I fell in love with Paediatric Urology in the early seventies sitting in the back of a tiny crowded room as my (later) mentor and paediatric urological deity, Sir (plain ‘Mr’ then, his knighthood arrived much later and for other contributions) David Innes Williams expounded eloquently to an attentive audience every week at X-ray (remember them??!) meetings at Great Ormond Street and The Shaftesbury hospitals in London. It was a fatal attraction which ultimately led to my appointment as his ‘number 2’ in 1977. This was a short-lived idyll as in 1978 he moved on to direct all the post-graduate medical specialities in the University of London and that was the end for me of a period which allowed experience to be gained by osmosis and I was alone. So many people became involved in the evolution of Paediatric Urology in London and the UK that this is another story in itself, but central to progress were the encounters with others who had embarked on a similar journey. The Paediatric Urology meeting.
I used to love going to meetings. In the pre-electronic era there was a tremendous sense of a journey into the unknown, an adventure into uncharted territory where ‘Here, there be dragons’ was more likely than as depicted on the maps of long ago.
The meetings were different then; smaller, more time for debate, and more intense as a generation learned to stand on its own two feet on a precarious platform created by such a small number of outstanding predecessors. We were part of the era when PU changed from being the province of pioneers to a regulated state and everything was up for debate. The process of submission and selection was very much the same as now although the selection rate was probably a little lower and of the order of 20%, as discussion times within the programmes were sacrosanct. To be accepted was wonderful, two was a bonus and you were riding high on three. There was healthy competition and if in one year Boston or Philadelphia had six accepted (as happened) then the efforts for the next year began the day the meeting ended.
In those days before the ESPU, APAPU, SIU and other societies came into being the Oscars were won at the AAP, The American Academy of Pediatrics, Section of Urology. This was the Mecca, demanding an annual pilgrimage and delightfully separate from any other urological association giving everyone the feeling that we were standing on our own two feet. A small room with maybe 2–300 people and only a couple of floor microphones where queues formed and everyone could see who was in line. Perhaps, like pain, the tingle factor from sparks is greater when it can be anticipated. Fond memories, romantic nostalgia, a generation thing. However, if you talk to the participants in that gladiatorial era the one thing that they remember are the discussions. No-one remembers the presentations but most can still place some encounters of 30 years ago by contestants, location and time, such was the impact of these verbal altercations. Coming back closer to home, one of the most memorable ESPU meetings was in London in 1996 when the room was too small and people had to sit on the stairs. It is the only meeting where I have seen people coming back into the room early from the coffee breaks in order to claim a seat and nobody moved during the sessions because they couldn't. The atmosphere it created was wonderful and the discussion benefited enormously. Quick fire, often without a microphone and John Duckett on song. What a tragedy that he was lost to us only one year later.
What has happened? Well the meetings have got bigger. Up to 1000 people, Six or eight floor microphones scattered in the gloomy recesses of a cavernous room. Perhaps part of the screening process for moderators should be their ability to identify individuals in the dark at 50 m. Maybe we can harness face-recognition technology to flash up instantly a discussant's identity, expertise and favourite colour. More people, larger room; more abstracts, less discussion; it is a downward spiral but I think that by analysing the problems we can find a solution to bridge the gap until meetings disappear into a virtual world and we all sit at home and allow electrons to do the travelling. The decline in quality of the meetings is evident and an universal experience. Everyone talks about it in small fraternal groups either at the meeting or after they get home and are asked ‘How was the ESPU in Lyon?’ There are feedback forms but they are a crude guide to the real experience and in my view have served to reinforce the cycle of deterioration. I once scored 0.9 out of 5 when the median was 4.5 but at least everyone remembers the occasion.
So, what has gone wrong and what can we do to change the situation. The purpose of these jottings is to try and understand the problems and to offer some possible solutions to be tried out by those organisers brave enough to take the risk. The comfort of a well-tried formula delivering a satisfactory financial if not academic balance is a hard fireside to leave and to expose oneself to the cold wind of change.
Probably the fundamental flaw in our present arrangement is the increasing size of paediatric urology gatherings and the persistence of a single auditorium serving all presentations. The effect of room size was beautifully illustrated at the ESPU Lyon meeting. For some years now the case presentation pre-congress session has been immensely popular although somewhat frowned upon by the scientific elite. The little room in the basement of the congress centre was always packed and the sessions were fun. In many ways they were an annual reminder of my own first tentative steps in paediatric urology all those years ago. In any event they were very provocative and educational. In Lyon the popularity of the session was finally acknowledged and moved to the main auditorium. It was well attended, and the cases presented were as fascinating as ever, but the session died. Slow and without continuity it deteriorated into a few intermittent questions and answers and the vitality of discussion was completely lost, another victim of environmental change.
The problem with numbers is not only the increased attendance which has doubled and then trebled in recent years which is a healthy reflection on the development of Paediatric Urology worldwide. The meetings have expanded but the number of abstracts has also increased to the detriment rather than the benefit of the quality of the meeting. One of the driving factors for many organisations is that profit from the annual meeting is a major source of income which has become more important as sponsorship has declined. Accordingly the more people who come the better but then the argument is put forward (for which there is little if any evidence) that they will only come if their abstracts are accepted and so we end up with a synergistic set of factors; More people, larger room; more people, more abstracts; less time for discussion. So often the meeting reports sent out to the membership are simply a series of numbers championing success: “This year there were 870 delegates from 27 countries who presented 211 abstracts and we made a profit of €100.000”. An index of quality is missing and if you seek to hide behind a satisfaction average, I think you are delusional. The bigger the meeting, the more people who have never known anything else.
You can look at the financial aspects of a meeting in a different way. At a meeting of the SPU in San Francisco a couple of years ago, I made the modest estimate that if we considered the TOTAL investment made by the delegates to be there (Air travel, hotel, registration, meals etc but not including loss of earnings for those in private practice) then to have everyone sitting together in one room for the purposes of education and scientific advancement was at least $3million or more than $2000 a minute for the entire congress. However, if the reason for being there was only for the discussion then this represented an investment of $10.000/minute. One was forced to question if this investment was paying adequate dividends. In fact, the meeting suffered badly from LRS (Large Room Syndrome). There was often only a handful of people scattered around a large auditorium and the discussion was short and stilted. Ironically it was sometimes hard to hear well on account of the noise from the other 500 delegates networking noisily in the corridor outside. The ESPU fares slightly better than this with a ‘discussion only’ investment of about €3000/minute but the returns on this investment are still poor and declining as meeting quality slides into recession.
I am not trying to be only negative. One has to recognise the other aspects of meetings which have come to the fore in recent years. The teaching sessions, practical workshops, sponsored debates, language and paper writing courses have all served the community well and enhanced the input from areas where the speciality is still very much in its infancy. The nominated lectures have increased and generally serve us well, but the main sessions have deteriorated to the point of being almost worthless. At its extreme you have to acknowledge that a series of 3 min presentations with 1 min of discussion into a hall holding a thousand people doesn't work. In truth, in this type of setting, discussion is a misnomer and question and answer (or more precisely question and non-answer) has become the accepted standard.
In the past we have tried some other approaches. On one occasion we posted the papers on line one month before the meeting and, rather than have them presented again, the moderator made a brief summary at the beginning and the entire time was given over to discussion. It didn't work. Maybe it was ahead of its time, maybe just a bad idea, but it seemed at the time that the real reason it didn't work was that the delegates hadn't understood what was happening and hadn't read the papers. They therefore spent the entire session time hurriedly trying to read them on their tablets rather than participating in discussion as planned. Maybe it is worth another try or maybe some more imaginative variant which replaces presentation with discussion time.
At a recent congress in Doha the most successful sessions were variations on the theme of a round table discussion. The round table can be a very successful way of resolving issues and highlighting the way forward. In general, the round table has deteriorated in recent years. A 30 min round table with 3 eminent speakers setting out their stalls for 5 min each and 15 min for hard hitting discussion never seems to work that way. With the meeting already running late and each speaker overrunning their times the flame spluttered and died before any heat could be generated. This was avoided at the Doha meeting in both sessions but in different ways. In one there were no presentations, no slides at all, only discussion and in the other the only presentations were made by the moderator. This can work perfectly well in a large hall but involvement of the audience is undoubtedly better and easier in a smaller room.
This brings us back to meeting size. Traditionally most paediatric urology meetings have not run parallel sessions but maybe the time has come, especially at the joint meetings where there can be more than a thousand delegates. If the rooms are smaller and debate does take off again within our meetings, then it will become important that senior figures return to the platform. In the early days this was the norm, but it seems to have become accepted that most presentations these days are given by trainees who are often not in a position to shoulder the burden of debate or to resist the malicious questioner while the chiefs sit silently in the darkness. Yes, sometimes it is theatre and the better for it.
Maybe now is not the most appropriate time with the coronavirus threatening widespread cancellation of meetings but I would plead with the large societies which have an adequate financial cushion to take the risk for a meeting or two of not simply being bean counters but giving priority to education and debate and to be prepared to experiment. In fact, in the interval between submitting this manuscript and proof stage, the world has changed, and many societies are already looking to make greater use of digital media to replace the traditional getting together at a meeting. Let us embrace this challenge and find a way for the simple release of information to be a web event and to restore the debate and discussion to centre stage. It is not too farfetched to think that one more click on a journal website would take you not just to the full-length article but to a powerpoint presentation by the author. Could it be that we will see accepted papers published before a meeting rather than after? and the effort and expense of attending a congress will be rewarded by witnessing the debate by which the science of our speciality is kept alive. There is little evidence that people won't come to a good meeting unless their own paper is accepted. ‘Who dares wins’ may become the motto of the successful society that breaks the mould and becomes the place where everyone wants to go.