𝙳𝚊𝚟𝚒𝚍 𝙲𝚊𝚗𝚎𝚜

Drowning in bureaucracy & EHR hell? Step into the OR. Subtle and still surprising varations in renal hilar anatomy. The ureter peristalsing like clockwork. The course of the obturator nerve... Unchanged since the dawn of surgery. Untouched by spreadsheets. Untouched by admin. It's breathtaking. Lucky us.

@Uniquekatie02 Aja. Steely Dan.

Name an album so good you can listen to every single song without feeling the need to skip any track.

@KaiXCreator Raycast notchnook Obsidian

I’m a Windows user, just switched to macOS for the first time What should I do first?

@SalaryDr @Davembmd It isn’t ____. it’s ______ If you’re gonna write posts with AI at least strip out contrastive reframing. It’s not just lazy — it’s infuriating.

Hot take: "Production-based compensation" is the most polite phrase in medicine for "work harder for the same dollar." Every RVU target moves once you hit it. The treadmill isn't a side effect of the comp model. It IS the comp model.

@blader @grok explain this in more detail

protip: adding a adversarial subagent review gate to my plans has been a HUGE unlock to make /goal runs higher quality, and longer running. prompt: "update this plan: before marking a task as done, validate the task with an adversarial subagent review"

Best basic description of how AI works

32 patients isn’t a big series. Do you worry about rectourethrsl fistula in these patients with less prostate tissue in the radiation path especially after more definitive BPH procedures like HOLEP? In the literature baseline rate is <0.5% globally, but if you look at that group, more of them have had outlet procedures

A recent study on radiotherapy after HoLEP for prostate cancer:
RT following HoLEP was associated with low GU/GI toxicity and no significant increase in urinary incontinence. Patients maintained improved urinary function after treatment, supporting HoLEP as a safe option before RT in men with significant bladder outlet obstruction and large prostates. #ProstateCancer #HoLEP #Radiotherapy #UroOnc RT after HoLEP appears safe in prostate cancer patients:
🔹 Grade ≥3 toxicity: 0%
🔹 Biochemical control at 18 months: 78%
🔹 Local control: 94%
🔹 Significant improvement in urinary flow/IPSS maintained after RT. HoLEP may reduce obstructive symptoms before definitive RT.

A 78-year-old man presents with acute urinary retention, PSA 80 ng/mL, abnormal DRE, and a 109 cc prostate. mpMRI reveals a PI-RADS 5 lesion with extracapsular extension and seminal vesicle invasion. Neither acute urinary retention nor a large prostate should limit a thorough evaluation for possible prostate cancer when PSA and clinical findings are highly suspicious. When radiotherapy is planned in men with large-volume prostates and significant LUTS, #HoLEP should be strongly considered beforehand to optimize outcomes and quality of life. #ProstateCancer #HoLEP #Radiotherapy #mpMRI

@VincentRK @Davembmd I agree the very first thing is it’s ability to summarize will be very useful for patients

AI is not a medical expert. AI is a pseudo expert. It possesses incredible a capacity to scour all of the available information and put together a coherent answer or summary. This answer or summary will greatly help the general public and physicians who are not experts in a given disease by making search, retrieval, synthesis of available information. But it’s not an expert. AI cannot be expected to know data that’s known to experts but is not yet published. It cannot know when data in published form differs from that experienced in real world practice by clinicians who see a large volume of patients with the same disease. Where the published data are wrong or exaggerate benefits or minimize risks. It cannot judge the right treatment option among similar competing treatment options (except superficially), especially based on what the patient evaluation reveals on history and examination. AI appears to be an expert in everything in the world by knowing what experts have written and made public but lacks wisdom by the very nature of how it works to produce the answer. It’s not thinking. It knows as the famous saying where the puck is but not where it’s going to be. That’s why the even the most ardent proponents of AI including the uber rich who own the models will always seek out the best human expert available for serious diseases. They may use AI to provide a summary of their disease for the expert but they are not going to mistake or substitute AI for the expert. I don’t see this changing. Because medicine is more than knowing everything that’s published or being able to retrieve it quickly. We live in a world of medicine where it’s easy to confuse pseudo experts who have gained or granted prominence with real depth of expertise and wisdom. So it’s easy to see how a lot of us are mesmerized by the speed and eloquence of AI to answer queries. Yes it does that well (and is probably sufficient 90% of the time). But as you learn how LLMs and other AI tools work you know it’s no expert, but a useful side kick. I do think it can help both experts and non experts but we must know what it’s capable of and what it’s not.

@stuboo oh that's a good one

@CanesDavid A personal favorite… caffeinate -t 21600

sudo pmset disablesleep 1 #IYKYK

@LauraBukavinaMD @alantanmd @Papa_Heme I can’t wait for this to make it way into guidelines. I hate ordering scans on the schedule, knowing the scans are not useful.

@alantanmd @Papa_Heme Me too! Scans are … meh I mostly use for post operative hydro monitoring and fluid collection/ lymphocele these days, incidental findings etc post Cystectomy but ctDNA is a must

Honestly I can’t wait until ctDNA becomes prime time for monitoring response to cancer treatment. I’ll gladly never order a scan again.

@DrAdamBitterman @GlopesMd Always room for improvement. I totally agree. Only surgeons understand the horror and privilege …of the responsibility of being a surgeon

Easy to say and there is always room for improvement. I try and notice where everyone is and hear their conversations along with the phone ringing in the room. Let’s not forget anesthesia switching for their break or the circulating RN needing their break and having their colleagues come in and out of the room. Oh and perform the surgery safely and efficiently.

The surgical timeout is one of the most important patient safety interventions in modern medicine. We've spent years teaching surgeons that patient safety begins with the timeout, and for good reason. Over the years, the timeout has undergone multiple iterations and refinements, evolving into a more comprehensive and standardized process designed to improve communication and reduce preventable errors. But the timeout remains a static event. Patient safety is a dynamic, continuous process. Despite universal adoption of surgical checklists, wrong-site surgery, wrong implants, retained foreign objects, communication failures, equipment issues, and workflow disruptions continue to occur. Perhaps the question isn't whether the timeout is important. It is! The question is whether we've asked too much of a single pause. The timeout verifies the correct patient, procedure, equipment, and surgical site before incision. Yet surgery continues for hours afterward. Implants are opened. Equipment is exchanged. Unexpected findings alter the operative plan. Staff members rotate in and out of the room. Decisions are made in real time. Many opportunities for error arise after the timeout has ended. Perhaps the next frontier in patient safety isn't another revision of the timeout, but maintaining situational awareness from incision to closure through continuous communication, verification, and shared accountability. A timeout can verify how we start. It cannot guarantee how safely we continue. What does the next evolution of surgical safety look like? #MedEd CC: @TomVargheseJr @KevinBozic @JBMatthews @aorn @AAOS1

@DrAdamBitterman @GlopesMd This is what being a surgeon is all about, though. The surgeon needs situational awareness, team awareness. Maybe AI will help? Some kind of overarching AI observer that can keep a broader context for things the team may miss, with timely reminders when they matter.

@CanesDavid @GlopesMd What about staff change outside of surgeon? Hard to control nursing and anesthesia.

@beschur I’m not sure that’s what they’re after. Building an EHR is a tremendous cobweb.

Where this goes next: → Evidence that flags drug interactions and contraindications before you ask → Specialty-aware reasoning — oncology, cardiology, surgery — not one-size-fits-all answers → Closed-loop follow-up on incidental findings and overdue surveillance → Ambient capture that turns the visit itself into the query Patient-aware, enterprise-scale, and nothing retained after the patient leaves Here’s what I’m wondering: all of these great additions to make the EMR palatable- when do we ask if these third party products can fill in as our primary EMRs? @AmCollSurgeons @AmerMedicalAssn @UrologyUS

@DrSpratticus Fair point

@CanesDavid No question. Difference is when I ask humans some of these questions they say I don’t know. They don’t give a confident but wrong answer.

This is kind of a big deal

@DrSpratticus Now do humans. How often do they miss a lot

Interesting for sure. I have to say that Open Evidence helpful but I find it misses a lot and end up using PRO thinking models by openAI to get often more comprehensive results. It may be that I am not looking at high level questions which I would think most specialists would know already.

@Andrew_Hefley Exactly the kind of response that has left us resistant to progress and innovation for decades. How trustworthy are the humans?

@CanesDavid Definitely a step in the right direction. I wonder what % of patients would actually consent to this if given the opportunity. I feel like I know a number of people who wouldn’t trust AI with their chart.

@dradammcleod Of course

@CanesDavid I’m assuming this is an epic add on that the organization will need to pay for?

@Urology_MD @Figure_robot Let’s make a bet your timeline is wrong. Over/under 10y

@CanesDavid @Figure_robot Robotic surgery will be the first to convert not open or even endoscopy. Why? The tracked moves are there! the video feeds are stored. Like a resident learning cases from surgical videos or first assisting in the OR, the AI robots will learn these techniques. 10 years away.

Surgeons at #AUA26 should be watching this space carefully. That's a 100% autonomous robot from @Figure_robot Yes the human "won" in this head to head. But the robot doesn't get carpal tunnel, lateral epicondylitis. It doesn't get tired, lose concentration, take pee brakes, vacations, complain, or need sleep. Still -> does this extrapolate to completely autonomous surgery? In my personal opinion, no.