Urology workforce shortage and teaching residents at private hospitals

Hello, friends.
It's been awhile since I've posted, so sorry for the hiatus.

We have just released a paper in the journal Urology about teaching residents laser prostatectomy in the private practice setting.

Pubmed Citation for Paper

There is a serious shortage of urologists in America.  To compound the issue, there are only 225 or so urology residents graduating per year - well short of what this country needs.  Medicare dollars are also getting squeezed which means that the graduate medical education (GME) environment will only be more challenging (Medicare pays for the bulk of graduate medical education currently in this country).  Going forward, this means that the paradigm of the academic medical center being the sole nexus of surgical education may have to change.

In our paper, we show that residents can be taught cutting edge surgical techniques in a private hospital, in this case laser prostate surgery, without any change in the safety profile or surgical outcomes.  The only difference in cases with a resident was a slight increase in operative time (57 vs. 46 minutes).

More urologists need to be trained in the future to tackle the needs of our population.  Since GME dollars are fixed and are surely going to be tightened up in the future, institutions need to be creative about training opportunities.  High quality private practices can be a great resource to train the next generation of urologists.  In the future, I also see more private institutions creating their own residencies outside the confines of a Medicare system.

Our paper received an editorial...which was a great compliment to the impact of our article.

Pubmed citation for editorial

We composed an editorial reply please find a link below:

Our editorial reply (Pubmed citation)

I hope to continue posting with some regularity....though the periodicity is uncertain at this time.  It has been difficult in the past few months balancing family, my MBA program - only 2 classes left!, research, and a busy clinical practice.  However, there's a bunch of stuff going on in my urologic mission so I want to continue to share and educate.  Any words of encouragement and support are greatly appreciated!

Our laser prostate surgery research is in this month's British Journal of Urology

We're happy to share with the world our work in this month's British Journal of Urology.

Pubmed citation

Full Paper

The paper deals with laser prostate surgery for benign prostatic hyperplasia (BPH), commonly known as an enlarged prostate.

Our experience with the procedure reveals that it is safe to perform this surgery with a discharge within hours of the procedure. This case series is important because having an ambulatory pathway can reduce hospital resource utilization, allow patients a more comfortable recovery in their home environment, and avoid further exposure to hospital based problems such as infections, errors, and falls.

In a laser prostatectomy, a laser fiber is used to destroy prostate tissue that is blocking a man's urinary flow.  An advantage from a laser based approach is less blood loss due to the sealing action of the laser.  This allows patients the potential for a same day surgery. 

The classic, surgical approach to BPH is the TURP or transurethral resection of the prostate.  As a opposed to a laser fiber, a cutting loop is used to shave away the obstructive prostate tissue.  Due the amount of bleeding postoperatively, patients are generally admitted to the hospital for at least one day with a bladder irrigating catheter.

Our research group is currently studying other aspects of advanced laser prostate surgery as well as the use of mobile apps in urology....so stay tuned!  More abstracts and papers to come...

Sharing our research at the NEAUA Meeting

Entrance to the Meeting at the Westin in Boston

I was at the 81st New England American Urological Association Annual Meeting in Boston last week.  The meeting was well attended with participants hailing from not only New England but also from many other parts of the US.  I had a great time catching up with colleagues as well as former residents I trained who are now colleagues (!).

At this year's meeting, I was also active as a member of the Scientific Program Committee, reviewing abstracts and helping the Program Chairs outline the format for the sessions.

My research group had a podium abstract at the meeting about laser prostate surgery.
Check out this prior blog post for more details about the abstract as well as my meeting involvement.

Drs. Ben Herrick (right) and Ron Yap (left) after our presentation.
See how relieved Ben looks?

Dr. Ben Herrick did a great job presenting our findings in the session.  The abstract was favorably received and marks the 4th time he has been able to share our research at a scientific meeting.  At this past American Urological Association Annual Meeting in May,  Dr. Herrick was first author on three abstracts for my group.  This is no small feat for such a large and competitive international meeting.  So kudos, Ben.  Keep up the good work!

Presidential Proclamation on Prostate Cancer Awareness Month

As a urologist, I'm in the front line everyday with my patients in the battle against prostate cancer.

Despite the controversy regarding PSA based screening for prostate cancer, the fact remains that prostate cancer is a leading cancer for men as far as incidence and mortality.  This disease is also the cause of much suffering in the world.

I'm pleased to see President Obama issue a proclamation yesterday acknowledging the burden of prostate cancer on American men, their families, and the healthcare system.

I urge my readers to check out this statement and spread the word about September being Prostate Cancer Awareness month.

Here are some suggestions for the month:

• Attend an educational event in your area about prostate cancer
• Consider a donation to a prostate cancer related charity
• Raise money to support prostate cancer research
• Talk to your doctor about prostate cancer   
• Talk to a family member or someone you know with prostate cancer and give him your support

If you have any other suggestions to support prostate cancer awareness please drop in a comment!

New Statement from the American Academy of Pediatrics on Circumcision

Today, the American Academy of Pediatrics (AAP) has released a new Circumcision Policy Statement. This release is an update to their last statement in 1999, reaffirmed in 2005.

I've linked to the primary sources in the medical literature because I think it's the best way to parse out any changes.

Here is a critical passage from today's statement (2012):

"Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV."

This is a more definite statement when compared to the 1999 statement:
"Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision;"

Today's policy statement explicity highlights the medical benefits of circumcision and notes that overall the benefits outweigh the risks.  However, the statement stops short of recommending the procedure to all males.

The new policy statement's recommendation to have access for the procedure addresses the current lack of coverage for Medicaid subscribers in 18 states.

My analysis:
The circumcision debate has very entrenched camps for and against.  This issue is not simply a medical one.  It also involves the social, spiritual, and religious realms.  As a urologist by trade, my expertise lies with the medical.  There is burgeoning evidence that is hard to refute as noted in the AAP statement regarding the health benefits of circumcision.  However, ultimately, the decision as to whether or not to circumcise lies with the patient and family whilst receiving the appropriate informed consent from their physicians.  Families that elect to have circumcision should have appropriate support from insurers to due to its health benefits.  The health benefits of circumcision may cause the procedure to be classified as a preventative service.

Additional references/sources and for further reading:
LA Times Article (Brown)
USA Today Article (Painter)

Check out the Men's Health Checklist by the AUA

The American Urological Association recently released a "Men's Health Checklist" as a pamphlet and as mobile apps for Apple and Android.


Here is a link to the pamphlet. 


Here is a link to the app for Android.


Here is a link to the app for Apple.


The checklist breakdowns the health concerns by age: (18-39, 40-49, 50-69, 70+) as well as "Urology Specific" vs. "Related Health".


I think it's a great reference for men and healthcare providers alike. So, check them out and share them with the men in your lives!

What is a urethral or "Foley" catheter?

A urethral or "Foley" catheter is used to provide continuous bladder drainage. The catheter is named after a Boston urologist, Dr. Frederic Foley, who was instrumental in creating the catheter in the 1930's.


Here are some reasons why a patient would have one:

• monitor urine output
• alleviate urinary retention or severely dysfunctional voiding
• realign the urethra and bladder after urologic surgery or trauma
• help stop lower urinary tract bleeding

They are sized on the  French scale.  The diameter of the catheter x 3 = French size.  Here is a good link on Wikipedia on this scale. The most common sizes for routine use are 16F and 18F.

Urethral catheter
 Source: Wikimedia Commons/Olek Remesz
Creative Commons Attribution-Share Alike 3.0 Unported License

The catheter is placed inside the urethra and allows the bladder to continuously drain via a closed drainage system.  One the left side of the diagram there is a balloon port and a urine drainage port. The balloon port is where a syringe is placed to fill the balloon with fluid at the right side of the diagram.  The balloon is needed to keep the catheter in the bladder.  Without the balloon, the catheter would simply slip out.


The urine drainage port is connected to a drainage bag.  There are two types of drainage bags:


Leg Bag- a small bag with elastic straps that can be placed on the leg.  This allows the patient to discretely wear the bag under pants and move about.


Overnight Bag - this bag is larger and is usually used at night because of its capacity.  This is placed at the side of the bed, attached to an IV pole, or carried by a patient.


There are many other catheters out there that urologists primarily use.  One noteworthy example is a 3-way catheter that is used to treat urinary tract bleeding.  This catheter has an additional inflow port that is used to irrigate the bladder.  This fluid then goes out the drainage port with the urinary output.  


Reference: http://en.wikipedia.org/wiki/Foley_catheter

Radiation oncologists against new USPSTF prostate cancer guideline

The United States Preventative Services Task Force issued a new guideline in May recommending against PSA screening for prostate cancer altogether.  This government based panel has been getting the deserved pushback from the American Medical Association (AMA) as well as from the American Urological Association (AUA).  


Here's a prior blog post with my thoughts on this as well as the AUA response with current PSA screening guidelines from the AUA as well the American Cancer Society.


I wanted to share in this post a statement from the American Society for Radiation Oncology (ASTRO).  These doctors are on the front lines with us (urologists) in fighting prostate cancer.  ASTRO also has lined up against the new USPSTF guidelines.  

ASTRO statement

My analysis:


I agree with Dr. Gunderson's quote on this issue.  There certainly is an over diagnosis issue with prostate cancer.  However, as active surveillance is becoming a viable method to keep track of the disease, advocating for a wholesale cessation of PSA based screening is like throwing out the baby with the bathwater.


Dr. Sandler also makes a great point in the release. The prostate cancer screening issue is not a problem that a cookie cutter approach can solve.  With multiple factors such as age, expected longevity, race, symptoms, and family history, each situation is unique and each man should have the opportunity to make an individual informed decision on the matter with his physician.

Bladder Pal supporting overactive bladder awareness on AUA Foundation site

The American Urological Association Foundation (AUAF) has launched a site to increase awareness of overactive bladder (OAB).  The web presence is part of a multifaceted patient outreach initiative entitled - "It's Time to Talk about OAB."


In the site is a link to Bladder Pal for Apple and Android under the "Assess Your OAB Symptoms" heading. 


The site also has high quality information regarding OAB facts, symptoms, treatment options, and a resource to find urologic care.


I'm happy to partner up with the AUAF on this effort and am glad that many more people around the world have access to Bladder Pal to track their urologic health.


This OAB outreach initiative coincides with the release of new clinician guidelines for OAB that was disseminated at the AUA Annual meeting in May.

NEAUA 2012 Meeting - my involvement and podium abstract

My American Urological Association annual section meeting (New England) will be taking place in Boston at the Westin Boston Waterfront from September 6-8.   I've been involved with this meeting as a member of the Scientific Program Committee.  My duties on the committee have been to review abstracts as well as participate in planning discussions.  It has been a fun and gratifying experience to shape the structure and content of the meeting.


Here is the preliminary program.


My research group has an accepted podium abstract at the meeting!
It is entitled: "Laser Prostatectomy in the Severely Ill - Outcomes and Feasibility of a Rapid Ambulatory Discharge Pathway".  Dr. Ben Herrick, intrepid Dartmouth Urology resident, is lead author on this study. We show in the abstract that patients who are considered to be "severely ill" by American Society of Anesthesiology classification system can safely and effectively have a rapid ambulatory discharge from the hospital after laser prostate surgery.  In fact, 80% of patients benefited from the ambulatory pathway, 8% were admitted for 23 hour observation, and 11% were in the hospital for longer than 23 hours.


Laser prostate surgery for BPH has reduced bleeding compared to transurethral resection of the prostate (TURP) because of the sealing action of the laser.  As a result, it is feasible to send patients home the same day of surgery with a urethral catheter.  In contrast, patients are routinely admitted to the hospital after TURP.  Such an ambulatory pathway decreases utilization of hospital resources and allows the patient to recover in the comfort of his home.  Decreasing a patient's exposure to a hospital setting also decreases the possibility of hospital based or "nosocomial" errors, falls, and infections.  Though it would seem counterintuitive to send higher risk surgical patients home from surgery the same day, I believe that it is actually safer to do so because of such an avoidance of the hospital environment.  Our data shows that this can be done in a safe and effective manner.


I encourage all those out there to "save the date" and support this meeting in September!

AMA tells USPSTF to incorporate specialists in guideline creation

Resolutions were passed at the American Medical Association House of Delegates Meeting admonishing the USPSTF regarding their screening guidelines on mammography and PSA screening.


Here are the passed resolutions: (Source: AUA e-mail alert)

RESOLVED, That our AMA expresses concern regarding recent recommendations by the USPSTF on screening mammography and PSA screening and the effects these USPSTF recommendations have on limiting access to preventive care for Americans.

RESOLVED, That our AMA encourage the USPSTF to implement procedures that allow for meaningful input on recommendation development from specialists and stakeholders in the topic area under study.

Here is coverage from ABC News on the topic. 


The recent USPSTF guidelines for PSA screening were done without the input from the American Urological Association.  This is a big tripping point for me on the guidelines since we urologists are the main doctors who take care of men with prostate cancer.


Further, the USPSTF membership lacks oncologists and urologists. Here are the current members of the USPSTF: 


I applaud the AMA for taking a stand on this. Specialists represent a great resource for the crafting of these guidelines and need to be involved at the ground level, not after the fact.  Not involving main stakeholders who implement such guidelines reduces buy-in from the medical community as well as patients.

Men's Health Week table debrief

Last week, I hosted a Men's Health Week table at the Concord Hospital cafeteria on June 12th, 2012.  

The purpose of the event was to increase awareness of the Men's Health Week celebration as well as distribute educational materials regarding men's health concerns.  

We had free granola bars and popcorn at the table, courtesy of the Society of Urologic Nurses and Associates (SUNA).  Special thanks to New Hampshire SUNA Chapter President Kris Green, RN, CURN for the support.

Me at the table

At the table we had free information on:

• Prostate health
• Testicular self exam
• Fatherhood
• Low testosterone
• Mens and women's health checklists
• What women should know about men's health
• Highway safety

A plethora of free giveaways was graciously provided by the NH Highway Safety Agency.  Many thanks!  Did you know that the #1 cause of death for young men in America is "unintentional injury"?  I have a prior blog post about this issue.

The event was a success with about 150 people coming by.  I had many good conversations with people about men's health issues and was happy that people were not shy about approaching the table.
It was such a good experience that I hope to make this an annual event.

My Men's Health Week message in the Concord Monitor

This week, I wrote an op-ed piece regarding Men's Health Week and submitted it to my local papers.

Thank you, Concord Monitor, for publishing the letter.

Here is the article. 

Earlier in the week, I hosted a Men's Health Week awareness table at my hospital that went very well.  I'll post about that later, since I have several nice pictures of the event.  Stay tuned.

Hope you are all having a good Men's Health Week, and Happy Father's Day in advance!

Next week is Men's Health Week 2012!

Do you know when Men's Health Week is?  It's easy to remember.  It's the week up to and including Father's Day.  This year it's June 11-17, 2012.  Actually, the whole month of June is designated as Men's Health Month.


Here is a link about Men's Health Month and Men's Health Week from the Men's Health Network - a great resource for men's health advocacy.


On Tuesday, June 12th I'll be hosting a Men's Health Week table in the Concord Hospital cafeteria in Concord, NH from 8am to 2pm.  There will be free munchies, swag, brochures about men's health conditions as well as injury prevention materials (check out this prior post on young men and "unintentional injury").  If you are reading this and can drop by please do so to support our efforts!


Going into the week here are my public service messages:


Men - Get medical care and be responsible for your health - not only for you but for your loved ones too.


Women - Tell the men in your lives to get medical care and be advocates for their health needs.

Zytiga (abiraterone) for advanced prostate cancer before chemotherapy - ASCO 2012

Testosterone is a major fuel for prostate cancer growth.  Despite use of agents to induce clinical castration, men can continue to have advancing disease.  Zytiga (abiraterone) is pill that directly suppresses the synthesis of testosterone at multiple points in the body to further decrease testosterone production.   It is currently FDA approved for advanced castrate resistant prostate cancer after use of Taxotere (docetaxel) chemotherapy.  This indication restricts to use of this agent to the most advanced cases.


At this year's American Society of Clinical Oncology (ASCO) meeting, there was an exciting abstract about treating men suffering from advanced castrate resistant prostate cancer with Zytiga (abiraterone) before using chemotherapy.  Abiraterone caused improvement in progression free survival, time to narcotic use, time to use of chemotherapy, time to deterioration in clinical performance status, and time to PSA progression.  The study was terminated early due to the degree of improvement at interim analysis.


Here are links to media coverage of this abstract:
Reuters for a general audience.
Medpage Today coverage - more technically inclined.


This will likely lead to an expanded FDA indication in the future for use prior to chemotherapy.  Men will then have earlier access to this oral agent to combat the disease.

My take on USPSTF final prostate cancer screening guidelines

The US Preventive Services Task Force (USPSTF) released its final prostate cancer screening guidelines on May 21st, 2012, during the American Urological Association Annual Meeting (curious timing...in my opinion).


The task force recommended against PSA-based screening altogether for prostate cancer by giving the practice a "D" rating.  From the USPSTF grade definitions site this means: "The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits."  The task force suggests that healthcare providers: "Discourage the use of this service." This recommendation is no different than the draft recommendations issued in October, 2012 despite vocal opposition from many sources.


The American Urological Association (AUA), American Cancer Society (ACS), and National Comprehensive Cancer Network (NCCN) have issued guidelines recommending men to have discussions with their healthcare providers regarding the risks and benefits of prostate cancer screening.


AUA Guideline
ACS Guideline
NCCN Guideline


The AUA has expressed its vigorous opposition to the the final USPSTF recommendation.  AUA President, Dr. Sushil Lacy, released this statement about it on behalf of its members.  The AUA also has a website about the issue and prepared a fact sheet about PSA testing for its members.


My take:
The PSA screening controversy is a complex issue.  There are many factors involved in screening such as age, expected longevity, race, family history, and urologic symptoms.  I believe that at this time, the USPSTF blanket recommendation is too simplistic.  I urge men to talk further with their healthcare providers regarding this issue and consider referral to a urologist if there are still lingering questions about prostate cancer screening.  Also, the diagnosis of prostate cancer does not necessarily mandate treatment.  Depending on the clinical scenario, monitoring of the disease or "active surveillance" can be a viable option for many men.

Useful prostate cancer video from NH Prostate Cancer Coalition

A very informative video from the New Hampshire Prostate Cancer Coalition (NHPCC) about prostate cancer and prostate cancer screening was just uploaded to their website.  It features Dr. William Santis, my partner, who is Director of Prostate and Urologic Cancer at Concord Hospital.


He honestly explains in layman's terms prostate cancer screening as well as the screening controversy.  The video has a nice diagram of the lower male urinary tract as well as useful facts about prostate cancer.


Please check out the video and post any feedback so I can relay this the NHPCC and Dr. Santis.

Thank you Memorial Sloan-Kettering for referencing Prostate Pal

I'm happy to share this link from the Memorial Sloan-Kettering Cancer Center (MSKCC) Library Blog.

They have referenced "Prostate Pal" as a mobile resource for patients dealing with prostate cancer.  MSKCC is one of the premier cancer hospitals in the world. I think it's great to have such a prominent instution advocate for mobile apps as a way to further empower patients and increase efficiency of care.

Their library also has a reference page for other healthcare apps for patients and their families.  The resources were selected by their staff librarians.  I encourage those who are interested in mHealth to look at the site and check out the apps.

Caricatures of men's health in the media

I just read an interesting article on KevinMD regarding men's health issues on TV.

If you read the comments after the article, I chimed in on the piece, but also wanted to drop it in my blog because I think it's quite topical with Men's Health Week coming up.

My comments:
Great article, Joel.  As a urologist who deals with the conditions you referenced, I can relate to the lack of respect for male health at times in the media.  There needs to be more constructive awareness of men's health concerns from reputable medical professionals, not just caricatures and off colored jokes.
Here is a challenge. When is Men's Health Week?  Answer - The week up to an including Father's Day (June 11 - June 17, 2012). I doubt that most in the blogosphere knew of such a celebration. 
It is up to us in medicine to get out there and increase advocacy for male health concerns!

Bladder Pal at the AUA Annual Meeting

Entrance to the AUA Meeting - Georgia World Congress Center
Photo Credit - Ronald Yap, MD

I recently returned from the American Urological Association Annual Meeting in Atlanta.

I did a few things at the meeting, but wanted to focus this post on "Bladder Pal".  If you want to read about what I was doing altogether at the meeting please check out this prior blog post.  For more background info on "Bladder Pal" check this post out.

On Sunday, May 20th, I demonstrated "Bladder Pal" to members of the AUA Foundation (AUAF) and Overactive Bladder (OAB) Expert Panel.  New guidelines for the management of OAB were released at the meeting and the AUAF is doing a patient outreach initiative to increase awareness and treatment of this condition.  To help support this effort, "Bladder Pal" will be highlighted as a tool to empower patients to track their urologic health in conjunction with their healthcare providers.  I'm honored and excited to be working with the AUAF on this and hope that "Prostate Pal" can also be helpful to the Foundation in the future.

Me demonstrating "Bladder Pal" at the AUA Foundation Booth
Photo courtesy of Alaina Willing - AUA Foundation

As you can see from the picture, my tie looks quite short.  Prior to my booth appearance, I taught a "hands on" course on laser prostate surgery and had to tuck it in my tie to keep it out of the way.  The only problem is that I forgot to untuck it and was walking around most of the day with it looking like that.  I was talking to all sorts of people with that thing tucked in and no one said a thing!  

On Tuesday, May 22nd, "Bladder Pal" was discussed during a podium presentation at the meeting.  The reception was very positive and the downloads skyrocketed after the presentation.  The abstract even made it to the highlight reel for the meeting.  Click on the Urodynamics/Female Urology link and "Bladder Pal" is profiled starting at 7:53.  

I'd also like to give some kudos to Dr. Ben Herrick, a Dartmouth Urology resident, who presented the "Bladder Pal" abstract and two other abstracts with me at the meeting.  He has been part of my research group for the past year and has been doing one heck of a job.