I am in the OR with Coach K on Monday and his partner Comedian Tom on Tuesday. I see three TURPs (transurethral resection of the prostate) on each OR day. After the patient is under general anesthesia (anesthesiologist chooses between endotracheal tube versus LMA) and draped, Coach K inserts the rigid cystoscope into the urethra. He points out several anatomical landmarks in the urethra and bladder on the screen. He points on the screen to the verumontanum, a subtle elevation of tissue identifying where the ejaculatory ducts enter. “As long as we remove tissue distal to the verumontanum, the patient should recover full control of the bladder. The external urethral sphincter and levator ani (pelvic floor) are just proximal to this landmark.”
He inspects the bladder, there are trabeculations and several indentations into the bladder surface. I ask why they’re there. “The bladder, like any muscle, hypertrophies from the increased pressure trying to push urine through the prostate obstruction.” The diverticula look exactly the same as a patient with diverticula of the colon. He withdraws the scope to the prostatic urethra, inserts an electrocautery device, and uses its 5mm-diameter semicircular wire to cut through the urethra and prostate to open the channel. As he shaves the prostate, a few bleeders are seen piercing through the clear water. He cauterizes the bleeding vessels. “The prostate is a poorly perfused organ so there isn’t that much bleeding when you cut into it; these bleeders are perforators.”
The nurse periodically hangs another bag of 7.5 percent glycine on a post near the OR table. A tube flows down to the scope to keep the bladder distended so we can see the entire prostate. Coach K explains that we use glycine because the electrocautery device would not work in saline. “The current would not be discharged to the local targeted tissue, but instead be conducted through the salt water. Glycine does not conduct so the path of least resistance is to whatever tissue is touching the wire. If we are just scoping the patient we use saline. Pure water would work, but it would kill cells from the osmotic pressure gradient. There is a small risk of hyponatremia [low blood sodium] after these procedures which is why we try to keep the irrigation time under 1 hour.”
There was a noticeable contrast between Coach K’s technical skills in the TURP versus Comedian Tom. Coach K carved out the prostate creating an elegant circular channel that was all cauterized with no bleeders. I felt Tom struggled to get good visualization during the procedure because he couldn’t completely coagulate off the bleeders distorting the picture. He didn’t “butcher” the patient, but it wasn’t as technically satisfying. I couldn’t tell if the channel was circular or how much he removed at the end. His patients still get benefits but I wonder if they have different 10-year outcomes. Coach K: “90 percent of patients at 10 years after TURP do not have any obstructive symptoms. 10 percent get regrowth that requires either medical management or re-operation.”
Although these doctors operate at our hospital, they are partners in their own practice. “Private practice is hard. There is a reason it’s a dying breed,” Coach K explains. “We are clinging to paper charts for as long as we can. EMRs are so expensive for a small practice such as ours, but we also get penalized by Medicare for not having meaningful use.” He picks up a patient’s folder. “This patient was admitted for an obstructing stone. I was called in and removed the stone. Here is the fax from the stay. Is this meaningful?” He hands me a 25-page print out from our hospital’s Epic EMR for the two day admission. The first five pages are demographic information, mostly blank (e.g., address 1 filled in, addresses 2 and 3 unfilled). There are numerous nursing notes, a CT report with paragraphs describing how radiation exposure was minimized, and his operative note. “This is all checking boxes. You cannot find actionable information.” When patients come to his private office for a follow-up after hospitalization he ends up throwing nearly their entire hospital record into the protected health information (PHI) shredder bin.
Another assault on his income is that our hospital has gradually bought up clinics and practices to form a regional health system in which providers are encouraged to refer to specialists within the system. The private practice doctors end up with the worst parts of working for the hospital, e.g., taking call, and none of the benefits. The private partners are also at a disadvantage when purchasing supplies, sometimes resorting to Amazon for scarce items.
[Editor: this was before the “supply chain” catastrophes that started in 2020]
Our last patient is a 73-year-old self-deprecating truck driver who walks in with a USA 45 hat. He has classic symptoms for BPH and an elevated PSA. He introduces himself, “I’m all healthy doc, except for my pee-pee.” The nurse measures a post void residual of 490 mL (this is pretty close to what would be considered full in a healthy individual; less than 50 mL is considered normal). He explains to me that he drinks 2 jugs of coffee to stay awake on his daily 8-hour drive. He sleeps with one of the cups due to fear of urgency and leakage. We start him on tamsulosin, and schedule a one-month follow up appointment.
One of our classmates just matched into urology. Coach K helped mentor him so is quite proud. My classmates meet at Buff Bri’s house for a penis celebration. Sarcastic Sally gets decorations from a bachelorette party store, including penis hats and straws. Mischievous Mary brings assorted nuts for snacking. We reflect on senioritis. Pinterest Penelope summarizes: “I have instagram and snap chat to deal with. I can’t be at the hospital.” Mary shares her latest experience: “I was doing an APR (abdominal peritoneal resection, removal of the rectum and anus) with a jewish colorectal surgeon and a resident. The Poop Doc was across from me, while the resident was in between the legs struggling to remove the rectum through the anus with all his might. Poop Doc: ‘You can help the resident by pushing on the abdomen from above.’ As I do this, the rectum shoots out with liquid poop, which seeps down the resident’s gown. The resident exclaims, ‘It’s in my socks!’ Poop Doc, ‘Oy vey.'”
Statistics for the week… Study: 4 hours. Sleep: 7 hours/night; Fun: 1 night. Penis party.
The rest of the book: http://fifthchance.com/MedicalSchool2020
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