Dr. Todd Brandt answers the question: Why Urology?
Dr. Todd Brandt answers the question: Why Urology?
"Are You Busy?": Steve Martin, Aequanimitas, and the Path to Success ep 93
What is success? What does a successful life look like? What does it mean to be a success?
For too many urologists including myself the primary way we measure our lives as successful is through the building of a large and lucrative practice.
For the record, I believe these are important things to measure. A medical practice is after all a business and we must always pay attention to the bottom line.
Ultimately, it’s not about how many patients did you see, but about how many patients received excellent medical care.
In 1889, William Osler called the “Father of Modern Medicine”, who would himself become a world-famous physician and educator by working long days and nights, had this to say to graduating medical students at the University of Pennsylvania in his most famous Speech “Aequanimitas.” Remember, this was in 1889…
“…I would warn you against the trials of the day soon to come to some of you—the day of large and successful practice. Engrossed late and soon in professional cares, getting and spending, you may so lay waste your powers that you may find, too late, with hearts given away, that there is no place in your habit-stricken souls for those gentler influences which make life worth living.”
There is a book I read by an author called Cal Newport. The title of the book is “so good they can’t ignore you.” The book is about how to build a career that you love through skill development, not by pursuing of a “passion.”
The title comes from a Steve Martin quote.
Here is his simple message. Focus on being good. Really good. Undeniably good. The rest will probably follow.
The successful physicians, the ones I look up to, seem to be able to juggle the demands of being both “good” and “busy”. They possess that certain “Aequanimitas” that William Osler describes in his famous speech. They have developed skills through years of deliberate practice that allow them to be efficient and effective.
They do not forget what makes life worth living.
Here is a poem written in 1904 by Bessie Stanley of Lincoln Kansas as an entry into a magazine contest. The requirement of the contest was to define success in 100 words or less.
He achieved success who has lived well, laughed often, and loved much;
Who has enjoyed the trust of pure women, the respect of intelligent men and the love of little children;
Who has filled his niche and accomplished his task;
Who has never lacked appreciation of Earth's beauty or failed to express it;
Who has left the world better than he found it,
Whether an improved poppy, a perfect poem, or a rescued soul;
Who has always looked for the best in others and given them the best he had;
Whose life was an inspiration;
Whose memory a benediction
Jumping Back Into the Water After COVID 19 ep 92
I have spent half of my life as a physician, beginning as an intern just before my 26th birthday.
It began in an inauspicious start on July 1st as an intern at the VA hospital. On our first day we spent most of the day in orientation, but at the end of the day I reported to my assigned general surgery team, currently on rotation at the VA hospital and doing afternoon rounds. When I arrived, I was informed I would be taking call that night, was shown to my call room at the end of rounds, and was given a few basic orientation tips.
I will never forget being handed the “code” pager for the first time. The chief resident explained to me that carrying the code pager as a surgery resident wasn’t a big deal. Be professional; be prompt; stay relaxed; work with the team; do your job. Basically, he said, you have to run to the code blue, announce that “surgery” was there. Surgery’s responsibility was to make sure tube and lines, things like IV access were present and functioning well and, if needed, to perform whatever bedside procedures needed to be done.
I nodded my head and said goodbye for the night to my fellow residents and medical students.
No sooner had I sat on the bed in the call room than the pager went off for a code blue.
Code Blue. Intensive Care Unit. Room 9.
Up I jumped, and made my way quickly to the intensive care room 9.
There I found a number of doctors and nurses already gathered around a patient and performing CPR and delivering medication. This ICU patient had plenty of tubes and IVs but I was there and I thought I should let people know just in case.
“Surgery is here!” I said as I entered the room.
“What?!” said the nurse standing at the bedside, “Who are you kidding? Get out of here!”
I took a look around the room, decided that surgery was not needed during this particular code blue, and slowly backed out of room 9 in the ICU and back to my call room.
Such began my life as a physician.
I learned two things that night
You are not as important as you might think. Be professional; be prompt; stay relaxed; work with the team; do your job. And there are many days where I feel about as relevant as I did that night. But, like Sysiphus, I keep pushing my rock up the hill. And I have been doing so over the last 26 years.
Enter 2020 and the abrupt halt to what I have come to know over the last half of my life. Clinics and surgeries cancelled, telehealth and video visits replacing in person interaction, time spent at home in isolation, wearing a mask not only the OR but many other places as well.
Our practice faced the challenge head on, adopting telemedicine quickly, shutting down clinics and cancelling unnecessary surgery in preparation for the COVID-19 surge. Our changes felt and still feel like the right answer. We were ahead of the curve, if only slightly, still we were ahead.
At first it was a break. An unwelcome break, but a break nonetheless. I vowed to take the time for personal development, hoped to make a few podcasts and videos, and, to be honest, did not expect our hiatus to last too terribly long.
My positivity waned a bit after a few weeks as I personally began to feel more and more distanced from my family, my friends, and actually more concerning for me, my work.
Without patient interaction, without the ability to touch people, either with a handshake or a scalpel, the practice of urology just isn’t as fun…at least for me.
But it’s summer, which has always allowed me one of my life’s simplest pleasures. I live on and grew up on body of water called the St. Croix River, on section of the river called the Lake St Croix because it widens into an area that is the size of a very large lake. The river is designated as a National Scenic Riverway, and it is fantastic in the summer.
A near nightly ritual for me in the summer is to put on a bathing suit a
Kidney Stones: Cystinuria and Sir Archibald Garrod ep 91
This episode is another in the long line of podcast episodes I have done about kidney stones. In this episode we are going to talk about a less common form of kidney stone called a cystine stone, and a metabolic disorder called cystinuria.
Cystine stones comprise about 1% of all stones in adults and about 6% to 10% of stones in children.
Cystinuria is as you would expect by its name is disease that is characterized by high concentrations of cystine in the urine. Because cystine is highly insoluble in urine, frequent kidney stones are the result. Patients with cystinuria are at risk of forming many, many stones over a lifetime.
And the stones begin to form very young in life. Elevated cystine excretion can even be seen in infancy and symptoms of this disorder typically begin between 10 and 30 years of age. The average age at first presentation for cystinuria and kidney stones is around age 12 or 13.
Cystinuria is an inherited disease, one is born with it. It’s an autosomal recessive genetic mutation, which means that you have to get the gene from both your mother and father. The disorder is relatively uncommon, but far from rare. The disorder occurs in approximately 1 in 7,000 to 1 in 10,000 people in the United States. The prevalence of cystinuria varies in different countries and ethnicities. The Swedes, for instance have a low incidence of 1 in 100,000. Cystinuria affects males and females in equally.
There are two gene locations that are involved in creating cystinuria, mutations form in the genes SLC3A1 and SLC7A9, which code for the 2 subunits of a transporter that mediate nearly complete reabsorption of cystine and other dibasic amino acids in the renal proximal tubule and the intestine.
The dibasic amino acids are cystine, ornithine, lysine and arginine (C O L A, cola). In cystinuria all those amino acids can all be found in elevated amounts in the urine. But cystine is the only one that matters to a great deal because it is the one that forms kidney stones. Ornithine, lysine, and arginine are soluble and do not form stones and are merely lost in the urine.
Cystinuria was first correctly described in 1908 by Sir Archibald Garrod, describing it along with three other metabolic abnormalities that he classified as inborn errors of metabolism. The tetrad comprises four inherited metabolic diseases: albinism, alkaptonuria, cystinuria, and pentosuria.
In any young person with a new diagnosis of kidney stones, cystine stones must be considered. Kidney stones are sent for analysis to determine their composition. Cystinurics tend to form stones that are 100% cystine. Cystine stones may be pink or yellow in color after removal, but later they turn to greenish due to exposure to air. People with cystinuria typically produce jagged stones that are small, though some form very large stones. Stones may be accompanied by urinary “gravel,” which consists of yellowish-brown hexagonal crystals.
If a stone cannot be analyzed a suspicion for diagnosis can be made based on other clinical parameters. As I said any young patient presenting with stones should be suspect. The crystals of cystine are easy to distinguish from other crystals in the urine under the microscope. They are hexagonal, translucent, and white.
The urine of a cystinuric may be identified by a positive nitroprusside cyanide test. When urine cystine excretion is greater than 75 mg/L, this spot test will turn the urine purple in color. Quantitative testing is then recommended, such as 1) 24hour urine cystine measurement or 2) Random spot urinary cystine, ornithine, arginine, and lysine excretion normalized by creatinine excretion.
Cystine stone show up only faintly on standard xray of the abdomen due to the sulfide group. Ca
Cancer: How a Cancer Starts and Grows ep 90
Where does a cancer come from?
Cancer begins with one cell.
A normal cell has cell membrane, a cytoplasm with lots of working parts within it, and a central nucleus. The nucleus contains the instructions, the DNA, that tells the cell exactly what it needs to do. A cell has a specific purpose, become a prostate cell for instance or skin or a brain.
Our DNA is incredible. Using the nucleobases adenine, cytosine, guanine, and thymine base pair nucleosides of adenine-thymine and cytosine-guanine can be stacked, one on top of another, into chromosomes, long chains of coiled double helix code that is read by the cell as the ultimate instruction manual. The instructions contained within a single cell is more complex than any how-to book you have ever read. The full set of instructions is so long that it would take more than 3,000 books to print all of the instructions assuming that each book would have 1,000 pages. If you could take the DNA out of a single cell and stretch it into a line, it would be more than six feet long.
To grow a prostate or skin or a brain, a cell must replicate itself over and over. Cell division and replication happens in a process called mitosis. During mitosis a cell’s DNA needs to be replicated exactly to form a duplicate cell. One cell into two, two into four, four into eight and so on. The cells must then all work together to create a prostate or skin or a brain.
Here is the origin of a potential cancerous cell.
Any loss of integrity to the DNA causes the entire cell to be dysfunctional, either completely or partially. The new imperfect DNA contains an imperfect set of instructions.
Most often the mutation will be fatal to the cell. That cell dies. No big deal.
nfrequently, a mutation will form a non-lethal cell change and the abnormal cell will not follow the normal growth pattern.
A cell that continues to grow and does not get the appropriate instructions for growth eventually becomes a problem. It continues to grow and divide, replicating its own DNA. One to two, two to four, four to eight and so on until there is a mass of cells, a tumor, that is not following normal instructions.
An individual cancer cell, depending on the type of mutation within it, will have its own unique growth pattern. When we look at a cancer cell under the microscope we can predict how aggressively it will behave by how undifferentiated the cell is. Each cancer has its own grading system.
Cancers start within one organ. Prostate cancer starts in the prostate cells, breast cancer from the breast, skin cancer in the skin, and colon cancer in the colon.
Then it spreads to other parts of the body. Cancers metastasize.
Cancers spread in one of two ways They grow 1. by local spread and 2. By distant spread, travelling hematogenously (through the blood) or lymphatically (through the lymph system). A metastatic cancer is one that has spread to other organs through either local invasion or through the blood or lymph.
A cancers stage is often classified in a staging system we call TNM. T, tumor. What is the tumor doing? Is it confined to the organ or has it advanced locally? N, lymph nodes. Are there any swollen lymph nodes that would indicate that a cancer has spread to the lymph system. M, metastases. Is there evidence of cancer in other parts of the body? TNM each are given a number. An overall stage is often a number as well and is a consolidation of the TNM classification.
How does a cancer do this, grow such that the body doesn’t fight it off?
Your body often does not recognize the cancerous cell as abnormal, or just downright turns its head away and ignores it until its too late.
Our immune system detects and kills bad stuff through a complex interplay of B cells, T cell, Natural killer cells, humoral immunity and cellular immunity working together to detect the abnormal and destroy it.
Uric Acid Kidney Stones: The Little Sister of the Kidney Stone Family
80% of all kidney stones are calcium-based stones, mostly calcium combining with oxalate or phosphate to make calcium oxalate or calcium phosphate stones.
This episode is about another kind of kidney stone mineral called uric acid.
Uric acid stones makeup about 15 % of all kidney stones.
Calcium based stone and uric acid stones make up the vast majority of stones that we treat. What I want to do for the this episode is highlight 5 areas where uric acid stones differ from calcium based kidney stones in diagnosis, treatment and prevention.
If you want to hear all of the episodes on kidney stones there is a link in the show notes to the category list of kidney stones on the website at whyurologypodcast.com.
World No Tobacco Day May 31, 2020, 100%, and the Golden Gate Bridge ep 88
May 31 is world no tobacco day sponsored yearly, since 1987 by the Member States of the World Health Organization.
World No Tobacco Day every year informs the public on the dangers of using tobacco, the business practices of tobacco companies, what the world Health organization is doing to fight the tobacco epidemic, and what people around the world can do to claim their right to health and healthy living and to protect future generations.
This year’s theme is prevention of smoking by our youth and awareness of how tobacco companies market to younger generations.
This year, the World Health Organization is encouraging efforts that empower young people to stand up to big tobacco companies by resisting their ads and marketing and refusing to use any tobacco or nicotine products including e-cigarettes and other vaping devices.
Here are 5 reasons your urologist may tell you not to smoke according to the Urology Care Foundation:
Bladder Cancer: May is bladder cancer awareness month. This year over 80,000 will be told they have bladder cancer. Smoking causes harmful chemicals to collect in the urine. These chemicals affect the lining of the bladder and significantly raise your bladder cancer risk. Erectile Dysfunction impacts 20-30 million American men. Erectile Dysfunction is most commonly a result of poor blood flow to the penis. Smoking harms blood vessels, mostly arterial health, which impacts the blood flow to the penis with the result in not being able to get or keep an erection firm enough for sexual intercourse. Kidney Cancer. Kidney Cancer is in the top ten most common cancers for men and women, combining for more than 70,000 cases of kidney cancer expected this year. When smoking, carcinogens are drawn into the lungs and then into the bloodstream where they are filtered by the kidneys. The harmful chemicals increase your risk of getting kidney cancer. Incontinence, urine leaking, and Overactive Bladder (OAB), impact more than 33 million men and women. The chemicals from smoking and vaping bother the bladder and can contribute frequent urination. Smoking can also cause coughing spasms that can lead to urine leakage. Smoking can harm the eggs in the female and sperm in the male. The infertility rate for smokers is twice the rates for those who do not smoke. You don't have to do it alone. Your family, your friends, and your doctors will help you.
Get ready. Set a date to quit. Get support and seek help.
The national tobacco quit line: 1-800-QUIT NOW (1-800-784-8669).
Free smartphone and tablet apps are available. Try the National Cancer Institute's QuitPal.
Websiters such as Smokefree.gov offers a ton of support and resources including a text messaging program called SmokefreeTXT.