Urological

This episode is an announcement that this podcast is set to close at the end of this month, August 2023.

Thank you so much for listening to these episodes of Urological and to my previous episodes from the Why Urology podcast here on this feed. 

You still have time to go back to relisten to or save the episodes you really enjoyed or found particularly helpful. 

Thank you so much for listening.

Be well and do good.

Thank you for listening to this episode of Urological. 

 

This podcast is an open ended conversation of ideas and topics that center around the practice of medicine and the field of urology. 

Recently, one of my younger partners asked me the following question, “Todd, do you have a spot?”

IHere is a quote from Stephen King. 

“It starts with this: put your desk in the corner, and every time you sit down there to write, remind yourself why it isn't in the middle of the room. Life isn't a support system for art. It's the other way around.”

I love my spot at a small desk in the corner of my screen porch. I cherish the time I get to spend here. As an introvert this quiet time fills me.

Having a spot is critical to our lives if we are professionals, We need places to be quiet, to think, and to work to solve the world’s problems and even some of our own.

Life does not exist to support our art. Its the other way around. 

As physicians our “art” is medicine. 

Life does not exist to support our practice of medicine. It's the other way around. Our practice of medicine exists to support our lives.

 

 

 

 

In this podcast we explore topics and ideas center around the practice of urology and the field of medicine. I am a urologist based in Woodbury and St Paul MN.  

Patients ask me all of the time if anything is “new” since their last visit as they try to figure out what options they have as they consider treatment for whatever condition ails them.

This is a challenging question because something is always “new.” There is always innovation, ideas, and new iterations.

Change is constant.

The reason this is top of mind for me is because within the last couple of weeks my partners and I have been exploring and discussing opportunities to innovate within our practice, as well as seeing some significant changes outside of our practice in our local medical community that have the potential to significantly change the way we practice.

And I have lost a lot of sleep because of the expected changes. I am concerned that some of the ideas I have heard are a bit too much, impractical if not damaging to our practice if not executed or navigated properly. 

There are only two responses to innovation, ideas, and iterations. The first response is to be skeptical, to find the fault in the ideas and to figure out all of the holes in the idea and to determine all of the ways in which the idea doesn’t work. The second opposite response is to look at a half baked idea and to say, “Maybe there is something here” and then to build it despite its imperfections

I wonder which of the two I am, a skeptic or a dreamer.

The reason I have been thinking about this is that I have spent a fair amount of time this past couple of weeks shaking my head, skeptical of ideas, concerned about radical change, I see and essentially asking over and over again, “Why? why, why, why?”

I am afraid that as an older physician, one who views myself as starting the last phase of my career, I am too resistant to change, and afraid of the new, the bold, and the crazy.

But I think I should still be dreaming, to see the things that never were and ask, “why not?”  

In this episode, we will be  talking about kidney stone prevention and a very common problem for kidney stone formers, idiopathic hypercalciuria, or having too much calcium in the urine but otherwise normal body calcium metabolism.  This condition is often referred to as renal-leak hypercalciuria. 

Calcium is one of the most important minerals in the body. The average adult body contains in total approximately 1 kg of calcium, 99% of which is stored in our bones and teeth.  In our bloodstream calcium also has many regulatory functions. Calcium enables our blood to clot, our muscles to contract, and our hearts to beat.

Because calcium is a mineral that is so necessary for life our bodies regulate its metabolism very closely. The system monitoring calcium balance in the body is elaborate and our bodies sense when there is too little or too much calcium in the blood and will work hard to restore balance.

Our bodies cannot produce its own calcium. We get our calcium from our food. When we don’t get the calcium our bodies need in our diets, calcium is taken from our bones if our bodies need to maintain calcium balance. A lack of calcium in the diet, or disorders of calcium metabolism, can lead to osteopenia and osteoporosis.

What is adequate calcium? Around 800mg-1200mg of calcium is adequate for most healthy, active men and women. Calcium supplementation is used for patients with bone loss or at risk for osteopenia or osteoporosis.  

Because calcium is so important in our bodies our kidneys hold on to as much calcium.  That’s a good thing that our kidneys work to resorb the filtered calcium because elevated levels of calcium in the urine can lead to kidney stones. 

Calcium readily binds to other minerals in the urine, combining with oxalate and phosphate to produce the common calcium oxalate or calcium phosphate stones. Calcium oxalate stones form the most common form of kidney stones. 80-85% percent of kidney stones are calcium-based.

People with normal kidney function lose very little calcium in the urine, less than 150 mg a day, as measured by 24 urine collection.

But in kidney stone formers a common finding on 24-hour urine collections is hypercalciuria, higher than normal calcium excretion.

A person’s risk of forming kidney stones increases as the calcium levels in the urine rise. 

There are a number of reasons there may be too much calcium in the urine but the most common one is idiopathic hypercalciuria.

Idiopathic Hypercalciuria is not a disease per se, it is a condition and a risk factor for other diseases, kidney stones being one of them, but also long term, osteopenia and osteoporosis. 

No red line determines when a patient has or needs treatment for Idiopathic Hypercalciuria. We know that values above 200mg of calcium excretion for 24 hour is a risk factor for kidney stones but historically we have used cutoffs slightly higher for patients to determine when to start or use medication, as high as 250 mg/day for women and 300 mg/day in men.

Often simple dietary changes can be enough to lower kidney stone recurrence risk in patients with only a slightly increased level of calcium in the urine. Increasing fluid intake, moderating salt, animal protein and oxalate consumption, focusing on adding fresh fruits and vegetables and adding Lemonade (often in the form of Crystal Light to decrease sugar load), orange juice or even Lemon juice to increase citrate in the urine may be all a patient needs to help prevent stone formation. 

If dietary changes are not effective, however, or if the calcium excretion is very high, then medication is advised. Medication to treat idiopathic hypercalciuria to prevent kidney stones is an ongoing medication, one that is needed indefinitely.

The most common medication used for idiopathic hypercalciuria is a class of medications called thiazide diuretics, but another diuretic call indapamide can also be used.  

Chlorthalidone is the most commonly used thiazide diuretic because of its long half life but hydrochlorothiazide is effective as well. Thiazide diuretics decrease the calcium levels in the urine. Dose adjustment, increasing or decreasing the dose, is done according to results on 24-hr urine testing. Repeat 24 hour urine test are needed initially to see if the medication is effective but also on an ongoing basis because some kidneys become tolerant to the medication. A short vacation from the diuretic often resets the body and resets the medication’s effects.

Thiazide diuretics can have side effects. Thiazide diuretics can be potassium wasting and cause low potassium levels in the blood. A plant based diet or increasing fruits and vegetables in the diet (I joke that I’m a fan a the banana) can increase the potassium in your diet but some patients taking the medication will need to take potassium supplements, either in the form of potassium pills or in some kidney stone formers,  Potassium Citrate. Potassium Citrate has the advantage of not only preventing hypokalemia (low potassium levels) but also increasing urinary citrate excretion. 

So there you have it. Some of us have too much calcium in our urine leading to an increased risk of kidney stones as well as other conditions. For some kidney stone formers a simple diet change will be enough to offset the risk of a slightly increased amount of calcium, but for other people with very high levels of calcium in the urine medication may be needed. 

A picture, they say, paints 1000 words.

Throughout my practice I have tried to draw as many pictures as I can for my patients. I find that the time I spend in the office often drawing complex anatomical relationships for patients pays off for me in the form of needing to talk less and pays off for the patient in an increased understanding. I find a simple picture drawn for a patient along with an explanation is the easiest way to convey complex surgical techniques and anatomy to help patients understand what we do during specific procedures.

The problem is that I don’t draw nearly enough. It takes time and, as I explain to my patients before I start drawing anything, I failed eighth grade art class. My drawings and diagrams would never win any awards, and outside of the context of a clinic visit, probably shouldn’t be shown.

But, I have shown my work to others. There is a YouTube video I have on my YouTube channel of my drawing a hydrocele, a collection of fluid around the testicle. It's an example of the types of drawing I do for patients. You can find that here: https://youtu.be/06euCzs7uAQ

Our job as physician communicators is that same job that any scientist has in communication. Be brief, be clear, be simple. Don’t talk too much. Carve every word so you say exactly what you mean.  Lastly, stealing from the great physicist Albert Einstein, make it as simple as possible, but no simpler.

I understand how my patients must feel when I provide them with a simple drawing, even though I am not a trained artist. The picture remains even though nobody remembers exactly what I said. 

In medicine we deal with seemingly complex things, difficult to understand, stuff that fills textbook after textbook with big, and unfamiliar words. We treat patients with sophisticated lab tests, fancy equipment, and a knowledge that takes years to get. 

But we must remember that doctor means “teacher” and our job as doctors is to teach, instruct, and educate. To do this we must be brief and clear and as simple as possible. 

And a picture often paints a thousand words. I should draw more of them. And so should you. Even if we failed eighth grade art we should hope that our patients leave our office saying, "how can something this beautiful not be right?" 

 

Kind, Quiet, and Competent. That’s a good starting point for success. 

Kindness, Quietness and Competence. Are these foundation elements for success at work?

As I reflect on my own performance now over many years of practice I think my failures, times when I have not performed well, may all fall into one of three buckets, 1. A failure to be KIND 2. A failure to be QUIET, and 3. A failure to be COMPETENT.

Let me explain...

The best business strategy, plans, tactics and goals don’t matter if your people aren’t allowed to create or feel something beautiful or purposeful at work, to have a mission, and maybe make a little art that gives meaning to their job. 

Here is the automaker Henry Ford on the subject: “Business must be run at a profit, else it will die. But when anyone tries to run a business solely for profit, then also the business must die, for it no longer has a reason for existence.”

Hippocrates, often called the father of medicine brought high ethical and clinical standards to medicine in the years he practiced around 400 B.C, but  even Hippocrates, had to have business meetings with his partners, deal with human resources issues, figure out what his competitor practices and other schools of thought were doing at the time to stay current, hire new people and staff, and have enough money left over after a day’s work to buy food and clothes for himself. Sure Hippocrates had a higher calling, but I would have loved to have a video recording of his practice’s annual strategic planning meetings. 

Governance, commerce, and mission. Politics, business, and art. Those are the three pillars on which our independent medical practices are built.

We have to get our politics right and govern ourselves well, then we have to get our business right but we can’t forget that we have a purpose, a higher mission that gives meaning to our life, our work lives, and to society as whole. We have to remember to put art back into medicine, even if we can’t define it we will know it when we feel it. 

These episodes are my personal exploration into podcasting and the practice of medicine using my chosen specialty of urology as the pivot point. 

Most of the episodes that I write and record begin with a single idea, thought, topic, or quote. This episode is no exception, and begins with a book I read recently about James J Hill, one of the most successful railroad magnates of the gilded age in the late 19th century.

I recently read a book called James J. Hill: Empire Builder of the Northwest by Michael P. Malone and I read it as part of a book club assignment that, along with Wikipedia and other online resources, is the inspiration nad source material for this episode. 

James J Hill was an extremely wealthy man at the time of his death.

At the end of his life, Hill was asked by a newspaper reporter to reveal the secret of his success. 

Hill responded : "Work, hard work, intelligent work, and then more work.”

James J Hill worked. And worked. And worked. He once is to have said, “Give me Swedes, snuff and whiskey, and I'll build a railroad through hell.”

Work, hard work, intelligent work, and more work. Such was the life of James J Hill.

What fascinates me, what I would love to pick James J Hill’s brain about, is this idea of intelligent work. 

What did he mean when he said that? What for James J Hill would constitute intelligent work. 

What I am thinking about today in this short episode is the addition of more intelligent work along with work, hard and more work as the key to success as I move forward in my career.  What is that? What does it look like? How do I get it? 

This is the last in this five part series about content creation. in this episode we will talk about keeping a scheduling.

We need to be consistent. 

Consistency creates loyalty from the audience, but it has intrinsic benefit to the creator as well.

When we think about creation we need to think in terms of a defined length of time, usually daily, weekly, monthly, quarterly, biannually, yearly.

And we can even extend those numbers 

What should we do every Day, week, month, quarter, biannually or twice a year, yearly, bienially (every two years), quinquenially (every five years) decennially (every ten years) and quadracentenially (every 25 years)?

When we create content for the medical practice I believe we should have a long view. 

The practice of a physician and a medical practice doesn’t allow for the time necessary for regular tweets and facebook and instagram posts of any meaningful content in my opinion. 

Our daily responsibilities take up most of our time. Seeing and operating on patients. checking lab and X-ray results, calling concerned families and taking calls from the Emergency Rooms.

Content creation is something important, but it’s not urgent, and often gets pushed to the side and not done.

Your schedule will be determined by the type of content you are creating. Some content will take more time. A piece of written content will take you far less time than audio or video content. But audio and video content is all the rage, so choose your efforts wisely and plan acordingly.