30 years ago Young doctor: I hope to have a long career Now Young doctor: Oh god, I hope I can retire early or find something else to do – at South Carolina, USA

Sexual Medicine Society of North America (SMSNA) 2026 Honored that I was able to moderate an E-poster session. It was amazing to see the passion and interest of the residents and medical students. As always, great attending well, done sessions and connecting with friends and colleagues. Looking forward to San Diego next year. #smsna2026

Excited to return to SMSNA after several years away—looking forward to reconnecting with friends, learning, and being “in the room where it happens” again. Who else is attending? #SMSNA26

I do not do these injections. But I am assuming if he died of an embolus there was accidental injection into a vein correct ? I see that there are reports of this

A flawed study gets published. The media runs with it. Beliefs are created that last for decades. The sober study that eventually corrects the record becomes a quiet footnote. Vigen and Finkle did this with testosterone. WHI produced an enormous amount of data on menopausal hormone therapy. But an article or news segment needs a punchline, and “hormones are dangerous” was the one that stuck. The initial headline is simple. The methodological correction is complicated. People remember the warning, not the correction. And these assumptions are still everywhere. I hear it constantly: “My doctor said testosterone causes heart disease.” Patients remain untreated—or have effective treatment stopped—because of risks the best current evidence no longer supports. There is real harm when a dramatic but flawed conclusion becomes clinical common sense and persists long after the evidence has changed.

In Memory of Wendell Berry No fiction writer has shaped how I think about my own life in the last few years more than Wendell Berry. Jayber Crow especially—a barber who spends most of his life in one small town, tending to people and a place he never fully figures out. Somehow, that not-figuring-out is part of the point. There’s a passage in that book that has stayed with me: “You have been given questions to which you cannot be given answers. You will have to live them out—perhaps a little at a time.” Jayber asks how long that will take. “As long as you live, perhaps.” Then: “It may take longer.” There is so much of Berry’s ethic in that exchange: not cynicism or disbelief, but a deeply Christian humility before mystery. Faith did not mean having every answer. It meant remaining patient, curious, and faithful while living out the questions. I think about those words in my own life and work more often than I could probably explain. Rest well, Mr. Berry. Thank you for Jayber—and for making room for a faithful kind of not-knowing.

I may be overstating this analogy—but perhaps not by much. So bear with me. Imagine a patient with symptomatic supraventricular tachycardia (SVT) who prefers an ablation over lifelong metoprolol. Ablation is considered standard in many circumstances, and one of the biggest payoffs is stopping the med. In urology, we have evidence-based guidelines saying a medication doesn’t have to be utilized to discuss procedural options. Yet insurance authorization criteria often say no med, no surgery. Erectile dysfunction may be an even clearer example. The AUA guideline does not require a stepladder approach with meds. Personally, I would be uncomfortable placing a penile implant in someone who didn’t try pills (Viagra, Cialis). Yet that should be MY clinical decision. Medication is often the right first step, but it SHOULD NOT be mandated. Perhaps part of the disconnect is incentives. The physician and patient may be considering the next 10 or 15 years. The insurer may not even cover that patient five years from now. Guidelines increasingly emphasize shared decision-making. Step therapy risks turning that into shared decision-making—but only after you’ve made the insurer’s preferred decisions first.

One of the great success stories in urology over the last 20 years has been the transformation in treating advanced prostate cancer. When I was in medical school, our options for metastatic disease were pretty limited. ADT was the foundation, and once patients developed castration-resistant disease, there weren’t meaningfully effective options. We learned that even “hormone resistant” prostate cancer was often still driven by the androgen receptor pathway, leading to drugs like abiraterone and enzalutamide. Then we started moving those therapies earlier—treating metastatic castration-sensitive disease more aggressively from the beginning, with doublet and, in selected patients, triplet therapy with docetaxel. Now add PSMA-targeted therapy and treatments directed at specific genetic mutations, such as PARP inhibitors, and the landscape is almost unrecognizable compared with 20 years ago. It has been remarkable to watch this progress happen over the last 20 years. And after years when it felt like relatively little was changing, it’s great to see bladder cancer treatment being invigorated in much the same way.

The American Urologic Association released updated guidelines for BPH this year. There are a few points. I think all clinicians should know as this is a significant rethinking of the disease process compared to when many folks were trained 1. BPH treatment doesn’t have to be a ladder. “You must fail meds” to consider a procedure is no longer the right approach. Is it reasonable to try Flomax? Of course. Should we require it before discussing a procedure? Of course not. This mentality is a relic of the era when TURP was the only option. 2. Just because a patient has an enlarged prostate doesn’t mean it’s the problem. Men can get overactive bladder and symptoms not related to obstruction. If the main complaints are frequency, urgency, or nocturia alone, consider OAB and first-line treatment with OAB meds. 3. Individual anatomy matters. Patients need a cystoscopy and some form of prostate volume estimation. Otherwise, you aren’t customizing treatment for the patient, and you’re still using a one-size-fits-all approach. 4. Patient goals impact treatment—a LOT. What’s the patient’s priority? Never needing another surgery? Preserving antegrade ejaculation at all costs? Maximal symptom improvement? The answer to each of these will impact the direction of treatment. Rarely does one obvious answer present itself with no reasonable alternatives. Are these guidelines more complicated? They are, but they reflect our ability to engage the patient to find the treatment that best meets their health goals.

happy #bowtiefriday

I agree every word in the patient record matters BUT … If you knew beforehand a note would be scrutinized in a legal setting your note would change time constraints are real and shortcomings in notes often reflect that

I realize Kevin Reddington was advocating for Lyndsey Clancy during this tense cross-examination. Yet the implication was that Dr. Tufts did something wrong by prescribing Zoloft to a patient with insomnia because the package insert shows a higher incidence of insomnia compared to placebo. The expert consensus I have read is that this prescription was standard of care and first-line. We consider side effects, but if we assumed every side effect would happen, prescribing would be practically impossible. Further, I can’t think of a specialty that necessarily relies as extensively on subjective reporting as psychiatry does. Dr. Tufts acted reasonably and on the best information she had at the time.

I don’t think I’m the only one seeing this… But I have a lot of patients coming into my practice who had a prostate biopsy five years ago or so. They had a Gleason six prostate cancer. Never had a confirmatory biopsy or any follow up biopsy. I can probably stomach this for a 75 year-old with coronary disease. Before a healthy 60 year-old we are basically putting him on watchful waiting

If you could pull one thread to fix American healthcare for patients, what would it be? And then the harder question: Politically, how likely is your plan to actually happen? My starting point: make health insurers something closer to a France-style nonprofit, publicly regulated utility. But… Never. Going. To. Happen.

It matters. Twenty years. I don’t know why it suddenly struck me today that I entered medical school almost exactly 20 years ago. (And yes, I know the sunglasses I wore on graduation day in 2010 were cool.) Part of me feels far too young to have an event this major in my life be twenty years old, but here we are. Looking at that picture, I also realize how impossible it would have been for that version of me to understand what the next twenty years would hold. The journey from there to here would require almost every adjective imaginable to capture it. Some good. Some not so good. But what I keep coming back to is this: It matters. What I started learning 20 years ago—and what I have continued learning every day since—matters because it has allowed me to be of service. To people who need reassurance. To people who are sick. To people who need someone to stand with them during times of suffering. Undergraduates shadowing me, medical students, and sometimes just random encounters will eventually lead to the question: “Would you do it again?” American healthcare is more complicated and challenging for physicians, nurses, APPs, medical assistants—and, most importantly, for patients—than you could have bent my mind to comprehend twenty years ago. So, at the end of the day, I think I would do it again. Not because the journey has met my expectations. Not because every part of it has been good. But because I believe it has mattered. – at Fort Mill, SC

The problem with incentives is that they work