Clinical Visit Report: Ben Jackson, final year SpR in the East Midlands North Deanery
I am a final year trainee with a subspecialty interest in oncology and, as a consequence, have sought out experience in open and laparoscopic pelvic surgery throughout my training programme. However, my region does not currently contain a robotic unit and therefore I have had no structured experience of this technology.
I therefore sought help from The Urology Foundation to fund a trip to Weill-Cornell Medical College in New York to watch Dr. Ash Tewari in action. I received the invitation from Dr. Tewari after making contact with him on Twitter, which I have found to be a highly useful platform for urological networking and education since starting my own account. Dr. Tewari’s practice focuses exclusively on prostate cancer, and he has carried out over 5000 robotic prostatectomies to date.
So in June, 2013, I flew out to New York to begin my experience. I arrived on a Saturday, and had Sunday to explore the area and get over some of my jet lag. The following morning I set out bright and early for the New York Presbyterian Hospital, and after meeting Dr. Tewari’s helpful and welcoming admin assistant Amanda, went straight up to the OR.
I had the chance to see three radical prostatectomies on the first day, which is a normal day’s work for the team. That team consisted of several highly skilled physician assistants (Chip, Brian and Adam) who dealt with positioning, port placement and robot docking, leaving Dr. Tewari free to do other things until required to start the robotic part of the procedure. An additional advantage to the set up was consistent operating theatre staffing, with OR nurse John being an ever present member of the team. This consistency facilitated a highly efficient approach. The team were good enough to explain the ins and outs of the robotic set up to me, which was very useful to learn about. The cases including two cases with full nerve sparing and one with a wide excision of the neurovascular bundles for a more advanced tumour, and it was great to compare the different techniques.
The following day, two further prostatectomies were scheduled although one had to be cancelled intraoperatively for anaesthetic reasons. It was interesting to see how the team dealt with an unexpected difficulty like this, and Dr. Tewari explained to me the important considerations in his view when deciding when to terminate a procedure due to adverse physiological parameters during surgery. The earlier than usual finish allowed for an extended research meeting, during which I met Dr. Tewari’s large research team. As well as hearing about several fascinating projects ongoing within the lab, I was able to gain some insight into how to lead such a large research team. I was particularly impressed with the strong leadership and organisation that bound together both the clinical and research teams so effectively, and allowed them to function to their full potential.
The rest of the first week brought another four prostatectomies and there was again the opportunity to compare nerve-sparing and wide-excision techniques for differing tumour stages. The team operates on 4 days each week, with Fridays devoted to follow-up. Dr. Tewari’s team of physician assistants play a key role in clinical follow-up, and I discussed with them at length their approach to continence recovery and penile rehabilitation.
The use of physician’s assistants (PAs) is a key difference between the US and the UK, where they still play a fairly limited role. It was interesting to see how the PAs were integrated into the team. A common concern regarding PAs is that they might potentially usurp some of the role played by trainees and limit their training opportunities. Dr. Tewari’s team, however, showed how they could be utilised to enhance training. By undertaking the bedside assistant role, the PAs allowed the residents to focus purely on console training, and by handling the bulk of clinical follow-up they prevented the residents having to spend excessive time in clinic seeing routine follow-up patients.
During my second week in New York I observed another 6 cases, making 14 cases observed in total in 8 working days at the hospital. This volume of cases for a single surgical team is not seen in the UK, and certainly has advantages for refinement of both technique and process. I learnt a number of points of surgical technique that I intend to introduce into my own practice, which I am sure will improve my surgical outcomes when I enter consultant practice. These valuable surgical lessons are surpassed though by the lessons learnt about team leadership, patient safety, organisation and work ethic. For this I am extremely grateful both to Dr. Tewari and his clinical, research, and administrative teams and to The Urology Foundation without whose support this trip would not have been possible.
