E102 Sunil Patel on Robotic Colorectal Surgery and Spin in Surgical Research
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Sunil Patel 00:00
And each time I'd been accused of bias. So first I had bias against laparoscopic surgery then I had bias against robotic surgeries in favor of laparoscopic surgery. And then I had bias and in favor of taking university robotic surgery. So, I felt that if I pissed off everyone, then I must be doing something right and that must demonstrate that I'm actually an objective person.
Chad Ball 00:21
Welcome to the Cold Steel podcast, hosted by Ameer Farooq and myself, Chad Ball. We consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only masterclasses on clinical surgery topics, but also insights into achieving personal growth, productivity, and fulfillment as the surgeon or perhaps more importantly, as a human.
Ameer Farooq 00:48
This week, we're joined by Dr. Sunil Patel. Dr. Patel is a colorectal surgeon in Kingston, Ontario. The group in Kingston is one of the few general surgery groups in Canada that has really introduced robotics into their practice. And we wanted to understand both why and how they utilize robotics in their group. Dr. Patel has also done some fascinating research into the topic of spin in surgical research. And he walks us through the concept of spin, and how the astute reader can avoid being fooled by it. As always, we'd love to hear your thoughts and feedback. So, email us at [email protected]
Sunil Patel 01:30
I grew up in London, Ontario, I went to undergrad medical school there as well as the general surgery training in London. I went and did a fellowship in New York City, which was a combined fellowship between New York Presbyterian Hospital and Memorial Sloan Kettering. I started at Kingston in Queens, I think it was the end of 2015 and have been here ever since. So, I've enjoyed my time in Kingston so far. And it's been a really great experience.
Chad Ball 01:59
I'm curious, what was your fellowship like in New York? That's a pretty powerful combo. And then I'm also curious what led you to Queens coming out of New York?
Sunil Patel 02:08
Yeah, so New York was a great spot. I had done a master's degree in London, England at the School of Hygiene and Tropical medicine. And I did that partway through my training, my residency training. And after doing that, I really was motivated to do fellowship in a big kind of Metropolis going from London, Ontario to London, England was quite the eye opener. I was really keen to do a fellowship in a place like New York. I was also quite keen to do a fellowship in the US. I think, as some of your previous guests have talked about the training there, especially for things like robotics and innovative surgical care, I thought there were more opportunities in the US. So, I was quite keen to do that. And it was just a good mix that New York Presbyterian Hospital, the fellowship there was started by Dr. Milsom, who was one of the pioneers in laparoscopic surgery. And when I went there and kind of interviewed, I felt a connection to him in his program and was really impressed with that. And I was also really excited to think about doing training at Sloan Kettering, which, as you know, is kind of one of the preeminent cancer hospitals in the world. And they had a very strong robotics program. So, to me, it was kind of ideal to do a cross between laparoscopic and robotic to institutions with the intent to always come back to Canada. I knew that robotics was probably not something that'd be a focus of my career, at least early on. And so, I was really interested in ensuring I had a good laparoscopic experience. Coming to Queens was probably not an experience too similar to many of your listeners. I basically applied to any job that was available in colorectal surgery. At the time, I think Queens was probably the only job in academic surgery. And so, I was very fortunate to get the job here. And I actually hadn't had much familiarity with Kingston other than visiting some friends here from time to time. And so, I don't know that what I was expecting is what happened, but I really enjoy it here. I have a family, and this has just been an incredible experience for our family. It's a close-knit community, both the city and the hospital and the university. So, a very welcoming place to be and I've just really enjoyed it here. So, I've been very fortunate to get a job here in Kingston.
Ameer Farooq 04:20
Kingston is such a lovely place. I remember going there and interviewing for medical school, watching these university students walk around the campus with like, you have these like patented kind of football jackets that everybody wears that goes to Queens I think, at least back when I was interviewing. And this this guy was like carrying this boombox on his shoulder and his glasses on and I was like, oh man, this is an awesome city. Apparently, they have like the highest per capita restaurants as well in Kingston, or some statistic like that?
Sunil Patel 04:54
Yeah. Well, Kingston is an interesting spot because it's a small city. I think we're about 130,000 or something like that. But it tends to be a bit of a more touristy destination. It's kind of a historical city. So we certainly I think punch above our weight in terms of the quality and extent of restaurants we have. That's been really nice. And those football jackets, what they do is I think, if I'm right about this, is when they come in during the frosh week, they're all given like a brand-new leather jacket, and then they're supposed to kick it across campus without picking up with their hands. So, from like, wherever the school is to where they're living, and so it makes them kind of look old and faded. And I think that's a tradition. I think it's engineering, but a number of undergrad programs do that.
Ameer Farooq 05:35
So you came back to Queens after doing this, you know, high powered fellowship in New York. And I suspect no one was doing robotics when you came back. Is that right?
Sunil Patel 05:47
Yeah, so Queens in Kingston is a really nice place. So, we're small enough that, you know, the general surgeons, the urologists, we work closely together. There's not a huge number of us within colorectal Ghani on Urology. So, what was really nice is, you know, there was no robot here at all when I came, and it became very apparent, especially from the urology side that they are going to maintain any of their prostatectomy practice and maintain really their residency. They needed a robot, and our hospital was quite motivated to keep Kingstonians local and people in the southeast region local. And that prostate cancer was really an important part of this. And so, the robot was actually brought in, I think it was probably end of 2018, early 2019. And it was a generous donation from one of our long-standing donors to HSE that donated the robot as well as providing some kind of funding for ongoing support. So, when I came here, there was really no expectation that there'd be robotic surgery, we were doing some other things with laparoscopic and Ta-TME and whatnot. But it was a really great surprise to me that there was a lot of motivation to buy the robot, invest in the robot and invest in the program. And I think, you know, colorectal surgery was a huge beneficiary of this, because the emphasis was on prostate, but the prostate guys generally would use the robot about a day or a day and a half of the week. And there's a lot of capacity for other services to get involved. And they knew that I had had robotic training, they were very supportive of our colorectal program. And so, after prostate became established, we were the next ones in which was great, because we had a lot of capacity to get on the robot. I had done robotic training and fellowship. But it had been a couple of years since I'd done that. So, it gave us time to get the cases and the training and simulation in place, so that we could kick off the program. And I started with my colleague, Hugh McDonald, who's been a colorectal surgeon here for many years, and was doing laparoscopic rectal surgery, but really, I think with robotics has really taken off with that. So, it's been a fantastic experience for us. It's really shown, I think, the way that multiple services can work together, and we've done combined cases with dining, colorectal and whatnot. So, it's been just a really great experience for us.
Ameer Farooq 08:11
For our listeners, can you just describe the mechanics of like what goes into building a robotics program? Like, you know, it's like, it's not just about, for example, buying the robot. There's all these different pieces that have to kind of come together, you know. I've been talking to one of the former fellows in Calgary, you know, he would talk about having all these texts at Memorial Sloan Kettering that would just be there dedicated to the robot to ensure that there was very minimal time in transitions and in between cases and things like that and making sure things were working properly. So, can you talk to us a little bit about the mechanics of, how do you actually set up a robotic program?
Sunil Patel 08:55
Yeah, so the most important thing is having the robot. But in some ways, having someone buy the robot for your hospital is the simplest thing. Really, it's the personnel and the expertise that's just so imperative. And in Canada, the company that helps service the robot is different than intuitive, which is the one that sells and makes the robot in the US. And really, this is a venture kind of hand in hand with clinicians and the hospital administration working with the industry partnership. And really what we were focused on was safe rollout and efficient rollout of the robot. So, we had a lot of simulation training beforehand, just to make sure that everyone was up to speed on in terms of just the mechanical robot from the surgeon standpoint. But we also had simulation and in servicing for our nursing staff, what we thought was one of the most important parts of the successful implementation of our robotics program was having a dedicated group of nurses which wasn't all the nurses. It was really nurses that were very motivated, like the challenge of setting up a new program and we're really keen to see this success. So, we had a really strong nursing group that really took ownership of that and really made our life very easy, required support from the administration, especially early on. The cost of robotic instruments can be a bit daunting to some, especially when this is a new program where every cost is put under the microscope. And although we found that the robotic cost may be not that different than our other minimally invasive techniques, it's certainly something that was spotlighted. And our admin was very supportive in terms of committing to supporting us and ensuring the success of the program. And with that is the volume of cases you need. You can't do robotic surgery one day a month or one case a month and expect to get any proficiency from the surgeon side of the spectrum or even the nursing staff. So, we had sufficient volume to support it, we had dedicated OR time, which for us was often one or two days a week of robotic cases. And support from the admin that allowed us to run late if we were having some inefficiencies, they weren't cancelling their last cases, they want to cancel robotic cases. So really, I think this was a really strong team effort. And a really important component of that was just preparing our whole team from the surgeons, the nursing staffs to the people at the end PCs, cleaning estimates, just to make sure that we'd be successful in the implementation of the robotics program. There's pressure to do this innovative surgery, because that would draw your patients and thus support your hospital funding for the hospital where, as you know very well in Canada, there is not that pressure. I find that our Canadian patients, by and large, are quite deferential to the surgeons in terms of the techniques they want. And although some people feel strongly about minimally invasive surgery, I think there's unfamiliarity with robotics. So, my impression here, at least for colorectal surgery was no one was demanding that we do robotic surgery for them, or else they go elsewhere. And as you know, the robotic colorectal surgery was not being offered elsewhere. So, there wasn't really the pressure to start robotic surgery because of market pressures. So, what we kind of struggled with initially, and I think there's still a struggle, is showing what the benefit of this technique is, and approach? What's the clinical benefit to our patients? What's the benefit to the surgeons, perhaps in terms of ergonomics, and what's the benefit to the system itself in terms of savings. And, you know, we spent a lot of time talking about that. And our admin was a bit reluctant and hesitant. They had an idea about capping the number of cases we would do, for instance, to try to reduce the costs. And it was really, I thought, the onus on us as the clinicians to show the benefits to the patients and to the system. And for us, what that meant was really developing metrics that our admin could take to whoever and show and we could take to the administration, show the benefit to the patients in terms of length of stay, emergency department visits, which are often not captured in readmissions, which are very costly. We want to show how successfully we could do a minimally invasive surgery. So, we track kind of before and after cases in terms of what proportion of patients were eligible for minimally invasive surgery, what portions went through without conversions, and then we started looking at cost data. And probably Chad, as you know, and Ameer, you know, it can be challenging in the Canadian institution to really get an accurate idea of costing data. We do the best we can in our hospital. And I think it's fairly accurate. And in fact, it probably overestimates the cost of robotics, because there's such a spotlight on it. But we were able to show actually that for us, for our left sided resection, using robotic surgery, it saved a hospital about $1,000 per patient after implementation. And this was based on two years' worth of data. So, I think it was really important for us to show the metrics and kind of dispel the myths that you know, there is no advanced robotics over laparoscopic surgery, there's no cost. In fact, it's more costly. I think the onus was on us to show the benefits in a number of different domains.
Ameer Farooq 13:52
So you know, obviously you had experienced during laparoscopic surgery, I'm sure during residency and then obviously in fellowship, and we're doing that prior to robotics. Can you talk a little bit about what the big advantages you really see are? Because you know, I think many Canadian surgeons don't really actually have the chance to actually play with a robot or do any cases with a robot. So, a lot of our kind of impressions about the robot are perhaps coloured by all the things that you were talking about before, where we sort of poopoo American data because we think, well, you know, people are really trying to justify the use of the tool, simply because they want to have it anyways. So can you talk about, as someone who's sort of in a bit more objective place, what the advantages of the robot really are in laparoscopic surgery?
Sunil Patel 14:43
So, generally we exclusively use it for left sided colorectal procedures. So generally low interior sections, APR will be the bulk of them as well as sigmoid resections in patients with complicated diverticulitis, that generally is our criteria. In terms of the advantages, so it's funny, and probably you guys both know, you know, in our minds, we're all really incredible surgeons and we have zero conversions and really low complication rates. You know, and that was my impression too. And when I really started to look at our data and what I did was I compared the two years before our robotic implantation to the two years after. I realized that kind of as our program, we were really only attempting about two out of three rectal resections, minimally invasively, whether that was laparoscopic, or laparoscopic Ta-TME. And our conversion rates were much higher than what I expected. And for us, we defined a conversion as kind of anything other than just specimen extraction. So, if you stapled or if you took the pedicle, or something through an open incision, we counted that as a conversion. And so, we found that all in all, only about half of our patients with rectal cancer were going through and completing a minimally invasive procedure without conversion. And this is much lower than I thought. With robotics, it really takes that down substantially. So now less than 10% of our patients don't have a successful minimally invasive surgery for rectal cancer, which would mean starting and finishing either laparoscopic or robotically. It really allows you to efficiently mobilize distally in the rectum. As you know, when you're going through your fellowship that can be really challenging and time consuming. The retraction you can get with the robot is incredible. You know, I've heard it said before and I believe it but the instruments that we use robotically retract the mesorectum in the same way that the same marks does in terms of the retraction the exposure and your ability to exact which I was never able to achieve laparoscopically. You're also able to work in tight spaces with a camera that, you know is not causing any problems. As you both know when you work in tight spaces, often with a bit of fluid and gas and smoke, your laparoscope is often being smeared, you know, you may have the most junior person in the room running the laparoscope, which often can be a bit challenging, whereas with robotically, the operating surgeon controls the camera, it's in a fixed point, it's steady, and it's a 3d picture. So, what it's really allowed us to do is make it very distal, and in a very kind of straightforward manner. So, you know, before when I would see a patient with obesity with a bulky low tumor, in a male, especially with a narrow pelvis, I'd be quite stressed about whether I could operate minimally invasively. If I was doing it through a Ta-TME approach, that has its own challenges and laparoscopically, I knew more likely than not, I was converting. Now I don't even think about conversions. Our conversion rate for those that we start robotically is less than 5%. We have about 5% to 10% of our patients that start open because of recurrent disease or requiring pelvic separations or whatever, but I just don't have that stress anymore. And I just know that we're going to have a very high chance of success in everything minimally invasively. And I have to say, we have a lot of very skilled surgeons in the country and a lot of interest in Ta-TME. One of the surgeons that was a pioneer is Dr. Antonio Caycedo, who actually was recruited and started at Queens about a year ago, and he's done, probably the highest volume of Ta-TME. And he'll talk about the challenges of Ta-TME, the learning curve. He's now primarily approaching most of his rectals robotically. You know, I think he just finds it a bit more ergonomic, a little bit less stressful. And certainly, it's a faster procedure. We still think there's a role for Ta-TME. And we're very happy to have him here. He has a really complementary skill set. But we find that there's just so many advantages to the robotic platform. And it primarily relates to the articulation, and the great view that you get, and the availability to retract and see in a way that you just can't maintain laparoscopically.
Ameer Farooq 18:46
So, I have two questions. And I apologize to all our listeners, because this is the danger of having a colorectal fellow, talk to a colorectal surgeon - you can really get down the weeds here. But my first question is, when do you use Ta-TME now? Now that you have the robot, because I think you know, for a lot of people, these were sort of seen as tools to deal with that problem of the distal rectum in a narrow pelvis. And so, if you have both tools, I'm curious when you use one versus the other. And the second is, you know, everybody talks about these benefits of having the robot and just watching the videos, you can see how easy you know, the robot makes it look. But that hasn't seemed to translate into outcomes when you look at most of the studies on robotics versus laparoscopic surgery, at least the last time I checked. Why do you think there's that disconnect?
Sunil Patel 19:38
In terms of the role for Ta-TME, I think it's a complementary approach. And as you know, Ta-TME, I think the biggest advantage of Ta-TME is you can definitively set a distal margin. You are not stressed that, you know your statement across the cancer or your distal margin isn't good enough. And I think that that's the role and that's how we envision Ta-TME complementing robotic surgery is that you can do a great mobilization abdominally, robotically, and you can get very low. In fact, you can get centeric routinely from above. And the vision we have is that Ta-TME will compliment that and the low patients where the margin can be challenging to identify, and then you're concerned that you may risk a positive distal margin because of where it is. And so, our vision in terms of incorporating both and what we're working towards right now, the selected use of Ta-TME almost exclusively to get the distal margin, whereas almost all the mesorectal dissections would have been done robotically. The other way we've used it is in patients that have had anastomotic complications after oars, especially distal Mastodon complications such as strictures or chronic sinuses or leaks. Teaching is very helpful in that study. As you know, if you approach it abdominally, often you just tear the anastomosis apart, which can be unsalvageable. We've had probably about four or five patients now that have been referred to us where we've been able to basically use Ta-TME techniques to get below the previous anastomosis, mobilize and then use robotic surgery from above to get down to that same level. And that's allowed us to salvage low anastomosis, whereas previously, we tended to have to do kind of completion and APRs for this patient. So that's kind of where we see the role. And I think Ta-TME reflects the skill set of trans anal surgery, and I think there will always be a role for Tanis in terms of kind of early-stage rectal cancers or large, benign polyps that you don't want to do a low interior for. So, I think there's always gonna be a role for that skill set. In terms of the data, you know, I've seen that same data and I kind of questioned it in a way. And the way we looked at our data here was a bit different. So, we didn't compare laparoscopic to robotic surgery, per se. And the reason why is we thought that there was, and I think that there's a lot of selection bias to those who you select for laparoscopic surgery versus open surgery versus some sort of hybrid approach. And that was reflected in our practice pattern where about two thirds of patients were attempted laparoscopically and 1/3 weren't. Robotically, as I told you, we were doing more than 90% of our patients robotically for rectal cancers. And so, the selection bias there is pretty significant and so I think those that are able to go laparoscopically versus those same group within robotically, you know, you don't see much of a difference. The real difference, I think, is those that have the opportunity to have minimally invasive surgery. And in every center and program, I think that proportion of patients is going to be different in some centers, like where you're training Ameer. I think Carl Brown, and the rest of your faculty are very skilled at taking even challenging cases and doing everything minimally invasively. And that wasn't us. So, I think the biggest benefits of robotic surgery is allowing a patient to have the opportunity to start minimally invasive surgery. And we saw that advantage when we did just a strict kind of historical cohort study, we found our average length of stay went from just over eight days to just around four days. We saw readmissions to hospital drop dramatically by about half from I think it was 18 or 19%, down to about 10%. And a lot of those readmissions were wound complications and other kind of related complications. And we've seen a lot less pain medication on the floor, less hernia rates. And we've seen kind of early return to normal function for individuals. So, you know, as you know, very well, people may go home the same day, but some patients take six weeks or longer to recover at home, whereas our robotic patients, often they're back at the regular activities within a couple of weeks. And in fact, unlike my laparoscopic cases, and this may not be unique to me is that we've had patients go through volunteer resections or APRs, and be home within a day or two, depending on their motivation. Which I just wasn't seeing kind of before we start started robotic procedures. So, you know, I see the advantage, I think most surgeons that have experienced robotic surgery can see the advantage. I recognize that the literature doesn't always come out. But I think especially in the trials, we are very selective about who gets enrolled in the trials. And I suspect that's shading our perceived outcomes. Because many of us cannot achieve the outcomes that you see in those trials when we kind of look at our programs as a whole.
Ameer Farooq 24:23
Well, I really appreciate that perspective. And what you're saying makes a lot of sense. And certainly, you have the data at Queen's to back you up. You've already kind of talked a little bit about the culture and that kind of team approach that you had with nursing and everyone to make this possible and administration. Talk to me a little bit about or talk to us a little bit about your colleagues and sort of having that mindset of trying to do things differently than perhaps the way they've done it before because that's not necessarily easy to convince your colleagues that you should be trying something different, especially if that's not the way that they have been doing it for many years. And sort of the second part of that, is how do you mitigate the learning curve associated with any new technique? Because it does take a while to kind of, you know, obviously, you'd had some training in doing it. But as an institution, there's a learning curve in trying to figure this out. So how do you kind of mitigate that when you're introducing a new technique?
Sunil Patel 25:20
Yeah. So, connecting colleagues here was easy. You know, my partner, Hugh McDonald, it was the two of us doing colorectal surgery together. And he didn't take much convincing. I think, you know, he and most people recognize the value of minimally invasive surgery, but also recognize the challenges of trying to do things laparoscopically. We had actually, I think, maybe the bigger convincing was when I wanted to start a Ta-TME program here, which kind of proceeded our robotic procedure by about a year and a half. That was much more trying. I think we were very selective and supportive of each other. But even still, I think, you know, he kind of questioned the value of this when we're working away for seven or eight hours doing a Ta-TME versus kind of what he used to do in two and a half hours as an open procedure. But I think he recognized the value of this. And probably, as you know, anyone that gets on the robotic console, the simulation or kind of dry labs, or cadaver labs, you instantly recognize the potential. And that's what he did. So, we had simulation, we had training down in Atlanta. And you know, once he got on the console, he was basically hooked. And so, it took no convincing of him. And we were quite fortunate too, because he was the head of the division. So, he also had sort of an administrative role that was really supportive. So, you know, from a colleague standpoint, that was very helpful, I think. One of the other things that were unique in Kingston, in a lot of ways - we work under an ANP, so we're not fee for service. And what that really allowed us to do was that we made an effort, Dr. McDonald and myself and now Antonio, two of the three of us are in for every case. And I think that experience is probably pretty similar. What you're seeing here in British Columbia, with the Ta-TME means we have two faculty scrubbing in together. And what that's allowed us to do is basically troubleshoot together. It kind of doubles your experience, especially with the learning curve in terms of setup for placements, instrumentation, techniques. And it also frees the resident or trainee from being at the bedside. One of the emphases that we had is that...and some experience I've had in the past was that trainees were put at the bedside to kind of pass instruments and sit there and often bored to death during a four-hour surgery while the attending is working away. And you know, our trainees didn't want that. They didn't want to be bystanders. They wanted to be involved with the case, they need to know the bedside, but they want to be on the console. And so having Dr. McDonald scrub with me, or Dr. Ceycedo to be at the bedside is allowed. Our senior and chief resident to be at the console. And, you know, we have two outgoing chief residents, Dave and Lisa, who both match to colorectal fellowship. And both had I would, I would say, significant console time. So, Dave told me, I think he was 20 or 30 cases at the console of rectal cancers. And Lisa was probably around the same. And so, I think that that was a big motivation for us as well. In terms of the learning curve, you're right, there's kind of like an institutional learning curve and a surgeon led learning curve. Robotic surgery can progress through the learning curve, I think much quicker than you can for other techniques going open to laparoscopic is I think a big step laparoscopic to Ta-TME is a huge step, going from laparoscopic or robotic surgery is not that big. And the reason why is the approach is the same, the planes are the same. How you do your dissection is similar, except it's easier. The learning curve primarily revolves around for placement instance selection, and just trying to be efficient in that way. And that's something that we spent a lot of time talking to others, including people such as Mark Solomon, and, and just trying to kind of learn that and so we felt that the learning curve here was probably not as steep as some other places. And that actually progressed through fairly quickly and I think it was just really valuable for us to both be on the, on the, in the or at the same time helping each other and just kind of doubling our experience, which I think also progressively learning from well. So, you know, I think that this was a great technique and the reality is we always had a bail out for our robotic procedure and that we could always go back to the laparoscopic or within or wherever. The definition of spin in my mind - and I wasn't the one that defined this, it's been worked on previously - is either intentional or unintentional misrepresentation of your trial results or study results. And what this means is generally you're overselling what you're you found. I became interested in this topic when I was in my epidemiology school, because we were going through what trials look like, and the ethics of trials and how to report trials and studies. And most of their examples came from the medical literature, not the surgical literature. And they were very critical over how things were interpreted. And then I would go and look at a study and at the time, I was obviously interested in colorectal surgery, I'd look at studies looking at laparoscopic surgery for Crohn's disease, and they'd have like 12 patients and then the conclusions for it were just totally like overstating the safety and efficacy and the benefits based on such a small amount of patients that really there was no comparison group. And so, I thought to myself, well, like, you know, they think this is a problem with medical literature. I'm interested in seeing how this looks in surgery, specifically surgery that I'm interested in. So, the first paper on spin I did was looking at laparoscopic GI surgery, which really for me was things like laparoscopic small bowel resections, right colon, singlets, resections, etc. And what I did was I pulled all the trials that looked at comparing laparoscopic to open surgery over about a 20-year period. And I think it was about 60 or so trials that kind of fit that criterion. Looked at ones that really they didn't show any difference in whatever outcome they're most interested in, which tended to be things like length of stay complications. And I wanted to see, you know, are these studies just saying okay, well, we've shown that laparoscopic and open surgery are about equivalent, or we haven't seen differences, or are they overseeing their results. And it was very common to see that things were being overstated. Studies of kind of 20 or 30 patients with 15 in each group, claiming that, you know, we've shown equivalency of technique even though there is no equivalency definition, or talking about the benefits, like mortality benefits because they had like a statistically significant outcome. So, what I want to do is kind of highlight that it's not that I disagree that I think there's benefits to laparoscopic surgery, it was that I think we do a disservice to ourselves by overstating the facts in a way that are clearly easily able to be disproven. So, when I started doing these spin articles, what I was trying to highlight is that we can report our study results objectively and honestly, and that doesn't negate what we're trying to say, which is that there is the potential for great benefit for new and innovative surgical techniques. And I think we're seeing this in, you know, a lot of techniques. Like I'll use Ta-TME as an example. I think there's great promise to Ta-TME. I think they're excellent surgeons that perform Ta-TME with great results. But in some ways, we did a disservice because these results were emphasized. And I think a lot of people went through and started doing Ta-TME that didn't have the property that they required to know the bond they required and started to have poor outcomes, which then resulted in things like moratoriums on the use of the technique in some settings. So that's kind of the mindset I had when I when I started looking at all these things. And one of the things I like about the spin articles, so I did a spin article on laparoscopic surgery, spin article on robotic surgery, spin article on Ta-TME. And I presented them at our international and national meetings. And each time I've been accused of bias. So first I had bias against laparoscopic surgery, then I had bias against robotic surgeries in favor of laparoscopic surgery. And then I had bias in favor of Ta-TME versus robotic surgery. So, I felt bad if I pissed off everyone, then I must be doing something right. And that must demonstrate that I'm actually an objective person. Spin was defined in a paper published I think, like more than 10 or 15 years ago. And there's a number of like domains. And it was things like... so we tried to do objective identification of spin. So, it was things like focused on secondary outcomes as opposed to the primary outcome. Focusing on one of multiple outcomes, ignoring all the other outcomes that really showed no difference. Or in spite of nonsignificant claiming there was a benefit or a trend.
Ameer Farooq 34:15
When you define the term spin, or like when you're looking for spin, is that a subjective kind of like, oh, well, I think you're kind of stretching the conclusions? How do you kind of standardize the definition of spin? Because I thought you did a really good job of that.
Sunil Patel 34:32
Studies are interpreted that they kind of defined as spin being positive or negative. And so that's what we tried to stick with. I think there's always some subjective nature in identifying this. So, you know, in our studies, we kind of had the mind frame like you would for a meta-analysis where we had a couple of reviewers tried to look for agreements and disagreements and came up to conclusions that way. But there is always kind of a subjective assessment of this whether spin exists or not. And so yeah, we found high rates of spin in all those. So, like 60 to 70%, I believe, and all the studies we looked at in each domain, had some evidences. And you know, after I did these, I kind of conclude in my head, I said to myself, I don't think there's any role for an introduction, or discussion or conclusion for any trial. I think what you should put on is the methods and the results, and that everyone else should interpret the trial themselves. Obviously, that's not like totally possible. I think there's certainly a role for abstract, introductions, and discussions. You know, you want an interpretation of this. And I think we have to also accept that we can be easily misled. There was a really nice study by the original authors that kind of came up with this. And what they did was a randomized trial of physicians. And they randomized 150 physicians to getting an abstract with spin and 150 physicians to get an object with it. And it was the same study, the same kind of results, everything was written up exactly the same, except they put spin in one versus the other. And there was a much higher proportion of those that got the spin article thinking that there were benefits, whatever they were, whatever the intervention was, despite the fact that is pretty clearly laid out that there was no difference between the two techniques. And so, I think one of the things we have to be aware of, and I think this term has been thrown around a lot is we have a lot of biases in terms of what we believe to be true. And when we read an article that reaffirms our biases, we accept that as gospel. And if we read an article that doesn't, we kind of say, well, we pick it apart and say why it's not to be trusted. So, I think, as you know, physicians, surgeons, clinicians, I think when you're reading a study, I think you have to accept that, you know, part of this is your interpretation. Part of this is what the authors have told you is their interpretation. And I think we really got to get back to the methods, do the conclusions match the methods in the results? And I think, you know, we have to continue to be skeptical of that, especially for things that seem to be too good to be true, because often they are.
Chad Ball 36:55
I think that's beautifully said. As one of the editors of Canadian Journal Surgery, this is a really obviously important topic, not only us, but all journals and all editors. I'm curious, what do you think journals can do to protect themselves a little bit from the potential for spin other than, you know, vigorous peer review? And it's interesting, you know, to hear you talk about publishing, perhaps just the methodology and the results, but you know, outside of that, which is certainly very interesting as a concept, what else would you recommend for us to keep the ship straight?
Sunil Patel 37:29
Yeah, you know, it's challenging, I think, because I write articles and you write your articles for the reviewers and the editors to look and say, what you've done is important and different. And inherent in that is often kind of selling your work. And part of selling your work is generally kind of putting a bit of a spin on it. So, I think there's a role for that, like, the context may not always be obvious. And as an author of these papers, you want to find contacts and contacts and importance of your work. I think it's really prudent for the journal editors and reviewers to really focus on the abstract and the conclusions. You know, as you know well Chad, I think 90% of the people that read these articles really read the abstract, and that's about it. So, I think the abstract really needs to be a focus of being objective. I think it's really, you know, the editors and reviewers of these artists can really push back and say, you know, your conclusions really have to be toned down. We can't overstate our conclusions, you can make the case during your introduction and discussion, but the conclusions and the abstracts really has to be objective and reflect the actual findings. And I think that that, at least one solution in my mind. You know, as I say, trying to get your work published, you want to publish your work, you spent a lot of time on it, you think it's important, I think it's just inherent in all of us to try to sell it and perhaps oversell it. And the reviewers, I think accepting that, you know, it's fine to have a study that provides, you know, you know, there's no difference in the outcome. There's nothing groundbreaking, to say that perhaps these are, there's no safety concerns with this new technique. There's, you know, it's perhaps just as good as something else. And that questions still exist and that's why we when we make a decision about practice guidelines in standard care, we don't just look at one study we look at lots of studies and these studies can provide insight into that. So, I don't know. I'm sure Chad you've had those discussions when you review your articles or when you're looking to see whether the final version of a publication, but those are kind of some suggestions I would have.
Chad Ball 39:32
Yeah, that's well said and food for thought for sure. A lot of what you're talking about really, I think is a granular analysis. It's a detailed timing in your seat, paying attention to all these features of peer review and of submissions. But you're right of course, that the vast majority of folks browse through that abstract and that's oftentimes where it's left. You know, the probably the epitome or the pinnacle maybe is a better way to say it at a 30,000-foot drive though, is really the proliferation of visual abstracts. And I don't want you to get the impression or anyone to get the impression that I don't like them, we're gonna bring them into the Canadian Journal of Surgery - Ameer is well down that road thankfully, in doing that. I think they're important. And they're helpful for many reasons. But I'm curious in that exact regard, in particular, with the construction of them with regard to spin and maybe the superficial message at the end of it, what's your impression of visual abstracts? And how do you see them as helping or hurting?
Sunil Patel 40:33
Like you, I love digital abstracts. I think they add a lot. You know, it's so nice to, you know, do a presentation and put someone's visual abstract on a publication that you want to kind of reference as opposed to the boring like full title with authors and everything. I think there's such a nice way to demonstrate a quick hit on what this study looked at, what they found, and what it means. I think they're really great. And they fit perfectly kind of in the promotion of a journal and the authors, especially on social media. But the issue with them is not unique to medical literature, it's kind of the Twitter 140 characters, or whatever it is now. It's such a superficial look at what potentially could be a complex topic. And I think we've all seen on social media, the proliferation of kind of misinformation, misinterpretation of what was said, with like, in one sentence, you know, people getting themselves in trouble or being upset with others, because something was stated in a way that wasn't clear. So, I think visual abstracts are certainly a really nice complement to our literature and a great way to promote something that might be interesting to others. But I think what we really need to stress as visual abstracts is kind of the interest points, so that you click on the link to the article that gives you the details that you need to kind of say, yeah, I agree or disagree. But you know, you are right. They've been criticized in a way, but I think, I think they're just really great. I'm on Twitter, I love seeing visual abstracts. I may skip through and miss other articles that could be just equally interesting. But with the visual abstract, you get the sense right away about something, whether that's what you're interested in or not. And I think it leads to, you know, you reading the article in more detail. So, I actually think they're, like a net positive, but certainly, you're right. They have their own limits.
Chad Ball 42:28
I agree entirely. I think they can be very powerful when they're constructed with thought and effort for sure. You know, the only thing we know you're very interested in which is really obviously timely, like, so much of the things that you do is the concept of conflict of interest on editorial boards in surgical journals. Now, I'll maybe preface the first part of the question with - and you're probably aware of it - but in the past two years or so, since the public equity push, really all of the journals, the peer review journals of record, certainly in North America and southern Europe have really only come out with white papers and made a push to try and meet that that target and some of those goals. But, you know, we've really tried to redesign our editorial boards to reflect more equity. Now, that can be an easier, or a less easy experience, quite frankly, depending on your readership, your country and your population. Obviously, in the US, you have a lot more folks to draw from. The culture is quite different academically in terms of drive and effort than, say, Canada, but not as an excuse, but they certainly are different. So I'm curious how you view conflicts of interest in that context?
Sunil Patel 43:47
Yeah. So first of all, we have to admit that we all have conflicts of interest in anything we do, whether it's financial, or, you know, you've invested time into something that you believe in, you're going to support it. So, conflicts of interest are just inherent in everything we do. But I think it's also important to accept that we do have these conflicts of interest, and that we need to be transparent about it. So, you know, the conflicts of interest papers I've done and looked at, I've undeclared conflicts of interest, which is where I think the problem lies where if you have an obvious financial undeclared conflict of interest, there's an issue there. You have motivations to support and recommend or conclude certain things based on your potential financial conflict of interest. And to me, financial conflicts of interest are often criticized when I did this work in that, oh, the value is low, you know, it's $8,000. This surgeon makes half a million bucks, how can that possibly affect decision making. But it does, because if a company gives you 8000 bucks, you have a relationship, there's probably more to it than just the financial conflict of interest. And I think it's important that we are able to see that if you're making recommendations or conclusions or you're the gatekeeper for publications, it's important to know where those conflicts lie. And try to recognize whether those conflicts are impacting what we're saying and what we're doing. So I think you know, it's a challenge, I think. And I think sometimes you have a situation where everyone has a conflict of interest, even financially. And it can be very challenging. I've seen a lot of work on this in NCCN guidelines where you see these substantial conflicts of interest. And if someone publishes versus NCCN guidelines gets accepted, my understanding is that often you can get whatever drug is recommended and not funded by Medicaid and Medicare in the state. And that's a financial incentive for these people to potentially be influence. So, I see it as a problem in a way. But I also see it as a problem that hopefully can continue to be improved upon. The Americans have the Sunshine Act, which makes it basically I can search any American physician and see exactly how much financial conflict of interest they may have. I know there was some talk about doing the same in Canada, I think that that would be helpful. I'm not sure where Europe is on that standpoint. But I think transparency is what we need. I think we all accept that we have conflicts of interest, and we have relationships, and often the relationship with industry is beneficial both to the industry, they're making a profit, but also to the patients. A lot of innovation within surgery wouldn't have happened without that financial motivation by the company, minimally invasive surgery, for instance, like, we've had huge, huge steps forward with that. And that's been with industry partnerships. So, I think I see these as things that are going to continue. I hope that there'll be more transparency, and I really would like to see that. We accept that we could be, you know, biased in what we're saying because of these conflicts.
Ameer Farooq 47:03
Right, yeah, I think that there's no way to kind of get around that. But I'd probably argue that there's way more spin than we even want to admit, or that even found in those studies, because those were like looking at trials, we didn't even look at all these cohort studies or retrospective, you know, case report type things. Those are even worse, right? So, I suspect that like the amount of spin in surgical literature is enormous. So given your findings, which just to summarize, you found spin in all three domains - Ta-TME, laparoscopic surgery and robotic surgery. So, given this amount of spin, what advice do you have for readers of surgical literature? For avoiding or not getting misled by spin?
Sunil Patel 47:49
Yeah, well, you know, I think it's almost impossible to be impartial if you're working very closely with industry to develop what you believe is a device or an approach that you think will be better or beneficial for your patients. I think you'll be an advocate for that device. I think transparency is what's important. I think we would all accept a study that said, you know, this new device has shown great benefits, here they are in the declarations that I worked with the company, and I received funding from the company to help develop that. And we'd say, in our interpretation of that study, we'd say, well, we got to shade it a little bit, this person clearly has a relationship with the company. But it doesn't totally dismiss what's being said. And then it goes back to reproducibility. Are those follow up studies showing the same benefits? So, I see those partnerships between industry and clinicians and surgeons especially are the requirement for innovative care, like I don't know how an industry partner would develop a new device without input from the surgeons that are going to use it. But I think we just need to be transparent about when we are receiving funding and accepting that may shade our conclusions. And perhaps getting someone more objective to assess your device would perhaps be a bit better than the person that's helped develop it. That would kind of be my impression. But it is kind of an ongoing, complex topic. And you know, there's a lot of very strong opinions about this one way or the other.
Ameer Farooq 49:17
Well, it's been an absolutely fascinating and delightful discussion with you this morning. We really appreciate your time on all your thoughts, and hopefully, we'll see more of these cool, innovative kind of studies coming out from you in the near future. So, we really appreciate it. One of the questions that we try to ask most of our guests on the show is, if you could go back in time and give yourself advice as a trainee or even as an early attending, what would that advice be?
Sunil Patel 49:47
Yeah, that's a really great question. I guess one of the things that I would try to tell myself, especially in medical school and early training is that as a Canadian, often we see the world as Canada, you know, most people either emigrated to Canada or were born in Canada, they did their medical school in Canada, training in Canada and worked in Canada. The world is so much bigger than that. And for me, my most valued experience was when I lived in the UK during a grad degree. And when I went to fellowship in the US. And so, what I would tell myself kind of looking back is I would say, look for more of those opportunities. I suspect, you know, international electives into wherever would have been, I would have really enjoyed those. I think, you know, partnering or collaborating with people that are doing really exciting work internationally, I think I wasn't able to do those kinds of things. And getting mentorship from people that are more than just Canadian is very helpful. And that's not to say that I don't value the mentorship and the training I got in Canada. I think that was invaluable to me. But, you know, to me, the world is such a big place and people are doing such interesting things all over the world. I think it's just to me, I really, really enjoyed having more of those experiences.
Ameer Farooq 51:19
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. This podcast was edited and produced by Tyler Daniels. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your comments and feedback. So, feel free to email us at [email protected] or connect with us on Twitter @CanJSurg. Thanks again.