BackTable Urology

Special guest The White Coat Investor James M. Dahle talks with Christopher Beck about where physicians can start when it comes to financial literacy, including common financial mistakes docs make when start practicing, a primer on mortgage rates, and tips on insurance.---CHECK OUT OUR SPONSORDI4MDsProtect your most valuable asset, the skill and ability to practice your medical specialty. Be prepared by establishing a specialty specific disability insurance policy from the experts at DI4MDS. Contact them today at www.Di4MDS.com or call 888-934-4637---SHOW NOTESIn this episode, White Coat Investor founder Dr. James Dahle and our host Dr. Chris Beck discuss strategies for physicians seeking to manage their personal finances and gain financial freedom.First, Dr. Dahle explains the reasoning behind the famous quote, “live like a resident.” He explains that for an early career physician, their greatest wealth-building tool is their income. The income jump from residency to attending years can be extremely useful for quickly paying off student loans. Then, he moves on to discuss another way to resolve student debt, the Public Service Loan Forgiveness (PSLF) program. This option is ideal for physicians who have spent a significant amount of time working for a nonprofit institution (for example, during training and in academic medicine).Dr. Dahle advises all physicians to reflect on their priorities when deciding where to allocate their assets. Possible categories could include retirement funds, 529 college savings funds, payment of high-interest debt, and emergency funds. We talk about the power of having a written plan to stay on track with financial goals and prevent ourselves from making rash decisions.Next, we discuss different financial vehicles that can provide benefits for physicians. The “back door Roth IRA” strategy allows for yearly contributions to a tax-free retirement fund, even when a physician’s income exceeds the maximum limit for the conventional Roth IRA. Additionally, the funds in a Health Savings Account (HSA) can be used for investment, and then withdrawn at a later date, penalty-free. Dr. Dahle explains the difference between fixed rate and variable rate mortgages, noting that the latter is better for short-term loans because interest rates are unlikely to dramatically increase from year to year. Finally, Dr. Dahle covers the advantages of buying disability insurance as a way to protect physician income, especially for those working in procedural specialties.---RESOURCESWhite Coat Investor: https://www.whitecoatinvestor.com/White Coat Investor Podcast: https://www.whitecoatinvestor.com/wci-podcast/White Coat Investor Email: editor@whitecoatinvestor.comPassive Income MD: https://passiveincomemd.com/Physician on FIRE: https://www.physicianonfire.com/

In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Jennifer Anger from UCSD Urology talk about care for transgender patients and gender-affirming surgery. They discuss the importance of using correct terminology, how to work up patients seeking gender-affirming care, and the multidisciplinary nature of transgender healthcare.Reflect on how this Podcast applies to your day-to-day and engage to earn AMA PRA Category 1 Credit(s)™ via point-of-care learning activities here: https://earnc.me/FZmaCA---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Jen Anger from UCSD Urology about care for transgender patients and gender-affirming surgery.Firstly, Dr. Bagrodia and Dr. Anger discuss the importance of gender-affirming terminology and using the correct pronouns for transgender and gender-fluid patients. Dr. Anger encourages healthcare providers to always ask patients how they would like to be addressed before making assumptions based on anatomy and past history.Next, Dr. Anger describes her workup for patients initially seeking gender-affirming pelvic reconstructive (“bottom”) surgery. Most patients seeking bottom surgery will have already started hormonal therapy and puberty blockade. In concordance with national regulations, Dr. Anger only performs gender-affirming pelvic reconstruction surgery if a patient has already lived as their preferred gender and undergone hormonal therapy for at least a year and has secured 2 letters from mental health providers stating support for their transition. For adolescents, there is an additional requirement involving the consent of two parents.Dr. Anger emphasizes that transgender care is a multidisciplinary field. She works closely with many other physicians, such as the patient’s primary care provider, endocrinologists, mental health providers, other urologists, plastic surgeons, dermatologists, and fertility specialists. She notes that, although more attention, research, and resources have been directed towards transgender healthcare, it is still not widely available to the entire population. Thus, many patients are still seeking gender-affirming surgery in other countries, potentially exposing them to higher complication rates. Thus, she advocates for more research and advocacy in the United States for transgender patients and their medical/surgical needs.

In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Chad Ellimoottil, a Michigan Medicine urologist and Director of the U-M Telehealth Research Incubator, discuss advice and future projections for telehealth.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/rNETfY---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Chad Ellimoottil, a University of Michigan urologist and the Director of U-M Telehealth Research Incubator, discuss his advice and future projections for telehealth.Across all specialties, 15-20% of monthly medical visits are currently being conducted via telehealth. When deciding whether a consultation is appropriate for a virtual platform, Dr. Ellimoottill recommends assessing a patient’s unique situation instead of relying on their diagnosis. He emphasizes the importance of in-person visits if AUA guidelines require the physician to perform a physical exam.Next, Dr. Ellimoottil shares his tips for having a successful telehealth appointment. First, he notes that punctuality is even more important over a virtual platform, as many patients may assume they are using the virtual platform incorrectly if they do not see a provider at the scheduled time. Additionally, he encourages physicians to keep their eyes focused on the camera and dress as professionally as possible, whether it be through wearing a white coat or displaying their certifications in the background. Finally, he places great importance on asking the patient directly about their telehealth experience for suggestions on improving it. He notes that this action can greatly reduce the number of dissatisfied patients who do not show up to their scheduled visits.Furthermore, the doctors discuss the future direction of telehealth. Although he notes that interstate consultations were beneficial at the start of the pandemic, Dr. Ellimoottil acknowledges that these consultations have become very complex because of recent regulatory changes. He also commends the availability of virtual interpreters in telehealth consultations, but addresses the inaccessibility of setting up a telehealth appointment to non-English speaking patients, which has contributed to healthcare inequity during the pandemic. Both doctors agree that there remains much research and many initiatives to be carried out in order to make telehealth a possibility for indigent and elderly populations as well.Finally, the doctors discuss the impact of telehealth on physicians. Dr. Ellimoottil believes that physician satisfaction with telehealth is directly associated with their personal mindset about telehealth. Thus, telehealth may cause burnout for one provider but enhance the quality of life for another. Nevertheless, he believes that telehealth will benefit both patients and providers if it is proposed as an option to both parties.

In this episode Dr. Kumar and Dr. Bennett discuss various levels of racism found in healthcare, and share allegories of racism as outlined by Dr. Camara P. Jones, including the gardeners tale.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/Y1eaX6---SHOW NOTESIn this episode, guest host Dr. Vishal Kumar interviews Dr. Ayanna Bennett about how to train ourselves to recognize perpetuated health disparities within the medical system and how we can actively work to dismantle them.The doctors first talk about understanding racism on an institutional level, which results in a “machine” that selectively delivers better and worse aspects of healthcare to different populations. Dr. Bennett emphasizes that every disease process shows race disparities not because of inherent biological differences in racial groups, but because of unequal frequencies and quality of contact with healthcare systems.Throughout the episode, they reference the allegories of Dr. Camara Jones, a physician-epidemiologist and civil rights activist. These allegories provide a framework for discussing nature vs. nurture for health outcomes and also privilege defined as the lack of barriers to entry.In terms of actionable steps that providers can take toward reducing health inequity, Dr. Bennett encourages us to learn and engage with the communities that they serve. She advises us to be “counter-stereotypical” and show interest in patients’ lives outside of the healthcare setting. Finally, she calls us to analyze the impact that our institutions have on maintaining the health of the community as a whole, rather than solely focusing on individual patients.---RESOURCESThe Gardener’s Tale Allegory by Dr. Camara Jones:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1446334/Tedx Talk by Dr. Camara Jones:https://www.youtube.com/watch?v=GNhcY6fTyBM

We talk with Dr. Ashley Winter about the importance of educating physicians and patients on female sexual health, including common presenting symptoms and newer treatments.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/5vpkrH---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Ashley Winter discuss women’s sexual health.First, Dr. Winter explains her role as a urologist in providing hybrid sexual health consulting for men and women. Then, the doctors discuss basic sexual history intake questions for women. Although there are many screening questionnaires, Dr. Winter prefers to use the Female Sexual Function Index because it evaluates sexual desire, arousal, pain and orgasm ability. She also makes sure to ask about issues indirectly related to sex, such as lower urinary tract symptoms, recurrent UTIs, and pelvic pain.Performing a complete physical exam is important in patients presenting with sexual dysfunction. Dr. Winter explains her usual genital exam, paying close attention to any abnormalities regarding the clitoris, labia majora/minora, and vestibule. She also performs a pelvic floor exam. She does not usually order a hormone panel, but may check TSH and HbA1c to rule out diabetic neuropathy.Next, Dr. Bagrodia and Dr. Winter delve into the evaluation and management of specific sexual dysfunctions. Low libido, or hypoactive sexual desire, is a common issue for women. It can be a result of menopause, oral contraceptive use, cystectomy, postpartum concerns, vulvar disorders, selective serotonin inhibitors, history of breast/cervical cancer, or history of abuse/trauma. For patients in the last category, Dr. Winter encourages collaboration with social workers and therapists. She mentions that the American Association of Sexual Educators, Counselors, and Therapists (AASECT) is a great resource for finding these professionals. For peri/post-menopausal women, she recommends prescribing a testosterone gel. Additionally, non-hormonal treatments for low libido include flibanserin and bremelanotide.For issues regarding sexual arousal, Dr. Winter emphasizes proper education and screening for diabetes first. If arousal is inhibited because of a lack of lubrication, then correction of estrogen levels may be necessary. Estrogen supplementation, or topical/vaginal estrogen, can be used to treat problems with arousal, as well as recurrent UTIs and genitourinary syndrome of menopause (GSM). Dr. Winter notes that these low doses of estrogen preparations are unlikely to actually raise blood estrogen levels and cause systemic side effects.Finally, in patients who complain of pain with sex, Dr. Winter recommends education about lubricants and pelvic floor physical therapy.---RESOURCESAASECT:https://www.aasect.org/

Dr. Amit Patel, Dr. Ranko Miocinovic, and Dr. Jose Silva discuss focal therapy for prostate cancer and share their experiences with the NanoKnife System from AngioDynamics. Listen to the full episode to hear more about prostate biopsy techniques, benefits of the the NanoKnife System, surgical tips for a successful NanoKnife focal ablation, and future directions for incorporating focal ablation into prostate cancer guidelines.---CHECK OUT OUR SPONSORAngioDynamics NanoKnifehttps://www.angiodynamics.com/product/nanoknife-system/---SHOW NOTESIn this episode of BackTable Urology, Dr. Jose Silva discusses focal ablation for prostate cancer. He invites Dr. Amit Patel and Dr. Ranko Miocinovic to share their experiences with focal ablation using the Nanoknife System from AngioDynamics.If prostate cancer is suspected due to an elevated PSA and a suspicious MRI scan, a prostate biopsy is necessary to confirm the diagnosis. Both doctors prefer to perform their biopsies through a transperitoneal approach in an office setting with local anesthesia or ProNox. If a positive biopsy for prostate cancer is obtained, additional imaging to stage the lesion and radiation oncology is helpful in prognosing and treating the cancer, respectively.Focal ablation is a new minimally invasive surgical technique that allows destruction of the cancerous part of the prostate gland without having to destroy or remove the entire gland. Intermediate risk prostate tumors yield the best results with focal ablation, specifically in the context of preventing post-operative sexual and voiding dysfunction. Once the focal ablation sensors localize the tumor in the gland, a variety of ablation techniques can be utilized. Both Dr. Patel and Dr. Miocinovic use the NanoKnife System, an irreversible electroporation system that uses an electric current to break up cell membranes.Proponents of the NanoKnife System believe that it causes less peripheral destruction because it preserves connective tissue and minimizes destruction of nerves. Evidence also suggests that focal ablation using the NanoKnife system lowers the rate of scar tissue formation thereby lowering the rate of erectile dysfunction, improves protection of the urethra, causes less swelling of the prostate, lowers the risk of post-operative retention, and requires shorter operating time. Finally, this method of ablation allows for consequent follow up surgeries if necessary.Next, the doctors discuss NanoKnife procedural techniques, such as surgical approaches, and using ultrasound-guided probe placement. When using this type of ablation, it is important to monitor the wattage of the NanoKnife carefully in order to prevent the ablation from causing thermal destruction. Finally, both doctors discuss the future possibility of adding focal ablation procedures as a first line therapy to the AUA guidelines on treating prostate cancer.

Dr. Philippe Spiess from Moffitt Cancer Center discusses surgical and medical management of penile cancer. Listen now to hear more about punch biopsy techniques, surgical resection and lymph node dissection techniques, growing role of topical chemotherapy, importance of multidisciplinary tumor boards.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/75m8Ku---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Phillipe Spiess from Moffitt Cancer Center discuss surgical and medical management of penile cancer.When examining a patient for potential penile cancer, it is important to obtain a thorough history to classify the disease and perform a complete physical exam to describe the characteristics of the lesions. Frequently, a biopsy will be performed to confirm the malignancy of the lesion. Dr. Spiess prefers to use topical anesthesia over general anesthesia in his punch biopsies and sends the sample to specialized genitourinary pathologists. Imaging also reveals the presence and extent of metastatic spread of penile cancer. MRI scans are the best way to visualize the inguinal lymph nodes, but PET scans may also be used in multimodal imaging.Surgical intervention for penile cancer depends on the tumor stage. For T0 tumors, or carcinoma in situ, topical chemotherapy is preferred. However, excision surgery, Mohs surgery, or laser ablation can also be performed for very small lesions. In general, for excision surgeries, urologists should achieve a tumor margin greater than 1 mm and send skin, deep, and urethral margin samples to GU pathology for analysis. For more aggressive and advanced T2/3 tumors, the inguinal lymph nodes should be excised at same time as penile resection in healthy patients. However, if an infected, fungating primary tumor is observed, it should be resected first before lymph node excision. Dr. Spiess recommends that urologists choose the surgical approach that they are most comfortable with performing, whether it be open or robotic. Additionally, the preoperative state of a patient is crucial. Diabetes, nutrition, smoking cessation, and other factors should be optimized to ensure favorable outcomes. Post operatively, surgical staples should stay in until the patient is completely healed, and patients should be encouraged to wear compression stockings.The effectiveness of radiation therapy depends on the characteristics of individual tumors. Penile cancer tumors are usually radioresistant but radiation has been shown to limit retroperitoneal masses and are effective in shrinking HIV-positive tumors. Generally, radiation therapy provides symptomatic management but is not curative.The final treatment option discussed was a total or partial penectomy. Total penectomy should only be reserved as the last resort after exhausting other options. Instead, a partial penectomy is preferred, as maximal tissue sparing can maintain feelings of masculinity and gender association and preserve mental health.---RESOURCESInPACT Trial: https://clinicaltrials.gov/ct2/show/NCT02305654GSRGT: https://www.gsrgt.com/

Dr. Aditya Bagrodia and Dr. Geo Espinosa discuss holistic and integrative approaches to prostate cancer.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/D2CTDN---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Geo Espinosa discuss a holistic and integrative approach to preventing and treating prostate cancer. They delve into four areas of well-being: diet, sleep, exercise, and nutraceuticals/supplements.In a low-risk patient on active surveillance, Dr. Espinosa recommends a Mediterranean diet that includes fish, plants, and whole grains. He notes that intermittent fasting may be helpful but warns against a ketogenic diet, as prostate cancer relies on lipid metabolism. Additionally, because sleep strengthens the immune system and reduces chronic inflammation, he notes that patients should limit their screen time before bed and get at least six to eight hours of quality sleep every night. In terms of exercise, committing to four to six hours of High-Intensity Interval Training (HIIT) and strength resistance a week has been proven to cause regression of prostate cancer cells. Finally, some anti-cancer supplements he recommends are: curcumin, Vitamin D, Vitamin E, fish oil, zinc, selenium, and green tea extract (EGCG).In patients with advanced prostate cancer, he notes that all his prior recommendations should be followed even more closely. Patients with prostate cancer must adhere to stricter diets and prioritize weight training even more, especially if they are on hormone replacement therapy. Additionally in hormone replacement therapy patients, acupuncture or black cohosh can alleviate hot flashes, and magnesium can be prescribed for sleep optimization.

Emergency medicine physician and podcast founder Dr. Gita Pensa and our co-hosts Dr. Chris Beck and Dr. Aaron Fritts discuss methods of navigating malpractice lawsuits, maintaining professional identity, and prioritizing mental health.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/Mfo9EF---SHOW NOTESIn this episode, emergency medicine physician and podcast founder Dr. Gita Pensa and our co-hosts Dr. Chris Beck and Dr. Aaron Fritts discuss methods of navigating malpractice lawsuits, maintaining professional identity, and prioritizing mental health.Dr. Pensa starts by outlining her personal experience with a twelve year-long malpractice suit, which inspired her to start her own podcast, “Doctors and Litigation: The L Word.” She says that despite the fact that most physicians will face lawsuits in their career, there is a current lack of physician-centered educational resources over malpractice litigation. To combat this, she encourages physicians to share their experiences and learn from one another.The doctors walk through major steps of a lawsuit, starting with the process of getting served with papers. Dr. Pensa emphasizes that it is important to recognize that this step could be used as the first tactical move in a lawsuit and designed to make physicians feel uneasy. The next step after getting served should always be to call the insurance carrier and have them start the process of initiating a claim. Dr. Pensa strongly advises against accessing or editing patient charts after getting served, as these actions are recorded in the EMR and can be used against the physician. Finally, Dr. Pensa discusses the process of deposition and how it serves as both a fact-finding mission and a strategic way to distort a physician’s words. She recommends practicing with lawyers to answer deposition questions clearly and concisely.Throughout the episode, the doctors highlight the importance of maintaining one’s mental health during the litigation process. They advise listeners to seek support from friends, family, colleagues, and professionals, as long as the specific details of the case are not discussed. To close, Dr. Pensa reminds the audience that malpractice lawsuits usually have financial motivations, and they may not be an accurate representation of a physician’s competence or compassion for patients.---RESOURCESDoctors and Litigation: The L Word: https://doctorsandlitigation.com/“The Defendant” by Sarah Charles: https://www.amazon.com/Defendant-Sarah-Charles/dp/0394746635“Adverse Events, Stress, and Litigation” by Sarah Charles: https://www.amazon.com/Adverse-Events-Stress-Litigation-Physicians/dp/0195171489“How to Survive a Medical Malpractice Lawsuit” by Ilene Brenner: https://www.amazon.com/How-Survive-Medical-Malpractice-Lawsuit-ebook/dp/B005C65X2M“When Good Doctors Get Sued” by Angela Dodge and Steven Fitzer: https://www.amazon.com/When-Good-Doctors-Get-Sued/dp/0977751104

Dr. Phillip Pierorazio from Penn Urology discusses the management of small renal masses. Listen to the full episode to hear about imaging modalities for small renal masses, distinguishing between cysts and solid tumors, ablation, enucleation, partial nephrectomy, and special considerations for von Hippel-Landau (VHL) patients.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/hdRe9f---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Phil Pierorazio discuss the management of small renal masses.Most small renal masses found incidentally through imaging from another cancer workup or an injury, and most small renal masses are not cancer. It is important to take into account the patient’s family and social history, especially if there is a family history of renal cell carcinoma and renal disorders. Dr. Pierorazio looks specifically for flank pain, hematuria, and a history of smoking because these are all risk factors for cancerous small renal masses. In every patient, he orders a basic metabolic panel and a urodynamic analysis in order to observe renal function. Because CT scans are easily reproducible and interpreted, it is his first choice imaging modality. He also orders a chest x-ray, as pulmonary metastasis is common in renal cancer.Active surveillance is a reasonable option once a small renal mass under 3 centimeters is discovered. Before deciding to put a patient on active surveillance as opposed to surgical intervention, Dr. Pierorazio assesses patient age, life expectancy and related comorbidities, and tumor size. However, tumors smaller than 3 centimeters should be removed if there is a possibility that the masses are caused by hereditary, aggressive cancers. High suspicion for these cancers should be raised in young women with a history of hysterectomies for fibroids. Another distinction that must be made is the difference between benign cysts and solid masses. Renal tumors are often not always completely solid, so they may masquerade as cysts. In order to improve the accuracy of the diagnosis, it is important to confirm the mass characteristics with multiple modalities.A biopsy may be needed if the renal mass grows above 3 centimeters or if the patient is wanting more information. Additionally, a biopsy can help a surgeon decide whether a partial or radical nephrectomy is a better option. There are many different surgical options following the kidney biopsy: enucleation, nephrectomy, and ablation are three of the most common options. Surgical treatments can be sorted into two different types: partial nephrectomy and nephron-sparing options that maximize preservation of renal parenchyma. If a tumor is larger than 3 centimeters and well-encapsulated, Dr. Pierorazio favors enucleation. On the other hand, surgery may be contraindicated in older patients with multiple comorbidities because they are unlikely to progress to end-stage renal disease. For this reason, Dr. Pierorazio emphasizes the importance of listening to patients’ fears and desires, as both nephrectomy and dialysis can result in different risks and complications.---RESOURCESAUA Guidelines for Renal Masses and Localized Renal Cancer:https://www.auanet.org/guidelines/guidelines/renal-cancer-renal-mass-and-localized-renal-cancer-guideline