An interview I did for Student BMJ

Biography

Roberto Casula studied at Padua medical school in Italy, graduating in 1989. He came to the UK in 1993 and has worked in Glasgow, Cambridge, and London. He has a European qualification in cardiac and thoracic surgery and is a fellow of the Royal College of Surgeons. He is a consultant cardiothoracic surgeon and honorary senior lecturer at Imperial College London and a UK pioneer of minimal access and robotic cardiac surgery.

What first attracted you to cardiac surgery?

As a child I was told about the first heart transplant. This never left my mind and I was fascinated by the whole story. Since then I never considered any other path in life apart from studying medicine and then training in cardiac surgery.

What do you value about your job?

You hear about successful people being bored with their highly remunerated job after 10 years. I don’t think that this will happen in a specialty like mine. The technical improvements and technological refinements in cardiac surgery continue to stimulate me and remain challenging on a daily basis.

It is also rewarding to see that we can provide somebody’s problems with a solution and hear from them about how much they have improved after surgery and minimal invasive procedures.

What’s different about cardiac surgery compared with other sorts of surgery?

Dealing with the heart is challenging and fascinating: having to stop it and then restart it and—even more challenging—sometimes having to operate it while it’s moving. Performing microsurgery on a beating heart requires dexterity and skills that have developed in cardiac surgery to a high level.

What’s a normal day like for you?

There are days when I spend most of the time in the operating theatre. This is usually physically demanding. In a day I typically do one, two, or three operations and I often organise my meetings and do paperwork in between cases.

Some days I attend multidisciplinary team meetings or see outpatients. Regardless of the extensive use of technology in my clinical practice I enjoy talking and listening to my [out] patients because it allows me to ensure they continue to progress to our expectations.

I also spend some of my time reading, reviewing, or writing academic papers.

What does robotic enhanced minimal access surgery involve?

When we say “robotic enhanced” obviously it is not an independent intelligence that performs the operation. The system is guided by a surgeon, and moves pencil sized surgical effectors inside the chest that are positioned at the beginning of the operation.

The operation takes place through small incisions. This avoids opening the sternum, which is always required with traditional surgery, and this is what we mean by “minimal access.” The advantage is that we can reproduce traditional surgical techniques with reduced surgical trauma. We also do not use the cardiopulmonary bypass machine, and therefore we do not expose these patients to side effects [associated with the machine].

Usually patients treated with less invasive or robotic surgical techniques recover faster and return to their normal daily and professional activities sooner than the traditional patient.

What sort of operations are you doing using these techniques that other people are doing via traditional surgery?

The most common operation performed with robotic technology is a single bypass to a blocked coronary artery. We also undertake mitral valve repairs. Several other minimal access procedures are routinely performed to change or repair the aortic valve, remove heart tumours, or reset the normal sinus rhythm in patients with atrial fibrillation. These do not necessarily require robotic technology.

Why are so few surgeons offering robotic cardiac surgery in the UK?

The techniques are time consuming and require specific training. The set of skills needed for robotic surgery are different from those acquired when training for traditional cardiac surgery.

Another limitation is that several medical specialties offer treatments for cardiac disease. As a result, we don’t treat a sufficient number of patients surgically to reproduce robotic technology in large volumes.

What’s the best way to choose the most appropriate treatment for a patient with a cardiac problem?

In an ideal world the specialists discussing the case would be a conventional cardiologist who can do an angioplasty, a non-interventional cardiologist who is untrained in either angioplasty or robotic surgery, and a cardiac surgeon capable of performing minimal access/invasive surgery. This is what is suggested by European guidelines. Between the three of them they will be able to reach the best decision for the patient.

What innovations do you think we’ll see in cardiac surgery in the future?

I would like to see better integration between present technologies with better collaboration between groups of specialists. The best treatment is “hybrid treatment,” which means being able to offer a bespoke treatment to a patient according to his or her needs. An example of this might be a patient with multivessel coronary artery disease who has a robotic operation on the most important vessel, such as the left anterior descending, and angioplasty to a further vessel of lesser importance.

What advice would you give a student thinking of training to be a cardiac surgeon?

The best approach is to arrange to visit an operating room and watch an operation. If possible they should also see a minimal access operation, and perhaps even a robotic operation. If they are caught by this bug that caught me many years ago I think they will never regret entering into a career in cardiac surgery.

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Also published on BMJ blogs

I learnt some interesting facts about mobile phones the other day. For instance, there are 59 countries where mobile phones outnumber people. This refers to mobile phones actually in use, rather than forgotten ones in drawers, under sofas, or in the glove compartment of your car.  Worldwide there are six trillion texts sent a day, about which unexceptional Western teens are exceptionally keen as they send/receive an impressive 3,400 per month.  The average user of a mobile phone looks at it 150 times a day.  That’s every 6 minutes 30 seconds. 

We’ve known for while that mobile phones, and their newer, cleverer brethren “smart phones” are really going places.  They’ve become essential to our lives, supplanting other objects in our affections, as observed (tearfully?) by Jeff Hazlett, former CMO of Kodak. 

“Photographs used to be the item people would run into a burning building to go retrieve; today a mobile phone has replaced that”

Even a fairly humdrum smart phone now packs a terrific amount of computing power. Beyond making voice calls the initial uses of these phones were fairly unimaginative.  Since then a combination of advancing phone functionality and imaginative third party “apps” points to a future where mobile phones are not only ubiquitous but will be increasingly relied upon to help us to interact with, and make sense of, the world.  They also have a potential to substantially alter the practice and potential of healthcare. 

Key to this transformation is that smart phones can interact with the world around them. The first generation of mobile phones received input solely through a keypad. Today, just like me, my phone can see and hear, and can detect motion and direction.  Using an app like Layar I can overlay digital information onto my phone’s field of vision. Using SoundHound, it can tell me which song is playing on the radio. My maps app means I never get lost. 

So far, so useful, but my phone can also communicate with other devices wirelessly–something that exceeds my human capabilities.  This is already allowing smart phones to subsume the function of a credit card or a set of keys.  Using the same technology in the near future the world has the potential to become an “internet of things,” a huge network of interconnected devices. 

Imagine your ever smarter handset telling you that you have a window left open at home and asking you whether you wish to switch off your heating, or reminding you that your car is short on fuel. From here it’s almost no leap at to see a patient with coeliac disease scanning every item in a supermarket before purchase to ensure it’s compatible with their diet. Or to imagine a world where wearable sensors, that will allow us to routinely monitor our wellbeing, are commonplace.  If your heart beat rises unexpectedly, your phone will ask you if you’re stressed and advise you to take a break.

In many ways this all sounds fantastic, as it offers opportunities for the early detection of disease and for promotion of healthy living. I’m not sure I personally welcome a coming world where my phone moonlights as my super-ego, or where my body is viewed as simply being a more intimate extension of my social network. However even I can see it would be useful if my running shoes could tell me when they’re worn out.

Interesting link:  the future of health

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War may not be good for much, but it has proved to be an effective incubator for innovation. I’m not just talking about the Slinky: the development of nylon, polythene, and aerosol sprays also benefitted from conflict.

The urgency of war has also lead to many of the most important innovations in medicine. It was the battlefield surgeon Ambroise Paré who in the 16th century introduced the ligature of arteries (instead of cauterization) during amputation. An effective treatment for leukaemia emerged from nitrogen mustard’s use as a poisonous gas and Dwight Harken operated on wounded D-Day soldiers and demonstrated that shrapnel could successfully be removed via open surgery to the heart. 

A recent Royal College of Surgeon’s event, “Disability and the military,” discussed medical progress emerging from more recent conflicts. Most notably the chance of surviving an injury during combat is now much improved. During the Second World War wounded soldiers had a one in three chance of dying. Today this figure in Afghanistan is less than one in ten. 

Speaking at the event orthopaedic registrar Major Arul Ramasamy attributes this improvement to a variety of factors. Body armour plays an important role, as have improved helmets and ocular protection. The “continuum of care” is also vital. Treatment now starts the moment an injury is sustained, as all deployed troops are trained in battlefield first aid and carry tourniquets and haemostatic dressings. “We’re bringing some of the stuff that was always left to the hospital out to the battlefield,” said Major Ramasamy. 

The injured are evacuated quickly and soldiers receive medical attention, including blood transfusions, on the evacuation helicopter. On arrival at Camp Bastion the team aim for rapid surgical decision making. “The fastest time I’ve seen from a patient arriving to them being operated on is 45 seconds” said Major Ramasamy. To a psychiatrist like me, even thinking about this sort of speed makes my head swim. 

Soldiers are now living with injuries that five years ago were considered unsurvivable, such as the loss of two or even three limbs. This brings its own challenges and physically surviving such injuries is only the beginning of a long period of recovery. 

David Richmond, an army colonel wounded in Afghanistan, also spoke at the event about his own recovery and that faced by others. The majority of the injured are very young and “under different circumstances they would be in the 6th form at school” he said. “To have your life tipped upside down at that point of your life when you haven’t really worked out who you are in the first place is much more a battle of mind than it is a battle against injury.” 

Much of the provision for long term rehabilitation comes from the charitable sector with the Royal British Legion and Help for Heroes providing facilities such as Tedworth House. Colonel Richmond was keen to stress that injured soldiers are capable of much, including outdoor activities, and that one of the challenges of rehabilitation is persuading them of this. 

It remains to be seen how far the advances in treating battlefield injuries will translate into improved civilian trauma treatment as the advanced continuum of care the military can offer is unlikely to be replicable on civvy street.  Few civilian casualties, for instance, find themselves injured whilst standing next to friend trained in first aid.

Also published on BMJ blogs

Letter by me in the BMJ this week:

Inglis contends that the BMJ’s print run and thus carbon footprint can be reduced by a combination of increased reader sharing of print issues and greater embrace of digital distribution.

The whole picture is less straightforward. The BMJ is a commercial publication, albeit not an aggressively capitalist one, and it must pay its way. Part of its funding comes from print advertising, and advertisers remain reluctant to pay for online and iPad advertisements. Were the BMJ to make the transition to an online only publication, with most printed copies communally read in institutions, its business could prove unsustainable. “So what?” some might say, but unexamined healthcare is also wasteful inefficient healthcare.

The idea that a move from printed to digital distribution will automatically lower the BMJ’s carbon footprint is not a foregone conclusion. At least one comparison of the environmental impact of print, online, and tablet based consumption has been attempted and comes out only hesitantly for tablets.

A comparison of print and digital distribution must include all stages. A digital journal is free from the physical print and distribution costs of a print journal but data storage—“cloud computing”—and device manufacture/disposal must be considered. Greenpeace’s recent report on cloud computing data centres voices concern that many rely on “cheap but dirty” coal power stations.

Ultimately many factors determining an electronic journal’s environmental impact are down to reader behaviour. The fewer tablets, laptops, and smart phones we buy the lower our carbon footprint. Yet most of us own several devices with overlapping functionality, which we regularly replace. Few of us switch them off as often as we should.
Notes

Competing interests: SG is employed by the BMJ as editorial registrar.

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The first salvo in the Guardian’s recently published series of articles on academic publishing was delivered by veteran agitator George Monbiot.  Journals publish government funded research, written and often edited for free by academics says Monbiot.  “But to see it, we must pay again, and through the nose” he says. 

The monopolist practices of academic publishers make Walmart ‘look like a corner shop’ and Rupert Murdoch ‘look like a socialist’ he continues.

In a second article Ben Goldacre writes of Aaron Swartz, a digital activist.  Swartz is accused of downloading academic papers on a grand scale, intending to make them available for free on file sharing sites such as Pirate Bay.  Goldacre writes that in some respects this is a remarkable tale of “Robin Hood behaviour”. 

Thirdly David Colquhoun writes of the enormous pressure on academics to publish research  papers.  He says this has lead to a proliferation of journals and a shortage of qualified peer reviewers.  As a result the quality of published research has nosedived.  “The only people who benefit from the intense pressure to publish are those in the publishing industry” he writes.

Profits for some academic publishers certainly are healthy.  Monbiot reports that Elsevier made £724m on revenues of £2bn during the last financial year.  This is a profit margin of about 40%.  Can this be justified? 

In the past Reed Elsevier has defended their profits on the basis of their skilled staff, their support to authors and peer review panels, and their complex typesetting and distribution costs. 

A 2005 report from Deutsche Bank disagreed:

“We believe the publisher adds relatively little value to the publishing process.  We are not attempting to dismiss what 7,000 people at REL do for a living.  We are simply observing that if the process really were as complex, costly and value-added as the publishers protest that it is, 40% margins wouldn’t be available.”

The industry does face major challenges.   Libraries are struggling to pay escalating subscription prices and electronic distribution of papers is making the established business model redundant. 

Open access is an alternative paradigm, where authors pay a publishing fee to make  journal articles are free for anyone to access. 

In 2008 the BMJ formally became an open access journal and all BMJ research articles are free to access immediately upon publication.   Authors are asked to pay a publication fee per accepted research article if their research grant covered open access publication fees.  Other ‘added value’ articles, such as clinical reviews or editorials, require a subscription.  In addition to the BMJ, BMJ Open is an online only open access journal also owned by the BMJ group. 

A discussion of the pros and cons of open access is available on the open access Wikipedia page

A further option is self archiving, where freely accessible copies of an article are placed on the web.    In his article Colquhoun favours a variety of this approach with peer review provided through anonymous reader comments. 

Newspaper models

With ten daily national newspapers, the UK has one of the most competitive newspaper markets in the world.  Since the 1980s sales have fallen but innovative business models are emerging which may have lessons for academic publishing. 

The Guardian has long championed a comprehensive free online presence.  Although its website does provide a substantial income from advertising, the newspaper remains unprofitable and is famously underwritten by the less sophisticated Autotrader, a trading magazine for used vehicles, also owned by the Scott Trust. 

By contrast the Times does not allow any of its articles to be read online for free.  When introduced this move lead to a drastic drop in online traffic.  Whist dismaying to columnists, News Corp may not be concerned about this drop as occasional visitors tend to ignore ads and add little value.  The Times has concentrated on maximizing business from loyal readers; the site is awash with advertisements for tie-ins such as wine clubs and holidays. 

The Daily Mail has the world’s second biggest newspaper website, with 35m unique visitors per month.  Unlike the alarmist print edition, the online Mail focuses on the fashion choices of attractive female celebrities. 

Innovation is not restricted to online approaches.  The Evening Standard print edition is now entirely free, and its circulation has doubled.  Distribution costs have also fallen.  The paper is handed out at Underground stations and each issue is read multiple times as abandoned copies are moved around London by Tube.  It’s still not in profit, but its losses have halved.

The Independent’s approach is arguably the most experimental.  It has introduced an abridged version called ‘i’, which is distributed alongside the full newspaper.  The greater combined distribution of these two offerings makes selling advertising easier.

Lessons?

The approaches of UK newspapers indicate that new business models for academic publishing can include both print and online innovation.  Approaches such as those of the Mail may of course not be compatible with the brand values of academic journals.  Allowing increased free access will appease critics such as Monbiot and augment readership, but may not encourage loyalty.  A closed model, like that of the Times, prevents bloggers linking to the research they discuss, potentially decreasing a paper’s impact.   

It will be dangerous for academic publishers to do nothing.  In his article Goldacre suggests a grubby compromise may emerge.  Journals will stay afloat financially due to institutional subscriptions, whilst individuals will avoid excessive per article charges by downloading articles they wish to see from semi-legal content sharing sites. I expect that this is not a situation   most publishers would welcome.  “These are very interesting times for information” he writes.  I agree.

Also published on BMJ Blogs
 
Links:

Three archive articles from the BMJ suggest that these arguments are not new:

PubMed Central: creating an Aladdin’s cave of ideas

Scientific literature’s open sesame?

Open access publishing takes off

This, published on BMJ blogs

Last Wednesday I joined the BMJ as the Roger Robinson editorial registrar. This is my first despatch from the frontline of medical publishing.

The registrar role has been running for 22 years and is named after the late Professor Robinson who was an associate editor at the BMJ for ten years. It’s for one year and allows the post holder to take a break from clinical practice and develop skills in medical journalism and editing. This sounded like an excellent opportunity to me as I’ve been interested in writing and publishing since medical school. 

Although I’ve been in the job less than a week, I’ve already been put to work and have written my first news article. In the process I’ve learnt that news requires short paragraphs and quotes are vital to lend a sense of currency. BMJ style strongly discourages the passive voice. I also helped select letters from amongst the BMJ’s many rapid responses for inclusion in the upcoming issue.

I’ve not worked in an office for over ten years and there are lots of differences to my previous NHS foot soldier job. Clearly I’m not seeing any patients at the moment, which is a shock.  Another big change is how central the BMJ’s offices are – I’m used to working in the far reaches of the capital (where the riots are). It’s not been a complete culture change though, as amongst many medical journalists there are also plenty of medically trained staff. I find it quite exotic that a lot of people at the BMJ work remotely, some as far away as Sydney and Boston USA. At any meeting several people join us by phone.

I’ll save further details of how the journal is put together for future despatches. As a final reflection, unlike stereotypical journalists I detect no evidence of a habitual heavy drinking culture here, but the coffee in the canteen is tasty, keenly priced, and frequently very strong.