SUO 2019: Failing Forward: A Clinical Perspective

Washington, DC ( Dr. Tracy Downs from the University of Wisconsin provided a clinical perspective of “failing forward” at the YUO dinner program during the 2019 Society of Urologic Oncology (SUO) meeting.  Dr. Downs notes that this is important because all of us have a professional identity, closely linked to clinical and academic outcomes. The AAMC has a Faculty Forward Initiative that states that research demonstrates that an integrated, evidence-based approach to attracting developing and retaining talent is necessary to support transformative change. Health care organizations that have implemented and sustained well-designed talent management systems document substantial improvements in individual and organizational outcomes including:

  • Higher levels of employee satisfaction, engagement and retention
  • Positive individual-level performance of faculty and staff
  • Positive organizational-level performance

But Dr. Downs notes that what’s missing is professional development to build leadership skills and professional IQ (recognizing and responding to challenging dilemmas). He notes that one of the most important skills he has learned in his 16 years since finishing fellowship is to ‘avoid the pitfalls’. When managing difficult moments, it is important to manage yourself and develop your skills.

Dr. Downs then described a clinical situation that we as urologic oncologists have all encountered at some point in our career: an 83-year-old with muscle-invasive bladder cancer and multiple comorbidities, including COPD, diabetes, stage III chronic kidney disease, and a history of a AAA repair one month prior to the consultation. At the time of consultation, the patient looked deconditioned, and Dr. Downs recommended against a radical cystectomy at that point in time, however, over the next several months he became transfusion-dependent and was admitted to the hospital several times for gross hematuria and clot retention. Dr. Downs repeatedly counseled the patient regarding 90-day operative mortality of ~15%, however, his disease continued to progress to bilateral hydronephrosis and a creatinine of 5.0 dg/ml. Despite the high-risk, the family and patient desired a palliative radical cystectomy. The patient eventually underwent a robotic cystectomy with cutaneous ureterostomies, which went well with minimal blood loss. From post-operative days 0-2 the patient did well and was eventually transferred out of the intensive care unit. By 9 PM on the floor, the patient experienced cardiac arrest and passed away that evening.

The challenge for surgeons is that the very next day you have to perform the exact operation on a patient who is also high risk with several comorbidities. Dr. Downs asks what do you do? His decision was to call his patient for the next day the night before and tell him that it would be best to postpone his surgery. He notes that the patient was very understanding and that he encouraged him to “take your time and when you’re ready, you are my surgeon”. He notes that this was both humbling and comforting.

Several take-home points that Dr. Downs highlighted:

  • When you have complications, get more involved, not less – run closer to the patient and their family
  • Your instinct will be to flee the scene and run away from your “failure”, but resist the urge to pull away. Slow down and be there for your patient
  • As part of surgeon wellness – know yourself and how you differ from others. If we do not feel that we are ready to operate the next day after a catastrophic event, don’t put yourself in a situation where others may get hurt

Presented by: Tracy M. Downs, Urologic Surgeon and Fellowship-trained Specialist in Urologic Oncology, The University of Wisconsin, Madison, Wisconsin

Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md, at the 20th Annual Meeting of the Society of Urologic Oncology (SUO), December 4 - 6, 2019, Washington, DC