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Re: New American Cancer Society Process for Creating Trustworthy Cancer Screening Guidelines
560
SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS
difficult. As this article demonstrates, male reproductive care at present is highly skewed, making projections based on point of care observations erroneous. Craig Niederberger, M.D.
Urological Survey
Socioeconomic Factors, Urological Epidemiology and Practice Patterns
Re: New American Cancer Society Process for Creating Trustworthy Cancer Screening Guidelines O. Brawley, T. Byers, A. Chen, M. Pignone, D. Ransohoff, M. Schenk, R. Smith, H. Sox, A. G. Thorson and R. Wender American Cancer Society, Atlanta, Georgia JAMA 2011; 306: 2495–2499.
Guidelines for cancer screening written by different organizations often differ, even when they are based on the same evidence. Those dissimilarities can create confusion among health care professionals, the general public, and policy makers. The Institute of Medicine (IOM) recently released 2 reports to establish new standards for developing more trustworthy clinical practice guidelines and conducting systematic evidence reviews that serve as their basis. Because the American Cancer Society (ACS) is an important source of guidance about cancer screening for both health care practitioners and the general public, it has revised its methods to create a more transparent, consistent, and rigorous process for developing and communicating guidelines. The new ACS methods align with the IOM principles for trustworthy clinical guideline development by creating a single generalist group for writing the guidelines, commissioning independent systematic evidence reviews, and clearly articulating the benefits, limitations, and harms associated with a screening test. This new process should ensure that ACS cancer screening guidelines will continue to be a trustworthy source of information for both health care practitioners and the general public to guide clinical practice, personal choice, and public policy about cancer screening. Editorial Comment: Numerous organizations and professional societies generate clinical guidelines but 2 of the most influential are the American Cancer Society and the National Comprehensive Cancer Network (NCCN). This article describes the overhaul by the ACS of its guideline development process to reflect recent recommendations from the Institute of Medicine. The article is fascinating for a number of reasons. There is significant discussion regarding how to avoid conflict of interests in the guideline development process. This overview goes beyond the standard discussion of financial relationships with industry and addresses possible conflicts related to medical specialty. For example do urologists, by virtue of their clinical focus, have a conflict of interest when making recommendations regarding prostate cancer screening? The ACS believes this is a possibility and proposes reserving the actual guideline development and writing process for generalists. They acknowledge that they will solicit the opinion of specialists, although these individuals will not be involved in the final decision making. One cannot help but wonder if these generalists can truly appreciate the clinical situation or the nuances of the literature given their lack of real-world bedside experience in the disease processes under study. Furthermore, I find it offensive that the ACS believes that I, as a specialist, cannot objectively interpret the literature and make recommendations that are in the best interests of my patients. However, this is the approach they have decided to proceed with.
SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS
Another important point is that the ACS process will now be more evidence based and rely on independent entities for the literature reviews. Ironically this issue brings the ACS in line with the existing process of the American Urological Association regarding clinical guideline development. It is to the credit of our specialty society that we have been ahead of the curve in this area and have already created an outstanding and unbiased process for developing evidence-based guidelines, which is already consistent with the recommendations of the IOM. It seems as though the specialists may deserve more credit after all. Having said that, I sincerely hope that the NCCN will abandon its expert opinion based approach and follow the lead of the American Urological Association and use a more evidence-based guideline development process. If they do, I am confident that the NCCN, unlike the ACS, will see the wisdom of including knowledgeable specialists in the guideline writing process. David F. Penson, M.D., M.P.H.
Re: Postgame Analysis: Using Video-Based Coaching for Continuous Professional Development Y. Y. Hu, S. E. Peyre, A. F. Arriaga, R. T. Osteen, K. A. Corso, T. G. Weiser, R. S. Swanson, S. W. Ashley, C. P. Raut, M. J. Zinner, A. A. Gawande and C. C. Greenberg Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts J Am Coll Surg 2012; 214: 115–124.
Background: The surgical learning curve persists for years after training, yet existing continuing medical education activities targeting this are limited. We describe a pilot study of a scalable video-based intervention, providing individualized feedback on intraoperative performance. Study Design: Four complex operations performed by surgeons of varying experience-a chief resident accompanied by the operating senior surgeon, a surgeon with less than 10 years in practice, another with 20 to 30 years in practice, and a surgeon with more than 30 years of experience-were video recorded. Video playback formed the basis of 1-hour coaching sessions with a peer-judged surgical expert. These sessions were audio recorded, transcribed, and thematically coded. Results: The sessions focused on operative technique-both technical aspects and decision-making. With increasing seniority, more discussion was devoted to the optimization of teaching and facilitation of the resident’s technical performance. Coaching sessions with senior surgeons were peer-to-peer interactions, with each discussing his preferred approach. The coach alternated between directing the session (asking probing questions) and responding to specific questions brought by the surgeons, depending on learning style. At all experience levels, video review proved valuable in identifying episodes of failure to progress and troubleshooting alternative approaches. All agreed this tool is a powerful one. Inclusion of trainees seems most appropriate when coaching senior surgeons; it may restrict the dialogue of more junior attendings. Conclusions: Video-based coaching is an educational modality that targets intraoperative judgment, technique, and teaching. Surgeons of all levels found it highly instructive. This may provide a practical, much needed approach for continuous professional development. Editorial Comment: Surgical education continues to evolve and is a key component of quality improvement. As a field, urology has rightly embraced surgical simulators as a learning tool. However, this approach might not be enough. This study explores the use of video coaching to improve surgical education. While the study does not clearly document improved outcomes after the educational intervention, it certainly seems like video coaching would have positive effects. This approach is something our field needs to consider going forward. David F. Penson, M.D., M.P.H.
561
SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS
difficult. As this article demonstrates, male reproductive care at present is highly skewed, making projections based on point of care observations erroneous. Craig Niederberger, M.D.
Urological Survey
Socioeconomic Factors, Urological Epidemiology and Practice Patterns
Re: New American Cancer Society Process for Creating Trustworthy Cancer Screening Guidelines O. Brawley, T. Byers, A. Chen, M. Pignone, D. Ransohoff, M. Schenk, R. Smith, H. Sox, A. G. Thorson and R. Wender American Cancer Society, Atlanta, Georgia JAMA 2011; 306: 2495–2499.
Guidelines for cancer screening written by different organizations often differ, even when they are based on the same evidence. Those dissimilarities can create confusion among health care professionals, the general public, and policy makers. The Institute of Medicine (IOM) recently released 2 reports to establish new standards for developing more trustworthy clinical practice guidelines and conducting systematic evidence reviews that serve as their basis. Because the American Cancer Society (ACS) is an important source of guidance about cancer screening for both health care practitioners and the general public, it has revised its methods to create a more transparent, consistent, and rigorous process for developing and communicating guidelines. The new ACS methods align with the IOM principles for trustworthy clinical guideline development by creating a single generalist group for writing the guidelines, commissioning independent systematic evidence reviews, and clearly articulating the benefits, limitations, and harms associated with a screening test. This new process should ensure that ACS cancer screening guidelines will continue to be a trustworthy source of information for both health care practitioners and the general public to guide clinical practice, personal choice, and public policy about cancer screening. Editorial Comment: Numerous organizations and professional societies generate clinical guidelines but 2 of the most influential are the American Cancer Society and the National Comprehensive Cancer Network (NCCN). This article describes the overhaul by the ACS of its guideline development process to reflect recent recommendations from the Institute of Medicine. The article is fascinating for a number of reasons. There is significant discussion regarding how to avoid conflict of interests in the guideline development process. This overview goes beyond the standard discussion of financial relationships with industry and addresses possible conflicts related to medical specialty. For example do urologists, by virtue of their clinical focus, have a conflict of interest when making recommendations regarding prostate cancer screening? The ACS believes this is a possibility and proposes reserving the actual guideline development and writing process for generalists. They acknowledge that they will solicit the opinion of specialists, although these individuals will not be involved in the final decision making. One cannot help but wonder if these generalists can truly appreciate the clinical situation or the nuances of the literature given their lack of real-world bedside experience in the disease processes under study. Furthermore, I find it offensive that the ACS believes that I, as a specialist, cannot objectively interpret the literature and make recommendations that are in the best interests of my patients. However, this is the approach they have decided to proceed with.
SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS
Another important point is that the ACS process will now be more evidence based and rely on independent entities for the literature reviews. Ironically this issue brings the ACS in line with the existing process of the American Urological Association regarding clinical guideline development. It is to the credit of our specialty society that we have been ahead of the curve in this area and have already created an outstanding and unbiased process for developing evidence-based guidelines, which is already consistent with the recommendations of the IOM. It seems as though the specialists may deserve more credit after all. Having said that, I sincerely hope that the NCCN will abandon its expert opinion based approach and follow the lead of the American Urological Association and use a more evidence-based guideline development process. If they do, I am confident that the NCCN, unlike the ACS, will see the wisdom of including knowledgeable specialists in the guideline writing process. David F. Penson, M.D., M.P.H.
Re: Postgame Analysis: Using Video-Based Coaching for Continuous Professional Development Y. Y. Hu, S. E. Peyre, A. F. Arriaga, R. T. Osteen, K. A. Corso, T. G. Weiser, R. S. Swanson, S. W. Ashley, C. P. Raut, M. J. Zinner, A. A. Gawande and C. C. Greenberg Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts J Am Coll Surg 2012; 214: 115–124.
Background: The surgical learning curve persists for years after training, yet existing continuing medical education activities targeting this are limited. We describe a pilot study of a scalable video-based intervention, providing individualized feedback on intraoperative performance. Study Design: Four complex operations performed by surgeons of varying experience-a chief resident accompanied by the operating senior surgeon, a surgeon with less than 10 years in practice, another with 20 to 30 years in practice, and a surgeon with more than 30 years of experience-were video recorded. Video playback formed the basis of 1-hour coaching sessions with a peer-judged surgical expert. These sessions were audio recorded, transcribed, and thematically coded. Results: The sessions focused on operative technique-both technical aspects and decision-making. With increasing seniority, more discussion was devoted to the optimization of teaching and facilitation of the resident’s technical performance. Coaching sessions with senior surgeons were peer-to-peer interactions, with each discussing his preferred approach. The coach alternated between directing the session (asking probing questions) and responding to specific questions brought by the surgeons, depending on learning style. At all experience levels, video review proved valuable in identifying episodes of failure to progress and troubleshooting alternative approaches. All agreed this tool is a powerful one. Inclusion of trainees seems most appropriate when coaching senior surgeons; it may restrict the dialogue of more junior attendings. Conclusions: Video-based coaching is an educational modality that targets intraoperative judgment, technique, and teaching. Surgeons of all levels found it highly instructive. This may provide a practical, much needed approach for continuous professional development. Editorial Comment: Surgical education continues to evolve and is a key component of quality improvement. As a field, urology has rightly embraced surgical simulators as a learning tool. However, this approach might not be enough. This study explores the use of video coaching to improve surgical education. While the study does not clearly document improved outcomes after the educational intervention, it certainly seems like video coaching would have positive effects. This approach is something our field needs to consider going forward. David F. Penson, M.D., M.P.H.
561