Urology and the Art of Surgery w/ Dr. David Canes

Episode Information

February 4, 2021

Urologist Dr. David Canes talks about urology, robotic prostatectomies, the privilege of being a surgeon, how COVID has affected his work, and more

Topics Include:

• His childhood fascination with doctors
• The art of performing surgery
• That surgery is less of a technical feat and more about many other really cognitive skills
• That the arrival of robotic devices made a huge difference to urologists and how most of his work is doing robotic surgeries – mainly prostatectomies
• Why he enjoys robotic surgery and why it has made urologic surgery so much easier
• How you can live healthy and still get prostate cancer, especially if you have a family history
• How he likes his patients to ask questions
• How he recorded a video about prostate cancer and surgery for his new clients to watch before they came to see him, so they could use their time with him to ask questions specific to themselves and not for him to explain the procedure
• How coronavirus has changed his practice in that a lot of his work is now online video chats with patients instead of face to face meetings.
• The best compliments he has received as a surgeon
• The importance of online accurate medical education, how it is mainly lacking and how Doctorpedia is helping patients become more engaged in their health and recovery
• That medical understanding is not just for doctors: patients can understand if it is explained well
• His love for skiing

Highlights

• “There is an art to doing surgery. That doesn’t mean that if somebody has absolutely no artistic bent, they couldn’t be a masterful surgeon, but frequently there’s an overlap – I’ve met many surgeons who have hobbies that are creative in some way. I think you might find that a little bit more heavily in plastic surgery, but you’re right. Surgery frequently requires some kind of creativity and artistic eye.”
• “There is a difference between the sort of general public view of what surgery is all about and my own view from being behind the scenes. And that is that we expect that doing surgery is a technical feat, that surgeons must be very skilled with their hands and be able to be very steady. And as you say, draw a straight line without curving or shaking, but as it turns out, surgery is much more about decisions made and having good judgment and interpreting anatomy properly and staying organized and a whole bunch of really cognitive skills.”
• “Robotic surgery really means it’s almost like remote controlled laparoscopy. So it sort of has a connotation with the word robot where you think you press a button and you go have a cup of coffee and the robot does its thing, but there’s nothing automated. […] It’s almost like operating a puppet. And the surgeon is now sitting 10 feet away from the patient at what looks like a cockpit and they’re manipulating little joysticks that remotely control instruments that are inside the patient that just mimic the surgeon’s movements.
• “Essentially when you go to medical school, there’s a big fork in the road, which usually happens when medical students are doing anatomy, just like on TV, they’re dissecting a cadaver. Some people are totally enamored with the whole concept of learning anatomy and using their hands. And those people usually end up on a surgical path and then half the class can’t wait for this section of the education to be over and they end up going down a medical specialty. And I was sort of in the camp of, “Oh my God, this is amazing. I can’t believe I’m able to do this. I want to be a surgeon for the rest of my life.”
• “I think I was probably around five years old when I went to the pediatrician for something like a sore throat. And the doctor started asking me a list of questions like “Does it hurt all the time or only when you swallow, is your nose running, do you feel hot? Does your belly hurt?” And I remember thinking, “How does this person know every single thing that could go wrong with the human body?”
• “There’s nothing more trusting than going under anesthesia and letting another human being operate on you. I always think that is one of the most incredible privileges that I’ve ever been given and I think all surgeons feel that way. It’s something we just don’t take for granted.”
• “When you think about it, first of all, the patient by definition is going through a tough time, going through something they’d rather never have to go through in their life. And what does it take to be able to say ‘Yes. You’re the person that I’m entrusting for this job. I have no control and I’m just going to trust that you’re going to make the right decisions and take care of me as if I was your best friend.’”
• “I deal with a lot of cancer surgery and some of the most meaningful compliments have been something like, ‘Hey doc, it’s been five years. Every time I see my granddaughter, I think about you for a second and I think ‘Thank you for helping me be around to enjoy my life for so much longer’’ – that’s a kind of compliment or thank you that makes me so happy that I chose this as a profession.”
• “What Doctorpedia is trying to accomplish is to create a library of very high quality medical content, so that patients can be educated. And when they’re fully educated, they become engaged. And I see this over and over in my own practice that engaged patients take control over their own health.”
• “One thing in medicine is that there is almost a shroud of secrecy or a perception that medical knowledge somehow is only understandable by a select few. And this just couldn’t be further from the case.”

Relevant Links

• Doctor Profile
• Website
• Boston Magazine Profile
• YouTube: Robotic prostatectomy steps explained

Episode Transcript

Daniel Lobell: (00:00)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only, and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs. Hello, and welcome to the Doctorpedia show. I am Daniel Lobell and on the line with me today, I’m honored to have Dr. David Canes. How are you doctor?

Dr. Canes: (00:33)
I’m doing good. How are you?

Daniel Lobell: (00:35)
I’m doing well. I’m excited to talk to you because I know very little about what you do. I think it sounds cool. So I watched the video you put up online about robotic prostatectomies, which was interesting, but also a very information heavy, which you’d hope from a doctor. What I found most fascinating about it was that there are so many intricacies, it’s almost like talking about the prostate and listening to what you talked about on that video. It was almost like listening to a plumber on some level, because you’re talking about leaks and valves and drips. And I wonder if you feel that is a fair analogy to what you do.

Dr. Canes: (01:29)
It’s a very fair analogy. In fact, I jokingly tell patients that I’m a plumber – in particular if they ask me something that’s totally out of my realm, I’ll say, “You know, I’m just a plumber, right?” But you know, I’m the plumber of the human body.

Daniel Lobell: (01:47)
And the pipes of course being made of flesh and skin. I think a plumber would have it easier in that I think metal is probably a lot easier to work with. Wouldn’t it be?

Dr. Canes: (02:02)
Yeah. Getting replacement parts in the human body’s a little bit more challenging.

Daniel Lobell: (02:07)
And they’re tiny.

Dr. Canes: (02:10)
That’s correct.

Daniel Lobell: (02:10)
So what made you go into plumbing, so to speak?

Dr. Canes: (02:16)
Very few people go into medical school thinking they’re going to be a urologist. In fact, most medical students are like I was – I had never even heard of a urologist before. Essentially when you go to medical school, there’s a big fork in the road. And that fork in the road on one side is I’m going to go into some kind of medical specialty. And then the other fork is I’m going to do some type of surgical specialty. And this is a bit of a generalization, but that fork usually happens when medical students are doing gross anatomy, just like on TV, they’re dissecting a cadaver.

Daniel Lobell: (03:03)
You don’t mean gross as in disgusting, right?

Dr. Canes: (03:07)
[Laughs]. No, Not gross as in disgusting. But the class generally splits. Some people are totally enamored with the whole concept of learning anatomy and using their hands. And those people usually end up on a surgical path and then half the class can’t wait for this section of the education to be over and they end up going down a medical specialty. And I was sort of in the camp of, “Oh my God, this is amazing. I can’t believe I’m able to do this. I want to be a surgeon for the rest of my life.”

Daniel Lobell: (03:46)
That came out of that class. You had no idea until you were in that room doing it. Huh?

Dr. Canes: (03:52)
Yeah. So I had no idea until I was in that room doing dissections and learning about anatomy that I wanted to be a surgeon. And then that decision really became crystal clear. And what would happen is surgeons would come down and teach the medical students their expert part of the human body. And there was a urologist who came down and he must have seen how engrossed I was and he said, “You should think about urology.” And I said, “What’s urology?” He said, “We operate on the kidney, bladder, prostate; it’s the urinary tract in men and women. And it’s the reproductive tract in men. Just keep it in the back of your mind as you go through medical school, and check it out.” So he planted the seed that this was a specialty I should consider in the future. And then, fast forward a couple years, I shadowed some urologists and I was like, “This is incredible.” One thing about urology is we deal with such sensitive parts of the body, for lack of a better word, every urologist has a sense of humor. So I have fantastic colleagues.

Daniel Lobell: (05:13)
What are some of your favorite jokes that you’ve heard in the profession? [Laughs].

Dr. Canes: (05:20)
[Laughs]. Oh man, there’s too many. Too many rectal exam jokes to count.

Daniel Lobell: (05:27)
There’s so many rectal exam jokes, so little time.

Dr. Canes: (05:29)
Yeah, that’s right.

Daniel Lobell: (05:32)
You know, from doing this podcast, because I guess social media is spying on us all, and then target marketing us with advertising, I’ve started getting ads for surgery kits popping up on my Facebook page – ways to learn surgery. Today, in fact, I got one about how to practice doing sutures.

Dr. Canes: (06:03)
That just proves that our phones are listening.

Daniel Lobell: (06:03)
Yeah. They’re listening. In a way it’s kind of nice because our whole life, we’re hoping someone’s listening to us. [Laughs].

Dr. Canes: (06:12)
[Laughs].

Daniel Lobell: (06:12)
And now finally, at least an inanimate object is listening, right? It’s good for those of us who feel that we never were heard as a kid. Now at least we have maybe the Chinese government tuning in.

Dr. Canes: (06:32)
[Laughs].

Daniel Lobell: (06:32)
I’m watching this ad for this ‘learn how to do sutures’ kit. And I’m thinking, “They’re making incisions with the knife, they are removing objects from some type of latex material there that you learn on.” And I used to do sculpture as a kid and I did some woodcarving and it occurred to me as I watched that there’s a bit of an art to these cuts. I imagine that somebody who can’t make a nice clean cut is almost like someone who can’t draw a nice straight line. And I wonder, “Do you feel like an artist ever when you’re in there?”

Dr. Canes: (07:21)
That’s very insightful. I like what you’re saying. I think you’re correct. There is an art to doing surgery. That doesn’t mean that if somebody has absolutely no artistic bent, they couldn’t be a masterful surgeon, but frequently there’s an overlap – I’ve met many surgeons who have hobbies that are creative in some way. I think you might find that a little bit more heavily in plastic surgery, but you’re right. Surgery frequently requires some kind of creativity and artistic eye. There are many roads to travel in an operation and there’s not just one path forward. I think you’re right – there is an artistic side to it.

Daniel Lobell: (08:26)
I think from now on, if I ever have to get a surgery, I’m going to first ask the surgeon to draw a picture of me. [Laughs].

Dr. Canes: (08:33)
[Laughs]. Play Pictionary friends. See how it goes.

Daniel Lobell: (08:36)
If his lines look shaky, I’m looking for another surgeon. [Laughs].

Dr. Canes: (08:43)
[Laughs]. I’ll tell you one thing that’s somewhat tangential to what you’re saying, but I describe this to patients a lot, because sometimes jokingly they’ll say, “Let me see how steady your hands are” and I’ll oblige and I’ll put my hands out and they don’t shake. But there is a difference between the sort of general public view of what surgery is all about and my own view from being behind the scenes. And that is we expect that doing surgery is a technical feat, that surgeons must be very skilled with their hands and be able to be very steady. And as you say, draw a straight line without curving or shaking, but as it turns out, surgery is much more about decisions made and having good judgment and interpreting anatomy properly and staying organized and a whole bunch of really cognitive skills that at least while I was training, I was impressed by the surgeons that I really wanted to emulate. I thought to myself, “I want to be like this person.” It was more that I was in awe of their judgment than their manual dexterity.

Daniel Lobell: (10:03)
So you don’t have to be Hirshfield to do it?

Dr. Canes: (10:05)
You don’t.

Daniel Lobell: (10:08)
Well, that’s interesting. I think a new thing for me to consider is how organized is the doctor. Maybe I’ll go and take a look at their office.

Dr. Canes: (10:18)
[Laughs].

Daniel Lobell: (10:18)
[Laughs]. If everything looks a mess, I’m moving on to someone else, but I don’t know how you would test whether or not the doctor knows anatomy if you’re a layperson like me and you don’t know anatomy, short of playing a game of operation with them. I don’t know how you would know if they do or don’t have a good history of that.

Dr. Canes: (10:42)
No, it is very difficult to know – it’s difficult for a patient to judge. What is this surgeon’s decision-making capability? How would they change their plan if they meet a roadblock? It’s difficult for a patient. Although I think when you’re sitting face-to-face with a doctor, you can pretty quickly ascertain what kind of a person they are, how honest they are, how much they care, those things are intertwined, I think with decision-making.

Daniel Lobell: (11:25)
But you don’t know how quick they are to make a decision. Maybe you have to drop an egg unexpectedly and see how they react. [Laughs].

Dr. Canes: (11:32)
[Laughs]. I think a lot of the qualities that are important in a surgeon would be difficult for a patient to ascertain. Although if a patient said to a surgeon, “What do you think the most important qualities are in a surgeon?” I think the patient might be able to learn a lot from the surgeon’s answer. If I was interviewing a surgeon, I think I would ask a question like that.

Daniel Lobell: (12:02)
Do you think that you could tell from talking to a surgeon, much more so at least I would think than I can, if you were the one about to go under surgery?

Dr. Canes: (12:13)
Yeah. I think I probably could, because I might be zeroing in on aspects of a surgeon’s personality that a non surgeon might not clue into. I might be looking at their demeanor and their willingness to answer detailed questions and their thought process and attention to detail and those kinds of things. But then, I have to admit I would probably also going to resort to Googling them just like everybody else would. [Laughs].

Daniel Lobell: (12:50)
[Laughs]. At the end of the day, your online reputation matters.

Dr. Canes: (12:53)
It does matter. Yeah. You’ve performed over 450 robotic prostatectomies.

Dr. Canes: (12:58)
You know, whatever website said that was outdated by many years. At this point, it’s somewhere around probably 2000 or more. And you have robotic surgeries and in general, I also operate on other parts of the urinary tract, kidneys, bladder, adrenal, many more than that.

Daniel Lobell: (13:27)
That’s amazing. What can you tell us about the technique that you use and how does it compare to other methods of prostate surgery?

Dr. Canes: (13:34)
Let’s talk about this in general terms. So if you’re going to do surgery somewhere in the abdomen and the pelvis, the old-fashioned way of doing surgery is called open surgery. The doctor makes an incision and usually the incision has to be somewhat large in order to operate. And then in the 1980s, laparoscopy came along most famously doing gallbladder surgery. And so that meant instead of making a big cut, the doctor makes three or four little keyhole incisions and fills the belly up with carbon dioxide so that there’s space to work on the inside. And then using long slender instruments through these key hole cuts, almost like operating with chopsticks, the doctor is able to manipulate the tissue inside and accomplish the same operation. For challenging operations that were complicated, laparoscopy was very difficult. But in the early days of laparoscopy in urology, that is how I initially learned to do prostate removal.

Daniel Lobell: (14:56)
Really?

Dr. Canes: (14:57)
Yeah. I’m not trying to say gallbladder surgery is easy, but it is typically a straightforward operation and there’s plenty of room to work. When you’re working on the prostate, it’s a sizeable walnut and it’s tucked way down deep in the pelvis, under the pubic bone and it’s a really confined space. Laparoscopy was doable, but it was very difficult. And then robotic surgery came along. Robotic surgery really means it’s almost like remote controlled laparoscopy. So it sort of has a connotation with the word robot where you think you press a button and you go have a cup of coffee and the robot does its thing, but there’s nothing automated.

Daniel Lobell: (15:45)
It’s not like the Jetsons. [Laughs].

Dr. Canes: (15:47)
[Laughs]. Not like the Jetsons, I wish, but everything is fully under the control of the surgeon. It’s almost like operating a puppet. And the surgeon is now sitting 10 feet away from the patient at what looks like a cockpit and they’re manipulating little joysticks that remotely control instruments that are inside the patient that just mimic the surgeon’s movements.

Daniel Lobell: (16:15)
I guess the litmus test for this would be to take you to the supermarket and see if you could use that claw machine to pick up one of those stuffed animals.

Dr. Canes: (16:26)
Exactly. Or some kind of video game, see how well you play Fortnite or something like that. Urologists really celebrated the introduction of robotic surgery because we really needed it. We were operating in tight spaces and all of a sudden, we had this robotic instrumentation where the tips of the instruments can rotate and it feels like you’re actually inside the person’s body and all of a sudden able to do complicated maneuvers that were previously difficult to do. I just now described how amazing this technology seems. And what I’m about to tell you next might sound a little bit crazy.

Daniel Lobell: (17:19)
This would be a great place, if we had a commercial, to put it in, to keep people on the edge of their seats.

Dr. Canes: (17:28)
With all that said, the outcomes of these surgeries depend far more on the surgeon than it does on the tools. I mean, don’t get me wrong. Robotic surgery is my absolutely my preferred way of operating because I’ve been doing it since 2006. I do almost all of my surgeries that way and it’s become sort of my preferred world, when I operate. But remember I told you that my opinion about surgery is that it’s all about decisions that are made and really that’s true. So a surgeon can do an exquisite job removing a prostate, doing an old-fashioned open surgery. They could also do a not so exquisite job, the same goes for laparoscopy, same goes for robotic surgery. And I think that mostly has to do with the decisions they make, the way they interpret the anatomy, where they decide to make the little cuts that they make.

Dr. Canes: (18:31)
And whether a surgeon is holding a scissors in their hand or holding a laparoscopic scissors or directing a robot scissors, it matters where they make the cut. In the end, surgical experience and judgment is going to trump everything. There are some advantages with the robotic technique. The incisions are smaller. Recovery appears to be faster. There seems to be less pain associated with smaller incisions, but still, if I were on the patient side of things, let’s say I was diagnosed with prostate cancer – what I would be focused on is finding a surgeon who does the operation a lot, has a lot of experience, and I would focus less so on the exact tools that they use.

Daniel Lobell: (19:30)
So that brings me to my next question: “Is the majority of what you do work on people with prostate cancer?”

Dr. Canes: (19:39)
It’s a lot of what I do. My practice is primarily urologic oncology. That means I deal mostly with cancers of the urinary tract. And it just so happens that prostate cancer is the most common cancer of the urinary tract. I also operate frequently on kidney tumors and bladder tumors and some other less common ones. But just by virtue of what cancers are common, prostate cancer is usually number one.

Daniel Lobell: (20:24)
Do you have some advice for people on how to avoid getting it? I imagine that that’s something you would know more about than most.

Dr. Canes: (20:36)
Well, let’s just talk about prostate cancer. It’s very attractive to think that cancers are preventable and I think there are ways that we can modify our risk, but to some degree, the cards that we’ve been dealt as far as our future risk for getting prostate cancer has a lot to do with our family history. In other words, have a lot of men in the family, father, uncle, grandfather gotten prostate cancer? Have a lot of the women in the family been diagnosed with breast cancer? There is some association. There’s a significant genetic component. And then there are certain things that we just can’t prevent, prostate cancer incidents, like the prevalence of prostate cancer goes up just with the aging process in ways that cannot always be prevented. I wish I could be on the podcast and tell you that you should take such and such vitamin or supplement every day and that’s going to be your answer.

Daniel Lobell: (21:59)
It would have been nice. [Laughs].

Dr. Canes: (22:03)
You know, there’s no secret ingredient.

Daniel Lobell: (22:09)
Oh boy. So you can be in perfect health and it’s primarily genetic.

Dr. Canes: (22:17)
And you can still get prostate cancer. For all cancers though, I will tell you what’s healthy for your heart is likely also healthy from a cancer prevention standpoint. So in other words, there’s increased cancer associated with obesity, associated with alcohol use and abuse. And to keep it simple for those listening, when you think about a heart-healthy diet, you’re probably also describing a cancer-healthy diet.

Daniel Lobell: (22:53)
And I suppose it’s just a general health thing because if you’re obese or if you have an alcohol problem, your organs aren’t functioning as well as they could be. And therefore the whole body starts to break down. Is that a correct assessment?

Dr. Canes: (23:08)
Yeah, I think that’s a good way of describing it.

Daniel Lobell: (23:10)
All right, I’ll get in shape. [Laughs].

Dr. Canes: (23:17)
[Laughs].

Daniel Lobell: (23:17)
If only it was that simple to make the decision. So we talked a little bit about what pushed you towards surgery and even what pushed you towards working in urology. But we didn’t talk about what made you get into medicine in the first place. I did a little research and saw you talk about being a child and going to the doctor and being fascinated when he asked you if you had a sore throat or other things, and wondering how that was going to help him diagnose you. I was wondering if you could expand on that a little bit.

Dr. Canes: (23:56)
Yeah. I think I was probably around five years old. I remember it pretty vividly. And I don’t know if this is something that all kids think about when they go to the pediatrician, but I was there for probably some very easy complaint, something like a sore throat. And the doctor started asking me a list of questions. I don’t remember exactly what they were, but questions like “Does it hurt all the time or only when you swallow? Is your nose running? Do you feel hot? Does your belly hurt?” And I remember thinking, first of all, how does this person know every single thing that could go wrong with the human body? Maybe that’s odd for a five-year-old to think about, but that was my first thought. My second thought was, “I better give him the right answer to each of these questions cause I don’t want to throw him off. If I tell him the wrong answer, he’s going to think I have some other thing that I don’t have.”

Daniel Lobell: (25:02)
You were a pretty neurotic kid. [Laughs].

Dr. Canes: (25:03)
I was pretty neurotic. [Laughs]. So I was fascinated about the whole concept that doctors exist, that there’s somebody who learned the things that can go wrong and can figure it out for you. And so I think becoming a doctor was in the back of my mind.

Daniel Lobell: (25:31)
What did your folks do?

Dr. Canes: (25:34)
My folks were not doctors. What did they think or what did they do?

Daniel Lobell: (25:39)
I was asking what they do.

Dr. Canes: (25:44)
So they’re not physicians, there were no physicians in my family when I was making the decision. My father was trained as an actuary, very much a mathematically minded person, fantastic with computer programming, very analytical mind.

Daniel Lobell: (26:09)
Don’t actuaries predict when you’re going to die for the insurance companies?

Dr. Canes: (26:14)
Yeah, they do help with long-term mathematical predictions.

Daniel Lobell: (26:21)
So they’re almost like psychic doctors in a way. [Laughs].

Dr. Canes: (26:27)
[Laughs]. That’s right. My mother was gifted with languages and she taught French and Spanish.

Daniel Lobell: (26:39)
It’s funny that your dad was predicting when people were going to die and you were saying , “Hang on, maybe I could prolong it a little bit.”

Dr. Canes: (26:48)
[Laughs]. Oh my God. He’s going to like that if he listens to this. I think that my childhood fascination was the beginning. And then as I went through school, although I was interested in almost every subject that I came into contact with, I loved biology, so the interest grew from there.

Daniel Lobell: (27:13)
That’s interesting, because a lot of the doctors that I speak to are second or third generation doctors. So it is less common to find somebody who is the first doctor in the family. I remember when I was a kid and I went to the dentist and he told me, “Make sure you brush your teeth and make sure you brush them twice a day.” Then I said, “What about my tongue?” And he said, “What about it?” I said, “Should I brush my tongue?” He said, “It’s not a bad idea, nobody’s ever asked me that before.” And he said to my mom, “Your son asks some wild questions. No kid has ever asked me if they should brush their tongue.” And I remember that being a moment for me, where I realized I asked bizarre questions and I maybe that’s why I became a comedian. [Laughs].

Dr. Canes: (28:09)
[Laughs].

Daniel Lobell: (28:09)
If you had one thing that you wish your patients knew coming in, what would you say that is?

Dr. Canes: (28:31)
One thing I wish my patients knew is that I really like it when people ask questions. I feel like there’s typically an apology that comes before a question, “I’m sorry. Do you mind if I ask some questions?” and that must or might come from a place of many patients thinking that the doctor doesn’t want them to ask questions. I much prefer if I get questions, because that means the patients are engaged. They’re part of the discussion. They’re participating in the decision.

Daniel Lobell: (29:20)
And of course asking, “Can I ask a question?” is a question in itself.

Dr. Canes: (29:24)
Yeah, there goes one of your questions.

Daniel Lobell: (29:26)
I once interviewed Larry King for a show that I did. And I said, “Larry, can I ask you a question?” He said, “Just ask it. You don’t have to ask, “Can I ask a question?” just ask the question.” From that point on, I try to always be conscious not to ask if I could ask, but just to ask.

Dr. Canes: (29:48)
That’s what I would want patients to do too.

Daniel Lobell: (29:50)
Yeah. I wonder if it’s some kind of an insecurity or people think, “Oh, I don’t want to waste the doctor’s time,” but I think that is a great piece of advice because not only does it make the patient more comfortable because they now have these questions resolved, but it also develops a good a doctor-patient relationship, I would imagine.

Dr. Canes: (30:10)
Yeah, I think so.

Daniel Lobell: (30:14)
So what do you think are the most important facets of that relationship?

Dr. Canes: (30:20)
To me, it all boils down to one thing – it’s trust. That’s especially true in my specialty because there’s nothing more trusting than going under anesthesia and letting another human being operate on you. I always think that is one of the most incredible privileges that I’ve ever been given and I think all surgeons feel that way. It’s something we just don’t take for granted.

Daniel Lobell: (31:04)
I would say it’s that and getting into an Uber.

Dr. Canes: (31:12)
[Laughs].

Daniel Lobell: (31:12)
[Laughs].

Dr. Canes: (31:12)
Yeah. Those are exactly on par.

Daniel Lobell: (31:14)
Well, in both cases, you’re putting your life in somebody else’s hands. I don’t want to belittle surgery. [Laughs].

Dr. Canes: (31:23)
[Laughs]. Oh man. Well, getting into an Uber without checking the plate.

Daniel Lobell: (31:27)
Yeah. Okay. But yeah, I think that’s a very profound thing that you’re saying, you’re letting another human being cut you open and it’s not something you really think about too much because you walk in and the setting is a hospital and you see diplomas on the wall and you hopefully have some kind of ease in all of that. But at the end of the day, there is something almost primitive about it, right?

Dr. Canes: (31:56)
Yeah. That’s true.

Daniel Lobell: (32:00)
I never really stopped and looked at it like that, but you’re saying, “Hey, okay, I’ll make an agreement with you. You can knock me out and take a knife to me and let’s hope for the best.”

Dr. Canes: (32:10)
Yeah. I mean, there’s really so much that goes into it. When you think about it, first of all, the patient by definition is going through a tough time, going through something they’d rather never have to go through in their life. And then what does it take to be able to say “Yes. You’re the person that I’m entrusting for this job. I have no control and I’m just going to trust that you’re going to make the right decisions and take care of me as if I was your best friend.” So there’s a lot that goes into it: probably a combination of a gut feeling, doing some research, the interaction that you have with the doctor and the consultation, reputation, talking to friends and family. There’s a lot and increasingly now, which I find fascinating, frequently because of COVID, I’m meeting patients only virtually first with a webcam. And they’re still able to develop enough trust to have the next meeting be the day of surgery.

Daniel Lobell: (33:30)
Yeah. That was leading right into my next question. I was going to ask you how COVID has changed things for you. That’s certainly one way. How else do you see that things have become different since the pandemic?

Dr. Canes: (33:48)
That’s the biggest way. Before COVID, if you’d asked me, “How inclined do you think patients would be to sign up for surgery if they hadn’t met you in person?” I would have said, “Probably they wouldn’t.” And that turned out not to be the case, so that’s the biggest surprise. The other very tangible way that COVID has impacted things is, by necessity, we converted a lot of our office visits to remote TeleVisits. So they’re happening over secure video chat and probably depending on the day, 40 to 70% of my clinic is now virtual. A year ago, it was 0%. And I think it’s a good thing for patients actually, especially for minor visits or for return visits after surgery. It’s a big burden on patients to have to take a day off of work, drive all the way to the doctor’s office, in some cases pay for parking, wait in a waiting room. And to now be able to do this visit from the comfort of their home, work or car is fantastic.

Daniel Lobell: (35:15)
So I imagine it’ll stay that way after Covid.

Dr. Canes: (35:18)
I think it will. I think a lot of it will be here to stay- not to the degree that it had to be for a few months there, but it’s definitely going to remain in some capacity.

Daniel Lobell: (35:30)
What you don’t want to find out is that patients are more inclined to go into surgery if they don’t meet you in person. [Laughs]

Dr. Canes: (35:41)
[Laughs]. Right, that would be bad.

Daniel Lobell: (35:47)
What’s the biggest compliment a patient could give you?

Dr. Canes: (35:58)
That’s a good question. Let me think about that.

Dr. Canes: (36:09)
I deal with a lot of cancer surgery and some of the most meaningful compliments have been something like, “Hey doc, it’s been five years. Every time I see my granddaughter, I think about you for a second and I think, “Thank you for helping me be around to enjoy my life for so much longer” – that’s a kind of compliment or thank you that makes me so happy that I chose this as a profession.

Daniel Lobell: (36:59)
Yeah. That’s a powerful thing to be told. I don’t think too many people outside of the medical profession hear that kind of thing. Maybe pilots who saved people from a crash, but other than that, how many people can thank another person for giving them the years on their life? I think that’s profound. Do you remember the Miracle on the Hudson that happened?

Dr. Canes: (37:22)
Yes.

Daniel Lobell: (37:23)
The pilot was Sully Sullenberger. And when it happened, I had a comedy album that was coming out that week and I thought it’d be funny to make a parody Facebook account of Sully and have the only thing he posts is about how he was listening to my comedy album and it’s what got him through in those tough moments.

Dr. Canes: (37:50)
[Laughs].

Dr. Canes: (37:50)
And then everybody should buy it. I thought it’d be a fun little marketing idea.

Daniel Lobell: (37:55)
So I put it up and I was posting as him and saying, “Daniel Lobell’s album, some kind of comedian was what was playing in the cockpit and I wouldn’t have been able to pull off such a tough thing had I not been laughing and at ease and everyone should pick it up”, and I left it up there and I forgot about it. And then I went back a few weeks or maybe even a month or two later, just to see, maybe I should shut that account down now that the album’s out. And the inbox was filled with messages and it was messages from people who were on the flight and they didn’t recognize that it was a parody account. They thought it was really him and they were saying, “I didn’t know how to reach you. Ever since the landing on the Hudson, I’ve wanted to talk to you. I wanted to thank you.” And it was people saying, “Thank you for saving my daughter.”

Daniel Lobell: (38:48)
And I had to write to all these people and say, “This is not really him.” And I actually changed it so that it said in the title, “This is a parody account.” And I checked back a week or two later, and I still had more messages, people weren’t reading it. They were more people writing. I remember reading those messages and thinking, “I’ll never likely get a message like this in my life, what this guy did for all these people saving their lives and their loved one’s lives.” I thought for a minute, “I wish I could be a hero like that.” And that’s why I took pause when you said that about people coming up and saying, “Thank you for when I see my granddaughter”, there aren’t too many jobs that provide heroes in this world in that way. So I think that’s really something to be proud of.

Dr. Canes: (39:43)
Yeah. I have to say that the way you encapsulated that concept was apparent to me when I was in college. I remember actively thinking that every job has its frustrations and don’t get me wrong – surgery does too. We have administrative things that we need to take care of. And we battle with insurance companies and the job has its frustrations, but I thought to myself in college that every job has frustrations. But the high points of just getting a sincere thank you for helping me, moreover from a family member who gets to spend more time with their loved one, that’s what I was after. And it’s really fresh every time.

Daniel Lobell: (40:44)
Yeah. It’s pretty amazing. To shift gears, how’s technology changing health and wellness? I know we talked a little bit about robotics. What about in terms of apps, computers, websites and that type of thing?

Dr. Canes: (41:04)
Interesting. For the patient, or for the doctor?

Daniel Lobell: (41:07)
I was talking about for the doctor.

Dr. Canes: (41:12)
I was thinking from the patient’s side. I’ll give you two examples about apps that are making a difference. When patients have kidney stones, they’re told that they need to make life changes. And from this point forward, they need to drink just a ton of water every day. And it’s one thing to get that advice and then another to actually accomplish it. It’s very difficult to drink the volumes of water that you have to drink to not get kidney stones. You’ll be acquainted with every bathroom in a one block radius. So somebody created an app that allows people to track their fluid intake and make sure they’re on track. There’s another app. Sometimes patients come to a urologist with urinary troubles and the doctor will assign them the homework of doing something called a voiding diary, which basically means write down every time you pee, how much you’re peeing and every time you drink, how much you’re drinking. And as far as I know, apps have been created to help with that kind of thing.

Dr. Canes: (42:32)
So from a patient’s perspective, I think some of the tasks that doctors assigned to their patients can be a little bit onerous and technology can step in and make those tasks a little bit easier to accomplish.

Daniel Lobell: (42:46)
Yeah. And what about you, do you use any apps to monitor your own health?

Dr. Canes: (42:55)
I use the Apple watch. I monitor my workouts, the frequency of my workouts, my steps, my activity level, my heart rate when I’m exercising, to look for improvements, look for trends. That’s about the extent that I monitor for my own health, but I do find it useful.

Daniel Lobell: (43:30)
Yeah. You recently joined Doctorpedia as a founding medical partner and as a chief medical officer of our cancer channel. What do you hope to accomplish with this channel and what are your big goals and ideas for your place in Doctorpedia and Doctorpedia’s place in the world? It’s a loaded question.

Dr. Canes: (43:53)
No, I think it’s a good one. What Doctorpedia is trying to accomplish is to create a library of very high quality medical content, so that patients can be educated. And when they’re fully educated, they become engaged. And I see this over and over in my own practice that engaged patients take control over their own health. And I feel like this is currently missing online, and I’ve personally watched my patients become more empowered when they’re educated. I’ll give you an example from before I knew that Doctorpedia existed: As we’ve discussed, I see a lot of patients who have received a prostate cancer diagnosis, and they’re coming to me to talk about what their treatment options are, to decide if they want to have surgery. And even more than that, if they want to have surgery, am I the person that they want to trust with that task?

Dr. Canes: (45:16)
And I found that in my own clinic, it takes a lot of time to explain what happens during a robotic prostate removal. And what I really want to talk to the patient about is whatever is specific to their situation. Everybody’s situation is unique. And so I decided “God, you know, it’s not a waste of time. I’m spending a lot of time discussing something that I wish the patients could come in already knowing. And if they could come in already knowing this stuff, then I could focus just on their particulars. They’d probably enjoy that better. And I would enjoy it better too. We’re both part of the equation.”

Dr. Canes: (46:00)
So I recorded a video – the one that you referenced on YouTube – and I started reaching out to patients before they came into my clinic, saying “Hey, listen, I saw that you’re coming in to see me. Do you have an email address? Do you have online access? I’m going to email you a link to a video, do me a favor and if you can, watch it before you come in and see me,” and the reaction could have gone one of two ways. On the bad side, patients could potentially have been offended. I didn’t know how they would react. Why doesn’t this doctor want to spend time explaining this to me in person, he’s pawning me off on his video. Thankfully I’ve never heard that reaction, quite the opposite – people seem to really love it. They come in already with a fund of knowledge that serves as just a launching pad to talk about their specific situation. And then they have all these questions that previously they would have left the office and they would have been at home thinking, “God, I wish I’d asked Dr. Canes this question.” They’re coming in with pretty advanced questions and it’s fantastic. Patients really can absorb the information quite easily if it’s explained well. And that’s sort of a use case. My own clinic is a use case for what Doctorpedia could be. So this is what I envisioned for the cancer channel for men’s health channels for really, for any aspect of Doctorpedia.

Daniel Lobell: (47:52)
Yeah, it’s great. You’re basically empowering people with knowledge and information.

Dr. Canes: (47:58)
And I think generations back, I don’t know whether this view was generated by patients or by physicians, but the sort of view of the paternalistic doctor who’s just going to tell you how it is and “What would you do, doc?” And then the doctor declares the treatment going forward, and then that’s what we do. And that’s really not how things are now, not how it should be. And as I said, I don’t want to sound repetitive, but patients really can grasp complicated medical information if it’s presented properly and the more the patient knows, the better it is for everyone.

Daniel Lobell: (48:51)
I think so too. I completely agree. I think that’s true in everything. I think the more you know going into anything, the better it is.

Dr. Canes: (48:58)
I think you’re right.

Daniel Lobell: (49:00)
But certainly it alleviates a lot of stress and anxiety for people going into what can be a terrifying surgery.

Dr. Canes: (49:10)
I think that one thing in medicine is that there is almost a shroud of secrecy or a perception that medical knowledge somehow is only understandable by a select few. And this just couldn’t be further from the case. If you just take the Coronavirus vaccine because today as we record, it’s December 8th 2020 and it’s a hot topic in the news, the idea of creating an RNA vaccine and the body’s immune system response to it is a complicated topic, but there’s plenty of examples of this explained very well online in a way that patients can understand and in the popular press, we talk about a problem of some patients fearing the vaccine or reluctant to have the vaccine. The answer to that is education.

Dr. Canes: (50:18)
And so no matter what example you choose in medicine or surgery, proper education is one piece of the puzzle, but it’s a really important piece. And that’s sort of what drew me to Doctorpedia where pretty quickly I thought, “Wow, they’re really onto something here. This is crucial and for the most part it’s missing.” And I can give you some more examples if you want.

Daniel Lobell: (50:52)
Yeah, please do.

Dr. Canes: (50:53)
So this question of ‘What is the current status of online patient education?’ has actually been studied by doctors who’ve published research on this. So there’s a few studies that stick out in my head. There’s one on breast cancer, where the doctors looked at the top 50 videos on breast cancer on YouTube, and then using some scoring systems, they scored the videos. Some of them were popularity, how many people liked the video, thumbs up, thumbs down, but then scientifically they looked at the video based on a bunch of criteria, like was the person giving the video an expert? Did they name their sources? Did they disclose whether or not they had any financial conflicts? How well did they explain the information? Was the information current? Was it balanced, or did it seem biased towards some treatment or another? Were they honest about areas of uncertainty? Did they talk about benefits and risks? So they scored the videos and they found that something like 86% of the videos were either poor or very poor and only 2% of the videos were judged to be excellent.

Daniel Lobell: (52:34)
I’m not surprised.

Dr. Canes: (52:35)
Yeah. And there are other studies, one that looked at videos about male infertility, another one looked at the 150 most viewed videos on prostate cancer. By the way, mine is not one of the 150 most viewed, but more than half of them had plain factual errors. So there’s a huge need for credible up-to-date video content. I don’t blame patients for searching YouTube for their medical condition. I might do it myself if I had a new diagnosis, but it’s sort of scary what’s out there, because anyone can upload a video.

Daniel Lobell: (53:20)
And if you have no quality control, who knows what you’re watching, you might wind up getting a surgery with a broken beer bottle. [Laughs].

Dr. Canes: (53:26)
[Laughs]. That’s right.

Daniel Lobell: (53:31)
Doctor, it’s really been a pleasure talking to you and it’s been informative and eye opening. Thank you.

Dr. Canes: (53:41)
No, thank you. Thank you for having me on the podcast. I really appreciate it.

Daniel Lobell: (53:44)
It’s my pleasure. I’m going to end the interview with the same question I end with in every one of these I do, which is what do you do to stay healthy?

Dr. Canes: (53:54)
Well, it depends on the season. In winter, I am an avid skier. I ski somewhere between 30 and 40 days a year.

Daniel Lobell: (54:06)
Wow.

Dr. Canes: (54:08)
On some of those ski days, instead of skiing, I snowshoe up the mountain, which is like one of the most unbelievable workouts you could possibly imagine. It feels like you come close to death trying to get up to the top. I ride a stationary bike and in warmer weather, I go running. So those that’s what I do to try and stay healthy.

Daniel Lobell: (54:37)
Wow. So do you recommend that we all start skiing? I’ve heard it’s pretty dangerous. [Laughs].

Dr. Canes: (54:47)
[Laughs]. Yeah, you know, it probably is quite a dangerous sport. I mean, the chances of my breaking a bone at some point are probably high. I’ve been lucky so far. Every time I go skiing, the chairman of my department says, “Don’t break your wrist or your hand.”

Daniel Lobell: (55:08)
Yeah, that’s a good point. But at least you get the robots, if everything goes wrong, you can lean on the joystick hopefully. You could operate it with your feet at worst case scenario. [Laughs].

Dr. Canes: (55:20)
There you go. [Laughs].

Daniel Lobell: (55:24)
Let’s hope that never happens. Dr. Canes, it’s been a pleasure. Thank you so much. I hope you enjoyed it.

Dr. Canes: (55:29)
I did. It was great. Thank you, Danny.

Daniel Lobell: (55:34)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only, and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs.