Dr. Toby Chai is the Chief of Urology at Boston Medical Center, professor and Chair of the Department of Urology at Boston University School of Medicine, and now the recipient of the NAFC’s annual Rodney Appell Continence Care Champion award.On today’s podcast, he discusses some common misconceptions about what urologists do and who they serve, the obstacles that insurance providers can create for patients, why “cure” can be a four-letter word and much, much more. You can read more about Dr. Chai here, and you can learn more about the National Association for Continence on our website at www.nafcpatient.wpengine.com.
Introducing Dr. Toby Chai, NAFC’s Newest Continence Care Champion
The following transcript was generated electronically. Please let us know if you see any transcribing errors and we’ll get them corrected immediately.
Bruce Kassover: Welcome to Life Without Leaks, a podcast by the National Association for Continence. NAFC is America’s leading advocate for people with bladder and bowel conditions, with resources, connections to doctors and a welcoming community of patients, physicians, and caregivers, all available at NAFC.org.
Welcome back to another episode of Life Without Leaks. We’re talking today with Dr. Toby Chi, chief of urology at Boston Medical Center, professor and chair of the Department of Urology at Boston University School of Medicine, and most recently the recipient of the National Association for Continence 2022 Rodney Appell Continence Care Champion award. Dr. Chai, welcome. Thank you for joining us.
Dr. Chai: It’s a pleasure to be here, Bruce. Thank you so much for the invitation.
Bruce Kassover: Excellent, thank you. Now I was hoping you could tell us a little bit about yourself. How did you get into urology?
Dr. Chai: I would say one of the driving reasons was my teachers at Indiana University School of Medicine were wonderful people. They showed interest in the students, and so, naturally, students want to follow what their teachers, they like, they, they want to do what their teachers do. So that’s pretty much what got me into urology, but I would say subsequently, you know, after I got into urology, I realized it’s such a big field. And I was very lucky to encounter Dr. Edward McGuire during my residency at University of Michigan, who was one of those people I think most would consider him a leader in the field of continence. And that’s how I got, you know, interested in bladder function, urinary continence, urinary incontinence. And he taught me many things, mostly clinical.
And then I would say where I am today, I would put, uh, some weight on my last teacher, which is, uh, Dr. Bill Steers, who was at university of Virginia, where I took some time off and did research in bladder physiology and got to think like a scientist and do experiments to answer mechanistic questions related to bladder control. So that’s how I came to where I am now.
Bruce Kassover: Outstanding. So tell me a little bit about your practice as it is today. Do you specialize in anything in particular or are there any particular types of patients you tend to see?
Dr. Chai: Yeah. So I got grandfathered into the subspecialty called female pelvic medicine and reconstructive surgery or urogynecology as it’s now going to be called.
I did not do a formal fellowship in that, but because of, you know, my long term interest in this area and concentrating clinically in this area, I got what they call grandfathered into the subspecialty, because it was just created in 2013. So my patients typically are anybody who has a bladder complaint.
Bruce Kassover: You’re saying that this, this really only got created in 2013. If I heard you correctly, what is it like working in something so new and what does it mean to have something so new?
Dr. Chai: Well, obviously the patients aren’t new, they’ve been around. I think this subspecialty was recognized by what is called the American Board of Medical Specialties in 2013.
The official recognition just means there’s a structure for education, testing and re-certification, so it just formalized people who are doing this area such that there’s standard operating procedures now, so to speak in getting this certificate of sub-specialization. But the patient problems have been around, obviously, before 2013, and the people who did a lot of this obviously went to all the same meetings, talked to each other, but now there’s a piece of paper one could hold. This is a way pretty much any subspecialty area has developed in terms of getting an ABMS recognition.
Bruce Kassover: Okay, that makes sense. So are there any sort of particular common types of conditions or set of symptoms that you tend to see or does it run a really broad range?
Dr. Chai: Well, so usually it’s urinary incontinence, being a big area, voiding difficulties, being another area, lower urinary tract symptoms – that’s a term that most people understand, but urinary frequency, urgency, nocturia, certainly bladder infections. And then, I also, because of the reconstructive surgery, will have anatomic problems with the urinary tract that impedes urine flow, obstructions and things that basically are anatomically oriented that may need surgical surgery to solve.
Bruce Kassover: Okay, well, that sounds like you have a pretty varied day on a typical day. I would imagine then.
Dr. Chai: It’s very fun. That’s why I’m still doing it. I love seeing patients smile when they’ve been helped and you know, that gives me the energy and impetus to continue to go forward.
Bruce Kassover: Now I’d imagine that a lot of patients would not use the word “fun” when they’re describing what it’s like to have to go to a urologist. I guess you probably deal with a lot of apprehension, maybe some embarrassment, some people who are a little reluctant to discuss what their symptoms are, does that, is that a fair characterization of a decent group of patients?
Dr. Chai: I would say to a certain degree. I think we live in a age of, you know, information overload and we have a lot of access to information, and I do believe that talking about what I call quote unquote taboo subjects have been sort of… those barriers have been knocked down in other areas of medicine as well. There are going to be, for sure, people who I think are less open to talking about these areas, but for the most part, I, myself always am trying to get the patient side of the story.
And so I think my philosophy has always been trying to develop a rapport with the patient so they feel comfortable saying what they need to say.
Bruce Kassover: I guess though, since you are a specialist, many patients have already had some sort of conversation with the primary care physician, or do you get a lot of people just coming directly to you?
Dr. Chai: Yeah, so, that’s another good point. I would say my practice is primarily referral based, so they have had to, you know, talk to somebody else like the primary care doctor to get a referral into my practice, although most urologists are open to just a patient calling in and making an appointment, but probably over 70% of my practice is referred in patients or patients referred from other providers. So when I see the patients, most of them have already had to talk about their bladder or problem with another healthcare provider. So I guess I’m lucky that it makes it a little simpler for me already.
Bruce Kassover: So tell me, what do you think are the biggest challenges facing the field of urology today?
Dr. Chai: I think it’s not just urology. I think it’s medicine in general, we’re becoming so corporatized. I hate to use this analogy: We’re becoming like, McDonald’s where the service is impersonal. You can’t get a hold of the doctor and everything seems to be a checkbox. I understand the reasons for that. Obviously there are benefits, and we can go too far to one side. You know, life is always about a balance. We tend to swing from one side to the other side, sort of head long, a lot of times without trying to hit that perfect balance. But what’s the challenge for urology? The challenge for urology is understanding that, you know, the best doctors – the three A’s for the best doctor is Ability, Affinity and Availability, and not in that order. So how do, how do we make the doctor have all three A’s?
Bruce Kassover: So tell me this from a patient’s perspective, what do you think are the biggest issues or challenges that are facing urology today if you could put yourself in the seat of a patient who’s talking with you?
Dr. Chai: Yeah, so, I think, if I were a patient, I think access is an issue because appointment times are getting longer and longer. I think I also want to be able to talk to the person who has most expertise about it, and it’s not always a doctor you’re going to see, right? And I don’t mind seeing a nurse practitioner or a PA, but somebody who obviously, so, knows about your problem and then cares about your problem. It’s actually probably the same three A’s I just talked about what makes a good doctor. I want a doctor or a healthcare professional that have those three A’s and, and, oh, the other challenge – yeah – the other challenge, I think, as a patient is the interference between a patient and the healthcare provider and the interference by the third party, which is, like, insurance companies, telling doctors and other professionals what they can and cannot do.
Bruce Kassover: Ah, yes. I think that that’s going to resonate with a lot of people. There’s a frustration all around on that. So I’m wondering, when somebody comes to you and, and I suppose this is probably an unfair question because you described an enormous range of different problems that people will be visiting you for, but can you tell us a little bit about outcomes? I mean, what sort of are the range of outcomes that patients with typical urologic problems can expect? Can we, are we talking about cures for a lot of these conditions? Are we talking about better ways to manage? What are you thinking?
Dr. Chai: So, you know, what’s interesting is “cure” is an elusive four letter word, and I actually don’t like the word “cure” because I think, how can I put this, every day we live, we’re one day closer to the end of our life.
Right? And I don’t think we could ever say that that is not the ultimate reason and I don’t want to get so morbid here, but getting back to outcomes, I’m trying to be, you know, sort of put this in perspective. I would call my field “functional urology.” It is not cancer. So I think everyone’s familiar what cancer is, because that is a very, you know, big area of medicine, outcomes and cancer has what we call hard metrics, overall survival or disease-free survival.
Those are, I think relatively easier to count than functional urology outcomes, which are patient reported, which are subjective, which are dependent on a lot of other factors. So I think to define outcomes in functional urology, there, it’s a little bit of a softer area. The word “soft” means that you can count it in different ways and people may not always agree in how you counted it.
I think the other thing that we really have to think forward is, we put patients’ expectations into the outcomes, because I don’t think every patient has the same expectations when it comes to functional urology.
Bruce Kassover: What sort of expectations do you think are are more realistic?
Dr. Chai: Let’s say you have somebody who has a lot of comorbidities. Okay. They’re diabetes, high blood pressure. Maybe they’ve had a stroke. You know that, this is a person who can have all three of these. Maybe they’re partly disabled, maybe more frail. Is the expectation of that person for a functional issue going to be the same as a patient who has, say, less comorbidities?
And again, I think this is going to have to be patient-centric. And I think patients can be realistic. Some patients may be less realistic, but I think we sort of have to query the patient what their expectations are. Cause many times, you know, doctors have their own expectations; they’re expecting a patient’s going to agree with their own expectations.
Bruce Kassover: Now before a patient comes to see you, then what do you think a patient should be doing to help, you know, maximize their opportunity for some successful outcome?
Dr. Chai: I, I think a patient should really do some homework and understand, you know, about their symptoms and you know, their condition. Now, I understand there’s people who say, oh, don’t go on the internet.
It’s full of bad information, but you know, there’s some information there that can be trustworthy and you can find, from the internet, some background information. And I think writing some questions are really important to ask the doctors about your condition. And finally, what I said earlier about if patients don’t say, I always say, well, “What do you expect to get out of this visit?
What do you want to know?” And, you know, sometimes it’s as simple as, “oh, I just want make sure it’s nothing more serious.”
Bruce Kassover: So what about things like bladder diaries, you fan of those?
Dr. Chai: Yeah. I mean, I think a bladder diary is important. Now, I don’t get a bladder diary on everybody, carte blanche. It gets back into… here’s a funny way I think about the blotter diary when I want to separate it between a sort of a lower urinary tract problem, which the bladder is a part of the lower tract, versus a non-lower urinary tract problem. And what do I mean by that? So a bladder diary, I’ll give you a practical example, can pick out a person who drinks way too much fluid, because when you add up the total volume voided in the bladder diary, you realize, oh my gosh, there is something outside of the bladder world, ‘cause drinking fluid is a behavior, it’s drinking fluid, it’s kidneys concentrating, you know, urine or not concentrating urine. So someone who has polyuria, which is basically too much volume of urine made, will be picked up by the bladder diary, but that isn’t a bladder problem. So for me, a bladder diary helps me separate a not, not perfectly, but in a global sense, it can help me sort of stratify patients into different causes of their bladder problem.
Bruce Kassover: So another question regarding speaking with patients, do you find that they expect that you’re going to be offering them medication, you’re going to be recommending treatment like surgery or an implant or something, or are they expecting, you’re just going to tell them to use absorbent or change their behavior. What do you think their expectations are?
Dr. Chai: Well, so you’ve mentioned a lot of things in what I call my toolbox. So I’m willing to offer anything that I can do to try to help a patient. Now, you know, there are what I call societal guidelines for different conditions, whether it’s stress incontinence or overactive bladder slash urgency urinary incontinence.
And, and so there are ways that we’re supposed to follow things based on the guidelines, but, you know, guidelines are sort of just that. I mean, they don’t necessarily dictate what you must do, but, so, when a patient comes in I think they, every patient has different expectations, but it’s my job to explain to them the different options and say, “You know, we probably do something less evasive.”
It doesn’t matter what the functional urologic problem is. We always think less evasive to most invasive, that’s a way ‘cause it’s a non-life threatening disorder we’re treating for the most part. Very rarely would it be life threatening.
Bruce Kassover: Say for example, medication or surgery does make sense for your patients, is there some resistance to that or people pretty open to whatever makes sense?
Dr. Chai: You know, it depends on what I call the risk-benefit profile is. And again, you know, this is part of the, also a process called “shared decision making.” You present patients options. You talk about their expectations. You talked about medicine, you talk about surgery. So we have to explain what, you know, not every surgery is surgery, right. You know, you can do a minor surgery – that’s called surgery, or you can do a heart transplant, that’s also called surgery. So some are major surgery; some are very minor surgery.
So you have to explain what the, each step, what it entails and the benefit-risk profile of each of those. And of course, people will say, “oh, medicine is probably less risky than surgery.” Well, it depends on which medicine you’re talking about also. And so patients then have that education and that information, and then can hopefully, again, help me as the treating physician come to a consensus decision between the provider and the patient to select what’s right for them.
Bruce Kassover: What about third line therapies? So I would imagine patients really, aren’t very familiar with them.
Dr. Chai: Yeah. So third line, I think you’re talking about overactive bladder, third line. So first line is behavioral modification. Second line is medications. And then the third line are the surgical options, which again are relatively minor surgery in the bigger scheme of things, but they’re Botox injection of the bladder or sacral neuromodulation, which is putting a lead into the third nerve root foramen in the sacral bony area, and then hooking up that to a electrical or battery that provides electrical impulses to stimulate the nerve, to help control the bladder, to reduce urinary frequency or episodes of urgency urinary incontinence. Again, there’s pros and cons for, you know, those two third line options. There was one large randomized trial comparing Botox injection in the bladder versus the sacral neuromodulation.
And even after having read the trial, one does not jump out. It just depends on different factors that maybe even what a patient’s, sort of, a whim, you know, a whim, it’s not scientific. It’s like, oh, “I just don’t like that.” ‘Cause they heard something that make them think a certain way. That’s kind of whimsical, so to speak, but both are both are effective, if you will, but they have different side effect profile.
Bruce Kassover: Now, but that does bring up another point because I would imagine that to a lot of patients, when you talk about things like sacral neuromodulation, it sort of sounds a little, you know, futuristic or innovative, what do you see as innovation in the field of, of urology? Do you, do you feel like it’s sort of behind the curve in terms of medical innovation or keeping up with things or ahead of the curve? Any thoughts on that?
Dr. Chai: Sure. Well, traditionally I think I’m very fortunate to be in the field that has been populated by innovative thinkers, you know, from the days of shockwave lithotripsy brought to clinical practice by urologists, which basically totally, it made open surgery on kidney stones obsolete. It just totally stopped surgery, to, you know, being the specialty that drove robotic assisted laparoscopic surgery in the pelvic area, specifically in prostate removal for prostate cancer, urologists have always sought the most innovative way to do things. And I think I do want to just mention this: I, it is very important to maintain innovation, you know, the whole thing about intellectual property and being able to have a marketable product that makes a profit for the company. Those are also important. You know, earlier I mentioned insurance companies and I try to be balanced in everything I say, ‘cause there are always two sides to every story, right.
There’s always the pros and the cons, and we don’t want to sway too much to one side or the other, but innovation involves ability to, you know, create something, market it and make money. That’s part of the innovation aspect. And so early innovation’s always going to cost more, right? And things tend to get cheaper as the product gets more mature in the market.
But in terms of functional urology, where innovation is, well, we talked about, you know, sacral neuromodulation and Botox injection. Both of those came out during, you know, I’m sorry, they were not during my training – it was after my training. So in my lifetime, I saw those two treatments come forward and I’m loath to not mention, I totally forgot the, another, and whether you put it as second line, third line, even the document I helped create in the first version, the OAB guidelines, I forgot were posterior tibial nerve stimulation, but that’s an external nerve stimulation of the ankle area where you don’t have to have an implant, although there’s some new products coming down the line on posterior tibial nerve stimulation where it’s a small implant.
But one area that I think needs more innovation is drug therapies in the area of functional urology. I think a lot of the pharma companies got out of developing drugs after beta three agonists and call it what you will, market forces, lack of interest from the stakeholders, but we seem to hit a rut in pharmaceutical development, but, hey, you know, down the road, who knows, these things tend to come in cycles also, there’s down trends and up trends like the stock market.
Bruce Kassover: Considering the literally millions of people who, who suffer from these conditions, you have to think that there are some drug companies out there that would find that research worthwhile.
Dr. Chai: I hope so. I mean, I’ll give you another drug product that has a hard time being developed is antibiotics. And I’ll tell you why antibiotics have hard time, and I think doctors are partly guilty for making a, because, doctors and other healthcare providers as well, we tend to overuse antibiotics such that, you know, and we’re getting better. There’s a whole concept of antibiotic stewardship, which means being a good steward of the resources that we have.
So, but bacteria develop resistance to antibiotics – they always do. So even a new drug, new antibiotic gets brought out like in, you know, five years. It may not be good anymore ‘cause of the bacteria resistant to it. So the drug companies are loath to bring on antibiotics because they can’t, the return is too short and not guaranteed in terms of financial investment and the return on investment.
Bruce Kassover: So speaking of research, do you happen to be involved in research yourself or do you concentrate most of your efforts now on seeing patients?
Dr. Chai: Well, research had been the mainstay of my career for, I would say about 20 of my 23 years. It’s only after I became the chair of urology here, I sort of said, I have a big proportion of my life now spent in administration and running a department.
So I gave up my lab when I started my chair position, but for 20 years I ran a basic science lab, and as you heard about my own background, I had, you know, additional lab post-doctoral training when I finished my residency. So I’ve done a lot of lab research. I’ve also done clinical research specifically in urinary incontinence as part of the NIH-funded urinary incontinence treatment network.
So I did both basic science as well as clinical science and loved both aspects, but, you know, discovery is really, really fun and the pleasure of looking at results that suddenly, the light bulb goes off and you found something new is ,you will always remember those days.
Bruce Kassover: So that brings up another point. So you have had a really notable career over more than two decades. What achievements do you think you’re most proud of if you had to go back and pinpoint anything?
Dr. Chai: Well, so, professionally, I would say it’s being able to successfully balance the, what I call the research side of my career, and then the clinical side of my career. The ability to do both, I think is always challenging, and there’s not a, a real clear-cut way of how to do this. I will give the lion’s share the credit actually to my wife, who’s also a physician and I think she made the conscious choice of, foregoing her career and say, you know, you go do your career and I will be happy doing what I, you know, want to do, but you know, you go pursue your thing.
And so I was able to have, I think, a little bit more flexibility and time wise of being able to balance that, sort of that research aspect as we were just talking about, and then also taking care of the patient aspect. So that’s what I’m most proud of is being able to do that, but, you know, I had a lot of help.
Bruce Kassover: Now, you were just selected as the NAFC Continence Care Champion for 2022. Can you talk about what you were cited for in particular that that helped you stand out?
Dr. Chai: You know what? I will make this little statement: I wish life would continue in the way that, when I was being promoted through the academic ranks, I’m a full professor now, but you have to go through assistant, associate in full, I was told, you know, the way it works is you just work hard at your job, then one day you come in, someone pats you on the back, says, “Congratulations, you’ve been promoted to the next rank,” and you go, “Oh, great” and then just go back to your work and you do your best. But nowadays, people know what the criteria are for, you know, both promotions or winning an award or whatever, they know, “I have to have all these things,” and I think then we become sort of this metric-oriented thing, and you’re not pursuing something because you want to, because you like to, because this is what drives you. It becomes… and I get it, you do have to know the criteria. It has to be transparent. The medical school has to let you know.
So, I’m not here coming to work, saying, “I need to get an award and this is why I need to get an award.” It’s like, “How do I do my job well? How do I pursue what I’m interested in? How do I help the patients?” I think I’ve been able to pull off those different things in the balance. Well, enough to where I think they said, “Oh, he’s worthy of the CCC job,” but I don’t really know because, you know, at the end of the day, I could say, oh, is it this award, that award, but I’m also a little bit embarrassed by all the awards, because it also reflects a lot of the people who’ve helped me through, you know, all my time. Like my lab, it’s a team effort when I was doing lab work. There are a lot of people doing stuff, but no, I was very honored to get the CCC, but I hope it’s because I was successful in, you know, the different domains that I was talking about earlier of what I needed to do.
Bruce Kassover: I mean, it’s not just the NAFC, that’s recognized you, you have a list of awards that I would imagine is the envy of a lot of people in your field. You’ve got the American Urological Association’s Politano Award for outstanding work and achievement of urinary incontinence innovations and bladder research, the Society of Urodynamics Female Pelvic Medicine and Urogenital Reconstructions Distinguished Service Award. That’s some pretty significant recognitions. It does have to be rewarding, I would imagine.
Dr. Chai: Well, yeah, thank you. I like to be surprised, pleasantly surprised by research results, so getting the awards, including the CCC, I’m very honored obviously, and this is something that I would never dreamt that I would’ve won, but I think it’s just me keeping my nose to the grindstone and, you know, just come in, do my work, be happy with what I’m doing. I’ve been fortunate. So in my, in our little discussion, by my teachers, by my patients who, I like seeing their smiling face when I being helping them, by the, my team, when I’m in the lab, you know, coming up with interesting results.
So I think. You know, my, my life has been very fortunate and it’s a reflection of a lot of different people.
Bruce Kassover: That’s excellent. Now I think, did I hear correctly? Did you say something earlier about writing the standards for OAB or something along those lines?
Dr. Chai: Yeah. So I was in the first version of the OAB guidelines, the a AUA SUFU OAB guidelines.
Bruce Kassover: Can you tell me a little bit about what that mean?
Dr. Chai: So it was basically getting a synthesis of all the literature on OAB treatment and trying to look for what level of evidence each of the treatments is, and then writing up a white paper on recommendations based on synthesis of the data that has been published. So that’s where we got the first line, the second line, the third line that we were talking about earlier.
Bruce Kassover: So I would imagine that’s, that’s got to be very meaningful for the entire industry then.
Dr. Chai: Yeah, exactly. There’s been actually two more versions, which I only participated in the first version. And obviously that’s the basis that the second and the third were based off, but I think yes, many in the industry, many in healthcare, you know, they look at the guidelines as sort of the standard paper, if you will. And so those kind of papers are interesting to write. They’re not certainly hypothesis-testing, that that just means doing experiments to find out if your idea is right or wrong. It is really just look, reading lots of papers or hearing about the summary of papers from professionals who actually know how to extract that data and then coming to a consensus amongst a group of experts.
Bruce Kassover: Can you tell me when your patients come to see you, do you see any common misconceptions about urology or incontinence or what you’re able to do for them that, that you might be able to disabuse them of?
Dr. Chai: So I think one misconception is urologists just see men. And I think urology has a big prostate-centric type of concept, you know, with prostate cancer and BPH. But some patients seem surprised that we also take care of women.
Bruce Kassover: That also does bring up another thing for right now: Is there anything else that you wanted to mention?
Dr. Chai: As I’ve gone through my 23 years or so of doing urology, I’ve appreciated a lot more in the area that I’m doing, which is again, bladder-related conditions as well as you know, urinary incontinence, is that there’s so many other body systems, biological systems that affect bladder function from the brain to diabetes to neurologic – other neurologic problems. I hope one day as we move forward, you know, that we’ll be able to look at a patient when we evaluate them and be able to tell what proportion of their bladder complaints are due to any of the biological systems.
I only mentioned two or three of them in what I just said, but I know there are many more. And if we get all of those that we know and develop a way to test for that patient and then say, “Hey, your bladder problem is 70% in the bladder, 10% in the urethra and 10% in the brain.” Is that 80 or 90 percent? But whatever adds up to a hundred percent, you can name all the different system based on a panoply of testing you do, so then you can direct treatment in a more sort of directed type of way, instead of using sort of what I call the guidelines way, which is we try this one treatment for a symptom that we don’t really know the mechanism for.
So I’m looking for the future where we get much more precise and we get personalized for each patient.
Bruce Kassover: That’s encouraging, and you think, you think that we can realistically get there?
Dr. Chai: Of course, that’s why I am so happy doing what I’m doing, ‘cause I think we’re close.
Bruce Kassover: Well, Dr. Chai, I want to thank you for joining us today. I really appreciate your insight. I want to congratulate you on receiving the Continence Care Champion award and all of the other honors that you’ve received as well, and look forward to seeing your continued success in the field and for your patients to continue to receive the excellent care from you as well. So thank you for joining us today.
Dr. Chai: Thank you, Bruce, my pleasure.
Bruce Kassover: Life Without Leaks has been brought to you by the National Association for Continence. Our music is “Rainbows” by Kevin McLeod. More information about NAFC is available firstname.lastname@example.org.