ACPE meeting debrief - Make your life more like a casino

Just got back from the American College of Physican Executives Annual Meeting.
It was a very enlightening time.  I really enjoyed meeting physicians from all over the world with a deep interest in shaping the future of healthcare.

I presented a poster on my mobile apps - Prostate Pal and Bladder Pal that was very well received!  I got some great feedback for future directions of the apps...as well as my career with respect to mobile healthcare technologies.  Thank you to all those who came by and engaged me about this.

I'd like to focus a little bit on our keynote speaker - Peter Sims, author of the book "Little Bets: How Breakthrough Ideas Emerge from Small Discoveries".  He gave a great talk about making small low risk pilot projects and prototypes to drive creativity.  Some references he used to support this process were Frank Gehry's extensive use of models to create new buildings, Pixar's way of creating films, and the comedian's use of small venues as a lab to create new material.  After his lecture, we participated in fun exercises to demonstrate the "Little Bet" principles that really let our creative juices flow.

Thanks to the meeting,  I feel more empowered to take more creative stabs at things and approach life like a player in a casino rather than a nervous soldier in a minefield!

New drug approved by the FDA for ED

The FDA has just approved a new agent for male erectile dysfunction -  Stendra (avanafil).

This medication is in the same class as Viagra (sildenafil), Levitra (vardenafil), and Cialis (tadalafil) - phosphodiesterase type 5 inhibitors, or PDE-5 inhibitors.

How does this new agent compare to the existing drugs?   Avanafil's reported time to maximal blood level or Tmax  is 0.593 hours compared to 1, 0.7, and 2.0 hours for sildenafil, vardenafil, and tadalafil respectively.  The reported half-life is 1.19 hours compared to 3-5, 4-5, and 17.5 hours for the other three respectively.
Reference: Drug Des Devel Ther. 2011;5:435-443

Based on this pharmacokinetic data, avanafil should work faster then be more quickly eliminated from the body compared to the other currently available drugs.  It's targeting the end of the market where people want a fast onset of action and only have the medication in their system for the least amount of time.

Tadalafil targets the other end of the market where a man can take a daily formulation (2.5 mg or 5 mg) to be ready at any time or an as needed formulation (10 or 20 mg) where he can be ready for up to 36 hours.

It's too early to say what the differential impact will be between all of these drugs clinically.  In the end, as some of the older drugs come off patent in a few years and the US market is flooded with generics, the relative cost of each agent will likely be a significant driving factor as to what oral agent patients choose.

Why is the testis called the testis?

I have a pet peeve.  Over the years, I've heard many people call or spell the testis a "testi" or "teste", perhaps from seeing testis or testes and removing the "s" thinking that it's plural.  Since it's a latin word, the singular form is testis and the plural is testes.

So where does testis come from?  Well, there is a commonality between the male gonad and a court of law.  No, this is not a lawyer joke.  Let me explain...When you are a witness in court you testify and in a man's scrotum are testicles or testes.

They share the same root word, testis, which means a witness.

Some related words from Wiktionary are:
test
testament
testify
testimony

How does this word relate to a the male anatomy?  This root word was applied to the male gonad because it is a "witnesses for a man's virility".

It's funny how I've been involved in urology for many years and didn't know all these details about the word until now!

Union Leader Forty Under 40

I've recently been named by the New Hampshire Union Leader as one of the Forty Under 40 for 2012!

Union Leader profile

The awards ceremony recently happened at the Manchester Radisson.
It was a great occasion with the Governor presiding over it.

Here's pic with me and the Governor (right) and someone from Citizen's Bank (left)

Unfortunately, it's only a preview picture!  I had to spend $7.50 to get a digital copy for my home photo album. The commercial one-time digital right to post a real pic on this blog was $100!  There's also other merchandise for sale on the site.  I'm sure all of you out there in the blogosphere are dying to get your hands on a coffee mug of the event! ;)

All that minor griping aside, I'm definitely honored to be part of this year's class and thank the Union Leader for bestowing it on me.  It's gratifying to see mobile healthcare technologies, urology, and male health  being spotlighted through this award!

Warren Buffett and President Obama vs. USPSTF guidelines

As an 81 year old man, it's ironic that Mr. Buffett is in the demographic that the United States Preventive Services Task Force (USPSTF) recommends against screening.  The current official recommendation from this body is that people aged 75 years of age or older should not be screened.

USPSTF prostate cancer screening guideline - 2008 (in revision)

This guideline is old and their current draft guidelines advise against screening altogether.  This new proposed guideline was released in October, 2011 and had two comment periods after release.  Their final recommendation is pending.

USPSTF draft guideline against all screening for prostate cancer

The new proposed guideline has drawn the ire of many groups, with the American Urological Association leading the way.

AUA page with USPSTF response

I too have been involved in the response, sending an editorial to the Concord Monitor.  In particular, I detail the interesting fact that while this controversy is going on that President Obama just had a PSA test. If the new draft guidelines were used, he would be advised against having the test.  I feel that he should have the test and continue to do so, especially since he's in an at-risk demographic by being African-American.

As stated in my prior blog post about Warren Buffett's cancer, I think using age alone is a very simplistic cutoff.  Prostate cancer is quite complex and the medical data is still evolving.  There is little controversy that there is a problem with the over diagnosis of prostate cancer.  However, diagnosis does not necessarily mean treatment.  One good aspect of this controversy is that there is more awareness that many men have very low risk disease and can be managed with active surveillance.

The bottom line is that we currently don't know which patients with prostate cancer will die of that disease.  Until this issue is further clarified with more clinical studies or a breakthrough in prostate cancer detection, men should have an informed discussions with their doctors regarding this issue on a case by case basis.  It is premature for the USPSTF to issue such a blanket statement that affects the health of millions of men in the United States.

Warren Buffett's prostate cancer disclosure and treatment

Since Warren Buffett's recent disclosure of prostate cancer has made a lot of headlines, I thought I'd share some commentary on it today.

Mr. Buffett's letter to shareholders revealing that he has prostate cancer.

My thoughts as an outside observer:

It seems that he has T1c or prostate cancer detected by PSA testing alone.  Since we don't know his PSA history, Gleason score (a number that tells us how aggressive the prostate cancer cells are), or number of cores positive in his biopsy, it's difficult to know exactly how much disease he has in the gland or how risky it is.  Warren Buffett's treatment with 2 months of external beam radiation therapy is a mainstream option for someone electing to be treated for this disease.

It is controversial in the medical community as to whether nor not a man of his age (81 years) should have been screened in the first place.  Since Mr. Buffett seems to be a man in excellent health with a likely expected longevity of 5-10 years, such screening may have been reasonable.  In my opinion, a chronologic cut off for who should and shouldn't be screened seems overly simplistic.  There are many factors aside from age such as anticipated longevity, family history, and race that also need to be taken into account.  Therefore, I encourage men to have an individualized discussion with their doctors regarding the risks and benefits of prostate cancer screening. 

Mr. Buffett's prognosis is excellent.  Since we don't have his cancer specifics, we can rely on general prostate cancer survivorship data.  From the American Cancer Society, his 5 year relative survival rate is nearly 100%, his 10 year relative survival rate is 98%, and his 15 year relative survival rate is 91%.  Plenty of time for him to work out a succession plan for Berkshire Hathaway.

American Cancer Society survivorship page for prostate cancer

Best of luck to Warren Buffet and his family as he embarks on his treatment.

What is a urologist and how do you become one?

The public, my patients, and even some colleagues ask what a urologist does.

Here is some general information regarding the speciality of urology, including some material gleaned from the American Urological Association (AUA) and the American Board of Urology (ABU) websites:

What is urology?

Urology is a surgical specialty that deals with diseases of the male and female urinary tract and the male reproductive organs.  This includes organs such as the kidneys, bladder, and prostate gland.  In addition to surgical knowledge, urologists also must be familiar with specialties such as internal medicine, pediatrics, and gynecology to care for the broad spectrum of problems that affect these systems. 

What is particularly enjoyable about this specialty is that we can care for patients of all ages.   Many medical students are drawn to urology because of our stereotypical easy demeanor and our facility with both the medical and surgical treatment of genitourinary diseases.

How does someone become train to become urologist?

Urologists complete at least 4 years of medical school after college to obtain a MD. Thereafter, urologic graduate medical education occurs at training hospitals.  This consists of 1 to 2 years of general surgery followed by urologic training for a total of 5 to 6 years after medical school.  Some urologists do fellowships ranging from 1 to 3 additional years of training to further subspecialize.

 

The AUA has identified seven subspecialty areas within urology:

• Pediatric Urology
• Urologic cancer such as prostate, kidney, bladder, and testicular cancer
• Kidney Transplantation
• Male Infertility
• Stone disease of the urinary tract
• Female Urology 
• Neurourology

How is a urologist certified? 

In America, board certification is done by the American Board of Urology.  There are generally correlate bodies in other countries of the world.

The certification process consists of two parts:

1. First part - qualifying written examination as well as a review of credentials, education, and training.
2. Second part - After passage of part one and a minimum of 16 months of practice, candidates can then submit a practice log and undergo peer review and review by the board.  If the candidate is qualified, he or she can take the second oral certifying exam.

Beginning in 2007, ABU has initiated a maintenance of certification process for those who become certified or recertified.

Here are the reference links:

American Board of Urology

American Urological Association - What is urology?

We’re quite enthusiastic about our craft and enjoy discussing it with any interested party. So please talk to one of us for further information!

NCCN cancer guidelines for doctors and patients

The National Comprehensive Cancer Network (NCCN) is a consortium of 21 leading cancer centers across the country.  They write clinical guidelines for oncologic care with panels of doctors who are some of the best minds in cancer care.  As an active clinical urologist, I use their guidelines frequently to give my patients the most up to date, evidence based care.

If you are a clinician or interested patient here is a link to their clinical guidelines:

NCCN Clinical Guidelines

They encompass all major human cancers and are listed by site.  Since I'm a urologist, I almost exclusively use the prostate, bladder, kidney, and testicular cancer guidelines.

The NCCN has also produced an excellent guideline for prostate cancer patients.  Here's the link:

NCCN Patient Guidelines

It uses very clear language and starts from the basics.  With so many treatment options out there, it is nice to have an unbiased resource for patients during such a difficult time in their lives.

Describing your urinary symptoms to your doctor

The urologic system can be quite a mystery to many people.  When you see your doctor for urinary issues, it can be difficult to find the right words to describe your symptoms.

In this post, I'll review some symptom terminology so that you can communicate more effectively with your healthcare provider.

"Urias":

• dysuria - pain with urination
• hematuria - blood in the urine
• nocturia - night time urination
• pneumaturia - passage of air with urination

Leakage:

• urge incontinence - urinary leakage due to feeling like you need to urinate and not making it to the bathroom in time
• stress incontinence - urinary leakage due to coughing, straining, laughing, or other strenuous activities

Symptoms:

• frequency - how often you urinate
• urgency - how rushed you feel when you feel the need to urinate
• hesitancy - a difficult to start urinary stream
• intermittency - starting and stopping stream
• retention - sense of incomplete emptying after urination

Knowing a few buzz words can really expedite your visit and let your doctor know how empowered you are about your urologic health!

Sharing the Apps at the ACPE 2012 Annual Meeting

I will be speaking about patient empowerment through the use of the Prostate Pal and Bladder Pal mobile apps at the American College of Physician Executives (ACPE) Annual Meeting in San Francisco.

Here's a link to the meeting

If you don't know about the apps here are my previous blog posts about each of them:

What is Bladder Pal?

What is Prostate Pal?

It will be a poster presentation during the "Share Your Story" session on April 28th from 12:30 pm to 1:30 pm.

For those who won't be at the meeting, here is the poster:
(my apologies if the font is real small, it was hard to get it to fit within the borders of the blog text box)

ACPE 2012 "Share Your Story" Poster

Over 3,000 users have visited the apps over 10,000 times from countries all over the world!
It's quite gratifying to see that many people use the app to facilitate the tracking of their urologic health.

About me and the ACPE -
Since I have a deep interest in medical management, I've been a member of the ACPE for several years. The organization is at the forefront of physician leadership empowerment. With healthcare in turmoil, I'm happy that the ACPE is giving doctors the training and encouragement to be difference makers and facilitators of change. I'm currently working towards an MBA through the ACPE and U. Mass - Amherst.

About 2/3 of the way through!

Creating Bladder Pal

When Prostate Pal came out, there was a great launch.  The media attention related to the Associated Press article really made the downloads happen.  Due to the buzz, many women became aware of the app and asked for an app that would be more pertinent to their needs.  No woman was understandably interested in downloading Prostate Pal for their own use! 

I received lots of great feedback from Prostate Pal and sought to improve it with a second version.  At the same time, it made sense to spinoff a unisex version that women could use as well.  It turned out later that parents of children suffering from urologic conditions also found Bladder Pal very helpful.  

So soon after release of Prostate Pal, the work started on the update and the Bladder Pal app.  Once again, the LeBaron Foundation was the crucial funding in this endeavor through the Concord Hospital Trust and 9Magnets, LLC was the app development partner.  The main things I wanted to add to the app was leakage data, incontinence pad data, and an export function.  In May 2011, the updates were complete and Bladder Pal joined Prostate Pal in the App Store!

Bladder Pal has the following components:

• Bladder Diary - This is used to track fluid intake, urine output, urinary leakage, and incontinence pad changes.  The information that is logged will help your healthcare assess your urinary health and response to therapy.  Containers to measure output can be purchased at your local drug store.
• AUA Symptom Score - This is a questionnaire produced by the American Urological Association. It has been validated with numerous medical studies.  The list of questions are used to help men and women in conjunction with their healthcare providers assess their urinary symptoms and response to therapy.

Bladder Pal Home Screen

I'm particularly proud of the e-mail button as well as the clear home screen which includes daily leak and incontinence pad data.  9Magnets did a great job on the implementation.

Here are links to the Bladder Pal:

Bladder Pal for Apple

Bladder Pal for Android

Prostate Pal Initial Reception

When the app was submitted, it only took a few days for the Apple team to review it and clear it for distribution on the App store.  It was definitely gratifying to see it go live for the world to download!
Upon release, it was even listed as a "New and Noteworthy" app in the medical app section. That was an unexpected surprise.

Soon after release, an additional surprise was being approached by a reporter at the Associated Press for a story about the app!  It was exciting to relay to them my vision for utilizing mobile healthcare technology to improve doctor/patient communication and increase efficiency of care within urology.

Things truly move fast in the internet age because I spoke to the reporter about Prostate Pal in the morning and it was released on the newswire that afternoon.  Soon, it was carried by tons of news outlets and was all over the internet. When I was driving home from work that day, I even heard the story on the radio!

Short form of story

Long form of story

So the initial reception was truly beyond my wildest dreams.  I was just very happy that the increased exposure meant that more men would be aware of such a tool for their mobile devices and feel empowered to use it to improve their health.

Secondarily, by getting the app out there and having such press, I hoped that the stigma of prostate diseases can be lessened somewhat.  As the story revealed, many men believe that you should just live with prostate conditions....when in actuality proper urologic care can improve quality of life and be life saving in some cases.

Prostate Pal Mobile App

With the mobile technology revolution in full swing, I believe that this is an opportunity for healthcare to harness this energy to further empower patients, facilitate doctor/patient relations, and improve the efficacy of care.

Since I'm a urologist, I naturally think about such things within my realm of expertise.
For men, prostate disorders impact millions of men throughout the world.  In an effort to marry mobile healthcare (mHealth) with these interests, I came up with Prostate Pal.

Prostate Pal is a free app.  By free, I mean the real free - no in app purchases, "liteware",  or banner ads. By releasing the app in such a manner, the goal was to give men worldwide the ability to track their urologic health.

It's available on Apple and Android platforms:

Prostate Pal for Apple Devices

Prostate Pal for Android

The app consists of three parts:

• Bladder Diary - This is used to track fluid intake, urine output, urinary leakage, and incontinence pad changes.  The information that is logged will help your healthcare assess your urinary health and response to therapy.  Containers to measure output can be purchased at your local drug store.
• AUA Symptom Score - This is a questionnaire produced by the American Urological Association. It has been validated with numerous medical studies.  The list of questions are used to help men and women in conjunction with their healthcare providers assess their urinary symptoms and response to therapy.
• PSA Tracker - Prostate specific antigen or PSA is a blood test that is used to screen for prostate cancer and monitor response to prostate cancer therapy.  The tracker has a table and graph format.

Prostate Pal Home Screen

I first came up with the idea in early 2010.  Initially, I tried to program it myself with the Apple Software Development Kit.  However, the programming was too time intensive as well as too complex for me to fully implement my vision for the app.

Thankfully, two things happened that allowed the app to come together.  First, I received funding from the LeBaron Foundation and Concord Hospital Trust for the project.  Second, I ran into Cameron Banga and Mike Phelps from 9Magnets, LLC - an app development company. They did a great job executing the app and it was first released in January of 2011!

In other posts I'll talk about the further development of the app and stuff that happened after the release, It's been a pretty crazy ride since I thought about this app in my living room on a cold, New Hampshire winter night!

How is the Prostate Examined?

The prostate is felt or "palpated" via digital rectal exam or "DRE". 

See figure below:

Source: Wikimedia Commons and NCI

In this cutaway side view, the doctor's finger is in the rectum and digitally examining the prostate gland.

When your doctor does a DRE he or she is assessing several attributes regarding your prostate:

• Size - How big is the gland?
• Symmetry - Is one side or "lobe" different in size compared to the other one?
• Contour - Are there any lumps or "nodules" within the gland?
• Consistency - Are there any firm areas within the prostate?

A well trained clinician can detect all these factors pretty quickly from the exam.  If an abnormality is found the patient may be offered a prostate biopsy to determine whether or not the prostate harbors cancer.

As a urologist, I believe that when a patient elects to be screened for prostate cancer a digital rectal exam should be part of the process.  Though screening for prostate cancer is a controversial issue, much of the attention has been around PSA testing alone with little acknowledgement of the utility of the DRE.

The DRE is also helpful in assessing the prostate for other conditions such as benign enlargement of the gland or "BPH" or prostatitis.

What exactly is the prostate anyway?

Let's start with basics:

The prostate is a sexual gland located between a man's bladder and penis.  It is located in the pelvis behind the pubic bone (bone you can feel just above the penis) and in front of the rectum.

Check out the figure below:

Source: Wikimedia Commons and NCI

This shows a cutaway side view or "sagittal" view of the male pelvic area.  The prostate is located in the boxed area.










This is a closer view of the prostate and the seminal vesicles which store the semen created by the prostate.








The main purpose of the prostate is to create semen.  Semen is the vehicle for sperm transport to the female reproductive system. The semen is also critical in helping the sperm become active within the female reproductive tract, a process called capacitation.

So hopefully this post has shed some light on what it is and where it is.  I'll do another post next on how the prostate is examined.

First Post

Hello, world!

I've created this blog to educate the public regarding urology and male health as well as share with you my exploits.

First of all, who am I?  I'm a urologist in Concord, NH with a clinical and research interest in male health and mobile apps.

Here is my LinkedIn profile - this will give you more details:
My profile

The blog is called Prostate Pals because I think it has a nice ring to it and because it is also the title of the free urologic health app (no ads too) I created for Apple and Android devices.  Here are some links to the apps:

Prostate Pal for Apple Devices

Prostate Pal for Android

There is a unisex app called Bladder Pal also for Apple and Android:

Bladder Pal for Apple Devices

Bladder Pal for Android

If you are reading, please comment...and send over any request you have for topics.

I hope to start generating further content real soon, so stay tuned!