Dr. Schulman is a urologic oncology fellow at Duke Medical Center, Durham, NC.

Ariel Schulman, MD

Ariel Schulman, MDThere is an old surgical adage that “the best surgeon knows when not to operate.” While much of early residency is focused on how to operate, there is an expectation that more senior trainees become more familiar with non-surgical strategies for indolent disease or patients with significant competing morbidities. This is particularly relevant for men with localized prostate cancer where the patient’s functional state and life expectancy must be integrated into screening, diagnostic, and management decisions.

	While no resource is perfect, it is worthwhile to familiarize yourself with some contemporary methodology and predictive tools to integrate into clinical practice. Sammon et al published a well-done study in 

	Age is the best predictor of life expectancy. According to the Social Security Administration (SSA) Actuarial Life Tables from 2013, life expectancy for newborn males and females in the United States is 76.28 and 81.05 years, respectively. And the longer one lives, the longer the overall life expectancy becomes so that the average 60-year-old man has a life expectancy of 81.48 years.

Research success during residency: Seven useful strategies

	In addition to age, comorbid conditions and functional limitations must be integrated. Validated indices including the Charlson comorbidity index and more recently the Elixhauser comorbidity index offer objective tools to quantify comorbidities. But it should be noted that neither was designed or validated to predict 20- to 30-year longevity. The Eastern Cooperative Oncology Group (ECOG) Performance Status and Karnofsky Performance Status are widely used functional classifiers, particularly in the medical oncology community, to guide prognosis and treatment strategies.

	In recent years, there has been significant interest in the surgical community to better integrate objective tools to quantify perioperative risks. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) risk calculator and Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (POSSUM) incorporate multiple clinical variables to predict complications and mortality after surgery. While these scores identify high-risk surgical patients, they were not designed to guide the other required management decisions.

National Comprehensive Cancer Network Guidelines for Prostate Cancer Version 2.2017

	The current National Comprehensive Cancer Network Guidelines for Prostate Cancer Version 2.2017 endorse “the clinician’s assessment of overall health” to supplement the SSA tables. Men deemed to be in the best quartile of health have a 50% greater life expectancy, while life expectancy is reduced by 50% for men considered to be in the worst quartile. Men in the second and third quartile would have the life expectancy assigned by the tables. It is worth noting that the uniformly accepted American Society of Anesthesiologists (ASA) score for patients undergoing surgery similarly relies on a subjective assessment of overall health.

	Consider a 60-year-old man as an example. Actuarial tables predict an additional 21.48 years of life expectancy. Those determined to be in the best quartile of health would have 50% more years (21.48+10.74=32.22 years) and would be expected to live to age 92.22, while those in the worst quartile of health would have a 50% reduction (21.48–10.74=10.74 years) and would be expected to live to 70.74 years. Thus, 60-year-old men in the lowest projected quartile have a 10- to 11-year life expectancy, the middle two quartiles have a 21- to 22-year life expectancy, and the highest quartile has a 32 year life expectancy.

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	Interestingly, calculators from large insurance companies incorporate a range of additional factors not considered during most physician visits. An online lifespan calculator from Northwestern Mutual incorporates compliance with medical care, stress, diet and exercise, and driving history. In this model, binge drinking or a driving while intoxicated conviction in the past 5 years reduces life expectancy by 5-10 years. Divorce has also shown to have a detrimental impact on male survival in longevity studies. Thus, as we know intuitively, what is listed in the medical chart doesn’t always tell the whole story.

	Like many tools, risk calculators offer additional objective data to improve decision-making, but are used optimally when incorporated with other available information. In the end, the clinician’s “good judgment” is required to put together all of the pieces and offer reasonable options to each patient. Ultimately, being familiar with one or two scoring systems to use when treating more complex patients and to justify management in the medical record will likely be to your benefit.

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While no resource is perfect, it is worthwhile to familiarize yourself with some contemporary methodology and predictive tools to help determine life expectancy in localized prostate cancer patients.

How to estimate life expectancy in men with localized prostate Ca

	“Research” brings up a spectrum of sentiments among trainees. For some, it is simply a prerequisite, while for others, it sets the foundation for an academic career. A yearly project is usually required by most programs, but actual training in research practices varies in both quality and quantity. Similarly, the pre-existing skill set of residents is highly variable.

	The Accreditation Council for Graduate Medical Education (ACGME) requires that some members of a faculty demonstrate scholarship through obtaining funding, publication of articles, presentation at society meetings, and/or participation in national committees or educational organizations. The American Board of Urology defines the minimum time in training and case requirements, but research requirements are left to the discretion of each program director.

	Across all programs, there are several steps individual residents can employ to make research a positive experience that enhances training. Here are seven general strategies I have found useful:

 Projects related to my own ideas and initiatives have always been more fulfilling, better received by faculty, and more clinically relevant then those assigned to me by others. Identify your own interests and look for “gaps” in knowledge that need to be addressed. Direct your research activities to these areas. Look for mentors and resources with similar interests.

Consider Choice E: Effective learning during residency

It is critical to identify mentors that have successfully integrated research activities into clinical practice. Interestingly, successful academic clinicians have widely diverse skills and interests. In other words, there is not one recipe for success. Aligning yourself with someone you can relate to is often more fruitful. Also, it is critical to differentiate mentors whose career you would like to emulate from those who can help you bring projects to completion through ideas, resources, and relationships. Ideally, you should find both.

Start early and create a long-term timeline.

 Research activities, both basic science and clinical, take time to develop. If you are starting a new project, administrative processes alone can take several months. I try to consider new projects on a 9- to 15-month timeline including a target meeting for presentation and manuscript for publication. Display submission deadlines in a visible place to keep projects moving ahead.

 Many programs are particularly strong in two or three subspecialty areas, but it is important to also consider topics relevant to the national urology community. One invaluable resource is archived video sessions of recent AUA annual meetings. These are freely available to members through the AUA website. Proceedings from the plenary sessions cover the most important issues in urology today. In addition, look for opportunities to collaborate with colleagues in different specialties within your hospital (anesthesia, ob/gyn, surgery) who may be addressing topics related to urology and can offer a unique perspective. Broadening your research circle typically harnesses skills and resources that may not be available within your particular division or department.

Sound trial design and statistical methodology are critical components to all research projects and should be delineated from the start. A collaborative working relationship with a biostatistician is invaluable. Most statisticians will help you understand the fundamentals of the analysis. This will allow you to truly understand the meaning of your findings and help you build your own statistical skill set.

Use new data to inform unique patient group

 There a number of project scheduling tools used in various industries to keep activities on track. The 

 is one example. Break your projects down into the critical sequential steps (administrative approvals, data collection, statistical analysis, etc.) and create an estimated timeline for completion. These tools make larger projects less daunting and allow you to identify your progress and needs across the life of a project.

 Some advanced planning can lead to presenting at national meetings, giving you exposure to a larger peer group. Well-done projects may introduce you to the thought leaders and fellowship directors in your area of interest. Further, specialized knowledge and skills acquired during research engagement may offer strategic advantages in the job market.

	Success in research endeavors during residency is similar to success in acquiring surgical skills-a proactive approach can make all the difference in your experience. Focus your efforts in areas of clinical interest and find good mentors to emulate to help get your projects done. Be sure to get rewarded for your hard work, because it is almost time to start thinking about next year’s research project.

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Urologic oncology fellow, Ariel Schulman, MD, shares some tips to help residents make research a positive experience.