From our anonymous insider…
A suave 35-year-old male urologist introduces diseases of the external genitalia, testicles, and prostate. A urologist completes a four-year residency with a one-year internship year, typically in general surgery. “In medical school you are not going to get much exposure to urology because we are a surgical subspecialty. If you are at all interested, come shadow us for a day. You can shadow an academic urologist or a community urologist.” Gigolo Giorgio: “That’s quite exciting. You become a specialized surgeon in five years.” (In a surgical field other than urology, six or seven years is more typical, plus, of course, four years of medical school.)
Cryptorchidism is failure of the testicle to descend from its embryological origin in the abdomen. If the testicle is not descended, it will involute (curls up) because the warmer temperature is too high for spermatogenesis (production of sperm). “We wait until age two before we surgically descend the testicle. Most undescended testicles will descend on their own in the first year. If it doesn’t, the child still won’t remember anything if he gets surgery at two. The mother bears the brunt.” Even if the testicle undergoes orchiopexy (peg it to the scrotum), there is still an increased risk of testicular cancer. “If you see cryptorchidism, immediately think testicular cancer on board questions.”
After skin malignancies, testicular cancer is the most common malignancy in 15-35 year old males. “Testicular cancer is four times more prevalent in white than in African Americans. I have never seen a black male with testicular cancer.” The mortality of testicular cancer has decreased substantially over the past two decades. “Testicular cancer is completely curable with less than a five-percent mortality rate. We hit it strong and fast, some of the highest levels of chemo, but we get it.” (Younger patients can handle higher doses of chemo.) He emphasized how every testicular mass should be considered malignant as opposed to ovarian masses that are commonly benign. We learned a common board stumper: a 20-year-old male presents for a left testicular mass. After an ultrasound confirms a mass, what is the next step? Answer: orchiectomy (removal of the testicle). “Never biopsy a testicular mass,” said our urologist. The testicles drain into a different lymph system than the scrotum. “If you shoot a needle through the scrotum, you can potentially seed a whole new lymph basin [with cancer].”
We spent the next two days focusing on the “controversial” prostate, a gland that wraps around the urethra and secretes the majority of the ejaculate fluid. Prostatitis is painful inflammation of the prostate, typically from an infection, but also from pressure. “Always ask the guy if he is a biker or motorcyclist.”
The urologist continued: “Every guy over 50 will have BPH [benign prostate hypertrophy] with varying degrees of urinary symptoms. BPH is one of the most under recognized, easily treatable health issues.”
Persevering Pete: “What could internists and family medicine Docs do better?” Our lecturer: “I think BPH screening should be part of the standard wellness check. So many 50-60 year olds have hesitancy, difficulty starting and inability to unload. Most men with BPH get accustomed to it as it is a slow decline in function, not abrupt. We have several lines of drug treatment. We used to have to perform surgery, which is now reserved for the severe refractory cases.”
Our patient case: Robert, a comedic 5’4″ 68-year-old recently retired Ob/Gyn, presents to the urology clinic after a routine wellness check discovers an elevated prostate specific antigen (PSA), a commonly used screening blood test for a protein secreted by the prostate. Robert denies dysuria, urgency, hesitancy, dribbling or erectile dysfunction. The internist was unable to palpate any prostate mass on DRE, but Robert is referred to a urologist who palpates a small nodule on the left lobule. Needle biopsy reveals an intermediate-grade prostate carcinoma. Contrast MRI of the abdomen and pelvis does not show any nodal involvement, and a PET-CT does not show any metastatic bone lesions. (First Aid: “Prostate Cancer loves the bone.”) Robert underwent radical prostatectomy with clear margins.
Robert: “The diagnosis caught us completely off guard. My wife and I were preparing for our long-awaited retirement entertaining all sorts of crazy ideas. The Caribbean, Florida, Wyoming, who knows where we would have ended up.” For 15 minutes, we discussed how he determined to get surgery. “I had fantastic doctors. I went into surgery knowing it was the right decision, even with the potential side effects. I had 2-3 years, now I am cured. I will die of my heart, not my prostate. I live a great life. I fish, enjoy walks with my wife, and celebrate being a grandfather.”
Straight-Shooter Sally: “Are you able to have sex?” The nerves that control blood flow to the penis for an erection travel travel through the prostate into the penis. Invasive prostate adenocarcinoma can invade the nerve sheaths. The radical prostatectomy can damage these nerves as the cancer tissue is removed. Robert replied, “Oh, yes. Finally, someone asked. Last year it was the very first question from the class. My wife and I had sex last night! After surgery. I had urinary incontinence and erectile dysfunction. The erectile dysfunction improved over six to seven months. My urinary incontinence has still not returned to normal, but it is improving. I stopped wearing adult diapers about six months ago.”
Gigolo Giorgio: “Does sex feel the same?” Robert replied, “Mostly. As you should know, I do not ejaculate. I still orgasm, but nothing comes out.” Classmates turned to each other. The urologist, sensing the general ignorance and confusion, explained that radical prostatectomy removes of the prostate and seminal vesicles, and ties the vas deferens.
A discussion ensued regarding the new USPTF [US Preventive Services Task Force, government-funded panel of physicians] recommendation against PSA screening? Our urologist: “I still recommend males over 50 get annual screening involving a PSA blood test and DRE [digital rectal exam]. I understand that it is not a specific test, but I see so many patients diagnosed with prostate cancer prior to metastasis. The screening saves their lives. It is the best we have.”
The urologist continued: “The challenge with prostate cancer is stratifying risk. 1 in 7 males will be diagnosed with prostate cancer… probably 75 percent of males by age 75 have prostate cancer. Most people will never be affected by their prostate cancer, but we do not have an effective screening method. Most patients present with metastatic disease when it is too late to treat. I am asking each and everyone of you to discover a better way to detect high-grade prostatic cancer. There is some hope with the new bound/unbound PSA ratio test. More and more doctor offices are offering this as a second test if an individual has an elevated PSA.”
In the small group discussions Type-A Anita expressed her displeasure that we spent much of the week on prostate cancer and male reproductive system. “It is not that serious or complicated compared to other GU issues. Typical male-dominated field.” A female group-member: “That is just because you hate men, Anita.” Anita: “Just the bad ones.”
After hours, Anita shared a “Showing Up For Racial Justice” Facebook group’s post regarding Roy Moore’s Alabama senatorial election loss:
@ white people: we need to get serious about changing minds and voting patterns. White people overwhelmingly made a disgusting choice in Alabama, and Jones’ victory was because of black voters. How long is this party going to demand the absolute fucking most from people of color and not address the real fucking problem: white people.
Also @ white women what the actual fuck.
Our Dean lead a mandatory 45-minute session to review an LCME-required survey that our class completed back in May. Highlights of the survey: 15 percent fewer students in our class report they enjoy being a medical student compared to the class of 2010. Students are surprised that only 10 percent of the class felt there was unnecessary competition amongst students. The biggest issue continues to be “work/life balance” (but nobody has a job?). Our Dean: “We created an entire department [two years ago] to improve these issues. Stay tuned for more wellness events.”
Most of the session regarded mistreatment among students and between faculty and students. The Dean just returned from the annual American Association of Medical Colleges [AAMC] meeting in Boston: “Three of the four lectures were on mistreatment in the learning environment.” He shared a PowerPoint with the LCME’s definition of mistreatment, which starts with “a behavior that shows disrespect for the dignity of others.” Examples include language that “can be perceived as” rude, sarcastic, loud or offensive.
Our school has a committee composed of two student representatives from each grade, three deans and rotating faculty that meet monthly to respond to anonymous reports of mistreatment. The accuser need never be involved unless more information is needed. Following the committee’s investigation, disciplinary action has included removal of a faculty member’s appointment.
After class, Luke, Mischievous Mary, Persevering Pete, Jane, her trauma nurse sister and I go to our weekly Thursday beers-and-burgers spot. Lanky Luke: “A student could anonymously report a perceived insult from a resident or attending, which would immediately kick off a multi-month investigation. You don’t see an issue when people feel entitled to not be offended?” After a 5-second silence, he added, “I am referring to mistreatment outside of sexual conduct. I agree you need a channel to address sexual harassment.”
Jane’s sister: “Almost every unmarried nurse on my floor is romantically engaged with another nurse or resident. Most of my coworkers who have gotten married found their spouse through work. There is nothing wrong with that. It just should not be someone you work directly with like your charge nurse, attending, subordinate, etc..”
Mary: “As a woman, I kind of take being flirted with as a norm. It’s not good or bad. It’s just life. And it serves a purpose. It lets you know who’s interested in whom. Pretty quickly you can tell if someone is interested or not.
Jane’s sister: “I flirt all the time with this Colombian critical care resident who passed through our floor. We went on a few casual dates. If you did not know him, some women would probably think what he is doing is inappropriate. His English is good, but he does not understand colloquial sayings and expressions. We tricked him to say dirty words to the new nurses. It was hilarious. In this day and age he could get fired for that. There needs to be a mechanism to report if something is inappropriate without that accused individual getting terminated. They should be given a warning.”
Mary: “Sorry, but someone who cannot figure out how NOT to sexual harrass someone is an idiot and should be fired.”
Jane’s sister: “All I am saying is there are going to be a lot fewer happy couples because of this culture.”
Pete changed the subject. Pete and girlfriend, an M3 who competes in bodybuilding competitions, co-signed an 18-month lease on an expensive apartment. She was unfaithful to him on an “away rotation” (extended interview at a different hospital system where one is interested in applying for residency). He broke up with her, but she will neither move out nor approve his removal from the lease. “I either have to move out and pay for two apartments, or stay living in misery. What do I do? Also, her brother is a lawyer and is not afraid to sue me.” [Editor: Note that, as marriage rates decline, there is a trend to allow plaintiffs to sue in family court after living with someone for at least two years (e.g., in British Columbia and Scotland). Pete can think of the extra rent as alimony.]
Later that evening, Jane and I attend an optional heart workshop led by a 55-year-old cardiothoracic (CT) surgeon and his fellow. The surgeon was crude and direct, laying frequent F-bombs. Anita described him as a “Dick”. Jane asked him about the lifestyle of a CT surgeon: “My residency is nothing like surgical residency is now. We would be 32 hours on, 8 hours off. while being on call every single evening — that meant we were at the hospital every single day. I moved into the hospital for three months on one rotation. I did not see my wife for weeks on end. I learned many years later my wife went to therapy. We both did not think we would make it through my residency.” She divorced him five years ago. He concluded: “There are many things I regret. I should have tried harder in my marriage. Despite this, I would do it all again.” CT surgery plus divorce apparently does not yield financial security: he wasn’t able to pay off his student loans until age 50. [Editor: She might not have divorced him if they’d lived in Nevada, Texas, or Germany, where the only reliable way to spend a surgeon’s income is to stay married to the surgeon; see Real World Divorce.]
He is a vocal critic of the new CT residencies, which don’t require starting in general surgery. “First, how do you know you want to be a CT surgeon in medical school? You don’t know anything. I did not know I wanted to be a heart surgeon until my fourth-year in residency. Second, I do not trust the new graduates of these programs. We are hiring one now, and all my partners will treat him as a fellow. He will not be ready for the independence of an attending. He did not get a solid foundation in general surgery, or enough surgical hours.”
Friday morning begins with a 40-year-old internist teaching how to conduct a sexual history. She starts with an explanation of the CDCs “6Ps”: Partners, Practices, Protection against STDS, Prior history of STDs, and Protection against Pregnancy. “Patients now expect you to ask about sexual history. 20 years ago, it was a little offensive.”
She had been to the same recent AAMC conference as our dean and attended a session specifically on the subject of how to teach taking a sexual history. She read aloud from a copied AAMC slide: “Cultural competency, the understanding of and respect for the cultures, traditions and practices of a community, requires cultural humility. To obtain cultural humility we must undergo self reflection and self-critique as lifelong learners and providers.”
We learned about the difference between sexual behavior and sexual identity. “Sexual behavior does not always match up to sexual identity. You need to use the correct terminology to keep the dialogue going.” We also were instructed to use precise terminology when charting: not “patient is gay” [sexual identity], but “patient engages in sex with men” [practice or behavior].
Our lecturer cautions against stereotyping and racism: “There is a high risk of marginalization due to sexual history taking.” Patients who feel marginalized by their healthcare workers experience increased risk of mental health issues, substance abuse, and unhealthy lifestyle. She explained that black males and males under 28 are the least likely groups to disclose to a healthcare provider they engage in same-sex sexual activities.
Surfer Saul, a laid-back Southern Californian, commented on his experience working in a free Los Angeles clinic. “I find it helpful to use terminology the patients use. For example, pussy for vagina, dick for penis, blowing for oral sex, rimming.” The class went silent, while a favorite 45-year-old former Army doctor sitting in front of Saul slammed his head to the table trying to suppress his laughter. The female doctor acknowledged his comment, and said “Yes” but maybe put it in a clinical perspective. After class, Gigolo Giorgio congratulated Saul on the number of profane words used.
At lunch, Lanky Luke objects to the standard of asking every patient where he or she falls on the LGBTQIA spectrum. “It seems offensive if the patient is an elderly woman. I would like to use my discretion.” Jane joked: “So you are confident enough in your Gadar?” Type-A Anita: “You need to ask every patient, period. You wouldn’t not ask about IV drug use… If only you knew what it was like to be in the minority for a second.” [Anita herself is a white, native-born, and suburban-reared.]
The conversation is diffused when Wild Willow shares Ackanator, a phone app that asks questions until it can guess a user’s chosen fictional character. “I stayed up all night trying to stump it. It’s full proof.” Students volunteered two characters: Porkins and a Dragon Ball Z character. We were unable to stump it. Jane: “I want to know its top pick at every question. What is its differential?” Another student added, “Stop doing that! You are making it smarter. It’ll take our jobs.”
I attend an optional evening workshop on opioid abuse led by two EM physicians in their mid-thirties. We had been cautioned by the CT surgeon that surgery was not a likely path to driving a sports car on three-day weekends; these two guys are both rumored to drive fancy sports cars. Physician A: “The CDC in 2002 issued guidance to err on the side of the patient. Treat pain. In 2012, the CDC released really a groundbreaking, earth-shattering statement to every physician in the country. It said, ‘We messed up.’ When does the government ever say that? Now the official doctrine is that every opioid prescription has the potential to be addictive.” Physician B: “This has completely changed our practice.” (Nobody asked why doctors en masse were listening to the CDC to begin with.)
Physician A described how his brother-in-law is struggling with opioid addiction and has been in and out of rehab. “After rehab he was sober for three months. It really seemed he was turning his life around. He was bored one night, and called up an old friend to hang out. Another friend came over and asked if they wanted to shoot up. My brother-in-law was not seeking. You have to realize how difficult staying sober is. You have to give everything up, start fresh. Delete everyone’s phone number because it has become so ingrained in the whole community. He ODed that evening, was saved by Narcan [naloxone], and now is back in rehab.”
What can we do to help an addict in the ED? Both physicians chuckled. Physician B: “It depends how jaded you are. Frankly, not much.” Physician A: “I agree. A patient has to hit rock bottom before waking up. That usually is losing a job, losing a family member, almost losing his or her life. Families blame themselves when in reality they are mostly helpless. This is a disease.” Physician B: “You still have to try. I’ve had one patient come back after six months to explain that my talk in the ED behind curtains turned his life around. He went to rehab because of it. The patients that respond are never those you expect.” We were trained and supplied with two uses of Narcan.
Facebook excerpt of the week: Anita shares TIME magazine’s cover page of women who have accused various men of sexual misconduct. She adds “A fabulous way to highlight an awesome movement and the perfect antithesis to the sexual predator-in-chief’s tweet vomits. #MeToo”
Statistics for the week… Study: 14 hours. Sleep: 6 hours/night; Fun: 1 night. Example fun: we celebrate Jane’s birthday at Luke and his wife Samantha’s house. Luke and I drive to Lowes the previous weekend in his pick-up truck and built a fire pit. Sarcastic Samantha, finishing her Ob/Gyn PA rotation in a rough urban neighborhood, recounted her on-the-ground experience with the importance of conducting a thorough sexual history. Two days ago she saw a couple who came in due to infertility. “After ten minutes, my preceptor [also a PA] and I were concerned they were not having correct sexual intercourse. We had to explain to the couple that you do not get pregnant by swallowing. That’s not how you do it.” Luke: “I wonder if you should have told them.” Jane: “That’s eugenics!” Samantha described her disillusionment from the six week experience: “A mother of four from three different fathers came in for prenatal care of her soon to be fifth child. One child was born addicted to heroin. All she cared about was getting her government check in the mail for this additional child. It made me sick to my stomach imagining how these children are going to grow up. How does my preceptor deal with this everyday?” [Editor: If the patients are covered by Medicaid or Obamacare, the preceptor is also getting checks from the government!]