Dr Potts Radio Interview On Pelvic Messenger
January 17, 2017
On April 2, 2015 Dr. Potts was interviewed by the Pelvic Messenger, which is supported by the International Pelvic Pain Society and Beyond Basics Physical Therapy, and is devoted to promote diagnoses, recovery, and success in treating Chronic Pelvic Pain (CPP) conditions in men, women and children. Their mission statement is to provide educational talk radio shows on various chronic pelvic pain topics. In addition, they seek to provide hope and healing to individuals who suffer from pain related symptoms. Below is the radio interview with Dr. Potts.
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- INTRODUCTION: Welcome to the Pelvic Messenger. The show that dives into the world of chronic pelvic pain. The Pelvic Messenger brings to you a fair and balanced message of hope. Empower yourself with the knowledge, understanding, and tools to best manage your pelvic problems and pain. My own personal struggles with endometriosis, interstitial cystitis, and pelvic floor dysfunction have led me to be an advocate and a voice for all of the diseases, syndromes and complexities of the pelvis. It is with great empathy and compassion that I bring this show to you. Enjoy the next hour, and together let us learn and inspire one another. Together we can create real and lasting change.
- INTRODUCTION: The content of this show and the website for Pelvic Messenger are for informational purposes only, and are not a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician, or other qualified health care provider with any question you may have regarding concerns and medical conditions.
- Alexandra: Hello everyone, and welcome to today’s Pelvic Messenger interview. My name is Dr. Alexandra Milspaw and I’m a sex therapist here in Bethlehem, Pennsylvania specializing in pelvic and sexual pain disorders. Today I’m really looking forward to talking with Dr. Jeannette Potts about her experiences in the world of male pelvic pain and everything that goes along with that. Both within the urological and physical standpoint, but also within the realm of gender studies, and how male pelvic pain is perhaps viewed or seen or treated differently than female pain as well as vice versa. She’s with us here today to talk about that. She has a very dynamic history which I will go into in just a moment. But, first I’d like to welcome Dr. Potts. Thanks for coming on the show today.
- Dr. Potts: Oh, thank you for inviting me. I’m very excited about the opportunity to speak about all of these things.
- Alexandra: Yes, I’m excited to have the joy of being able to be the one that speaks with you on the show. So, you have a very dynamic and very interesting and layered biography. As I was reading it, and learning about you. I’d love to hear it from you as well from your standpoint, but as far as an overview for the listeners, Dr. Potts was born and raised in Northeast Ohio. She attended Lake Erie College for women where she received her Bachelor’s of Arts and Science in fine arts in 1983. And then after that she attended a university I believe in France, but I do not speak French and I’m afraid I’m not able to pronounce it. How would you pronounce it Dr. Potts?
- Dr. Potts: L'Universite de Caen
- Alexandra: Yes, where she studied the french language, civilization, and also conducted independent study of cattle in art in history with assistance from a university in Barcelona, Spain, which I’m unable to pronounce as well. As only one of 23 post grads applying for a Fulbright Scholarship, she was specially selected for the ITT fellowship for the post graduate study abroad. From there she spent two years conducting anthropological research in Mexico. After a brief period working as an exporter of automotive and heavy duty equipment, she followed her heart and applied to medical school. She attended Case Western Reserve University in Cleveland, Ohio. She then completed her residency training in family medicine in 1994. This is the point where her career took a different and unique turn, which is when she joined the department of urology at the Cleveland Clinic Foundation. The chairman of CCF Urology created this special fellowship in Urology for Dr. Potts. Enabling her to explore expertise in all aspects of the office of urology over the course of the following year. Subsequently she spent 15 years as a member of the prestigious Glickman Urologic Institute at the Cleveland Clinic. So although starting as a general office urologist, she quickly gravitated to men’s health where she developed several areas of specialization. Including but not limited to a signature biopsychosocial approach to Urological Chronic Pelvic Pain Syndrome, prostate needle biopsy strategy and active surveillance for prostate cancer as well as no scalpel vasectomy.
- Alexandra: She is now in California. Prior to that she was the director of pelvic pain alternative therapies in urology at the University Hospitals of Cleveland and help them initiate a multidisciplinary center for researching chronic pelvic pain. So she’s really spent many years within the pelvic pain world really diving head first into men’s health and how male pelvic pain syndromes are interwoven through everything that we talked about on the show previously. She is internationally recognized for her work. She is the editor of three urological textbooks. As an artist and a physician, Dr. Potts believes the art of medicine is threatened by the growing seduction of certain technologies and constraint of time on patient visits. Which is definitely something that we’ve talked about on the show before. In the limited time the patients really get to meet with the doctors and obtain a full, well-rounded history, which is really important for the integrated approach, which I’m sure you’ll talk about today.
- Alexandra: So, without delaying anymore, but certainly worth the while, because your biography is fabulous. I do like to start off with getting your story as far as how did you find yourself within the world of pelvic pain? What drew you to that area?
- Dr. Potts: Well the thing is that in between all the facets of my medical training I really wanted to be a general surgeon, and it just did not work out with my family balance. I missed it so much that when I was working at the Cleveland Clinic in my fellowship I recognized a very significant void in the care of people with chronic pelvic pain. Soon I gravitated to specifically male pelvic pain because there were even fewer resources for the men and it was interesting to revisit the motivation for going into medicine in the first place. I had been like a granola chick before medical school and I wanted to go to medical school to have the credibility because I really believed in the holistic way of life even as a very young college student. I was very fortunate to be able to go to medical school to have the credentials to promote that kind of living or lifestyle. It was very strange to rediscover that when I started taking care of people with pelvic pain, because then I thought, “Wow!”, I had forgotten through my training, and through my love of surgery, which I still love, I had forgotten why I went to medical school in the first place, so I think that sums up pretty well how we found each other again.
- Alexandra: Right, right it really helps you connect all aspects of who you are rather than just in the medical piece of it. Well, overall, you mentioned the regimenting void in pelvic pain treatment. Particularly fewer resources with men. What were some of the resources that you noticed that weren’t available to men, but perhaps were available to some women?
- Dr. Potts: Well in terms of, just even if we go outside medicine, like if we think of circles within the circle. Culturally, most people don’t even recognize pelvic pain for men, just in general. It’s the population that advocates for itself, Everyone accepts the fact that women have pain issues and pelvic pain issues and such and so we start with that circle, and if we go more internally or through specialization in medicine, we never even learn about that in medical school. In residency, the teaching still continues to be that this is prostatitis. If you go down the prostatitis or the prostatocentric route, you are limited to only a pool of medications.
- Dr. Potts: Clearly, at the time, great physicians even now it continues, I’m still astounded how many folks still only look at this only as a prostate problem.
- Alexandra: Right, right.
- Dr. Potts: Also, the fact that when one is dealing with pain and as you mention in your introduction, there is such a great need for empathy and compassion. I think that that’s yet another hurdle. I mean, physicians are human and they subscribe to the same cultural norms and biases. So I think men in general are not dealt with in a compassionate and empathic way because it’s culturally not part of our acumen.
- Alexandra: Right, and it’s interesting that you speak from that direction and I appreciate that cause you’re really challenging some notions that I had in my mind and I think bias cause I think I’ve worked mostly with women, although I’ve had a handful of male pelvic pain patients. But I had commonly heard a main difference which was with the women, their sense was the doctors gave up a lot quicker and just went straight to the psychological piece. You know, “we don’t see anything on the tests or the scans, so therefore I just think you need to see a counselor, it’s all in your head.” But with the male pelvic pain patients there was always more of a history of the doctors not giving up, of “OK there must be something, we’re just not finding it yet.” So, almost less likely or less of a rush to go to the psychological piece of it. So, I think that caused me to have in my mind “Oh at least men have it easier in some way”. You know it’s not easy at all, and I don’t want to come across sounding that way, but I appreciate your perspective on hearing that side of it.
- Dr. Potts: You know Alex, I think it’s a really important point and it’s( unintelligible)
- Alexandra: Oh sorry your voice is going in and out I’m not sure if the connection is bad I just want to make sure that what you’re saying is heard…...Ok, I can hear you now.
- Dr. Potts: OK forgive me I’m in a little remote area here with some irregular phone service, but please stop me again if there is any kind of disruptions. In general, I remember in medical school, it was a movement really across the country where feminists were arguing that doctors were dismissive or the healthcare system was dismissive and ready to call or label women as histrionic or neurotic or like you said going immediately to a psychological realm instead of addressing the physical. The way I look at it was that actually if we reframe it, men are not being diagnosed or recognized to have depression or stress or suffer from these disorders, so I felt that in a way while it was maybe an overrepresentation of women in a negative bias, there was the risk that we were biased against men and underdiagnosing them and therefore undertreating them for the very same conditions.
- Dr. Potts: So, it is really important to look at it in a balanced way. The other thing too, is that when a doctor pursues only the physical realm, there is also the risk of unnecessary testing or overuse of invasive testing. This is harmful in many ways, I mean it’s economically costly, it actually has been shown in multiple research studies to increase anxiety and therefore increase the symptomotology with very, very little yield for the patient’s good. So, that’s the other thing, too, is that it’s nice to have the validation that your condition is physical, but we need to find a way to validate the patient’s physical suffering without putting them through a battery of tests which are often unnecessary.
- Alexandra: Absolutely, absolutely. You’re really highlighting the importance of balancing the mind, body piece of it both for women and for men, and how that’s an imbalance for both, but in a different way.
- Dr. Potts: Exactly, because again, it can look really good, that “Oh it’s really good that this person is taking my symptoms so seriously, so I’m going to have X, Y and Z procedure”, but that can be very misrepresentative of what that patient truly needs and eventually, one has to address the psychological aspects because whether it was the chicken or egg, it is a big part of what is possibly perpetuating or promoting the physical suffering and I think a lot of times folks are afraid to go into the psychological realm because they are worried about angering or offending the patient, but I think that if one is sincere and practices like I have a rap that I do that it doesn’t make the patient feel that I’m saying “Oh guess what I think you’re a hypochondriac all this is in your head”. No, instead one is saying that “you know you suffering so much and I see you as more than a prostate gland or more than your pelvis and your genitalia, I see a whole person who is suffering with how this is affecting work and family and relationships.
- Alexandra: Mmmhmm, and how to express that balance and find a team to share the importance of that balance. And then even as you were talking one circle inside of the other, maybe going larger than that and being able to find a business system within the healthcare system and the insurances, how to make that work for everybody that’s involved currently.
- Dr. Potts: Well, you know it’s very interesting, I found out through someone who is with the board certification that there is not a single question on the board’s exam regarding the management of prostatitis, or more specifically pelvic pain in men. And when you know that that’s the number one diagnosis of men under 50 who seek an outpatient consultation with the urologist, that’s really shocking, and it speaks to how unimportant this is, because well, it’s just pain. I’m putting in my editorial comments there, but you know when you value something either because it’s morally important or economically important, it gets a label and it gets a diagnostic code and it gets a procedure code and it gets a question on the board. So, we’re not seeing that, and the other day I was actually looking for a code for a localization culture which is a cumbersome process, but it rules out infection and it’s reassuring to patients , and I think the physicians who feel dependent on their prescription pads in terms of antibiotics, it gives them the confidence to break the antibiotic codependency. And yet, nobody really does this procedure. Nobody really does this test. I was looking for myself and my own practice because we’re getting electronic medical record and there is no code for that process. I had an “Aha!” moment. Wow, if there’s no code and it’s not billable, it’s not important, and so maybe that’s why we don’t do it. So, it’s very interesting, and I’m still very naive I sometimes wish I was still naive about a lot of things.
- Alexandra: Yes, you’re right about the board, I mean I remember being told that in medical school. Don’t feel bad if they’re not taking notes or not paying attention, because if they’re not being tested on it, then they really don’t care. So I thought “Wow!”. So I remember specifically meaning to open up the lecture saying “I know this isn’t tested on, I know you feel this isn’t important to remember, but you should at least put this in your back pocket, because you are going to see this, guaranteed in whatever field you’re gonna go into.” And how to really help people understand the importance of seeing things, even though they’re not supposed to see them or they’re not required to see them.
- Dr. Potts: Exactly, and yes, the training is so misleading because when you are in your office with a general practice, even if you’re a specialist, some places will require people to see a general docket of patients and yes you can’t escape it, and why not try your best? Just because it’s not your specialty, why not just do the best thing you would do for the patient?
- Alexandra: Absolutely, and you touch on an important note as far as how some do invasive tests or diagnostic exams and that sort of thing, as a way to keep going, but how a lot of that is unnecessary, yet sometimes a patient can feel, or even a doctor can feel it’s being, proactive you are being productive. That also goes along with something I’ve heard of recently which is, I don’t mean to go on a tangent, but as far as antibiotics are given perhaps too frequently, but at least it helps the patient feel like they’re doing something or they’re being proactive, how that can really be harmful in the end if you’re just given antibiotic every time that you get sick, so same concept as far as really finding that balance of treating the body, identifying what’s going on in the body, but also finding out how it’s affecting their life and however it’s affecting their life is therefore affecting their emotions, be it anxiety, depression, different fears. Cause it really, particularly, the pelvic pain affects so many aspects of life. It can really interfere with functioning, daily functioning, sexual functioning, relationship functioning.
- Dr. Potts: Well, something that you probably brought up in your show other times, is that issue with time. Now, granted there is quantity of time and then there is the quality of time which is much more difficult to control in busy practices, but when you talk about antibiotics for instance in any realm. You know, the mom who’s stressed out by her crying baby, and wants antibiotics for an ear infection, but it’s viral. Or, the patient who thinks he has prostatitis because that’s what he read online and the two doctors before him said he had prostatitis. So, again to do these things, actually take less time, and I’m piggy backing on what you said about giving the patient something and appearing to be proactive, I mean this also happens in the realm of prostate cancer. Where if a patient has a low-grade, low-volume disease, you know, it takes time, as it should to counsel him and his family and assuage their fear. But the least expensive thing, is to ride the fear, and immediately book them for a treatment, when it’s actually been published that a very significant percentage of men who are eligible for active surveillance are not even counseled about the possibility. So you can imagine, if a person is afraid of the C-word and they’re not given the appropriate time to actually have a relationship with their caregiver where there’s trust, and you know there is the big buzzword these days of the shared decision making. Well, the shared decision making is only possible in the setting of trust. And you do need a little bit of time to do that. There’s all these tricks about how to make the patient believe that you spent more time with him or her, but ultimately you do need real time to do some of these things and we’re not rewarded in medicine to do it, and I think the patients also need to be a little bit more accountable as well. Patients want the most economic way of treating something, patients want everything to be covered by their insurance even if it is the lowest tier, lowest paid premium they want all those things and yet when the physicians are double booked sometimes because there is no other ways to keep the practice going they blame the physician and I think it really has to be seen as a two way street and I think patients really really need to be more accountable um because again I could blame our practice, I could blame our medical culture but you know that would be unfair it would be very unfair to put it all on one side.
- Alexandra: Absolutely, absolutely, and I think you’re speaking about the importance of shifting lifestyle and how to be counseled on that aspect of it, on the patient’s responsibility of how they can really take their health into their own hands and is there a way to divide those tasks up as far as how to guide and counsel the patient on how to do that as well as helping the patient have the resources to access the appropriate counsel. But then really almost convincing them that it’s worth paying for. People always think of the alternative therapies as far as seeking a nutritionist or seeking a health psychologist or seeking meditation or tai chi or yoga or something that’s going to really going to help their health overall, and then be able to do the poignant medical pieces that are also equally important. But to go to one person and expect everything to come from that one person is unrealistic and it’s limiting to both the provider as well as the patient.
- Dr. Potts:Well, exactly, and you know it is ironic that people are more willing to pay out of pocket for unproven, alternative care than to actually pay someone who has gone into great debt and many years in training, but again, this is a very complicated dialogue and unfortunately in our general public it’s been politicized. So, hopefully, we can have a healthier dialogue about that in the future. But going back to the pelvic pain realm, it’s really wonderful and rewarding to a physician when the patient really understands what a partnership in care is and again, that’s a two-way street, too. You know I have to be honorable and respectful towards the patient to conjure that partnership and not be authoritarian about it. However, what makes it challenging in pelvic pain is that the pain and the chronicity of this suffering often places patients in like a victimized role. So, I feel that the first step in their healing is empowerment and to help them get back into the driver’s seat and again that requires time and the establishment of a relationship because it’s frightening I would imagine to go through so many different diagnoses, and again I think in the realm of female pelvic pain there are so many more names for what could be going on you know there’s the ovary and the cysts and the torsed fallopian tube and the endometriosis and such and for a man if you’re in urology and it’s prostatitis or this pelvic pain prostatodynia, but again every specialty has a different set of names that go for the pain. But the patients can be frightened, and if they’ve tried certain types of treatment and they have the frustration, and then they begin to also lose faith in the general health care system. All of these things are for a tertiary care specialist even more challenging, because now we have to deal with again the psycho/social layers that have come with you know the disappointments in their care.
- Alexandra: Right. Absolutely, so within your care of the male pelvic pain piece, you know there’s prostatitis and there’s interstitial cystitis or painful bladder syndrome and then from there you can also have the pudenal neuralgia or pelvic floor dysfunction, for both the patients and the providers that will be listening in to this interview and discussion, could you explain how you approach your evaluation and identification of all the different pieces that are going on?
- Dr. Potts: Well, the interview cannot be overstated. The interview needs to focus on what was going on in the months or up to a year before the pain started. The interview should also allow for the patient to do a little bit of just open speech, because sometimes things are revealed without answering a direct question, and so there should be a little time allowed for them to give their narrative. I also include a genogram, which takes the family history to a whole other level because in the genogram I get the information that pertains to dynamics in the relationships and also some patterns that patients will reveal and again these are not revealed with “Well, tell me what diseases run in the family”, and “Did your grandparents have diabetes or hypertension”, so it’s more like building a family tree, and sewing in relationship observations. In the exam, of course it’s a general medical exam from head to toe, and then when it comes to pain, first we’re looking at any signs that this could be a rare infection. Again, i want to emphasize of all the people who have chronic pelvic pain, all the men who have chronic pelvic pain, 5% may have prostatitis. That means 95% do not have infection or inflammation of the prostate. And that’s easily ruled out by realizing that the patient is not febrile at the time of the exam, and that the patient had never had a documented fever with any of the flare ups or symptoms. And then, you do a urinalysis to make sure there’s no inflammation, and this can be done with a dip. I do have my cross dippie and most people have that ? in their office to check it microscopically. If one is so worried that there could be prostatitis then you can do localization culture and withhold antibiotics until you have the localization culture done. But again, that’s a lot of work for something that will only occur 5% of the time or less. However, the unforgivable part of this formula is that doctors will still go ahead and prescribe antibiotics. So I feel if you are not compelled because of the low yield to not perform a localization culture that then by the same logic, one should not write a prescription for antibiotics. If anyone has any doubt, all you do is come back in a week or two and reevaluate them. And for both of the self confidence of the patient and the physician, one will know nothing happened in those two weeks. No one got septic, there was no fever yet, and the urine remains negative. So I think that we may have to take these drastic steps to start breaking what I call antibiotic co-dependency. Ok, so enough on that. Now, the exam, I think we need to pay more attention to musculoskeletal factors, look at the spine, look at the spine in motion, check for anti obliquity and then we have to stand our patients up for the exam anyway, so that’s when I check for hernias and all these kind of orthopedic issues, pronation of the feet, leg lymphs, etc. Going back to the supine position, looking for abdominal wall trigger points, looking for abductor trigger points, looking at any connective tissue problem. And then internally, one would first do the outside of the perineal area, and then internally assess the anal sphincter tone, assess the obturator, assess all the components of the vader group, the coccis for mobility, and then finally the prostate.
- Dr. Potts: One of the things that I have found so rewarding in my past 20 years at the practice is actually reproducing the pain that the patient has and being able to look him in the eye and say “I am not even touching your prostate.” And then at the end of the exam, doing an exam of the prostate but warning the patient that yes, it’s going to feel sensitive, yes, it’s going to feel uncomfortable but it’s not heralding an infection by any means. So, that’s what I do and I think that when a patient witnesses the time and the effort in doing a meticulous examination, the patient is bearing witness to that level of engagement, it’s much easier then to have the talk about a) I’m not writing any prescription for you b) you’re not leaving with something or a diagnostic procedure and c) I’m asking you to be a partner in getting better. You cannot have that discussion if you have not put in that initial part of the work. That’s my opinion. I think that if you really do demonstrate that genuine dedication to this patient and validating their care / symptoms, then they are much more receptive to hear your assessment, and far more compliant in doing the work that they have to do to get better.
- Dr. Potts: Ya know, I’m reminded of a study I did many years ago, I sent out a survey to my patients, asking them who went and did their follow up and actually corroborated it in our medical record, too. So, any patient that I recommended specialized physical therapy, I was able to follow had they also made the appointment and then also do an assessment at their follow up. And it turned out that when I first started doing this, the compliance rate on the part of the patients was under 40%. Five years later I repeated the study and the compliance rate was 75%. And I asked myself what happened in these five years. Were my patients different? Did the demographics change? And by no means was there a difference in those patients I had seen in the 5 year time span. What was different was my level of confidence. Even though, when I began doing the alternative care, ya know not doing the antibiotics, and using more of a physical therapy type of paradigm for their healing, I knew I was doing the right thing, I was still lacking that confidence. I realized that the difference was me and my level of confidence was what really enhanced patient compliance.
- Alexandra: That’s really good to know, that’s really interesting.
- Dr. Potts: Yeah cause there’s a lot of people that are like “well , I don’t want to waste time doing this and this, and what does Dr. So-and-so do?” Well, if you don’t own it, how can you expect the patient to own it?
- Alexandra: Right, absolutely. That’s a really great point. I had a quick question with the exam part, I’m certainly no expert in anatomy, but is it true the urethra in men goes/travels through the prostate, correct?
- Dr. Potts: That’s correct.
- Alexandra: So, if interstitial cystitis is present and the sensitivity is not only within the bladder, but also within the urethra would touching the prostate, and therefore stimulating or triggering the urethra, which would trigger that pain, could that be confusing to some urologists as far as “oh, well that’s where the pain is, therefore it’s the prostate”, rather than more looking into the urethral, IC aspect of it.
- Dr. Potts: Absolutely, and imagine if it’s confusing to the healthcare provider, imagine how confusing that is to the patient. When I lecture to my colleagues, one of the things I remind them about is ya know, we’re doing hundreds of prostate exams a week, and when a man comes in because his PSA’s elevated, or because he’s got lower urinary tract symptoms due to VPH, we do his prostate exam. And many times when we’re doing a prostate exam on these mostly older gentlemen, they’ll go “Whoo” because you touched their prostate, and even if you’re doing it gently, ya know, it’s like “wow, what a sensation!” Yet if you’re seeing a patient right off the block, who’s saying to us he’s in pain and he’s under 50, and we do that same exam and we get that same response, we use that as an excuse to blame the prostate and to use antibiotics when most men’s prostates are very sensitive. You can’t also do a prostate massage and expect someone to be comfortable. So, we have to understand why it is that we ignore the asymptomatic man who gives a little squeal when you touch his prostate, but the other guy, we’re ready to write 6 weeks of Sipro. So, that’s number one
- Dr. Potts: Our number 2 is that if there’s pain radiating, a lot of men have pain radiating up the shaft of the penis, up the urethra, to the tip of the penis, sometimes that’s caused by the abnormal contractions or tension of the external sphincter muscle. And if muscles are tightened and squeezed they’re not comfortable to begin with as a baseline and if you touch those areas they will be more sensitive as well, they’ll have a higher response. So, it is very confusing to see patients having one type of symptom and not finding any other evidence of inflammation or infection and it can be very tempting to just label that as a nonbacterial urethritis and interstitial cystitis painful bladder syndrome, or even prostatitis. But I think that when the antibiotics and all the other treatments aren’t working it’s very important to look at these other areas. Nerves and myofascial trigger points often are like fuse boxes. So, that’s how I explain it to my patients. When they have referred pain, it doesn’t mean that their pain is not real, it just means that something like a fuse box is being activated, and as we all know, you can have a fuse box where one of the fuses go out and a very distant part of the house is affected. So, I think that makes it easier for the patients to understand how some of these sensibilities in specific areas could be arising from a trigger point or a neurologic irritability or sensibility that is either proximal or even far away from it.
- Alexandra: Right, and that’s a good metaphor, a helpful metaphor for people to really be able to understand the concept of the neuromuscular piece of it.
- Dr. Potts: Yes
- Alexandra: How do you treat IC? I know the treatments are varied and limiting at the same time.
- Dr. Potts: Well, I have seen many men in the past who were diagnosed as having IC, and it turned out they had the same kind of pelvic pain problems that men who were diagnosed with having prostatitis may have. So again, the same level of care is taken in evaluating them for musculoskeletal issues, myofascial trigger points and neurological disorders. Men who are older or who have a smoking history do deserve a more aggressive exam to exclude the possibility of bladder cancer. And again that’s extremely rare, but it’s a very serious consideration if one contemplating that diagnosis in a man. Now, in men who really do have a bladder problem, even when I was in Cleveland, I would refer some of those patients to my now partner Dr. Payne who was at Stanford and now is my partner in private practice. And when there truly is an end organ problem, this would be almost analogous to the prostatitis issue. Ya know, maybe 5% really do have an infection in their prostate the other 95% have a pelvic or more systemic problem, that’s manifesting as pelvic pain. The same is true of interstitial cystitis is that there is a percentage that really do have interstitial cystitis. By that I mean a person who has hunter’s ulcers and truly under anesthesia has a reduced bladder capacity. And in those instances my partner will do treatment directed at the hunter’s ulcers and hydrodistention and those will work. I’m not saying that that’s what should be done, again, for too long that type of procedure was done empirically. In the same way that antibiotics are given empirically. That’s completely wrong, but if you have everything pointing towards this malady, then it does warrant that more invasive testing and that more invasive type of treatment. That treatment is not empiric. That treatment is targeting something for which there is objective finding.
- Dr. Potts: I do want to want to make one other really important point, because we see this all the time in our practice. Men and women who’ve been diagnosed with interstitial cystitis and have even undergone preliminary treatments such as bladder installations and even worse have undergone intraoperative procedures with dissention have very, very often not had a voiding diary. A fluid diary is the first step, and I think sometimes people think this is so pedestrian. But it is the most valuable, non-invasive, inexpensive - it costs nothing - to do this test. It’s amazing how I’ll give you a recent example. And this could be a man or a woman - it happened to be a woman in this case. And she was previously diagnosed as having interstitial cystitis but she had never had a fluid diary, so when she came for a second or third opinion, she was asked to do a fluid diary and it turns out that her voids were narrowly alear. Which means that she was drinking a lot of water. She did not have diabetes and sipatis. She, for some reason, because of a urinary tract infection perhaps a couple of years earlier, just became overly conscientious about consuming water. And this is a very smart, educated person, but it became normal to them to consume these large volumes of water and then pay attention erroneously to the fact that she had abnormal voiding. And had it been for the fluid diary right from the beginning with the first physician she would have never had to have any procedures, any treatments, except the behavioral therapy and limiting her water intake. I mean It sounds so incredible, but it’s really shocking that that’s still goes on, even when we were in training 30 years ago the mantra was you do fluid diary. And I’m talking about urology training, yeah.
- Alexandra: Right, right
- Dr. Potts: I guess that’s my other plug, too, is that technology is very seductive, but we really don’t need a lot of technology to take good care of patients. We really don’t. We just need our two years.
- Alexandra: Yes, two years and attention and as you had pointed out, authenticity, compassion, and listening goes so, so far with patients. Particularly in patients with pain. And particularly I would say with men in pain because of the gender/social/cultural issues of not being allowed to show pain. Not being allowed to show emotion and that sort of thing. as well even for women needing to play through the pain and keep going. There’s so much in our culture that’s all about kind of avoiding or ignoring pain and just keep going, and how that programs the nervous system and even the consciousness to what to pay attention to, what not to pay attention to.
- Dr. Potts: And that’s a good point, too because it is a communication system and if you don’t listen to your own body, then your body gets louder and louder at trying to tell you to change something.
- Alexandra: Absolutely. Absolutely, and we are back with the fluid diary and with the genogram, I mean it’s about recognizing patterns and seeing something that sometimes can be so obvious and so hidden at the same time and hence the importance of having a really integrated, comprehensive history and interview right from the get-go. Getting as much information as possible before moving forward and being so attached to the active part of it, as far as whether it’s prescribing or doing an exam or doing a test, or even diagnosing. Ya know really trying to get the bigger picture first.
- Dr. Potts: Yes, you know I don’t know if you know I’m a tango dancer, and one of the things that we’re taught. Well, it hasn’t been taught, you kind of realize it. Once you’re a more advanced tango dancer, you actually favor the pauses. And when you’re a novice, you’re very insecure, so you actually tend to dance on every beat. But you can imagine how boring it would be to watch or even to dance something on every beat but when you’re favoring the pauses, you’re actually really listening to the music and feeling it. And when I had had that epiphany I remember there was a speaker at the IPTS who said something about reversing the phrase “don’t just stand there, do something.” But, when we’re dealing with chronic pain we’re supposed to say “don’t do something, just stand there.”
- Alexandra: Yes
- Dr. Potts: Because we do so much harm, but we’ve got that emergency room or operating room attitude. “Hey don’t just stand there, hurry up, do something, do something.” And we get sucked into the patient’s desperation. But when you’re confident, just by listening to them, not doing anything you can do more good. Especially with a chronic issue, and plus there is no hurry. You know you don’t just want to add something and make things worse. It’s actually better to have a well-thought out strategy and not behave with urgency, because also behaving with urgency can increase patient’s anxiety.
- Alexandra: That’s great, it’s such an important point I’m glad that you made that pause, and I love how you used the metaphor of the tango dancing and I didn’t know that about you, so I will add that to your biography, that’s fabulous. How do you find the time? That sounds like fun.
- Dr. Potts: Well once you’ve gone a lesson, you try to do it at home as much as possible. (Laughs)
- Alexandra: (Laughs) The pause is so important in many aspects of life, again returning to the pain, the importance of pausing and not trying to rush so much and do so much, the importance of pausing and resting and relaxing and taking the time for yourself. For the self-care aspect of it. They even teach that with hypnosis. My hypnosis training was the pause is the best thing you can do to helps someone get down into that relaxed state. You know and it always feels like you’re pausing for longer than you are. But just the importance of the pause, the importance of taking a break. The power that’s within that pause.
- Dr. Potts: That’s a really great point. And the pause allows you not to have to backtrack I think that you’re alluding to the fast-paced, multi-tasking culture that we’re enveloped within. And actually if we thought less about efficiency, and took the pause, we might actually be more efficient. (Laughs)
- Alexandra: (Laughs) Right, absolutely, exactly. That’s what I talk to my clients about all the time. You know, “I don’t have time to do mindfulness, or I don’t have time to take a break.” And it’s just like “well, when your brain is completely overloaded you’re not efficient, you’re not effective”, so trying to encourage them and really showing them the data, that if they take that 10-15 minutes a day, to just be, how much more effective they will actually be during the day. During their active hours.
- Dr. Potts: Wow! Yeah, people could see that as an investment, that’s really, really powerful.
- Alexandra: Absolutely. So, we covered a lot of ground during this interview, during this dialogue and I greatly appreciate everything you had to offer. Did I forget to touch on something that you wanted to be sure to touch on?
- Dr. Potts: No, I’m really pleased with how the interview was conducted, and you’re a great interviewer. And I think that I got to cover everything that I had in mind.
- Alexandra: Ok, wonderful. Well, of course, listeners listening in, this interview is not only live, but it will certainly be archived. Dr. Potts, what is the best way, if someone would like to reach you, or connect with you, or know where you are, what would you recommend? I mean your website is very informative your website is www.vistaurology.com. Is there any other information you’d like to give to listeners both patients and providers that listen in?
- Dr. Potts: Well, at the website there is a contact tab and there is also the option to sign up for our newsletter that we intend to put out on a quarterly basis, and so you know one can sign up to our mailing list electronically. And again, we do receive our emails through the website very regularly, and we also do a great deal of care for people who are traveling, so we’re quite agile at doing again efficient, out of town types of consults and sometimes incorporating other consultations with colleagues after we’ve triaged our patients by phone.
- Alexandra: Great, that’s really helpful to know.
- Dr. Potts: Yes and we really love what we’re doing and we’re happy to be able to do it without any kind of constraints since we’ve set up our own model of care, so it’s a hybridization of a great career at Stanford for my partner and a great career that I had at the Cleveland Clinic and combining the two together, it’s really a privilege.
- Alexandra: I’d love to make it out there, I know you’re far away from San Diego, which is where the public pain conference is, the IPPS conference is this year. But I see you’re in San Jose, which is not too far from San Francisco, is that correct? About an hour?
- Dr. Potts: That’s correct. It’s an hour and a half flight at the most, actually an hour 15 minute flight. We’ll probably be at the IPPS, so we’ll look forward to seeing you.
- Alexandra: Yes, yes, I look forward to meeting you as well. And again thank you so much Dr. Potts for your time today and your expertise, I think everything that you covered is critical, not only to the providers that are listening in, but to the patient. The things that are sticking with me are the importance of building trust between the provider and patient and needing to create that partnership in healing. The authenticity, and the importance of the complete history the complete exam, the looking at the whole person not just where the pain is exuding from but to be really comprehensive. And to take the pause, to really make sure that you provide space for the patient to talk for us as well as within the treatment process itself. To have patients and know that you’re both working towards the healing which is always possible in my opinion.
- Dr. Potts: Yes, and the only thing I would add to that is that when there is a thorough history and a very meticulous physical examination, there is often no longer the need for other testing or other procedures. I have a theory, that if this were to be done across the board, we would make a great impact on the cost of healthcare, but for now I can only speak to our own experience and that is a very good bedside evaluation can readily replace other types of testing.
- Alexandra: Absolutely, wonderful, well this is fabulous. Thank you, I know I’ve said that a couple times, but I’m going to say it again . Thank you and have a wonderful day.
- Dr. Potts: Thank you and again I was very honored to be asked to do this and I would love to participate again, if the need ever arises, or the interest.
- Alexandra: Oh, that’s fabulous.
- Dr. Potts: This is really wonderful. Thank you very very much.
- Alexandra: Oh you’re very welcome and certainly you may contact us at any time. I know you’re involved in research and that sort of thing, so if there’s anything comes up that you would love to share with the listeners, the world, please let us know, and we can absolutely bring you on at any time.
- Dr. Potts: That would be fabulous, thanks.
- Alexandra: OK, great
- Dr. Potts: Bye Bye
- Alexandra: Thanks, bye bye.
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