Photograph: Vienna Medical University

Dedication, Repetition and Hard Work

Dedication, Repetition and Hard Work

A conversation with Prof. Shahrokh Shariat about urology’s enticements, young urologists’ generation and recent trends in society and medicine, including bladder cancer cystectomy  

Prof. Shahrokh François Shariat, MD, PhD is currently professor and chairman of the department of urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria.  He is also adjunct professor of urology at Weill Cornell Medical Center, New York, NY; adjunct professor of urology at the University of Texas Southwestern Medical Center, Dallas, TX, USA; adjunct professor of urology at the Faculty of Medicine, Charles University, Prague, Czechia; adjunct professor of urology at I.M. Sechenov First Moscow State Medical University, Moscow, Russia; honorary professor of urology, University of Jordan, Amman, Jordan; doctor honoris causa, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; and doctor honoris causa, Semmelweis University, Budapest, Hungary.

He has published more than 1680 peer-reviewed research papers (Scopus h-index 120, 57151 citations; Google scholar h-index 141, 80240 citations), >650 non-peer-reviewed papers, and 26 book chapters.  He is the holder of four patents stemming from his research into prostate and bladder cancer, and is the recipient of various national and international awards. He has, for example, received the prestigious Matula Award from the European Urological Association and the Gold Cystoscope 2017 from the American Urological Association.  He is a member of 25 academic societies and editorial board of 26 scientific journals.

Prof. Shariat is the main guest in the Urology section of the Scientific Conference (Wednesday 12 October, approx. 12:30) and will lead the Career Development workshop (at 4:15). 

Professor Shariat, you are going to speak about career development in urology and medicine. Can you tell us what recent trends in the field make urology attractive for young doctors?

I think the most important trend is that urology affects every man and woman in their lives sooner or later. Urology, different than other specialities, covers human life from birth to death: starting with paediatric urology diseases, genetic malformations, embryological diseases. You have gender and transgender experiences. Urology is not based only on one technique or procedure; in fact it offers a complete repertoire of medicine in one speciality. We do imaging, diagnosis, prevention, also intervention and rehabilitation strategies including internal medicine and surgery using imaging in diagnosis, prevention, also intervention and rehabilitation strategies. There is also a lot of sensitive matters, male infertility, erectile dysfunction and incontinence, for example; Taboo areas, where you need to have a lot of sensibility and sensitivity and because they are central to health, quality of life and specifically to long-term well being.

What about the surgical part?

The urologist is mostly known for his surgical skills and his affinity for new technologies, but urology is not limited to these. A lot of technologies start in urology and then go to other specialities. For example, robotic surgery, which got its start in urology and now is booming across specialities, with urologists being the most experienced. Beside that, using endoscopes, we see inside your body – everything that goes in the bladder, up the kidney and so on. Urology has much to offer to people who want to work with their hands but also to people who don’t. There are advanced surgical techniques and a trend to decreased invasiveness.

Do all the students need dexterity, then?

Over the years all of medicine has become more technological, specifically in the surgical area. Urology, in most countries, is still seen mainly as a surgical specialty, which it should not be limited to. Manual dexterity, hand-eye coordination and 3D concepts are essential for everybody who works manually. But today only a fraction of urologists. There are many urologic diseases that do not need surgical management – thanks God! – like urinary tract infections, advanced oncology and so on. The whole field of surgery is, indeed, becoming minimal and non-invasive. Nevertheless, to be a complete urologist, you need to have a certain level of dexterity. But the majority of surgical skills can be acquired through repetition, dedication and hard as well as smart work.

Are students today more dexterous than in the past? Relating to the expansion of IT and digital entertainment...

Well, there are no good data to answer that. It is certainly true that the doctor today has not only other skills but also other desires and expectations than the doctor, and specifically the surgeon, of the past. The training needs to adapt to that. People are more facile with technologies today than in the past, but whether that translates into a better surgeon? Obviously, a trained concert pianist will have an easier start – but the most important thing in surgery is to decide what to do, not only how to do.

Do you watch different priorities, like how they see the issue of work life balance, in the youngest generation of doctors? Is it different than, say, ten or twenty years ago?

I am always very careful with generalisations. Young gentlemen and ladies who finish medical schools in Prague may be similar to those in Vienna, but they may differ from those in New Delhi. But there are certainly changes of expectations and worldviews that we see through out all industries. Sociologists have outlined certain traits that come with the effect of globalisation and education in the western world. It is true that today’s generation’s work life balance expectations affect their dedication and energy towards specific tasks in the work arena.

How to understand it?

I think that many generations, not only the young generation but also mine, have misunderstood a major thing. It’s not about work and life, because you are spending so much time at work that it is your life. And if you think work and life to be two different things you have misunderstood your life and you will be miserable at work. You will try to always optimise something that you perceive as negative in this binary system. There is a multitude of shades of grey. If you want to become a good doctor, you have to work hard and be passionate about it. That comes with many hours of reading, learning, improving, failing and getting better again.

How popular and favoured is this concept today?

Excellence cannot be delivered through a forty- or forty-eight-hours working week as the European Union tells us to do. If you are a banker and so on I would care less but if you are a doctor, if you take responsibility for the life of others and feel not well trained to be a good surgeon, you will harm people just because your training was not good. In my opinion, one challenge we face today is this short-sighted EU regulation´s impact on the doctors´ education.

Number two is the false promises given by politicians to their constituency that health care is for free. Number three is that the “I” matters more than the “we”. I need more free time, I need this and that, and this is what enforces this egocentricism that has created a lot of problems for the society. With forty-eight hours you will have a mediocre training in five years and I do not think it is adequate.

British science anthropologist Mariya Ivancheva says that academia is dominated by males who do not need to take care of anybody, namely, family, parents... What is your opinion on this finding?

I absolutely agree that we need to re-think the environment of learning and establish a gender equality in taking care of the modern family. It’s something we need to be comfortable with and we need to ensure that the families are taken care of while the parents are at work, not just leave it to family members. Just a problem is that most of these big intellectuals that come with recommendations and ideas come from a very unilateral society and that they reflect only on their society. And the solutions are not that easy.

Are you a supporter of gender equality legislation?

Of course, the European Union, as well universities and institutions, are trying to increase the gender equality by regulations. These are drops, but we need to address the main issue from kids receiving the bottom up. We need to ensure that the healthy family can grow in these modern times, with attention and love from both parents, while giving both the opportunity to develop their careers and talents.  And that takes really a more ground-up work than just the simple patches that we have been using in the past. Promoting women even if they are not as good as men is not a solution. But yes, we need to ensure an equal number of women to be in leadership and university positions, otherwise we are losing fifty percent of our potential, it´s like working with half of your brain. It a very complex issue and hard to address from regulations and structurally. We need to be very dynamic and adaptive. And also, regionally rooted as each environment has a different structure, different family model – nowadays parents may not be married, partners change and so on...

Coming back to career development, can you sum up what is the most demanding and fragile in the relationship of mentor and mentee?

The role of the mentor is to facilitate the mentee’s wishes and potential. To advise, support, sometime coach, sometimes really challenge the person, for that person to fulfil his or her dream and not the mentor’s dream. It takes a lot of time and energy; the mentor needs to be able to project into the mentee’s worldviews. You need to take your ego out. Being a good mentee also takes a lot of effort: being well prepared, asking the right questions. I think this mentee-mentor relationship – across cultures, across genders, across cultural backgrounds, across specialities – is essential to the growth of each human being.

Can you tell us about your experience as a mentee? 

I have had the luck of having the most wonderful mentors. For me, for example, Marko Babjuk has been a mentor. When I came to Europe from the United States, he helped me navigate the complexity of European urology and academic scene. He helped me to establish myself in Central Europe, in a partnership, he helped me to grow a different outlook and to understand the language of the people here in Central Europe; how to think, how to interact. He has also helped me to understand the disease of bladder cancer on a different level. People like Marko are mentors one should be looking for. Someone willing to give part of their time and energy to you and your personal growth. Not for their benefit.

One of your areas of interest is bladder cancer cystectomy. Can you tell me about recent developments in this field?

Here, we’re talking, generally, about patients with invasive but non-metastatic bladder cancer. First, we do a PET scan (Positron emission tomography – editor’s note) to make sure that the disease is non-metastatic. Then, if the patient tolerates cisplatin, we give him/her chemotherapy, prior to surgery. If the patient cannot tolerate it, then he/she will not get it. After that, almost every patient responds well. But fifty percent of the patients do not get chemotherapy because of their renal function, and we proceed to radical cystectomy directly.

Today radical cystectomy is less invasive than five or ten years ago. We do it mostly with the goal of limiting the harm, but with the same oncological outputs. For me this entails always an extended lymphadenectomy, and removal of bladder with the prostate in males and female organs in females. We reconstruct a new outlet with limited impact on the quality of life as possible. And that is either done robotically, or open. We provide the patient with what we call an orthotopic neobladder when possible, which comes closest to the natural bladder. Big progress has been in limiting the invasiveness and ensuring optimal perioperative outcomes based on early recovery programs.

What do you do to minimise the complications and limit the adverse event?

There is a number of measures. The necessary one is what we call an early recovery protocol. The patient gets many steps in a programme that ensures the best outcomes such as prehabilitation, intra-operative steps such as limiting fluids, and postoperative rehabilitation. All measures that make the recovery better. One step of this ERAS (Enhanced Recovery after Surgery) protocol is trying to do the surgery as minimal invasive as possible, and that is, robotic.

Created: 22. 9. 2022 / Modified: 22. 9. 2022 / Mgr. Petr Andreas, Ph.D.