Latest Videos

Managing the Chronically Late Patient

Posted by | Jun 2022

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, discusses techniques for managing chronically late patients. He explains that every practice has a problem with late patients, and it is an issue which can wreak havoc with a practice’s schedule, impact productivity, cause stress to the physician and their staff, and negatively affect other patients who are on time. Dr. Baum recommends creating a written policy regarding lateness, advising patients to arrive early to complete paperwork, and explaining the impact of lateness on the physician and staff. He also suggests seeing chronically late patients at the end of the day. Dr. Baum notes that physicians and staff should listen to the reason for the delay, and give some “slack” to patients who typically are punctual. He observes that doctors must set a good example and make a commitment to being on time themselves. Dr. Baum advises against trying to solve the problem by overbooking, since that can result in significant delays in seeing patients. He also notes that charging patients who are late is difficult and rarely works. Dr. Baum discusses the rare process of discharging a chronically late patient, explaining that the physician must allow the patient several weeks to find another doctor. He concludes that medical practices cannot tolerate chronically late patients and must develop and implement a policy regarding lateness.

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ADT and Brachytherapy: The Good, the Bad, and the Ugly

Posted by | Jun 2022

As part of a special course on brachytherapy for prostate cancer from the American Brachytherapy Society and Grand Rounds in Urology, Mira Keyes, MD, FRCPC, FABS, Clinical Professor at the University of British Columbia (UBC) and a radiation oncologist at the Vancouver Centre of the British Columbia Cancer Agency (BCCA), discusses the pros and cons of using androgen-deprivation therapy (ADT) with brachytherapy to treat prostate cancer. After briefly discussing how ADT affects the tumor microenvironment, Dr. Keyes goes over the numerous clinical trials that have investigated how to combine external beam radiation together with hormone therapy. She explains that these trials found that the combination increases overall survival ~10-13% over ADT or EBRT alone, and longer ADT has a greater impact on OS, even with high radiation therapy dose. Dr. Keyes observes that ASCO considers brachytherapy a standard of care and recommends it be combined with ADT for unfavorable intermediate-risk and high-risk disease. She then considers the findings of ASCENDE-RT, the HDR UK trial, and the TROG 0.304 RADAR trial, all of which looked at the combination of ADT and brachytherapy, and discusses several ongoing randomized controlled trials on the role of ADT with prostate brachytherapy. Dr. Keyes also discusses a systematic literature review of ADT + prostate brachytherapy which concludes that the addition of ADT to brachytherapy provides no benefit to cancer-specific survival with ADT, and no benefit to overall survival with ADT, but does provide up to a 15% benefit to biochemical progression-free survival. She also notes that some believe dose escalation (prostate brachytherapy boost) may obviate the need for ADT in some high-risk patients. Dr. Keyes looks at a different meta-analysis which found that the addition of ADT to external beam radiation therapy provided a greater oncologic benefit than a brachytherapy boost and that there was a high probability that intermediate-risk and high-risk prostate cancer treated with EBRT + ADT would have superior overall survival to high-risk patients treated with EBRT + brachytherapy boost. Dr. Keyes argues that this paper misses the fact that the benefit of brachytherapy is that if brachytherapy is used, the duration of ADT can be reduced in unfavorable intermediate-risk and high-risk patients, which has a significant positive impact on quality of life and overall survival. She notes that ADT has numerous negative effects on quality of life, including erectile dysfunction, dementia, osteoporosis, metabolic syndrome, and more. Dr. Keyes particularly focuses on the negative cardiovascular effects from ADT, noting that observational data shows excess cardiovascular morbidity and mortality in patients on ADT with pre-existing cardiovascular disease. She concludes that ADT should be avoided in low- and intermediate-risk prostate cancer patients treated with monotherapy, that ADT for only 12 months in unfavorable intermediate- and high-risk patients is supported by randomized controlled trials, that ADT can be omitted in selected unfavorable intermediate- and high-risk patients, and that shorter ADT duration will improve quality of life and may increase overall survival by decreasing cardiovascular disease morbidity.

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Diversity, Equity and Inclusion in Urology

Posted by | May 2022

Fernando J. Kim, MD, MBA, FACS, Chief Emeritus of Urology at Denver Health Medical Center in Aurora, Colorado, characterizes diversity as a mosaic of differences and similarities—and dimensions—among people, including appearance, age, culture, ethnicity, race, language, gender, sexual orientation, religion, family environment, income level, and job title. Dr. Kim notes that communication is filtered through one’s cultural perspective, which includes characteristics and experiences ranging from things like age, race, learning style, military experience, and much more. All of this influences how people perceive one another. He points out that the “melting pot” theory of American society has evolved to where American culture values respect for individual groups and characteristics within society. Dr. Kim turns to equity and differentiates equity from equality, pointing out that equity speaks to fairness or justice while equality is the state of being equal. He explains that equity goes beyond fair treatment, opportunity, and access to information and resources for all, stressing the importance of intentionally and actively removing barriers, challenging discrimination and bias, and institutionalizing access and resources that address historical and contemporary social inequalities. Dr. Kim turns next to inclusion, which actively invites all to contribute and participate; it strives to create balance in the face of exclusive differential power and create a society where every person’s voice is valuable and no one person is expected to represent an entire community. He differentiates among Equal Employment Opportunity (EEO), affirmative action, and diversity and inclusion. Dr. Kim cites the fact that urologists today are usually men and explains that while this may be changing, the field of urology lags behind other specialities in the share of women practitioners. He explains that workforce diversity is good for business and discrimination and poor diversity management pose an economic cost, with the average EEO complaint costing an organization approximately $250,000. Further, 25-40 percent of the workforce attrition rate and 5-20 percent of lost productivity can be attributed to poor diversity management, and employee turnover costs 75-150 percent of the replaced employee’s salary. Dr. Kim cites NASA’s implementation of a strong diversity management program after the Report of the Columbia Accident Investigation Board found that organizational culture that squelched dissent, stifled differences of opinion, resisted external criticism and doubt, imposed a “party-line vision,” and prevented open communication had plagued NASA and contributed to the Columbia accident. Dr. Kim concludes by asking, “At what level do you value differences?,” differentiating among tolerance, acceptance, valuing, and the celebration of differences; he emphasizes the importance of celebrating individual differences and deeply understanding and respecting others’ viewpoints.

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