Ir J Med Sci (2014) 183:7–13 DOI 10.1007/s11845-013-1029-4
REVIEW ARTICLE
Advancing cancer care: the quality spiral Sir Thomas Myles Lecture N. O’Higgins
Received: 23 August 2013 / Accepted: 4 October 2013 / Published online: 30 October 2013 Royal Academy of Medicine in Ireland 2013
Abstract Hypothesis Good patient care, research and education should be so inextricably linked that each should drive the other towards improvements in quality of care, innovation and discovery. Discussion Each element of good clinical cancer care, including specialisation, multidisciplinary management, audit and systematic organisation, provides a powerful stimulus to research. The qualities required for good research inevitably enhance educational activity. High quality in education and training are essential in improving cancer care. Obstacles to good medical care are identified and the importance of supporting doctors is emphasised. The question of permanent staff-grade medical appointments or the grade of physician assistants is raised. Challenges to university-based and hospital-based research are outlined. Attention is drawn to issues concerning the training of cancer specialists, particularly in surgical oncology. Conclusion Good patient care stimulates research, research drives educational activity and education improves care. Interaction of these elements of medicine and science constitutes an interdependent upward spiral towards excellence.
university Training of cancer specialists Surgical oncology
Introduction I appreciate very much the invitation to present the Sir Thomas Myles Lecture. On behalf of everyone who has gained from them, I am pleased to thank all those, past and present, who have established, developed and refined the Sylvester O’Halloran meetings, now soundly established among the principal surgical events in the country. I am particularly delighted to have been invited to make this presentation here in Limerick on my home ground. Sir Thomas Myles was born in Catherine Street in Limerick in 1857 and lived a remarkable life. Sportsman, teacher, surgeon, Home Ruler and supporter of the Irish volunteers, he was also honorary surgeon in Ireland to the King. He was made a freeman of the city of Limerick and was knighted in 1902. His life has been recalled in an elegant biographical presentation by Professor Pierce Grace.
Global problem of cancer Keywords Cancer care Interaction of care Research and education Relationship of hospital and
N. O’Higgins, Chairman University of Limerick Hospitals Board. N. O’Higgins (&) Emeritus Professor of Surgery, University College Dublin, Dublin, Ireland e-mail: [email protected]
In this talk, utilising the cancer model, I plan to discuss broader issues of clinical care, research and education and to place them in the context of our region. The views are, of course, personal and not necessarily those of the board of the UL hospitals group that I am privileged to represent. Cancer is a global problem, because in spite of steady and occasionally spectacular improvements in diagnosis and therapy, it represents an increasing burden on mankind and remains an elusive and malignant enemy.
123
8
The World Health Organisation calculated that in 2008 there were 12 million new cases of cancer diagnosed, 7 million cancer deaths and 25 million people living with cancer. By 2030 it is estimated that there will be 27 million new cases diagnosed annually, 17 million cancer deaths and that 75 million people will be alive who have had a cancer diagnosed within the previous five years. This increase will be mainly due to three factors [1]. First, the global population will grow from 7 billion to 8.5 billion. Second, the fraction of the population who are aged will increase and the incidence of cancer increases with age. It has been estimated that two-thirds of the ‘‘seniors’’ who ever lived are alive today [2]. The third factor will be the introduction of risk factors for cancer from the developed world to poorly resourced countries and this will be added to those that already exist there. More than 40 % of cancer deaths are due to tobacco, diet and infections, and the relative proportion of these factors differs from resource-poor to developed countries.
The quality spiral My premise is that good clinical practice stimulates research, that research promotes standards in education and that education in turn is a powerful stimulus for improving clinical care. I suggest that this interlinked relationship is maintained, whether the starting point is with service, research or teaching. The essential point in the proposal is that each of these elements drives and urges the other on, not in a circle but rather in an upward spiral towards excellence. Although this hypothesis is relevant to all hospital practice, the example of cancer is used here to develop some of the relevant issues and to demonstrate obstacles that can interfere with these processes.
Good clinical care stimulates research My first proposition is that good clinical practice stimulates research. High-quality cancer care requires (a) specialists who treat a substantial number of patients, (b) multidisciplinary management, (c) a system of audit and verification and (d) a systematic organisation. Specialisation and volume When clinical practice is of high quality, data inevitably accumulate, creating scope and opportunity for analytical research. A seminal publication in 1979 [3] drew attention to the positive association of high-volume and reduced
123
Ir J Med Sci
mortality in surgery. This study generated extensive clinical research over the subsequent 30 years. All this research has come from institutions recognised for the high quality of care. It could be argued that only centres offering high quality can carry out such research and even that highquality care is a pre-requisite for clinical research. Different research methodologies in many health systems have resulted in a large mass of information about cancer management. The demonstration of variations in outcome for breast cancer between specialist and non-specialist centres provided eloquent and convincing evidence in favour of centralised or regionalised care. Longer survival for patients with all types of gastro-intestinal cancers, as well as cancer of the lung, prostate and breast treated in high-volume centres has been demonstrated in more than one hundred studies. Individual surgeon volume and specialist training also correlate with better outcome. Because so much data are collected and experience gained in highvolume centres, institutional guidelines and research almost always follow, demonstrating that good practice provides a solid research platform. The great majority of clinical research publications come from such hospitals. These centres are also more likely to take part in multicentre clinical trials and, because they are sources of much clinical information, they are likely to attract funding for clinical research. Multidisciplinary management Clinical judgement remains a core element in medical decision-making and cannot be replaced or superseded by protocols. Protocols are not substitutes for trained doctors. What is good for the many may not be good for the one. However, fears that multidisciplinary meetings would cause conflict between evidence-based medicine and clinical judgement and fears of conflict between team-management and individual accountability have not been realised. Multidisciplinary collaboration with other medical disciplines in oncology is of great importance both at diagnosis and the time of treatment. The combination of disciplines improves accuracy and minimises error. The participation of other professions has improved the quality of life for cancer patients and facilitated pathways of care. Research questions about diagnosis, treatment and eligibility for clinical trials almost always arise at these meetings. Multidisciplinary meetings are, therefore, valuable, not only in patient management, but in stimulating clinical research and in promoting clinical trials. Audit Audit is an intrinsic part of good clinical practice. The purpose is to raise standards of care. One aim of audit is to
Ir J Med Sci
drive research. Audit involves analysing results, identifying areas for improvement, putting them to the test in prospective fashion and then analysing outcome. It must, of course, be matched by administrative audit. The welcome alliance between clinicians and managers should lead to improvements and also generate administrative research. Audit, therefore, should inherently be both a research tool and an exercise in professionalism. Systematic organisation A systematic organisation is the basis on which all services depend. Irrespective of the quality of the staff, hospitals thrive or fail according to the ability and capability of the administrative organisation. Good systems invariably raise research questions in areas such as health economics, logistics of care pathways, risk management and information technology. A competent organisation is also a powerful supporter of clinical research. It is the velvet upon which the jewel of excellence can shine. The opposite is equally true. Without a sound supportive organisational infrastructure, it becomes almost impossible to conduct good research. Thus, I believe that the essential elements of good cancer care- specialisation and high-volume, multidisciplinary meetings, audit and a systematic organisation— provide strong, even necessary, platforms for research.
9
inefficiencies and wastages; lack of infrastructural support—offices and secretariat; parking issues; excessive waiting times for clinics and radiology; delays for elective operations; capacity issues; poor public perception; unattractive physical appearance; equipment cluttering corridors; inadequate clinical audit. Much needs to be done. The presence of a strong systematic organisation can raise quality of care quickly and comprehensively. An example is the development of cancer services where much has been achieved in recent times. The National Cancer Control Programme and the difficult and painful centralisation of cancer services have required much effort and patience. Comprehensive data analysis and in-built, verifiable measures of quality are functioning successfully at a level that, even if it remains far from perfect, compares well with other countries. The Cancer Control Programme also stimulates an increasing amount of research. Reconfiguration of a hospital’s functions produces strains among colleagues and institutions but understanding of what has been achieved in cancer services points to a paradigm for other services. The plan to organise hospitals in Ireland into six groups provides an opportunity to develop a coherent model of improved care [4]. The success of this policy requires medical and administrative leadership and co-operation as never before.
Supporting doctors Obstacles to good clinical care In promoting clinical care the question arises whether these elements are in place in our hospitals. Is systematic organisation in place everywhere? Managerial, medical, nursing and allied staff have drawn attention in recent years to several issues in many hospitals in Ireland, including the following: low morale; disaffected staff; lack of institutional pride; departments and services not functioning together; doctors working under too much pressure; lack of leadership; lack of clinical and corporate governance; missed opportunities; lack of consultation; lack of investment; too few specialised staff to deliver quality services; inadequate theatre time; IT systems not co-ordinated; no centralised control; no chain of command; poor communication at all levels; no vision for the hospital; doctors isolated and unsupported; clinical independence lost; much uncertainty; fragmentation of services; poor systems of recruitment of doctors-interns, trainees and consultants; poor training; lack of confidence in administrative processes; hospitals underpowered in bed capacity and diagnostic services; conflict between doctors and management; excessive bureaucracy; issues with procurement; overcrowding of Emergency Departments; absenteeism;
Almost all doctors want to help improve care of patients and are conscientious and committed to professional development. They understand that good practice requires being up-to-date, raising questions, attending meetings, reading journals, discussing developments, identifying moving points, indicating the direction and opportunities for further improvements. Any and all of these influences invite the prepared mind to engage in research endeavour and stimulate research opportunity. Yet doctors in Ireland are often portrayed in the media, particularly the print media, as the obstacles to, or even the enemies of, progress. When things go wrong, they are the prime targets for blame. Doctors and hospitals need to communicate better with the public. I believe that the Medical Council must do more to support doctors. It can do more to inform the public and the government about medicine. It can do more to promote high standards of clinical practice. It should not be silent in drawing attention to the need for improvements in training and in availability of facilities and opportunities required for good care. It should not be silent about the situation of dangerously overworked young doctors in hospitals—for many of whom specialist training has changed from a joyous experience to a harrowing one. During my Presidency of
123
10
the Royal College of Surgeons in Ireland (RCSI) I spoke and wrote about this issue and quoted Professor Ray Tallis, in support of our colleagues in training, when he stated, ‘‘It is upon such people that the future of medicine will rest. If their sense of medicine as a calling is not destroyed, they will be doing their best for sick people in the dark hours when the hostile critics of the profession are chattering away at their dinner parties or safely tucked up in bed’’ [5].
Research enhances educational activity I have attempted to demonstrate that good clinical care inevitably poses questions for research. I now turn to the second proposition—that research promotes and improves educational activity. Researchers analyse evolving evidence, promote enquiry, formulate hypotheses and inform teaching. An example in oncology is the molecular revolution in cancer research whereby genomic analysis will permit targeted therapy, individualising cancer care based on the biological properties of the specific tumour. This avoids undertreatment and overtreatment and lessens the toxic unwanted collateral damage of chemotherapy. Rapid change such as this must enter the educational curriculum and the teacher’s programme quickly. Shortening the interval between discovery and clinical application in oncology demands that the teacher and the curriculum are alert and responsive to significant research developments. The teacher, expert in the dissemination of knowledge, distinguishes between developments and advances, discards what is irrelevant or obsolete and also embraces the spirit of enquiry. Research of any kind requires extensive reading of a subject so that it can be understood and understanding is a prerequisite for good teaching. The network of intellectual capability from disparate backgrounds available in the university facilitates basic research and fundamental enquiry, clarifies thinking and thereby enhances teaching. The resources of the university provide encouragement for the development of scholarship and research at local and international level, adding further stimulus to the educational drive. Furthermore, the sacrosanct responsibility of the university to be fastidious in recording of data instils in the teacher and the student the integrity and the habit of truth that define the essence of scholarship and scientific exploration. Research enhances educational development of both teacher and student. Youthful thinking is recognised in a good teacher for as stated in by Dr Chris Johnson [6] in the British Medical Journal in 2005, ‘‘Learning something new is easy. Unlearning something old is difficult…because you have to alter information and, in so doing, you have to challenge your beliefs’’. As putative powerhouses of ideas the university welcomes innovation,
123
Ir J Med Sci
novel propositions uninhibited by history or experience-in short, it encourages youthful thinking and change.
Obstacles to research Although collaboration between the research engine of the university and the research derived from clinical questions in the hospital undoubtedly improve and motivate clinical education, the relationship between these institutions requires nurturing like a delicate flower. Although university medical schools and teaching hospitals share interests in education, research and clinical practice, the priorities and the financial considerations of each differ and the points of divergence often become the touchstone for tension and concern. The reputation of the university depends largely on productive research and income generated from research is one of the criteria by which quality and status are currently measured. Research is intensely competitive. Just as there is some truth in the adage that an expert is someone who knows more and more about less and less, the narrow focus and great depth of fundamental research makes it likely that only a small number of similar experts will be able to evaluate its significance and quality. It is unlikely that the clinicians with considerable clinical and educational responsibilities will be able to compete in this type of research but they can engage and all who do discover that this gives added value to their teaching. Engagement with the clinician gives relevance to the work of the basic researcher and there is evidence that this dialogue also shortens the interval between discovery and clinical application. In the hospital, increasing clinical demands erode time for research. In addition, clinicians now, quite properly, have greater managerial responsibilities. In hospitals there is often scepticism about the value of research since the endpoints are perceived as being unclear. Furthermore, research in hospitals is sometimes deemed irrelevant because of the long lag time between the conclusion of the work and its application. Surgical research in cancer presents a different set of difficulties from other cancer researchers—difficulty in getting time free from the operating theatre, difficulty because surgeons treating cancer are split across many surgical specialties and difficulties because of limited access to academic leadership and research training during a surgeon’s formative years. I believe that all surgeons in training should be exposed to research and surgeons who have been immersed in the discipline of research have found that it enhances the quality and clarity of their teaching. Hospital managers are primarily concerned with performance, outcomes and costs. They are interested in
Ir J Med Sci
systems and team development and are deeply and rightly concerned about risk of adverse events. As stated by Sir Cyril Chantler [7], ‘‘Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous’’. These differences and potential conflicts are summarised in a report by Universitas, an international collaborative academic grouping from 21 universities [8]. In the university research has a central role and is a source of revenue while in the hospital it is optional and carries an indirect cost. Education also is central and a revenue source to the university. The hospital has an important role in clinical education but this is not its central purpose and education imposes a cost upon the hospital. To the hospital the delivery of clinical care is central and is a source of revenue while its place in the university is often peripheral. A fresh dialogue between hospitals and universities is needed. Clinical education in medical schools could include courses in safety and quality, team training and simulation techniques. Organisational skills and financial management should be part of the medical school programme. More research should be devoted to pathways and logistics of clinical care and more effort made in multidisciplinary research both in hospitals and university.
Education improves care My third proposition is that education improves care. As part of their professional heritage, doctors must contribute to the teaching, training and assessment of students. It is well known that teaching and appraisal inspire learning in the teacher. In addition, student teaching influences teachers’ professional values and reinforces their competence. The instruction and assessment of students are helpful to teachers in their own professional development. These factors are complicit in improving patient care. The remarkable advances in medicine over a short time means that doctors who do not keep pace will be left behind. Within a few years what has been established practice may become obsolete. More than ever continual education is necessary if doctors are to retain competence and safety in clinical practice. The presence of students and specialist trainees in a hospital is an incentive to enhancing services as the curiosity of fresh enquiry always triggers debate. In a hospital the culture of sharing of knowledge with others can be of inestimable value to improving care. It supports the idea of access to learning and development opportunities among all members of staff. In so doing it boosts morale and contributes to harmony. Educational effort facilitates better communication. Support for educational activity throughout a hospital powerfully influences professional pride and
11
self-esteem. Education also tends to engender institutional pride, which probably encourages retention of staff, reduces the rate of absenteeism and is likely to make work more productive and enjoyable. I believe that public education should also be a function of the hospital and can be a driver to health promotion. An easily accessible area for informing the public on illness and wellbeing should be set up in each hospital. These areas can have changing themes and programmes including lectures, films and interactive sessions explaining science, biology, illness, disease prevention and health. Thus, education and educators in hospitals can in so many ways promote better care, which stimulates research, which enhances education which drives better care in an exhilarating quality spiral.
Obstacles to good education and training However, obstacles exist to this upward progression. The training in Ireland of our specialists is unsatisfactory. Surgical training remains too long, too uncertain and the quality of the experience is uneven and often does not contribute to deep learning. A trainee surgeon spends at least 11 years of postgraduate training before being eligible for a consultant post, an arrangement so unacceptable that a career in surgery is no longer attractive to young doctors. A shortened surgical training programme planned to make the progression continuous, introduced by RCSI this year will be a welcome development. The situation whereby trainee doctors are fulfilling roles that involve little or no training is intolerable and requires revolutionary thinking. Trainees should be in training posts and other mechanisms should be explored to provide medical service needs safely, such as a three- or four-fold expansion of consultant numbers, or by introduction of a permanent staff-grade or physician assistant model.
Physician assistants In many fields of medicine the position of Physician Assistant can work well. Developed in the United States over 50 years ago, there are now over 80,000 PAs in the United States, where they have become established as an essential component of the medical workforce. Training for PAs involves a 2-year diploma course open to graduates from a healthcare background. PAs are trained to carry out a broad range of medical services, all under the direct supervision of a doctor. Some years ago the RCSI investigated the feasibility and potential of PAs in surgical practice. Introduction of PAs could be a significant assistance to the Irish Health Service. Discussion among the
123
12
medical training bodies and the Department of Health/HSE is needed. Legislation would be required. With support, it might provide an opportunity for the University of Limerick to be the first to offer a Physician Assistant Diploma course.
Training of cancer specialists Training of cancer specialists is fraught with deficiencies and anomalies. Some universities have no programme of oncology in the medical school curriculum. Some countries, including Ireland, have no dedicated postgraduate training in surgical oncology. Training for the specialties of Radiation Oncology and Medical Oncology rarely involves time spent in Surgery. Such exclusion necessarily limits the ability of these trainees to understand the scope and the aims of operative surgery, either in the potential for cure or in palliation. They, therefore, tend to underestimate the value and overestimate the morbidity of surgery. The situation for surgical trainees is even more serious. There is no consensus within the surgical community or training bodies as to what a cancer surgeons should do or how they should be trained. Surgical oncology is not even recognised as a specialty in most countries. Surgical specialisation is organ-related and such trainees may have little specific training in the principles or developments in oncology and their trainers may themselves have deficiencies in oncological training. A need exists for the training bodies worldwide to come together to promote interdisciplinary training for all cancer clinicians irrespective of their specialty [9].
Ir J Med Sci
broad approach is needed nowadays in order to provide a valid clinical opinion and is indispensable in planning operative strategies. Since surgical oncology is not recognised in Ireland or the United Kingdom as a specialty, surgeons can seek Fellowships in Surgical Oncology in Australia or in one of the 17 approved centres in North America. Fellowships are also available in specialist cancer centres in Europe. An end-of-training examination in Surgical Oncology, recognised by the European Union of Medial Specialists (UEMS), is available through the European Society of Surgical Oncology, a vibrant organisation that formerly, but sadly no longer, was strongly supported by surgeons in Ireland. The future of oncology in Ireland has much to gain from strengthening linkages with Europe and it is regrettable that opportunities have been lost. The Irish Society of Surgical Oncology also seems to have perished. The new enthusiasm and expertise in the University of Limerick and the UL Hospitals provide an opportunity to recommend that a 2-year Fellowship in Surgical Oncology be devised and offered by UL. Utilising, perhaps in a formal way, the extensive international clinical contacts already built up by the academic medical staff, such a programme could involve 1 year in the UL Hospitals and 1 year in one of the recognised centres overseas. Such a development would certainly provide a sustainable supply of highly trained cancer specialists to our country. This educational enterprise would enhance clinical care, thereby pointing the way to new avenues of research and so on towards the ambitious moving target of excellence thus completing the quality spiral. Join the spiral if you can. It’s on an upward trajectory. Conflict of interest
None.
Surgical oncology as a specialty Surgeons must adapt to new developments in oncology [10]. In addition to technical skill in operative surgery, surgical oncologists need to understand the value of audit. They need to be able to assess new technologies in a discriminating fashion, recognising that not all developments are advances. They must have direct training and participation in clinical and laboratory research and be involved in clinical trials, even as Principal Investigator. They must have knowledge and understanding of the other treatment modalities together with an appreciation on how to select patients for multimodal care and they must monitor the progress of their patients. They must have an in-depth understanding of tumour biology, keep studying the literature and be involved in clinical research. They must be prepared to guide their patients through what is often a complex pathway. This requires organisational and networking skills in the context of the team system. Such a
123
References 1. Boyle P, Levin B, International Agency for Research on Cancer (2008) World Cancer Report 2008. IARC Press, Lyon, France, p9 2. Boyle P (2011) Demographic changes in Europe and the burden of chronic care. http://www.ehfg.org.fileadmin/ehfgF3-S2Boylepdf. Accessed 10 Oct 2013 3. Luft HS, Bunker JP, Enthoven AC (1979) Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med 301:1364–1369 4. Higgins JR (2013) The establishment of hospital groups as a transition to independent hospital trusts. Report to the Minister of Health. http://www.dohc.ie/publications/pdf/IndHosp.trusts. Accessed 10 Oct 2013 5. Tallis R (2004) Hippocratic oaths: medicine and its discontents. Atlantic books, London, p 3 6. Johnson C (2005) Unlearning. Personal view. BMJ 331(7518):703 7. Chantler C (1999) The role and education of doctors in the delivery of health care. Lancet 353(9159):1178–1181
Ir J Med Sci 8. Universitas 21 Working Party on University-Healthcare Systems Interaction (2001) The interactions between universities and hospitals: problems and possibilities. http://www.u21health.org/files/ U21UNI*PDF. Accessed 10 Oct 2013
13 9. O’Higgins N (2004) The world federation of surgical oncology societies: the global mission. J Surg Oncol 87:109–115 10. O’Higgins N (1995) Towards a high standard of surgical oncology throughout Europe. Eur J Cancer 31A(Suppl 6):S22–S24
123
REVIEW ARTICLE
Advancing cancer care: the quality spiral Sir Thomas Myles Lecture N. O’Higgins
Received: 23 August 2013 / Accepted: 4 October 2013 / Published online: 30 October 2013 Royal Academy of Medicine in Ireland 2013
Abstract Hypothesis Good patient care, research and education should be so inextricably linked that each should drive the other towards improvements in quality of care, innovation and discovery. Discussion Each element of good clinical cancer care, including specialisation, multidisciplinary management, audit and systematic organisation, provides a powerful stimulus to research. The qualities required for good research inevitably enhance educational activity. High quality in education and training are essential in improving cancer care. Obstacles to good medical care are identified and the importance of supporting doctors is emphasised. The question of permanent staff-grade medical appointments or the grade of physician assistants is raised. Challenges to university-based and hospital-based research are outlined. Attention is drawn to issues concerning the training of cancer specialists, particularly in surgical oncology. Conclusion Good patient care stimulates research, research drives educational activity and education improves care. Interaction of these elements of medicine and science constitutes an interdependent upward spiral towards excellence.
university Training of cancer specialists Surgical oncology
Introduction I appreciate very much the invitation to present the Sir Thomas Myles Lecture. On behalf of everyone who has gained from them, I am pleased to thank all those, past and present, who have established, developed and refined the Sylvester O’Halloran meetings, now soundly established among the principal surgical events in the country. I am particularly delighted to have been invited to make this presentation here in Limerick on my home ground. Sir Thomas Myles was born in Catherine Street in Limerick in 1857 and lived a remarkable life. Sportsman, teacher, surgeon, Home Ruler and supporter of the Irish volunteers, he was also honorary surgeon in Ireland to the King. He was made a freeman of the city of Limerick and was knighted in 1902. His life has been recalled in an elegant biographical presentation by Professor Pierce Grace.
Global problem of cancer Keywords Cancer care Interaction of care Research and education Relationship of hospital and
N. O’Higgins, Chairman University of Limerick Hospitals Board. N. O’Higgins (&) Emeritus Professor of Surgery, University College Dublin, Dublin, Ireland e-mail: [email protected]
In this talk, utilising the cancer model, I plan to discuss broader issues of clinical care, research and education and to place them in the context of our region. The views are, of course, personal and not necessarily those of the board of the UL hospitals group that I am privileged to represent. Cancer is a global problem, because in spite of steady and occasionally spectacular improvements in diagnosis and therapy, it represents an increasing burden on mankind and remains an elusive and malignant enemy.
123
8
The World Health Organisation calculated that in 2008 there were 12 million new cases of cancer diagnosed, 7 million cancer deaths and 25 million people living with cancer. By 2030 it is estimated that there will be 27 million new cases diagnosed annually, 17 million cancer deaths and that 75 million people will be alive who have had a cancer diagnosed within the previous five years. This increase will be mainly due to three factors [1]. First, the global population will grow from 7 billion to 8.5 billion. Second, the fraction of the population who are aged will increase and the incidence of cancer increases with age. It has been estimated that two-thirds of the ‘‘seniors’’ who ever lived are alive today [2]. The third factor will be the introduction of risk factors for cancer from the developed world to poorly resourced countries and this will be added to those that already exist there. More than 40 % of cancer deaths are due to tobacco, diet and infections, and the relative proportion of these factors differs from resource-poor to developed countries.
The quality spiral My premise is that good clinical practice stimulates research, that research promotes standards in education and that education in turn is a powerful stimulus for improving clinical care. I suggest that this interlinked relationship is maintained, whether the starting point is with service, research or teaching. The essential point in the proposal is that each of these elements drives and urges the other on, not in a circle but rather in an upward spiral towards excellence. Although this hypothesis is relevant to all hospital practice, the example of cancer is used here to develop some of the relevant issues and to demonstrate obstacles that can interfere with these processes.
Good clinical care stimulates research My first proposition is that good clinical practice stimulates research. High-quality cancer care requires (a) specialists who treat a substantial number of patients, (b) multidisciplinary management, (c) a system of audit and verification and (d) a systematic organisation. Specialisation and volume When clinical practice is of high quality, data inevitably accumulate, creating scope and opportunity for analytical research. A seminal publication in 1979 [3] drew attention to the positive association of high-volume and reduced
123
Ir J Med Sci
mortality in surgery. This study generated extensive clinical research over the subsequent 30 years. All this research has come from institutions recognised for the high quality of care. It could be argued that only centres offering high quality can carry out such research and even that highquality care is a pre-requisite for clinical research. Different research methodologies in many health systems have resulted in a large mass of information about cancer management. The demonstration of variations in outcome for breast cancer between specialist and non-specialist centres provided eloquent and convincing evidence in favour of centralised or regionalised care. Longer survival for patients with all types of gastro-intestinal cancers, as well as cancer of the lung, prostate and breast treated in high-volume centres has been demonstrated in more than one hundred studies. Individual surgeon volume and specialist training also correlate with better outcome. Because so much data are collected and experience gained in highvolume centres, institutional guidelines and research almost always follow, demonstrating that good practice provides a solid research platform. The great majority of clinical research publications come from such hospitals. These centres are also more likely to take part in multicentre clinical trials and, because they are sources of much clinical information, they are likely to attract funding for clinical research. Multidisciplinary management Clinical judgement remains a core element in medical decision-making and cannot be replaced or superseded by protocols. Protocols are not substitutes for trained doctors. What is good for the many may not be good for the one. However, fears that multidisciplinary meetings would cause conflict between evidence-based medicine and clinical judgement and fears of conflict between team-management and individual accountability have not been realised. Multidisciplinary collaboration with other medical disciplines in oncology is of great importance both at diagnosis and the time of treatment. The combination of disciplines improves accuracy and minimises error. The participation of other professions has improved the quality of life for cancer patients and facilitated pathways of care. Research questions about diagnosis, treatment and eligibility for clinical trials almost always arise at these meetings. Multidisciplinary meetings are, therefore, valuable, not only in patient management, but in stimulating clinical research and in promoting clinical trials. Audit Audit is an intrinsic part of good clinical practice. The purpose is to raise standards of care. One aim of audit is to
Ir J Med Sci
drive research. Audit involves analysing results, identifying areas for improvement, putting them to the test in prospective fashion and then analysing outcome. It must, of course, be matched by administrative audit. The welcome alliance between clinicians and managers should lead to improvements and also generate administrative research. Audit, therefore, should inherently be both a research tool and an exercise in professionalism. Systematic organisation A systematic organisation is the basis on which all services depend. Irrespective of the quality of the staff, hospitals thrive or fail according to the ability and capability of the administrative organisation. Good systems invariably raise research questions in areas such as health economics, logistics of care pathways, risk management and information technology. A competent organisation is also a powerful supporter of clinical research. It is the velvet upon which the jewel of excellence can shine. The opposite is equally true. Without a sound supportive organisational infrastructure, it becomes almost impossible to conduct good research. Thus, I believe that the essential elements of good cancer care- specialisation and high-volume, multidisciplinary meetings, audit and a systematic organisation— provide strong, even necessary, platforms for research.
9
inefficiencies and wastages; lack of infrastructural support—offices and secretariat; parking issues; excessive waiting times for clinics and radiology; delays for elective operations; capacity issues; poor public perception; unattractive physical appearance; equipment cluttering corridors; inadequate clinical audit. Much needs to be done. The presence of a strong systematic organisation can raise quality of care quickly and comprehensively. An example is the development of cancer services where much has been achieved in recent times. The National Cancer Control Programme and the difficult and painful centralisation of cancer services have required much effort and patience. Comprehensive data analysis and in-built, verifiable measures of quality are functioning successfully at a level that, even if it remains far from perfect, compares well with other countries. The Cancer Control Programme also stimulates an increasing amount of research. Reconfiguration of a hospital’s functions produces strains among colleagues and institutions but understanding of what has been achieved in cancer services points to a paradigm for other services. The plan to organise hospitals in Ireland into six groups provides an opportunity to develop a coherent model of improved care [4]. The success of this policy requires medical and administrative leadership and co-operation as never before.
Supporting doctors Obstacles to good clinical care In promoting clinical care the question arises whether these elements are in place in our hospitals. Is systematic organisation in place everywhere? Managerial, medical, nursing and allied staff have drawn attention in recent years to several issues in many hospitals in Ireland, including the following: low morale; disaffected staff; lack of institutional pride; departments and services not functioning together; doctors working under too much pressure; lack of leadership; lack of clinical and corporate governance; missed opportunities; lack of consultation; lack of investment; too few specialised staff to deliver quality services; inadequate theatre time; IT systems not co-ordinated; no centralised control; no chain of command; poor communication at all levels; no vision for the hospital; doctors isolated and unsupported; clinical independence lost; much uncertainty; fragmentation of services; poor systems of recruitment of doctors-interns, trainees and consultants; poor training; lack of confidence in administrative processes; hospitals underpowered in bed capacity and diagnostic services; conflict between doctors and management; excessive bureaucracy; issues with procurement; overcrowding of Emergency Departments; absenteeism;
Almost all doctors want to help improve care of patients and are conscientious and committed to professional development. They understand that good practice requires being up-to-date, raising questions, attending meetings, reading journals, discussing developments, identifying moving points, indicating the direction and opportunities for further improvements. Any and all of these influences invite the prepared mind to engage in research endeavour and stimulate research opportunity. Yet doctors in Ireland are often portrayed in the media, particularly the print media, as the obstacles to, or even the enemies of, progress. When things go wrong, they are the prime targets for blame. Doctors and hospitals need to communicate better with the public. I believe that the Medical Council must do more to support doctors. It can do more to inform the public and the government about medicine. It can do more to promote high standards of clinical practice. It should not be silent in drawing attention to the need for improvements in training and in availability of facilities and opportunities required for good care. It should not be silent about the situation of dangerously overworked young doctors in hospitals—for many of whom specialist training has changed from a joyous experience to a harrowing one. During my Presidency of
123
10
the Royal College of Surgeons in Ireland (RCSI) I spoke and wrote about this issue and quoted Professor Ray Tallis, in support of our colleagues in training, when he stated, ‘‘It is upon such people that the future of medicine will rest. If their sense of medicine as a calling is not destroyed, they will be doing their best for sick people in the dark hours when the hostile critics of the profession are chattering away at their dinner parties or safely tucked up in bed’’ [5].
Research enhances educational activity I have attempted to demonstrate that good clinical care inevitably poses questions for research. I now turn to the second proposition—that research promotes and improves educational activity. Researchers analyse evolving evidence, promote enquiry, formulate hypotheses and inform teaching. An example in oncology is the molecular revolution in cancer research whereby genomic analysis will permit targeted therapy, individualising cancer care based on the biological properties of the specific tumour. This avoids undertreatment and overtreatment and lessens the toxic unwanted collateral damage of chemotherapy. Rapid change such as this must enter the educational curriculum and the teacher’s programme quickly. Shortening the interval between discovery and clinical application in oncology demands that the teacher and the curriculum are alert and responsive to significant research developments. The teacher, expert in the dissemination of knowledge, distinguishes between developments and advances, discards what is irrelevant or obsolete and also embraces the spirit of enquiry. Research of any kind requires extensive reading of a subject so that it can be understood and understanding is a prerequisite for good teaching. The network of intellectual capability from disparate backgrounds available in the university facilitates basic research and fundamental enquiry, clarifies thinking and thereby enhances teaching. The resources of the university provide encouragement for the development of scholarship and research at local and international level, adding further stimulus to the educational drive. Furthermore, the sacrosanct responsibility of the university to be fastidious in recording of data instils in the teacher and the student the integrity and the habit of truth that define the essence of scholarship and scientific exploration. Research enhances educational development of both teacher and student. Youthful thinking is recognised in a good teacher for as stated in by Dr Chris Johnson [6] in the British Medical Journal in 2005, ‘‘Learning something new is easy. Unlearning something old is difficult…because you have to alter information and, in so doing, you have to challenge your beliefs’’. As putative powerhouses of ideas the university welcomes innovation,
123
Ir J Med Sci
novel propositions uninhibited by history or experience-in short, it encourages youthful thinking and change.
Obstacles to research Although collaboration between the research engine of the university and the research derived from clinical questions in the hospital undoubtedly improve and motivate clinical education, the relationship between these institutions requires nurturing like a delicate flower. Although university medical schools and teaching hospitals share interests in education, research and clinical practice, the priorities and the financial considerations of each differ and the points of divergence often become the touchstone for tension and concern. The reputation of the university depends largely on productive research and income generated from research is one of the criteria by which quality and status are currently measured. Research is intensely competitive. Just as there is some truth in the adage that an expert is someone who knows more and more about less and less, the narrow focus and great depth of fundamental research makes it likely that only a small number of similar experts will be able to evaluate its significance and quality. It is unlikely that the clinicians with considerable clinical and educational responsibilities will be able to compete in this type of research but they can engage and all who do discover that this gives added value to their teaching. Engagement with the clinician gives relevance to the work of the basic researcher and there is evidence that this dialogue also shortens the interval between discovery and clinical application. In the hospital, increasing clinical demands erode time for research. In addition, clinicians now, quite properly, have greater managerial responsibilities. In hospitals there is often scepticism about the value of research since the endpoints are perceived as being unclear. Furthermore, research in hospitals is sometimes deemed irrelevant because of the long lag time between the conclusion of the work and its application. Surgical research in cancer presents a different set of difficulties from other cancer researchers—difficulty in getting time free from the operating theatre, difficulty because surgeons treating cancer are split across many surgical specialties and difficulties because of limited access to academic leadership and research training during a surgeon’s formative years. I believe that all surgeons in training should be exposed to research and surgeons who have been immersed in the discipline of research have found that it enhances the quality and clarity of their teaching. Hospital managers are primarily concerned with performance, outcomes and costs. They are interested in
Ir J Med Sci
systems and team development and are deeply and rightly concerned about risk of adverse events. As stated by Sir Cyril Chantler [7], ‘‘Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous’’. These differences and potential conflicts are summarised in a report by Universitas, an international collaborative academic grouping from 21 universities [8]. In the university research has a central role and is a source of revenue while in the hospital it is optional and carries an indirect cost. Education also is central and a revenue source to the university. The hospital has an important role in clinical education but this is not its central purpose and education imposes a cost upon the hospital. To the hospital the delivery of clinical care is central and is a source of revenue while its place in the university is often peripheral. A fresh dialogue between hospitals and universities is needed. Clinical education in medical schools could include courses in safety and quality, team training and simulation techniques. Organisational skills and financial management should be part of the medical school programme. More research should be devoted to pathways and logistics of clinical care and more effort made in multidisciplinary research both in hospitals and university.
Education improves care My third proposition is that education improves care. As part of their professional heritage, doctors must contribute to the teaching, training and assessment of students. It is well known that teaching and appraisal inspire learning in the teacher. In addition, student teaching influences teachers’ professional values and reinforces their competence. The instruction and assessment of students are helpful to teachers in their own professional development. These factors are complicit in improving patient care. The remarkable advances in medicine over a short time means that doctors who do not keep pace will be left behind. Within a few years what has been established practice may become obsolete. More than ever continual education is necessary if doctors are to retain competence and safety in clinical practice. The presence of students and specialist trainees in a hospital is an incentive to enhancing services as the curiosity of fresh enquiry always triggers debate. In a hospital the culture of sharing of knowledge with others can be of inestimable value to improving care. It supports the idea of access to learning and development opportunities among all members of staff. In so doing it boosts morale and contributes to harmony. Educational effort facilitates better communication. Support for educational activity throughout a hospital powerfully influences professional pride and
11
self-esteem. Education also tends to engender institutional pride, which probably encourages retention of staff, reduces the rate of absenteeism and is likely to make work more productive and enjoyable. I believe that public education should also be a function of the hospital and can be a driver to health promotion. An easily accessible area for informing the public on illness and wellbeing should be set up in each hospital. These areas can have changing themes and programmes including lectures, films and interactive sessions explaining science, biology, illness, disease prevention and health. Thus, education and educators in hospitals can in so many ways promote better care, which stimulates research, which enhances education which drives better care in an exhilarating quality spiral.
Obstacles to good education and training However, obstacles exist to this upward progression. The training in Ireland of our specialists is unsatisfactory. Surgical training remains too long, too uncertain and the quality of the experience is uneven and often does not contribute to deep learning. A trainee surgeon spends at least 11 years of postgraduate training before being eligible for a consultant post, an arrangement so unacceptable that a career in surgery is no longer attractive to young doctors. A shortened surgical training programme planned to make the progression continuous, introduced by RCSI this year will be a welcome development. The situation whereby trainee doctors are fulfilling roles that involve little or no training is intolerable and requires revolutionary thinking. Trainees should be in training posts and other mechanisms should be explored to provide medical service needs safely, such as a three- or four-fold expansion of consultant numbers, or by introduction of a permanent staff-grade or physician assistant model.
Physician assistants In many fields of medicine the position of Physician Assistant can work well. Developed in the United States over 50 years ago, there are now over 80,000 PAs in the United States, where they have become established as an essential component of the medical workforce. Training for PAs involves a 2-year diploma course open to graduates from a healthcare background. PAs are trained to carry out a broad range of medical services, all under the direct supervision of a doctor. Some years ago the RCSI investigated the feasibility and potential of PAs in surgical practice. Introduction of PAs could be a significant assistance to the Irish Health Service. Discussion among the
123
12
medical training bodies and the Department of Health/HSE is needed. Legislation would be required. With support, it might provide an opportunity for the University of Limerick to be the first to offer a Physician Assistant Diploma course.
Training of cancer specialists Training of cancer specialists is fraught with deficiencies and anomalies. Some universities have no programme of oncology in the medical school curriculum. Some countries, including Ireland, have no dedicated postgraduate training in surgical oncology. Training for the specialties of Radiation Oncology and Medical Oncology rarely involves time spent in Surgery. Such exclusion necessarily limits the ability of these trainees to understand the scope and the aims of operative surgery, either in the potential for cure or in palliation. They, therefore, tend to underestimate the value and overestimate the morbidity of surgery. The situation for surgical trainees is even more serious. There is no consensus within the surgical community or training bodies as to what a cancer surgeons should do or how they should be trained. Surgical oncology is not even recognised as a specialty in most countries. Surgical specialisation is organ-related and such trainees may have little specific training in the principles or developments in oncology and their trainers may themselves have deficiencies in oncological training. A need exists for the training bodies worldwide to come together to promote interdisciplinary training for all cancer clinicians irrespective of their specialty [9].
Ir J Med Sci
broad approach is needed nowadays in order to provide a valid clinical opinion and is indispensable in planning operative strategies. Since surgical oncology is not recognised in Ireland or the United Kingdom as a specialty, surgeons can seek Fellowships in Surgical Oncology in Australia or in one of the 17 approved centres in North America. Fellowships are also available in specialist cancer centres in Europe. An end-of-training examination in Surgical Oncology, recognised by the European Union of Medial Specialists (UEMS), is available through the European Society of Surgical Oncology, a vibrant organisation that formerly, but sadly no longer, was strongly supported by surgeons in Ireland. The future of oncology in Ireland has much to gain from strengthening linkages with Europe and it is regrettable that opportunities have been lost. The Irish Society of Surgical Oncology also seems to have perished. The new enthusiasm and expertise in the University of Limerick and the UL Hospitals provide an opportunity to recommend that a 2-year Fellowship in Surgical Oncology be devised and offered by UL. Utilising, perhaps in a formal way, the extensive international clinical contacts already built up by the academic medical staff, such a programme could involve 1 year in the UL Hospitals and 1 year in one of the recognised centres overseas. Such a development would certainly provide a sustainable supply of highly trained cancer specialists to our country. This educational enterprise would enhance clinical care, thereby pointing the way to new avenues of research and so on towards the ambitious moving target of excellence thus completing the quality spiral. Join the spiral if you can. It’s on an upward trajectory. Conflict of interest
None.
Surgical oncology as a specialty Surgeons must adapt to new developments in oncology [10]. In addition to technical skill in operative surgery, surgical oncologists need to understand the value of audit. They need to be able to assess new technologies in a discriminating fashion, recognising that not all developments are advances. They must have direct training and participation in clinical and laboratory research and be involved in clinical trials, even as Principal Investigator. They must have knowledge and understanding of the other treatment modalities together with an appreciation on how to select patients for multimodal care and they must monitor the progress of their patients. They must have an in-depth understanding of tumour biology, keep studying the literature and be involved in clinical research. They must be prepared to guide their patients through what is often a complex pathway. This requires organisational and networking skills in the context of the team system. Such a
123
References 1. Boyle P, Levin B, International Agency for Research on Cancer (2008) World Cancer Report 2008. IARC Press, Lyon, France, p9 2. Boyle P (2011) Demographic changes in Europe and the burden of chronic care. http://www.ehfg.org.fileadmin/ehfgF3-S2Boylepdf. Accessed 10 Oct 2013 3. Luft HS, Bunker JP, Enthoven AC (1979) Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med 301:1364–1369 4. Higgins JR (2013) The establishment of hospital groups as a transition to independent hospital trusts. Report to the Minister of Health. http://www.dohc.ie/publications/pdf/IndHosp.trusts. Accessed 10 Oct 2013 5. Tallis R (2004) Hippocratic oaths: medicine and its discontents. Atlantic books, London, p 3 6. Johnson C (2005) Unlearning. Personal view. BMJ 331(7518):703 7. Chantler C (1999) The role and education of doctors in the delivery of health care. Lancet 353(9159):1178–1181
Ir J Med Sci 8. Universitas 21 Working Party on University-Healthcare Systems Interaction (2001) The interactions between universities and hospitals: problems and possibilities. http://www.u21health.org/files/ U21UNI*PDF. Accessed 10 Oct 2013
13 9. O’Higgins N (2004) The world federation of surgical oncology societies: the global mission. J Surg Oncol 87:109–115 10. O’Higgins N (1995) Towards a high standard of surgical oncology throughout Europe. Eur J Cancer 31A(Suppl 6):S22–S24
123
