Professor Ghulam Nabi, MD, M Ch, FRCS (Urol)
University of Dundee, Ninewells Hospital, Dundee, Scotland, UK
I express my sincere gratitude for the honour bestowed on me by the James IV Association. I take this opportunity to say thanks to the Association for the opportunity which facilitated these travels enabling me to meet and network with my colleagues from urology across the globe. Also, I had opportunity to see centres of excellence in patient care, research and education in particularly for robotic surgery. I am very grateful to hospitality of many individuals at all the three centres including some of the difficult administrative navigations they have to expedite in order for me to utilize my time most efficiently and productively.
The fellowship was undertaken in two parts; first in 2015 to the United States and second in August 2017 to Europe choosing centres with their unique strengths in patient care, research and surgical education.
United States of America (MD Anderson Cancer Centre (MDACC), Houston, Texas)- 5-10h April 2015
My fellowship started with a visit to MD Anderson Cancer Centre (MDACC), Houston, Texas for a week. Professor Kamat served as an excellent host and took extra steps to make my stay useful and enjoyable. I was invited as visiting Professor. I am also indebted to the help provided by Miss Medina Christina, Fellowship co-ordinator in the department of Urology. She was great in getting me through the paperwork etc facilitating permission to visit clinical areas. Paperwork can be tedious in the USA!
I had extremely useful interactions with a number of senior colleagues who were working in the surgical uro-oncology in the department of Urology at MDACC and I closely watched their clinical practice. The centre is well-equipped with the latest surgical robotic technology and there were six machines along with simulators available for surgeons to simulate and practice new procedures. I attended theatres, clinics and their diagnostic centre. On the last day, Professor Kamat arranged a visit to the bladder cancer research group located at a distance from the main department.
On April 6, I attended a ward Rounds presentation at the department of Urology which was very interesting. The cases were discussed in depth and plan was made for each case. The case presentations were mainly made by chief resident of the department. Afterwards, I met with training surgeons, faculty, and researchers involved in urological cancer research. I was led to a tour of the department and shown various facilities including outpatient’s services. I was impressed by the workload and dedication of the staff. There was total commitment to finishing lists on time. Being a tertiary centre, most of referrals from outside and complex in nature. In contrast, the NHS is also grappling with how to modernize and deliver the highest level of care through a networking system.
Next few days I spent in operating theatres, robotic simulation centre and clinics.
Surgical residency in the USA is quite different from here in Europe. Surgical residents and clinical fellow play a very central role in patient care and academics of the unit. The programmes in the United States are well structured, set clear objectives that need to be attained at each stage of the programme. They place a great emphasis on academic achievement and attainment. A well-working residency programme serves as an attraction to young doctors and attracts them to surgical speciality. There is an intense competition to find a place in the scheme and this prunes the best talent. Most of the fellows I met, it became clear to me that they considered a privilege to train in prestigious scheme in a particular institution Such as MDACC. Some of bright residents in the past from MDACC are leading urologist throughout the United States and in fact a few of them were working as faculty in the centre.
Several contrasts to the United Kingdom situations were observed: Firstly, clinical academics in the NHS have a very limited control of surgical training. Secondly, there is no ongoing interactions between training programmes and surgical academic units. Most of training programme directors and specialist authorities in the United Kingdom work with no academic input. This certainly denies trainees the opportunity to benefit from a joined up approach which delivers both development in clinical skills and judgement and also development of academic. This will certainly hurt in long-term both at national and international level.
There were a number of good things happening in MDACC, one of the leading cancer centres in the world, however compared to National Health Services in the UK, I found certain things could be made more efficient. There were unusual long delays between the cases, and not all cancer cases were discussed in multidisciplinary (MDT) meetings, but those selected for the discussions went through a thorough and detailed deliberations and all faculty members contributed to a good quality discussion. To achieve a balance between services driven MDT meetings and have a useful academic component is perhaps difficult to achieve in the UK.
The second gain in my knowledge was seeing a number of physician assistants (PAs) working in the clinics and each and every case goes through proper work up including review of investigations by PAs before being referred to a surgeon for the final word and explanation of the procedure. Presence of PAs also protected the learning opportunities for residents attending clinics and allowed consultants to spend time in quality teaching. This is something which I have brought back for discussions and in fact have started discussing with my colleagues in Royal College of Surgeons in Edinburgh through speciality advisory board in urology.
United States of America (Memorial Sloan Kettering Cancer Centre, New York) 13-17th April 2015
My second stop of visit in the USA was in New York. I visited Memorial Sloan Kettering Cancer Centre. Again, I was welcomed here by the Urology team, however Professor Eastham, my host had to apologise due to some pressing social commitments. I was asked to report to Dr Touijer, another excellent colleague. It was really eye-opening to see that all forms of surgical approaches were offered to men with prostate cancer including open retropubic. The later was fast disappearing in the UK. It was particularly useful as I was member of a committee responsible for implementation of robotic surgery in Scotland. In MSKCC, outcomes of prostate cancer surgery between different surgeons was not different irrespective of the technique (open, laparoscopic, retropubic) they used. I suppose this was more to do with the volume of cases they do and this had certainly overridden any differences which could have been due to approaches.
In urinary bladder cancer, first randomised controlled trial of robotic cystectomy had shown poor results and I had discussions with Dr Bochner (main author) and he confessed to have changed his practice to open technique after the results of the study (despite having six machines in his department). The study really impacted our decision in the UK and robotic radical cystectomy has not been commissioned by the NHS England and open surgery will continue for the near future.
Tumour board meetings or multidisciplinary discussions were of a very high standard. There were many hypotheses generating questions raised by many in leading roles in areas of their clinical practice. Paul Russo, world expert in kidney cancer research discussed contradicting evidence of renal failure and renal cancer. Incidentally, this was something we were working on in our research group and published a recent paper on this topic (Paterson C, Yew-Fung C, Sweeney C, Szewczyk-Bieda M, Lang S, Nabi G. Eur J Surg Oncol. 2017 Aug;43(8):1589-1597). I had a chance to meet and visit other specialists in Radiology (Ogus Akin) and pathology (Dr Tickoo). I shared our research interests and exchanged some ideas. Dr Touijer shared his work on organoids in prostate cancer and incidentally one of my Ph D students was working on a similar theme in bladder cancer and had submitted a paper (which later got published (Palmer S, Litvinova K, Dunaev A, Fleming S, McGloin D, Nabi G. Biomed Opt Express. 2016 Mar 7;7(4):1193-200.). In summary, there were many mutual interests identified during this visit and we agreed to keep working collaboratively in these areas in the future.
Robotic Surgical School, University of Nancy, France. 14th-20th August 2017
Continuing my fellowship in Europe, I visited department of Urology, Nancy in France. Prof Jacques Hubert had kindly agreed to host me. The main reason for choosing this centre was their robotic surgical school which Dr Hubert and his team have built through a variety of funding sources over the years. We intended to expand our surgical skills centre in Dundee and introduce robotic training and hence this was a useful opportunity to learn from team in Nancy. The robotic School in Nancy has two retired air force pilots who run the simulation centre. They plan and execute curriculum in a clock-wise precision. It is sometimes useful to include professionals in teams from other industry with large experience. I had very insightful discussions with both these gentlemen. One of the challenges which most of us responsible for delivering surgical training in the UK face is pitching our resources at levels of surgical curriculum and ensure effective incorporation of simulation in training. Urologists in France are in final discussions to re-shape their surgical training curriculum including role of simulation. Prof Jacques and his team kindly agreed to visit Dundee to help in establishing a similar facility for us and we will surely work on this in the future.
It was also a great opportunity to see the historic town of Nancy especially it’s city centre, Stanislas. There is an interesting piece of history behind this Polish name. Stanislas, a prince visited Nancy after deserting a battle in Poland and married to the King’s only daughter and succeeded local king. The place is full of restaurants for outdoor eating. It is a very busy spot of the town.
I had a very absorbing evening out with Prof Jacques and his team and had an evening in one of the historic places known as Basserie Flo with their excellent cuisine and traditional dessert. This was an excellent way to conclude my trip. In between the busy schedule, I did visit historic places of Nancy and I was fascinated to see the obsession of Nancy for their big decorated gates in all the important places of gathering and outdoor eating. Overall, an enriching experience both academically and socially.
Conclusions
The James IV Traveling Fellowship was a great opportunity for me to visit several renowned surgical centers of excellence in North America and Europe. This experience has contributed to broadening of my vision and view on surgical practice and research. I also learnt a lot about new healthcare organisations and on a personal note, made many friends. More importantly, the traveling fellowship has helped to build new collaborations and future areas of exchanging ideas. With rapid and changing face of surgery in urological cancers, in particularly robotic surgery, I consider the experience as one of the best in my life time and would certainly help me in expanding my research and surgical education.
Acknowledgements
I am deeply grateful to Prof. Ashish Kamat and his colleagues at MDACC for their support ensuring a useful time during the James IV Travelling Fellowship, I am also thanksful to the staff of the urology department. I would also like to thank Touijier at MSKCC, New York for hosting me and giving me an opportunity to explore research collaborations. I have special thanks to mention to colleagues in the department of radiology and pathology at MSKCC. I have to express my gratitude to Professor Jacque and his team for making my visit to his unit quite memorable and agreeing to work together in robotic surgery training area. Last but not the least, I sincerely thank my wife Asfia for her understanding and support of my wish to do the James IV traveling, and for taking care of our home during my overseas travel.
