding explanations of underperformance and subjective goals. Remediation was viewed as a 'performance' and tick-box exercise with superficial plans, with challenging trainee/supervisor dynamics. CONCLUSIONS: These findings about trainees' perspectives on remediation show a need for trainees to be better emotionally supported during remediation and that remediation plans must be improved to address deficits. Integrating the perspectives and experiences of surgical trainees who have undergone remediation should help improve remediation outcomes and patient care.

Costs and challenges of the curriculum vitae for SET Urology training positions: a qualitative analysis.

BACKGROUND: Surgical training programs within Australia and Aotearoa New Zealand have become more competitive. Applicants are required to build a strong application over curriculum vitae (CV), references and interview. The building of the CV often comes at significant financial and time cost with challenges. This study explores successful applicants' experiences of the costs and challenges to build a successful CV for acceptance onto the Urology training program within Australia and New Zealand. METHODS: Qualitative content analysis (QCA) was undertaken of semi-structured interviews conducted with 11 nSET Urology trainees. QCA focused on the identification and evaluation of costs and challenges experienced. Analysis was reviewed over the domain of CV components. RESULTS: Costs of building each domain differed significantly between trainees as they focussed on various domains. Challenges encountered were identified with four themes were identified with associated subthemes: Passion/Commitment (two subthemes); Researching Pathways (six subthemes); Challenges (two subthemes) and Acceptance Success (two subthemes). CONCLUSIONS: The commitment to a surgical specialty begins before acceptance onto a training program. A high-level CV is an integral component of acceptance onto the Urology training program. Each trainee had a different journey, including time and financial sacrifices, to obtain acceptance whilst demonstrating a strong motivation for success. The average cost of each trainee who gained acceptance was $50 779 over 3 years. Consideration should be given to making the CV component less onerous.

Barriers and enablers of active surveillance for prostate cancer: a qualitive study of clinicians.

OBJECTIVES: To identify and explore barriers to, and enablers of, active surveillance (AS) in men with low-risk prostate cancer (LRPCa), as perceived by PCa clinicians. PATIENTS AND METHODS: Urologists and radiation oncologists in Australia and New Zealand were purposively sampled for a cross-section on gender and practice setting (metropolitan/regional; public/private). Using a grounded theory approach, semi-structed interviews were conducted with participants. Interviews were coded independently by two researchers using open, axial, and selective coding. A constant comparative approach was used to analyse data as it was collected. Thematic saturation was reached after 18 interviews, and a detailed model of barriers to, and enablers of, AS for LRPCa, as perceived by clinicians was developed. RESULTS: A model explaining what affects clinician decision making regarding AS in LRPCa emerged. It was underpinned by three broad themes: (i) clinician perception of patients' barriers and enablers; (ii) clinician perception of their own barriers and enablers; and (iii) engagement with healthcare team and resource availability. CONCLUSIONS: Clinicians unanimously agree that AS is an evidence-based approach for managing LRPCa. Despite this many men do not undergo AS for LRPCa, which is due to the interplay of patient and clinician factors, and their interaction with the wider healthcare system. This study identifies strategies to mitigate barriers and enhance enablers, which could increase access to AS by patients with LRPCa.

Disease mapping: Geographic differences in population rates of interventional treatment for prostate cancer in Australia.

BACKGROUND: Treatment decisions for men diagnosed with prostate cancer depend on a range of clinical and patient characteristics such as disease stage, age, general health, risk of side effects and access. Associations between treatment patterns and area-level factors such as remoteness and socioeconomic disadvantage have been observed in many countries. OBJECTIVE: To model spatial differences in interventional treatment rates for prostate cancer at high spatial resolution to inform policy and decision-making. METHODS: Hospital separations data for interventional treatments for prostate cancer (radical prostatectomy, low dose rate and high dose rate brachytherapy) for men aged 40 years and over were modelled using spatial models, generalised linear mixed models, maximised excess events tests and k-means statistical clustering. RESULTS: Geographic differences in population rates of interventional treatments were found (p<0.001). Separation rates for radical prostatectomy were lower in remote areas (12.2 per 10 000 person-years compared with 15.0-15.9 in regional and major city areas). Rates for all treatments decreased with increasing socioeconomic disadvantage (radical prostatectomy 19.1 /10 000 person-years in the most advantaged areas compared with 12.9 in the most disadvantaged areas). Three groups of similar areas were identified: those with higher rates of radical prostatectomy, those with higher rates of low dose brachytherapy, and those with low interventional treatment rates but higher rates of excess deaths. The most disadvantaged areas and remote areas tended to be in the latter group. CONCLUSIONS: The geographic differences in treatment rates may partly reflect differences in patients' physical and financial access to treatments. Treatment rates also depend on diagnosis rates and thus reflect variation in investigation rates for prostate cancer and presentation of disease. Spatial variation in interventional treatments may aid identification of areas of under-treatment or over-treatment.

Prostate-specific antigen testing for prostate cancer: Time to reconsider the approach to screening.

BACKGROUND: Prostate cancer is now the most common cancer in men in Australia. Men should be aware of the potential risk of significant prostate cancer despite the lack of symptoms. Screening for prostate cancer using prostate-specific antigen (PSA) has been controversial. General practice guidelines can be confusing leading to men not being tested for prostate cancer. Reasons cited include overdiagnosis and overtreatment with associated morbidity. OBJECTIVE: This article aims to highlight the current evidence for PSA testing and advocate for updating outdated guidelines and resources. DISCUSSION: Current evidence shows that a risk-stratified approach to PSA screening helps to assess that risk. Recent studies show improved survival rates with early intervention compared with observation/delayed treatment. Imaging, including magnetic resonance imaging and prostate-specific membrane antigen positron emission tomography, have made a significant difference in the management pathway. Biopsy techniques have progressed to minimise sepsis risk. Quality and patient-reported outcomes registry data highlight the increased use of active surveillance in patients with low to intermediate risk of prostate cancer, reducing treatment-associated harms in men with low risk of progression. There have also been improvements in medical therapeutics for advanced disease.

Modern Active Surveillance in Prostate Cancer: A Narrative Review.

The use of PSA screening has led to downstaging and downgrading of prostate cancer at diagnosis, increasing detection of indolent disease. Active surveillance aims to reduce over-treatment by delaying or avoiding radical treatment and its associated morbidity. However, there is not a consensus on the selection criteria and monitoring schedules that should be used. This article aims to summarize the evidence supporting the safety of active surveillance, the current selection criteria recommended and in use, the incidence of active surveillance, barriers existing to its uptake and future developments in patient selection.

Prevalence and sequelae of penile lichen sclerosus in males presenting for circumcision in regional Australia: a multicentre retrospective cohort study.

Background: Lichen sclerosus (LS) in men commonly involves the external genitalia, with up to 20% of these patients developing urethral stricture disease, and a small group developing malignant transformation to penile squamous cell carcinoma (SCC). The objective of this study was to determine the prevalence of LS and its sequelae in males presenting for circumcision. Methods: A multicentre retrospective cohort study was conducted at 8 hospitals within 3 Australian regional centres. We identified males who underwent circumcision between January 2004 and November 2018 and obtained histological and clinical data. Histopathological confirmation of LS was the primary outcome. Development of urethral stricture disease and penile cancer were secondary outcomes. Results: Six hundred and eleven patients underwent circumcision, of which 313 (51.2%) had a specimen sent for histology. Of these, 199 (63.6%) had confirmed LS where the median age at diagnosis was 65 years [interquartile range (IQR), 40-77]. Even if the remainder of unsent specimens were free of LS, the prevalence would still be 32.6%. Amongst the patients with LS, 44 (22.1%) developed urethral strictures, 1 penile SCC (0.5%), and 1 penile intraepithelial neoplasia (0.5%). Conclusions: The prevalence of LS in patients undergoing circumcision where the foreskin was sent for histopathological review was 63.6%. In those with LS, the prevalence of urethral stricture disease was 22.1%.

Poor Employment Conditions Adversely Affect Mental Health Outcomes Among Surgical Trainees.

BACKGROUND: Poor mental health in junior clinicians is prevalent and may lead to poor productivity and significant medical errors. We aimed to provide contemporary data on the mental health of surgical trainees and identify risk factors relating to poorer mental health outcomes. METHODS: A detailed questionnaire was developed comprising questions based on the 36-item short-form health survey (SF-36) and Physical Activity Questionnaire. Each of the questionnaires has proven validity and reliability in the clinical context. Ethics approval was obtained from the Royal Australasian College of Surgeons. The questionnaire was aimed at surgical registrars. We used Physical Activity Questionnaire, SF-36 scores and linear regression to evaluate the effect of putative predictors on mental health. RESULT: A total of 83 responses were collected during the study period, of which 49 (59%) were from men and 34 (41%) were from women. The mean Mental Component Summary (MCS) score for both sexes was significantly lower than the population mean at ages 25-34 (p < 0.001). Poor satisfaction with one's work culture and a feeling of a lack of support at work were extremely strong predictors of a lower MCS score (p < 0.001). Hours of overtime worked, particularly unpaid overtime, were also strong predictors of a poorer score. CONCLUSIONS: Australian surgical trainees reported lower MCS scores from the SF-36 questionnaire compared to the general population. Increasing working hours, unpaid overtime, poor job security, and job satisfaction were associated with poorer scores among trainees. Interventions providing improved working conditions need to be considered by professional training bodies and employers.

Incidental adrenal masses - A primary care approach.

BACKGROUND: The common use of cross-sectional imaging for the investigation of abdominal and thoracic illness has resulted in the rise of the incidentally identified adrenal mass, or incidentaloma, which presents a diagnostic and management dilemma for the primary care physician. OBJECTIVE: This article provides a framework for the investigation and management of incidental adrenal masses. DISCUSSION: Adrenal incidentalomas are found in approximately 3-4% of abdominal computed tomography (CT) scans. It is important to evaluate these incidental adrenal lesions to determine what treatment, if any, is needed and when specialist referral may be necessary. In particular, incidentalomas must be evaluated in regard to their functional status and malignant potential, as lesions can range from being indolent, benign and non-functioning tumours that can simply be observed, to aggressive and hormonally active malignant lesions that require urgent surgical intervention.

Five year results of the prospective randomized controlled prostatic urethral L.I.F.T. study.

INTRODUCTION: To report the five year results of a prospective, multi-center, randomized, blinded sham control trial of the Prostatic Urethral Lift (PUL) in men with bothersome lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: At 19 centers in North America and Australia, 206 subjects ≥ 50 years old with International Prostate Symptom Score (IPSS ) > 12, peak flow rate (Qmax) ≤ 12 mL/s, and prostate volume 30 cc-80 cc were randomized 2:1 to the PUL procedure or blinded sham control. In PUL permanent UroLift implants are placed to hold open the lateral lobes of the prostate to reduce urinary obstruction. After randomized comparison at 3 months and the only opportunity to add more PUL implants, PUL patients were followed to 5 years. LUTS severity (IPSS), quality of life (QOL), BPH Impact Index (BPHII), Qmax, sexual function, and adverse events were assessed throughout follow up. RESULTS: IPSS improvement after PUL was 88% greater than that of sham at 3 months. LUTS and QOL were significantly improved by 2 weeks with return to preoperative physical activity within 8.6 days. Improvement in IPSS, QOL, BPHII, and Qmax were durable through 5 years with improvements of 36%, 50%, 52%, and 44% respectively. No difference was seen between Intent to Treat and Per Protocol populations. Surgical retreatment was 13.6% over 5 years. Adverse events were mild to moderate and transient. Sexual function was stable over 5 years with no de novo, sustained erectile or ejaculatory dysfunction. CONCLUSIONS: PUL offers rapid improvement in symptoms, QOL and flow rate that is durable to 5 years. These improvements were achieved with minimal use of a postoperative urinary catheter, rapid return to normal, and preservation of both erectile and ejaculatory function. Symptom improvement was commensurate with patient satisfaction. PUL offers a minimally invasive option in the treatment of LUTS due to BPH.

Citation indices for social media articles in urology.

OBJECTIVE: To evaluate the impact of publications on urological participation in social media (SoMe) by virtue of citations in the urological and non-urological literature. MATERIALS AND METHODS: On 15 March 2016, a PubMed search was undertaken using the names of the major SoMe platforms in current use and associated with the field of urology. The search term 'urolog*' was used to specifically capture articles that could be associated with 'urology', 'urologist' or 'urological'. Exclusion criteria for analysis included non-English language articles, articles published for the first time online in any form after 1 March 2015, articles irrelevant to the topic of SoMe, and letters of correspondence. Included articles were then searched in Google Scholar and citations analysed to determine if citations were from the urological literature or non-urological literature. Citations from non-urological journals were considered to be as such even if authored by urologists and on the subject of urology and SoMe. RESULTS: Prior to exclusions as defined in the methods, our PubMed search yielded 232 articles of which 17 were non-English language and 66 had been published after 1 March 2015. Allowing for 12 months after the most recent articles were published, we found that the mean number of total citations in any journal was 20.8. There were more citations in journals not specific to urology, with 8.3 citations in urological journals, compared to 12.6 citations in non-urological journals. CONCLUSION: Urological SoMe journal articles are highly cited, particularly in the non-urological literature. It is likely that the magnitude of citations has positively contributed to the impact factors of the almost all journals publishing these manuscripts.

Surgical education and adult learning: Integrating theory into practice.

Surgical education continues to evolve from the master-apprentice model. Newer methods of the process need to be used to manage the dual challenges of educating while providing safe surgical care. This requires integrating adult learning concepts into delivery of practical training and education in busy clinical environments. A narrative review aimed at outlining and integrating adult learning and surgical education theory was undertaken. Additionally, this information was used to relate the practical delivery of surgical training and education in day-to-day surgical practice. Concepts were sourced from reference material. Additional material was found using a PubMed search of the words: 'surgical education theory' and 'adult learning theory medical'. This yielded 1351 abstracts, of which 43 articles with a focus on key concepts in adult education theory were used. Key papers were used to formulate structure and additional cross-referenced papers were included where appropriate. Current concepts within adult learning have a lot to offer when considering how to better deliver surgical education and training. Better integration of adult learning theory can be fruitful. Individual teaching surgical units need to rethink their paradigms and consider how each individual can contribute to the education experience. Up skilling courses for trainers can do much to improve the delivery of surgical education. Understanding adult learning concepts and integrating these into day-to-day teaching can be valuable.