It's March 1, and an unseasonably warm and sunny day here in Washington, with a beautiful blue sky. Yesterday was Leap Day, an opportunity to account for the fact that the astronomical and Gregorian calendars are misaligned by a quarter of a day each year. The relative novelty of Leap Day—by the time it comes around, most of us have forgotten about our last Leap Day—lends itself to celebrations that are sometimes thematic (froggers at the gym), often tongue-in-cheek (“Happy Birthday! You look a bit long in the tooth for four, though.”), and generally, an excuse to celebrate ∗something.∗ In my case, Leap Day is, effectively, the gift of extra time: I'm gaining a full day, which is not insignificant, especially given that time is a single-use currency that is doled out to all of us equally and must be spent wisely. The Henry-Hanke Permanent calendar (www.hankehenryontime.com), designed by two Johns Hopkins University professors, offers a more structured version of the Gregorian calendar, in which there are 364 days, or 52 seven day weeks. This means that every holiday will fall on a Monday, and every 5–6 years, there will be a 7-day “leap week.” Professors Henry and Hanke provide a compelling argument for their calendar, specifically citing streamlined scheduling. Personally, I'm still on the fence: what if I don't want my birthday to be on a Thursday every year? Is this the calendar version of Natalie Babbitt's Tuck Everlasting, where the characters don't even need mirrors because they have looked the same for so long?
As you consider that, allow me to share some other recent events.
In the news
Wash Your Hands
Here in Washington state, and worldwide, COVID-19 is making headlines. Just yesterday, the first death from the virus in the United States was reported. COVID-19 was officially identified in December 2019 as structurally similar to the coronaviruses causing SARS and MERS, and as of this morning there are 183 peer-reviewed publications about COVID-19 on PubMed. It's clear that this crisis is still developing, as researchers race to find out as much as possible about the virus and its behavior. In the initial outbreak, elderly and immunocompromised patients were at greatest risk, and no cases were reported in children under 15 years of age. However, community-acquired cases are now being reported (at least three in the Pacific Northwest as of yesterday), and asymptomatic patients have been found to be COVID-19 positive. Parts of Paris Fashion Week have been canceled, and this summer's Tokyo Olympics may not occur; these are not simply social events but the culmination of years of work for many. COVID-19 threatens not only our health but our interactions with one another. As this saga unfolds, it is critical to balance knowledge and fear. Stay tuned.
Fauci AN, Lane HC, Redfield RR. COVID-19: Navigating the uncharted. NEJM, February 28, 2020 (ePub ahead of Print). DOI: 10.1056/NEJMe2002387
Megxit
On perhaps a lighter note (unless you are a member of the British monarchy), Prince Harry and his wife, the former Meghan Markle, decided last month that they wished to step down as working royals and to spend most of their time in North America. While I won't get into the finer details of the rationale behind their decision, their choice to effectively vacate their titles (they will keep but not use them) and step away from what is arguably one of the grandest institutions in history has highlighted, for me, the parallels (however limited) of their lives with mine. Academic medicine, like the British monarchy, is steeped in history and tradition: “see one, do one, teach one” was long the rallying cry in surgical training. Notably absent from that catchy phrase is any suggestion of “asking.” Without ongoing critical review of our knowledge and actions, tradition easily becomes dogma. The medical and pediatric urology communities have, in recent years, become more open to considering what we do, why we do it, what our (true) results are, and what improvements might be made. For me, Dr. Douglas Canning's talk at the 2015 European Society of Pediatric Urology was a game-changer: he discussed his complications openly and honestly, and encouraged others to do the same. Flexibility of thought is critical not only for self-improvement, but to adapt to new situations (see coronavirus, above).
https://www.nytimes.com/2020/01/23/podcasts/the-daily/harry-and-meghan-markle.html.
Food for Thought
Full disclosure: I had never heard of Dr. Stanley Dudrick until two days ago. I read the New York Times every day, including the obituaries. I've always liked obituaries (I even read them as a child): they're the best you'll ever look on paper. Dr. Dudrick would likely have approved of my ignorance of his existence, judging from his obituary: sixty years ago, as a young trainee, he wondered why several patients died unexpectedly despite “good” operations. The answer? Malnutrition. His solution, total parenteral nutrition (TPN), has saved countless lives. Interestingly, in order to maintain the accessibility of TPN, his invention was never patented. Aside from the clinical curiosity and dogged determination of the young Dr. Dudrick, I was struck by the impetus for his choice of a surgical career: the “compassionate care” he witnessed his ill mother receiving when he was a child. Dr. Dudrick reminds us that, as surgeons, being technically excellent is necessary, but not sufficient, to wholly care for our patients.
https://www.nytimes.com/2020/02/27/science/dr-stanley-dudrick-dead.html.
In the journals
Approximately 2% of people are gender non-conforming (GNC), and GNC patients have a higher prevalence of mental health concerns: 40% have attempted suicide. In this manuscript, Turban et al. surveyed over 20,000 transgender adults, finding that only 2.5% received pubertal suppression. However, the odds of suicidality was significantly lower (OR = 0.3) in GNC patients receiving pubertal suppression compared with those who desired but did not receive the treatment. This paper underscores the role of gender-affirming therapy as, quite literally, a matter of life or death.
Turban JL, King D, Carswell JM, Keuroghlian AS. Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation. Pediatrics 2020; 145 (2) e20191725 (ePub ahead of print).
Although this paper is from 2018 (!), I had not seen it before, and was surprised by its findings. Operating efficiently (or “paucity of motion” as one of my mentors called it) is a challenge, given the many factors that influence operative time. In teaching settings, it is especially important to balance the effects of longer operative and anesthetic times with clinical opportunities for trainees. This large-scale systematic review of publications in multiple surgical subspecialties gives surgeons yet another reason to be efficient: increased operative time is associated with a higher risk of complications (in one study, twice the risk of infection after laparoscopic cholecystectomies lasting >30 versus >60 min), even after controlling for patient factors. While these findings may seem intuitive to some, seeing the data in written form is a humbling reminder that patient and team safety require everyday efforts.
Chan H, Clymer JW, Chen P-H, et al. Prolonged operative duration is associated with complications: a systematic review and meta-analysis. J Surg Res 2018; 229: 134–44.
Urologists have the second-highest prevalence of burnout of any specialty. Women have higher burnout rates compared with men, suggesting that the factors contributing to burnout may vary by gender. As the number of women in urology continues to increase, and the overall number of practicing urologists remains stable despite a growing population, it is increasingly important to identify actionable areas for burnout prevention. Lu and colleagues performed semistructured interviews of male and female faculty at all levels, identifying factors associated with career satisfaction and others with burnout. Collegiality, supportive leadership, and interactions with patients and learners were cited as the major drivers of career satisfaction, with gender bias (women) and complications (men) the greatest contributors to burnout.
Lu PW, Columbus AB, Fields AC, et al. Gender Differences in Surgeon Burnout and Barriers to Career Satisfaction: A Qualitative Exploration. J Surg Res 2020; 247: 28–33.
It is that time of year when senior urology residents traverse the country to interview for fellowships. As Dr. Dudrick's life reminds us, it is not enough to be technically capable. Surgeons must deliver compassionate, patient-focused care. This week, JAMA Surgery published an opinion piece written by me and Dr. Munee Kapadia, calling on communication training to be integrated into graduate surgical education. Holmes et al.'s manuscript on how variations in personality traits exhibited in the presence and absence of stress predicted differences in communication skills goes several steps further. Since clinical communication skills often call for grace under pressure, even the most stressful interview day may not truly measure a candidate's communication ability.
Kapadia MR, Kieran K. Being Affable, Available, and Able Is Not Enough: Prioritizing Surgeon-Patient Communication. JAMA Surg 2020 (ePub ahead of print).
Holmes KS, Zuckerman JD, Maculatis MC, et al. Personality Predictors of Communication Skills Among Orthopedic Surgery Residents. J Surg Ed 2020; 77: 202–12.