How the experts deal with sperm DNA fragmentation

A better version of me.

Male Fertility-Palooza

All for re-opening...sort of.

 I am all for re-opening IF the following criteria are met:

R <1 o:p="">

Hospital capacity acceptable

Medical/nursing staff OK’s and input is critical

Adequate supplies PPE for medical offices

Bona fide exposure testing available

Adequate supplies of masks, gloves for public

Social distancing enforced

Parks to re-open with caveats

Social distance enforced

No bbq

No group sports

Beaches remain closed

If R>1, pause is resumed

Contact tracing

Give me these things and, yeh, I'll support re-opening.

Discussion with Tony Tsai MD

Post-Pandemic Practice Survival Guide

1: Furlough all but most critical staff

2: Cancel all but most critical recurring payments on credit card

3: Scrutinize each and every out going payment

4: Convert phone calls to tele-visits--better for practice and patients

5: Apply for Covid-19 SBA loan

6: Apply for PPP

7: Remain calm

8: Social distance

9: Wear PPE

10: Enjoy the change of pace

Good luck,
The IU

One Nice Thing, One Scary Thing, One Funny Thing

Nice: Being part of such a great group--the executive committee of the Suffolk County Medical Society as we discuss the issues of the day

Scary: No patients tomorrow in the office.

Funny: what my hair looks like. 

One nice thing, one scary thing, one funny thing

Nice thing: Watching a cute little movie with Emma

One scary thing: closing my office and facing the potential economic impact of that

One funny thing: Incredibly funny memes and videos being shared on SOME.

Stay safe.

Stay sane.

The IU.

One thing nice, one thing frightening, one thing funny

I am going to try to do this every day during this crisis

Nice thing: Family is coming together, grateful for support of each other.

Scary thing: having to see consult on Covid patient, even with N95 mask

Funny thing: cartoon a friend shared with me--you have to contact me to find out the content.

Be well.

I started doing yoga and I like it.

Yoga is a terrific way to get a solid core strength work out while passing the time.  I do it in my hotel room room using Peloton Digital.  I find it challenging: sweating, grunting, heart rate acceleration.  I also find it calming upon completion, from a psychological perspective, and that it loosens my joints like nothing else that I do. 

Good locum activity.

Good luck.

A locum Adventure

I unexpectedly had a call-free locum tenens night, which is a rare treat in an of itself, so I decided to head up to Canada to visit Kingston Ontario.  Kingston, so I had heard, is a wonderful city with nice shopping and restaurants and bars and culture and history.  It is a university town on the north shore of Lake Ontario and is basically just across the lake from where I was working as a locum tenens urologist.

I was alone.

I was bored.

And any who knows me well, knows that driving up to Canada, just because I could, is something I would jump at the opportunity to do.

So I found myself heading north on I-81 as the sun set, toward the Thousand Islands Bridge.

The Thousands Islands region of NY is spectacular, especially in the summer, and totally worth the visit.  The region is so named for the myriad and multiple islands of granite and vegetation that pop out from the surface of the upper St Lawrence River as she begins her 732 mile journey from Cape Vincent, NY, the spot where Lake Ontario ends and the St Lawrence begins, to the Atlantic Ocean, on a meandering course that, according to geologists, defies the laws of hydrodynamics.

Many of the tiny islands have even tinier summer homes on them.  Some tiny islands have mansions on them, the Thousand Island's equivalent to Long Island's "McMansion" phenomenon.   There are castles here that were built, on some of the islands, during America's Gilded Age.  Several of them are tourist spots and can be visited for a modest fee, thanks in part to the Underwood Act of 1913, which established federal income tax in the United States.  A result of income tax was the top to bottom wealth redistribution and the rise of middle class, which forced the super-rich to sell their assets to pay taxes.

But I digress.

The history of the region is fascinating.  During the war of 1812, Canadians living along the river were forced by the British to hand over food and supplies to the military in order to supply the war effort.  In order to survive, the people "accepted" food and supplies from American entrepreneurs, their enemies, on the New York side of the river.  The Thousand Islands, during the War of 1812--and again during Prohibition--saw intense smuggling that authorities on either side of the border found impossible to curtail due to the sheer number of hiding spots amid all the nooks and crannies the islands had to offer.  I suspect smuggling still happens here with some amount of regularity given the availability of inexpensive medication and legal marijuana from Canada. 

I'd find out soon enough that American Customs and Border Patrol suspected smuggling was rampant here as well.

I had toured the area several times over the past few years whenever I was in the area doing locum.  I didn't know much about the Canadian side because I was never willing to risk going to Canada while on call.  Was the Canadian side nice as well?  I suspected it would be and I'd find out soon enough.  What tension I felt faded as I crossed the Thousand Islands Bridge and I looked out on the St Lawrence River below me.

Magnificent.

I kept going and I approached Canada's border patrol stop.

"Good evening" said the Border Patrol guard. "May I see your Passport."

He asked me a few questions and without delay he waived me through the check point and into his country.  

Canada is a different country from the USA.  Many Americans find this fact surprising...and I was one of them.  But Canada is not the United States and she seems to not really want to be, either.  We may share common language and get along pretty well but the countries are distinct from each other.  I could sense this immediately upon entering it.  All signs are in English and French and the metric system is used, as opposed to the imperial system that we in the USA still use.  I still remember when the United States was contemplating adopting the metric system in 1975 under President Carter.

Epic fail.

Carter was just too far ahead of his time.

I began to notice the highway signage, mostly the speed limit of Max 100.

O-H, C-A-N-A-D-A-HHHHH!

Until I noticed the teeny, tiny KPH next to it.

Friggin Canadian wusses.

I had a moment of panic when I saw Kingston 36 and my GPS said Kingston 20 or so miles.  Does GPS not work in Canada?  Did I take a wrong turn?  Was I going to a different Kingston?

Oh yes.  Metric.

I noticed other interesting signs like the ones honoring Loyalists and Canadian military prowess during the War of 1812.  Yes, this is a different country, indeed.  Loyalists are never honored in the United States.  My daughter, Lex, had an assignment in grade school a bunch of years ago.  The students of her class were told to ask their parents if they, the parents, would have been Loyalists or Patriots in 1775.  Of the 23 kids in her class, she was the only student that had a dad as a Loyalist.  She was humiliated--her first in a long string of eccentric-father embarrassments.  I tried to explain to her that I could see the Crown's point of view.  The colonists were happy to accept King George's money when they needed the aid to defend against French led Indian attacks during the French and Indian War.  However, when the King needed to recoup some of his losses with modest and perfectly reasonable taxation, we, the colonists, went nuts.   I just thought I'd have seen it then for how I see it now, assuming I could have avoided the tar and feathering.

"Dad, you are a dork."

True-nuff.

I found other signs fascinating as well, particularly ones related to Canadian Naval victories during the War of 1812, which seemed to me to be the very same battles that Americans claimed as victories in our signage just across the lake.

Yes, it is true: history depends on who does the writing.

As I neared Kingston, the traffic began to grow as did my nerves.  I called Lex on the phone.

"Lex, I'm freaking out!"

"Why?"

"I am in Canada."

"I am busy."  Click.

I finally arrived in downtown, historic Kingston--aka Centreville--by 5:30 pm.  The night was moonless and pitch black, aside for the street lamps, and I was unable to see any of the beauty from the waterfront park where Lake Ontario, the St Lawrence and Cataraqui Rivers meet.  Plus, it was 11 degrees Fahrenheit, which in Celsius is, like, a lot less.   I walked around Princess Street for a bit and when my nuts were just about frozen solid, I walked into a coffee shop that had a roaring fire.  I purchased a delicious cheesecake brownie and a cup of latte'.

I only mention this because I truly believe that it was this very cup of latte' that was the deciding piece of evidence to keep me out of immigration detention upon my return to the United States later that evening.

I only stayed in Kingston for an hour tops because, one, it was cold, and two, my iPhone GPS no longer worked.  I read once that people's innate sense of direction and navigation has been worsening since smart phone usage has become so ubiquitous.  I believe that to be true.  I was not certain at all how to get home from Kingston without step by step directions from Siri, but I had no choice.  Rodgers, the mobile carrier in Ontario, would not give me access to Siri.

It took my full concentration but ultimately I found a sign reading "Bridge to USA" and I-81 next left.  I sighed.  Phew.

Home free.

Five minutes later I approached the US border patrol station.  I was remembering many years ago. when I came through Check Point Charlie into the American Sector of West Berlin, how amazing it felt to see my fellow countrymen.  I rolled down the window of my rental car.

We like to think of Canada as our wonderfully nice neighbors to the north but we forget that Canada is different from the United States and that going there is not like going, say, from Illinois to Iowa.  Crossing an international border entails the giving up of certain rights, one of which is to travel unimpeded.

"Hello" I said.

"Passport, please."

I handed the young US Border Patrol agent the blue passport of the United States of America.

"What is your nationality?, he asked.

"United States" I replied.  Duh!

"What were you doing in Canada?'

"Tourism."

"Where did you go?"

"Kingston."

"What did you do there?"

"Walked around, got coffee."

"You went all the Canada just to have coffee."

"No, I went to Canada to see Kingston.  I had coffee because I passed a coffee shop and decided to have some."

"Where are you staying in the United States?"

"Watertown."

"You are from Watertown?"

"No, I am from Long Island."

"What are you doing in Watertown?"

"Locum tenens."

Blank stare.

"Do you have any weapons in the car?"

"No"

"Any medicines?"

"No."  Though I couldn't recall if I my prescription Atorvastatin, 10mg, was in my bag or not.  I was getting nervous.

"Any biologics or plants?"

"No."

"How much cash is in the car?"

"I don't know.  However much is in my wallet.  Maybe 20,30 bucks."

"What is in the back pack?"  My back pack was in the back seat.  He shined a flash light at it.

"My computer."

"Anything else?"

"I don't think so.  Maybe some socks and a few tennis balls,"

"I need you to pull the car up 6 feet then stop."

"Ok."

I pulled the car up.

"Whoa, whoa, whoa!  I said 6 feet.  Does that look like 6 feet?"

I looked at how far I came.  It looked pretty reasonable to me.

"This is more like 8 feet." he said, annoyed.

I said I was sorry.  I thought it was 6 feet but now that he pointed it out I could clearly see I was wrong.

"Do you see the officer, over there, that is flashing the light?  I need you to pull the car up to her."

"Ok."  This is not going how I envisioned it would.  I pulled up to the female CBP agent.

"You can take your cellphone. I need the car keys.  Go to the office over there." and she motioned to the station house.

There were maybe 3 or 4 sullen looking people sitting on metal benches. A young male, CBP agent, pointed at me and said, "I'll take you over here. We'll get your passport back to you as soon as possible and get you out of here."

"Thanks." Sheepish.

"What were you doing in Canada?"

"Tourism.  I wanted to visit Kingston."

"Who did you meet?"

"No one."

"No one?"

"No one."

"What did you do there?"

"I walked around.  I got coffee."

"You went all the way to Canada to have coffee?"

"No.  I went to Canada to see Kingston.  The coffee was incidental."

"What do you do in Watertown?"

"I am a urologist covering call at Samaritan Medical Center."

He repeats me, robotical, "YOU ARE A UROLOGIST COVERING ON CALL AT SAMARITAN MEDICAL CENTER.  Do you see how rehearsed that sounds?"

WTF!

I paused, unsure how to proceed.  Is he going to start testing me on my urology knowledge?  I began to think that going to Canada might not have been a good idea.

"No.  I don't see that.  It is not rehearsed.  I am a urologist.  Samaritan has only one urologist and when he is away, the hospital needs coverage. I am covering beginning tomorrow."

"And they take you, all the way from Long Island?"

"Yes, that is correct."

"When did you come up?"

"Yesterday."

"How did you get there?"

"I flew JFK to Syracuse then drove, in this rental car."

"You said you work at Samaritan on occasion.  Do work on Long Island?"

"Yes, I have my own practice."

"What is it called?"

"Richard A Schoor MD PC."  He wrote it down.

"You said you got coffee.  Do you have any proof of that?  Any receipts?"

I began to search my pockets and I found the parking receipt.  I could not find the coffee receipt.  It was hours later, after I calmed down, that I realized I never got one.

"Here is the parking receipt." I handed it to him.  He took and studied it.  "No coffee receipt?   What was the name of the coffee shop?"

I shrugged and blew air out of my mouth.  "I am not sure.  Something Crave or something or other is coming to mind.  I don't know.  I am sorry."

He told me to have a seat and pointed to the metal benches.  He'd be back soon, he said.

I sat there on the bench.  I was reading on my iPhone, trying to stay calm, when I was yelled at.

"Hey, no cell phones.  You see that sign?  It says no cell phone."

I didn't respond but I put the cell phone away immediately.  In truth I was more annoyed than alarmed because I had done nothing wrong.  Perhaps they were just doing their jobs, perhaps I fit some profile, or perhaps they just wanted to mess with me; I did not know.  I did feel powerless, however, and I hated it.  I can only imagine how terrible it must be for people of color in the US for whom this type of encounter with law enforcement is a frequent occurrence.   Driving while black.

The CBP agent returned 15 to 20 minutes later.  He waived me over to him.

"We found a cell phone in your bag."  He paused to let that fact sink into my brain.

"Ok."

"Why do have 2 cell phones?"

"One is for work.  So I can call patients back."

"Why are they 2 operating systems?  Your other phone is an iPhone.  The one in the car is Android."

"It is a Google phone.  It is cheaper than an iPhone."

He paused and stared at me for moment or so.  He then indicated that the questioning--which to me was an interrogation--was over and that I was free to go.  I was given my car keys back and was allowed to return to my car.  I wasted no time getting the fuck out of there and I gunned the engine in acceleration back onto the highway, never looking back.  It was not until I was over the Thousand Islands Bridge and back onto the US mainland that I noticed 2 items in my cup holders.  One was my hospital ID badge from Samaritan Medical Center.  The other was a coffee cup.  There was still some liquid in it.  I picked it up and peered at the side of the cup.

Crave  Princess St  Kingston ON.

* * *

You have been reading an excerpt from my soon to be released book, Stream of Consciousness: A Tail of Male Infertility, Medicine, Life, & The New York Thruway (A Real Cock & Ball Story).

   

Staying busy while on locum tenens call

Waiting to get called into the hospital is no way to go through locum call.  Depending on how busy your facility's call typically gets, try these activities to stay engaged, occupied, and happy.

• Explore: most places have something of historic interest or local charm.  Get out of the hotel and take pictures, share them on Instagram.
  
  
  
  
• Go for a walk: just make sure you have phone service and can get back to your car in a reasonable time.
  
• Binge on a Netflix or HULU, etc series.  This is good for the evenings.
• Write: start a blog or add to your existing blog.  Better yet, write a book.
• Research: I write a lot academically and as part of a book project on which I am working.  I save the lion share of my research work for my locum weekends
• CME: I do at least 50 to 100 hours per year and the majority of it I tend to do on locum call.
• Work out: most hotels have gyms and with apps like Peloton Digital and others, one can have a personal trainer-type experience very economically.  Exercise also deceases stress, which can happen when on call.
• Go to a pet store.  Playing with dogs is always a good way relieve stress and have fun.
  
• Meditate: Peloton Digital and other apps have terrific meditation leaders.  I almost exclusively do this while on locum call.
• Take a bath: seriously.  Soak in a tub.  Just soak.  Is so luxuriant.  And I never do it while at home.  Some hotels have hot tubs.  That is nice option too.
• Take a swim: If your hotel has a pool, I suggest using it.  Get goggles.  
• Read a book for fun. The trashier the book, the better, IMHO.
• Do nothing.  Seriously.  Do nothing at all.  How often to you get the do that.  The Italians have a saying for this, Dolce far Niente, the sweetness of doing nothing.  

Good luck.

The IU.

An excerpt from my upcoming book due out May 2020

An excerpt from my upcoming book, 

Stream of Consciousness: A Tail of Male Infertility, Medicine, Life, & The New York Thruway (A Real Cock & Ball Story)

I find I have to remind myself to breath when looking under the microscope at glass slides that, in all probability, will contain very few, if any, sperm.  Each slide can take 20 minutes or more to look out and I have 24 of them in total get through.  For this reason, I like to schedule testicular mapping procedures late in the afternoon, after I have finished seeing patients.  I like--I need--to be 100% focused.
I go in a systematic fashion through each slide, left to right then down then right to left; kind of like a type writer without a functioning carriage return.  I hold my breath with each turn of the wrist to move the microscope stage, hoping, pleading, praying, that I'll see a sperm.  Just one will be sufficient.  I want it, I think, as much as Kathryn and Rhys do.  
I start to hallucinate:
Is that a sperm tail? 
I think I see a head.  
There, what is that?  No, that is nothing. Fuck.
With each completed slide that is devoid of a sperm, my heart sinks and my mood darkens.
My confidence withers.
Is it me?  Am I doing this correctly?  Can I trust the results?
Of course you can.  You know how to do this.  You have had successes in the past.  You got this, motherfucker.  You da man!
I argue with myself, self loathing and boasting simultaneously.
Maybe next time I do one of these friggin things I'll bring my shrink into the lab with me.
Minutes pass.  I lose track of time.  
Slide 1 then slide 2 then slide 3 and on and on and on.
The natural tendency is blow through the later slides if the earlier ones did not have sperm, sensing futility in the endeavor.
Resist that temptation. 
Sperm production is not uniform and can take place anywhere, even on slide 24.
Keep going.  One more slide.  Come on. . . 

You have just read an excerpt from my upcoming book, due out in May 2020.  If you have any questions or comments, please feel free to reach out to me.

The IU.

On Call Sanity

Let's face it: call blows.  Social science research has shown that on-call workers are prone to a variety of stress related afflictions such as exhaustion, irritation, sleep disorders, memory disorders, headaches, musculoskeletal pains, depressed mood, sleep deprivation, insomnia & sleepiness during the daytime, reduced cognitive function, and difficulty in concentrating.   There is also a relationship between on-call work and job dissatisfaction and also between on-call work and job-turnover.  On-call work negatively affects marriages, home life, and the so called work-life balance

The best way I know to get through call is as follows:

• stay busy
• exercise
• meditate
• yoga
• do CME

I also like to get outside and walk.



Good luck out there and stay positive.
The IU

Important legislation

https://drive.google.com/open?id=12W_KzMszwFOv4tcx5gq8HaMB3sThgj4f

Exploring: One of the Pluses of Locum Tenens Urology

Brownsville NY 

Cape Vincent Lighthouse: where Lake Ontario becomes the st Lawrence River

Lake Ontario from Sacket's Harbor, site of War 1812 Naval battles

Finger Lake

The Black River

Grand Hotel, Clayton NY

Lake Ontario

Black River Trail, Watertown NY

Black River rafting, Watertown NY

Black River State Park

Night Skiing, Watertown NY

Typical winter evening, Watertown NY

Samuel Clemens, resident Elmira NY

Mohawk River Bridge, part of Erie Canal-way

Watkins Glen State Park

Finger Lake

Elmira College, 2019 Women's NCAA Hockey playoff

Chemung River, Elmira NY

Elmira NY

Street Fair, Elmira NY

Tribute to vets of the Spanish American War, Elmira NY

An excerpt from my newest book

An excerpt from my newest book coming out soon

Stream of Consciousness: A Tail of Male Infertility, Medicine, Life, & The New York Thruway  (A Real Cock & Ball Story)

I decided to drive.  I like a good road trip but what began with the excitement of a road adventure and good audio book soon gave way to increasing stress and tension with each passing mile.  The first 3 hours was pleasant enough but as I turned onto I-90 heading west from Albany, melancholy overcame my cheery disposition.  Interstate 90, which is known as the New York Thruway, traverses the state and passes some of the most important yet forgotten historic locations of our nation.  This is the region of the eastern edge of the Erie Canal, built in the early 19^th century by Irish immigrants, at a tremendous cost in both dollars and lives.  The Erie Canal may well be one of the greatest construction achievements in US history and even world history, on par with the Panama Canal and maybe even the Pyramids at Giza yet as I was driving along the highway all I could see was economic despair.  I turned off the audio book, unable to concentrate.  The river was pretty but the towns along its banks looked destitute, slum-like.  I had to look up on the map to learn the name of the waterway; the Mohawk.   Old bridges and locks; a canal system.  I had to ask myself, “What is this canal?”  I don’t recall ever learning about it in school.  How is that possible?  I made a mental note to learn about the Erie Canal during any downtime I might have this upcoming weekend of locum tenens urology call, the mere thought of which making my throat dry.

The Erie Canal was built to connect the food production facilities of the Midwest via Chicago with New York City and then the world.  The Canal is what made New York City a world capital and had a great deal to do with our nation’s prosperity.  The canal’s slow death began with completion of the St Lawrence Seaway to the north with the final death blow occurring with completion of the Thruway in the 1970s.  The canal did make many of the cities along its path rich.  Towns like Amsterdam; Herkimer; Utica; Rome: these were once thriving industrial and manufacturing towns that to me, as I drove passed them, were in decay.  The recession of the early 1970s worsened things and the towns along this once prosperous corridor have withered on the vine.  Poverty in this region of NY is rampant with rates exceeding 30% in some cities.  

My mood worsened and dread crept into my head.  I no longer wanted to be here, on this depressing road, and when I got to Utica, a city with close to half its population living in or around poverty, I decided to get off the Thruway and take a local, rural highway, in search of some charm; some history.  I hopped onto NY12, a 220-or-so-mile rural highway that starts near Binghamton and ends along the St Lawrence River, skimming the western edge of Adirondack Park.   NY 12 skirts Adirondack Park but is not part of the preserve, with its pristine lakes, dense forests, remote wilderness and high peaks.  The Adirondack Mountains are old mountains, much older than the Appalachian Range or any other range for that matter, by 2 billion years or so.  In fact, the Adirondack Range is the oldest range in the world and was formed prior even to the period of Gondwana, the giant multi-continent land mass that preceded Pangea by more than a billion years.  Theodore Roosevelt successfully fought to preserve the Adirondacks from development, starting the conservation movement.  Adirondack Park is magnificent.  But NY 12 remains outside the park, a world away from magnificent, as it winds its way along the Black River passing town after town filled with decay, dilapidation, & despondency.  

I was going upriver into the heart of darkness.

---

Let's catch up

It has been a while since I wrote about independent practice.  What can I say?  I've been busy.  Very busy.  That is a good thing. 

It has been 13 years and a few months and I enjoy solo practice as much as I did on day one, even more so. 

The early years were tough.

Lean.

Now is good.

Phone rings non-stop.  I had added 13,000 plus patients to my practice and I am really appreciated.

I have built the practice I have always wanted but never thought I could have.

I have a solid sub-specialty practice in male infertility, have a vasectomy center, do vasectomy reversals in-office and I have client depositor sperm bank. 

How many other urologists have that in Suffolk County?  Zero.  Nassau County? Zero.  New York State?  Zero.

Am I proud of this?  Hell yeah!

I have a strong referral base of independent docs, like me, who have resisted acquisition for all these years.  They ain't going anywhere.

The majority of my patients come from professional referral, word of mouth referral & web.

I do advocacy work for https://nysurologicalsociety.org/  on their exec committee and I am the President of the http://www.scms-sam.org/index3.html

It is all good.

Lov'in it.

The IU.

The New SCMS President Speaking

Sperm Talk Radio with Dr Doug Stein