There is stable trend in the US to pay physicians based on their "productivity".  That has become a word that elicits a reaction of nausea amongst many physicians these days.  I find this among the worst ways a compensation plan could have been developed.  It basically took the old "fee for service" plan and morphed it so that instead of directly getting dollars for your "work" you get a number attached to it - an "RVU".  Hospital administrators then decide how much money to give you per RVU which then determines how much money you earn in any given year.  So if you treat more patients you make more money.  And by corollary, if you spend the exact same amount of time in a year with patients but see fewer and spend more time, you earn less money.  See the problem?  

Let me start by saying there is no "perfect system", at least that I know of.  And I don't have all the answers.  My area of expertise has never really been in healthcare administration.  That said, it seems fairly obvious to me that the near national adoption of a system that pays doctors based on how many patients they can see in a day and how many surgeries they can perform during the year has some pretty obvious and potentially serious pitfalls.  So much so that the only thing that should really surprise us is that there has not been more of an outcry against this system already.  

If a doctor wants to bring home more money, he or she then needs to see more patients and/or operate on more patients.  Let's all remember that doctors are also patients.  I want what my patients want - for my doctor or surgeon to spend time with me, to explain things clearly, to make me feel comfortable with whatever decision is being made, etc.  To the credit of my profession, I think that is still what happens most times ... but it is happening in spite of and not because of the system in place.  And I'm sure there are instances where this is not always the case.  

​Of course I'm biased, but I think physicians should be well compensated.  But compensation should come based on experience, patient care, value to the community and hospital you serve, etc.  It should not be tied directly to squeezing in as many patients in a day as humanly possible.  There's a big difference between quantity and quality of work.  A physician that does a good job and takes great care of patients is a better physician than one who rushes through more patients in a day in a less thorough fashion.  There are doctors who are supremely efficient and can see a high volume of patients AND do great work.  Fantastic, pay them more.  But those doctors should be obvious to any good healthcare system and they should simply have a higher base salary.  

Healthcare, I think, is poised to undergo major changes legislatively over the next few decades.  My hope is that whatever system is ultimately reached is one that pays physicians fairly and takes the emphasis off of how many people we treat.  Pay a fair salary and get the focus back on quality of patient care instead of quantity.  

Our new space is now up and running.  We have both renovated our existing space but also increased our capacity by about 30%.  We now have 3 brand new and spacious procedure rooms, additional exam rooms, and brand new equipment.  Personally, I have a new office which was decorated / organized by SOLD Home Organizers (thanks Christine!).  Patient feedback has been overwhelmingly positive for our new digs.  It certainly provides some breathing room as we continue to grow and expand as the premier provider of Urologic services in Eastern Connecticut.  Speaking of which, we have a new and experienced doc joining in December, 2018 - more on that to come later.

So come and check out the new office!  As always, we remain conveniently located in medical office office building which is attached to Backus hospital.  

Our office has grown cramped over the years and it is time for some updating!  We have acquired the empty office space adjacent to ours so not only will this be a modernizing renovation - it will also be a substantial expansion.  I am very excited to begin this process and the architectural designs are spectacular.  Everyone in my office is giddy with excitement to have this process finally underway.  However ... please bare with us as we go through this process.  There will be some daytime work being done and like any renovation project, it gets worse before it gets better.  We will be putting an architectural rendering in the waiting room.  Hopefully the renovations will go quickly and we will be in our new space before we know it!

We are all familiar with the use of Botox (botulinum toxin) in cosmetic surgery.  What is less well known is that this same treatment can and is used effectively for bladder conditions.  For Urological conditions, Botox was originally approved as a treatment option for "neurogenic bladder".  This is when the bladder is overactive, resulting in severe urinary frequency, urgency, and often incontinence, as a result of a neurological process.  This includes conditions such as multiple sclerosis, stroke, Parkinson's syndrome, and spinal cord injury, to name just a few.  It is now also approved for use in the treatment of what we call "idiopathic" overactive bladder.  This simply refers to causes that are not neurological.  Expanding the indications for Botox use has resulted in a significant increase in the number of people eligible for this form of treatment.

Botox works by paralyzing the muscles of the bladder wall.  This results in less frequent and severe bladder contractions.  It is a great option to have available for patients who have bothersome bladder symptoms and have not had success with medications for overactive bladder.  The most common side effect is about a one in twenty rate of urinary retention.  This is typically a short lived problem but may result in the need to have a catheter placed.  When considering this type of treatment, it is important to have a full discussion of the possible risks with your Urologist.

We know that overactive bladder (OAB) is an extremely common medical condition.  What is important for patients with OAB to know is that treatment options exist.  If this applies to you, talk to your Urologist or find a qualified Botox specialist near you by clicking here.

Vasectomy is one of the most common surgical procedures performed in the United States each year.  In total, about 600,000 are done annually.  Most of these are done by Urologists nowadays although traditionally the workload was shared with general surgeons and primary care physicians.  

Before having this procedure, all men must be sure that they are done having or do not ever want to have children.  The reason for this is simply that a vasectomy is meant to be a permanent means of male sterilization.  While we can do vasectomy reversals, these can be costly procedures which result in successful pregnancies in only about one half of cases.  The bottom line - make sure you and your partner (if you have one) do not want any more children... ever!

Potential vasectomy patients should know that there is a failure rate of around 1 in 1,000 to 1 in 2,000.  All men should have a negative post vasectomy semen analysis prior to commencing with unprotected intercourse.  Men also have the option of having a secondary sample checked as well, which can be done at any point after the first collection, even years later for those that just want to be sure.  Current AUA guidelines recommend that only a single negative sample (defined as fewer than 100,000 non moving sperm) needs to be collected, but it is very very important to obtain this sample.  Samples are usually collected two to three months after the procedure to allow time to "clean out the pipes" and eliminate residual sperm.  

There are many different variations of the technique used to perform these procedures.  Current guidelines state that cautery (burning, welding closed) of the vas deferens (tube that carries the sperm) comes with the lowest risk of failure.  These are usually done as brief in office procedures with a local anesthetic and minimal discomfort.  Rest and ice after the procedure are critical to aid the healing process.  Men should avoid strenuous activity and sexual intercourse for about one week after the procedure.  All men should also be aware that this procedure does not protect against sexually transmitted diseases.  

As with any surgical procedure, talk to your doctor and make sure that you feel comfortable with him or her before proceeding.

When I began my training in Urology, robotics was a brand new field.  The vast majority of our prostate cancer surgeries were done with a traditional open approach.  By the time I completed my training, I was performing about half of my prostate cancer surgeries with robotic assistance.  Now, roughly 85% of prostate cancer surgeries done in the USA are done robotically, and that number is likely to continue to rise.

Robotic surgery has many advantages, such as less blood loss and improved visibility.  Many believe the long term outcomes to be better but the science behind that assumption is only now materializing.  Using a large cancer registry, Hu et al have recently published a study looking at over 13,000 men and concluded that robotic surgery is, in fact, superior to open surgery.  Patients undergoing robotic surgery were less likely to need second line cancer treatments than patients undergoing open surgery.

This study gels with my own personal experience.  As one of the few Urologists equally trained in robotic and open surgery, my robotic outcomes have now outpaced my open outcomes.  Because of these improved outcomes, I now perform robotic surgery almost exclusively.  With the recent release of the latest daVinci Xi robot (which I just sat down for a test run today) we should continue to see improved outcomes as this technology continues to rapidly advance.

Erectile Dysfunction (ED, or "impotence") is a common problem, affecting about one half of men by the time we reach age 65. Treatments for ED were largely popularized and in the mainstream after Bob Dole (former presidential nominee) openly discussed his erectile difficulties in a TV ad in 1999.  There are many possible causes for ED - and many treatment options.

Over recent years a greater understanding has evolved about ED and its possible association with other underlying disease processes, such as diabetes and vascular disease.  Once a thorough evaluation has been completed, the next step in deciding on a treatment plan that best suits you.

I view the treatment of ED as having 3 layers.  The first and simplest is attempting oral medications.  We have a number now available, such as Viagra, Levitra, Cialis, Staxyn, and Stendra.  It is important to understand that these medications can help facilitate but do not cause erections.  

The second layer of treatment options can directly cause erections.  

• One is the vacuum erection device (VED).  This is a cylindrical tube that is placed onto the penis.  A pump (handheld or electronic) is activated to create a vacuum which engorges the penis and results in an erection.  Constricting bands (thick rubber bands) are placed at the base of the penis to prevent an outflow of blood.  Side effects can include bruising of the penis, pain, and a sense of numbness.
  
• Medicated urethral system for erections (MUSE) requires implantation of a pellet of alprostadil into the urethra (pee channel).  Intracavernosal injections (ICI) are direct penile injections of medications that cause dilation of blood vessels resulting in an erection.  Among the side effects is priapism, a prolonged and painful erection that requires immediate medical attention.  Pain, bruising, and scar tissue formation can also occur.
  

Lastly, we have the option of an inflatable penile prosthesis (IPP).  This option is typically met with a healthy degree of skepticism when first discussed.  However, most men who have an IPP placed are very happy that they did so.  In fact, patient and partner satisfaction surveys exceed 85 to 90%.  It is important to understand that this is a surgical procedure and once placed natural erections will no longer occur.  Instead, a pump, which is placed in the scrotum, is used to inflate the penis whenever sexual activity is desired.  Sensation, orgasm, and ejaculation all occur in an un-altered fashion.  When the device is no longer needed, the pump is used to deflate the device until the next time.  The implantation is done as a same day surgery but it is not activated until after 4 to 6 weeks of recovery.  Key risks include bleeding and infection.  Your Urologist can review the procedure in more detail so you can decide if such a surgery is right for you.

The take home message should be that there are many treatment options available to men who suffer from ED.  The first step is to discuss this problem with your healthcare provider so he or she knows about it and can get you started on your road to recovery.

Urinary incontinence (an unintentional loss of urine) is a common problem.  It affects about 25 million people in the United States and upwards of 200 million worldwide.  What continues to amaze me year after year is how commonly I hear patients tell me they just assumed it was a normal part of growing old or having children... it is not!  Losing the ability to stay dry is an abnormal process.  So common - yes, but normal - no.

There are many different types of urinary incontinence.  This affects both genders but women more commonly than men and will be the focus of this blog.  Two of the more common types of incontinence are "urge incontinence" and "stress incontinence".  Very effective treatment options exist for both although it is critically important to first arrive at the correct diagnosis.  I recommend consulting your local Urologist.  Depending on your presentation, there may be very limited testing needed.  In other cases we may need to perform diagnostic tests such as cystoscopy (looking in the bladder with a small flexible camera scope) or urodynamics (a test of how well or poorly the bladder is functioning).

Stress incontinence is when there is a loss of urine with an increase of abdominal force.  This can occur with laughing, coughing, sneezing, exercising, picking up heavy objects, or just moving from a sitting to a standing position.  It can range from a very small loss of urine to nearly continual leakage.  For mild cases, treatment options can include physical therapy and pelvic floor rehabilitation.  Surgical intervention most commonly consists of intra-urethral bulking agents or a mid-urethral sling.  These procedures are worthy of a detailed discussion with your treating Urologist.

Urge incontinence occurs when there is an unintended bladder contraction resulting in a sudden urge to urinate.  This can occur without any type of activity, in one's sleep, and often has triggers such as running water.  Typical first line treatment options will consist of dietary and behavioral modifications.  There are an array of medications specifically designed to help this condition which can be quite effective for many patients.  If these medications are not successful or you are suffering side effects, there are now several more advanced options such as:

• Percutaneous tibial nerve stimulation (PTNS):  an in-office procedure done once a week for 12 weeks.  Minimal risk of side effects and effective in over half of patients.  Results are not permanent but can last up to 12 months.
  
• Sacral nerve modulation (Interstim):  a surgical procedure to directly stimulate the S3 nerve that controls bladder function.  Effective in over half of patients and is a durable treatment option (if successful, it connects to an internal battery supply similar to a pacemaker).
• Botox:  yes, the same stuff used for wrinkles!  It can be injected (in the office or surgical suite) into the bladder wall.

Please also be aware that incontinence can be a sign or manifestation of other problems such as an underlying bladder tumor, bladder stones, interstitial cystitis, and others.  Consult your Urologist for a complete evaluation and discussion of management options.

It seems like every time you turn on the news or read the paper (yes, some of us still read newspapers), there is some new piece of information about PSA.  What is PSA, anyway?  PSA stands for prostate specific antigen.  Beginning in the 1980's this blood test began to be used as a screening mechanism to identify prostate cancer at earlier stages.  Before PSA testing began, all we had was the physical exam or other symptoms like bone pain, which typically found cancers rather late in the disease process.  We now find the vast majority of prostate cancers very early and that has lead to quite a bit of discussion.  Are we over-treating prostate cancer?  Does diagnosis and treatment do more harm than good?  Should we even be screening at all?  

So what do we truly know about PSA testing as it relates to prostate cancer?  Let's look at the incidence of prostate cancer before and after PSA testing began (these statistics are available online to all thanks to the SEER database):

The sudden increase in prostate cancer diagnoses in the late 1980's and early 1990's (the spike seen in the graph) resulted from increased and eventual widespread use of PSA testing.  In recent years the incidence seems to be leveling off.

It's one thing to be diagnosing more cancers.  The next question is what happened to prostate cancer mortality?  In other words, how many people were dying from prostate cancer during this time?

The trend we see for death from prostate is one of the more striking ones we have seen with any type of cancer.  For years, prostate cancer had been claiming an ever increasing number of lives.  Along came PSA testing and after an initial upward swing - as a result of a sudden increase in the number of men being found to have cancer - death rates took a plunge.  Year by year since that time death from prostate cancer has dropped.

Dramatic increases in survival combined with an increase in rates of diagnosed prostate cancer seems to be a very convincing argument that PSA testing has been very beneficial for men. 

There are other factors at work.  While early treatment for prostate cancer seems to be helpful, we need to understand that as cancer is now diagnosed much earlier than it had been a few decades ago, men will naturally live longer with their disease regardless as to what type of, if any, treatment were given.  A number of studies have attempted to answer the PSA screening question but were poorly designed and executed and the validity of the results have been hotly debated.  Teasing out how much of that downward swing is from statistical anomalies and how much is from saved lives has been a topic of much debate... and will not likely be definitively answered any time soon.

As many of you have heard the USPSTF (United States Preventive Services Task Force) came out with a recommendation essentially against PSA testing.  This has rightfully drawn sharp criticism.  At the time of this posting, there are 16 members of this government committee, not a single one of which is a Urologist - the specialty charged with the care of men diagnosed with prostate cancer!  

What is the bottom line?  The AUA (American Urological Association) to which I belong believes that prostate cancer screening - with PSA testing - should be done annually beginning at age 40.  I support that recommendation.  More importantly, I support the right of each individual to have the ability to decide for himself whether or not he would like to be screened for prostate cancer and not have the decision made for him by a small government committee.