“Keyboard Warrior”: In Conversation With Dr. Riccardo Bertolo

Welcome back to the Accelerators Podcast. We're bringing you on college news and views with guests from all over the field. The discussions on this show are not medical advice and they represent our own opinions and not those of our employers. Thanks for being here. Let's get on with the show. Welcome to a special episode of the Accelerators Podcast. I'm Simil Perique, Ray Sean College's practicing in Detroit, Michigan and I'm here with a special guest. Let him introduce himself. Yeah, thank you. Thank you for the introduction. I'm Ricardo Bertolo. I'm working in Verona as an assistant professor together with Professor Antonelli in the Erology Department of the Verona Academy hospital. Yeah, I'm 40 years old. Okay, and you're looking at Verona. I've been Italy before. I've not been to Rome. I know Verona from Rome, Juliet, but I looked on the map. It's the west of Venice. Looks like a beautiful city. Yeah, yeah, yeah. It's a very it's a famous one. I noticed it's famous all over the world for for the for Romeo and Juliet. For some for the red wine Amarone and also for the small Colosseum, let's say, is the arena. It's for the Roman origins. Okay, and Ricardo Lake, which is very close. Okay, yeah, I'm going to have to visit at some point. And so we talked a little bit before this. You did some training in the United States as well. Yeah, after, you know, starting attending the residency program in Erology, a PhD in touring, which is my hometown. I moved to Cleveland at Cleveland Clinic, walking with Giat Kaug for a research fellowship there. Also had some opportunity of training with preclinical model. We were lucky because when I was there, the first SP platform was installed at Cleveland Clinic, Cleveland, Ohio. So it was very nice here, very productive. And afterwards, I moved to Rome for working like for six, seven years as a staff hero just there, improving my experience as a surgeons as a minimally invasive surgeon. And afterwards, I moved to Verona, matching an application for assistant professor shift. Okay, well, cool. So the reason we're speaking today, there's been an article you published that caused quite a firestorm on social media. It is a discussion about radiation toxicity. And it was in the European Journal of Eurologic oncology. And well, let's let's talk about the study. What were you trying to look at? So, basically, thank you. Thank you for the question. Yes, actually the paper was published in European Eurologic oncology. And I saw that created great attention on the social media. The purpose of the paper was to collect. So as we are Eurologist, well, we were a consortium of like 20 institutions. And we have a chat together. Well, you know, every single week we probably post the same images, some imaging from patients admitted to the emergency department with some Eurological complications after, you know, everything, you know, can be can be after one procedure, one surgical procedure from another institution, from another specialty. And in this case was a complication, a genital re-euroinary complication after radiation, after radiotherapy. So after a couple of years, we are there in the chat. We decided to start a prospective collection of these patients because we notice they are not so anecdotal because they may be they require a longer admission in the inpatient setting, different kind of procedure. For example, I remember there was a patient like two years ago with osteomelitis after radiation of the prostate for prostate cancer. It started having a fistula from the bladder outside the skin, through the through the bone. So it was very, very complex. We started placing nephrostomy tubes afterwards. He ended up in surgery for Eurocterocutaneostomy. Otherwise, the nephrostomy were not enough to completely exclude the bladder downstream. So after these kind of cases, we decided to prospectically collect these cases. For one year, and this was the purpose of the registry to to analyze the kind of patients, the treatment patterns, the likelihood they have to undergo for major surgery versus endoscopic surgery for a complication or just conservative medical therapy. And to, you know, to to rebuild the the former history status post radiation. And actually, the fact that we we had the opportunity to split the treatment groups into two groups, which was radiotherapy as first treatment upfront treatment for localize for local disease versus prostatectomy upfront for the treatment of the primary tumor was a post post talk analysis. Basically, we, we, we, we, we did the prospective data collection. And afterwards, after closing the enrollment, we discovered that we had two cohorts very well balanced in the numbers, because we, we had like 50% on one side, 50% on the other side. This is why we also perform some some comparative analysis, which are only associational for sure, they are not, you know, trying to to think to talk about causes. Yeah. So, you know, I read the study, you know, I also looked at the the firestorm in the Twitter comments, but I read the study itself. And, you know, I emailed you my my critique or my criticisms. I think the number one issue, but before we get to what actually caused, you know, the big discussion, but the number one issue everybody has is like, we have no denominator, right? Because we're looking at a very specific subset of patients. And it was said, that was said in the conclusion, I believe it could be said a little bit earlier and kind of prominent because your audience is us too, you know, you're speaking not only Tirologist, but you're also speaking the radiation oncologist. And I guess some thoughts on that, on that issue. Yeah. You are completely right. Unfortunately, we have a we have an issue. I can fall for Italy at least. So, with surgery, we are able to to to know at the end of the year, of a given year, the number of surgeries performed and the number of read missions, for example, for complications of the surgery. Even if the patient that you operate at your institution is admitted to the emergency department of another institution, if you make the sum of all the admissions, read missions and all the surgeries, you have a denominator and you have a numerator. If the readmission is the is the ultimate measurement that you want to look for. Instead for your therapy, you don't have this kind of problem. Moreover, you also have the issue that the readmission usually is not early after the treatment, but can happen several years after the treatments. And this is what we kind of found in this data collection point one. And obviously, these are very, very selected patient because it's only patient with complications. So, it's a very, very selected cohort. Radiotherapy was performed in different the year of the radiotherapy treatments spend along more than one year, for sure. And so, we also have the issue of the obsolete radiotherapy treatments, pathways, workflows, which is another modern topic. So, several are issues, for sure. Yeah. So, yeah. So, the lack of the radiation registry makes it a little bit complicated for you guys to do that. I mean, we have some things like this. We have these NCDV databases, they have institutional databases. And then we have some perspective studies to kind of guess these things. You know, I message you on the side, like just playing around with AI and, you know, using, using like population data. And it was a bit of a joke, but it was like, you know, if we used the one to two percent rate, and we calculate the number of patients treated with radiation, and Italy, we come up with about 320 patients that would have high toxicity, which was approximately the number in your study. And I'm not saying that modeling is correct or accurate, but I think it would have been a little bit stronger had you at least came up with a gas or a range of what the denominator was. I think that would have helped give it some perspective. And this retrospective was to say this, but it's just a thought, again, I'm your audience, right? Like, I have the awareness to know that we're not going to see all our excessive toxicities. In 15 years of practice, I can remember one patient that had a very bad bleed that was difficult to manage. Oftentimes they get mad at us. They stop showing up to our appointments because they're pissed at the radiation oncologist, and you may never hear about it. I had a buddy who's a GI doctor at Hopkins, he was an endoscopic interventionalist, and he would often tell me he's like, you have this idea that your treatment is very safe, but I deal with the complications. And so I don't want to minimize that we do have these these very significant complications, but at the same time, I don't think it's that high of a percentage. Some of the responses on Twitter is like, you guys don't like, I'm the one fixing it overnight while you're sleeping and you know, and working eight to four or whatever. And you know, it's a little bit of a jab at us, but there's some truth to that, I think. Yeah, yeah, this is a very very important point. Unfortunately, by the moment we are unable to calculate this incidence, this true cumulative incidence, we just have this, we just presented this data, which represents a very very selected population, but it would be very nice to really understand which is the incidence of this kind of complication. Obviously, the perception from the urologist is like an epidemia because you only see the worst. On the other side of the coin, maybe you have the radiation oncologist, which kind of lose this kind of patients because they go, they are admitted into other hospitals. For example, in Italy, it's very it's very typical that you miss as a radiation oncologist. You don't have the impatient setting, so you just have to, if you if you hear for this patient, for one of your patients, you send, you refer them to your urologist. Is it also possible that you don't hear for your patient because your patient is right away, he right away went to to another hospital to a urologist that were a federal center to be treated for complication, but we don't know if this is 3% or 30%, we can't calculate honestly speaking. That's very difficult. It is difficult. Okay, so this turned into a dumpster fire very quickly after the posting on Twitter or X. That included an infographic and so the infographic was created by AI. It had a few issues with it and I think like I'll give you a chance to explain what what the issues were and what what the intent was because I I spoken to you enough to know that like I I I don't see this as an intentional or a fabricated that was the word used often. Yeah, it's fabricated because it's it's AI all things AI are fabricated or you generate it. So let me give you a chance to explain. Thank you so much for the opportunities. Exactly. So even even when you read when you see visual abstracts from created from peer reviewer journals, they are anyway kind of fabricated by AI because I was told that also visual abstracts created for journals by the journals are fabricated by AI. This was not the case. It was created by AI but was not peer reviewed by the journal. It was just created by myself to advertise the paper. You know, we are in a modern era in the past. The was kind of an adjo stating that most of the time the paper is read eventually by the writer but not at all by by the readership because most of the time was the abstract that is read and that is read nowadays maybe even the abstract is not read because we we we just rely on on the visual abstracts that we can find in our very very limited amount of spare time. So the we I kind of learned a lesson from from this in this weekend in the past days because I learned the power of the visual abstract in point one advertising a paper because first thing which was kind of positive. It was very catchy with respect to writing a couple of lines and just putting the link to to the paper on the other on the other end. The synthesis that you have of a very complex topic a very contextualized sample analyzed very very provocative topic also because radiation oncologist would be involved in this in in analyzing and discussing commenting on this plus some typos that sometime occur in when you generate unfortunately even the plus version of a generative I a large language model is enabled to generate images that are fully free from from from mistakes typos and the most important one was for sure the one in the ex-assess of the graph also the the number the number of patient from from the zero etc and also some some phrases which were highlighted like a terrific kind of disaster with the percentages they were catchy but on the other hand without a proper contextualization toning down softening they generated the the storm I would say yeah I mean I I have a sub stack I use a lot I'm very like AI friendly I use a lot I make a lot of images I use it to structure my writing it's easy easy for me to say this to you now but like I have to do like 10 attempts 15 attempts to get an image the way I want it to be yeah it's really yeah it's not that high quality very much sometimes I get kind of angry with a large language model because I I tried to you know to underline to highlight which are the mistakes and I asking I asked the language model to generate again the image with the corrections and there are novel mistakes new mistakes yeah so I get very very angry with a large language model unfortunately for example for this one I I just opened the image a copy-pasted in PowerPoint and I put some square to cover some phrases but I have the limited amount of time to do this and I missed for example the typo in the in the x-axis when it was I liked it on the internet obviously was kind of embarrassing if this was coming out after peer review from a journal but it was not the case okay so my responsibility at a certain point was to to to point out that to underline to a light to everyone that the visual abstract was AI generated it was it was kind of obvious even if some people said we discover that the abstract was the visual abstract was fabricated by it was kind of obvious I'm not a graphic designer I'm not understanding advertisements so I mean it's not my I'm just a urologist so yeah yeah yeah and I you know I person to person yeah I get it like I again I have I have some images I've generated that I actually published that were had had mistakes as well now the word that keeps coming up is misinformation misinformation and you know there's a definition of this because of so much that's happened politically and in the world and over the last several years and and that's differentiated from this information so I can say that the phrase misinformation refers to incorrect or misleading information unintentionally communicated and I you know I think this meets that you know I don't think there's intent but it was incorrect yeah yeah but you're right the keyword is unintentionally and also the most important thing I I I went back through the the AI generated the visual abstract it was not that far from the reality in terms of road numbers and road phrases but it it needed more than usually more than for another kind of the topic more than for another paper contextualization right which which is only possible with a long worded well worded discussion which which actually is in the paper but you have to find the time available to read it otherwise actually if this is decontextualized it's it's it's it can be too synthetic to be fully captured fully understood so yeah and that's how I said like I read the paper and if you read the paper and you didn't see the graphic and you didn't see the discussion I would have some pushback on certain things but all for sure I don't I don't like think it rises to like a retraction of the paper this type of talk now all right one more typo issue this was in the paper itself the number of patients yeah this is yeah yeah unfortunately in the clinically clinically relevant small paragraph which is part of the advanced practice text in the more recent European urology family paper there's this 1200 patients more than 1200 patients with was a typo I don't know where it where it came out but actually I I have already written I have already contacted the journal editor and it was and it will be fixed it they will write more than 300 because actually the population was like starting from I don't remember exactly it was 347 maybe at the enrollment and after screening for exclusion criteria for some missing data in possibility to to build up the past history we excluded like 27 patients and we we we arrived to the to the 321 but it was it was a typo and I can tell you that I'm already I already received an official letter to the editor which for example was by the guy with this issue yeah yes yeah so again this is like it's a perfect storm of an AI yeah graphic that was you know again generated by you that had errors a typo that was not your fault uh and I'm going to talk about something else in a bit but uh did you anticipate the scale of hostility was there was there sorry to say but what did you did you somewhat intend to provoke I would say no it was not is our intention was not to provoke we could have anticipate that some reactions but you know I was I was chatting with a friend of mine in Rome and we were we were saying you know you remember many years ago before you were reading a new paper published you have to wait for uh to check your mailbox uh for the for the journal to be printed and delivered if you were uh registered it for for the journal for receiving the journal at your place or at your university so nowadays we have this opportunity to right away have read the paper just after the publication um so yeah the rapid fire analysis uh and ability to immediately communicate with somebody that you don't know perhaps or even even haven't even met yet or spoken to or met at a meeting uh it's very different uh than than the old days when you you would have to wait or spend some time or write that letter or meet this person at a conference and have a discussion um so some of the stuff I read and we talked about it got pretty personal they were talking about like you're comparing your skills as a surgeon and saying that that's why you published this type of the paper like what do you think about that? No you know uh yeah this is uh another good point I unfortunately read and in the storm that someone was stating we were we we conceived this kind of analysis this kind of paper because because we we were unsure about our skills as surgeons um actually the out of shape of the paper include uh lots of prominent erologies most of them are chairman uh in the department of urology, full professors and I can tell you that the the outcomes of prostatectomy of their prostatectomy are very very good another point is that even if I'm younger uh I'm only 40 I perform my first prostatectomy like uh it was 2018 um I I had the privilege to start at a higher level with respect to the to what it was in the past because we have surgery on screen we have uh first with laparoscopy after was with robotics we surgery the surgical gestor is popularized nowadays it's very democratic because even if you don't operate in the OR you start with the opportunity of watching what it's happening this was not the case for open surgery and with the robotic platforms nowadays we have the facilitator uh the the surgery the surgical gestor is it isn't a lot so when you start from the first case I'm not saying you are proficient but you start at another level and um that's why the outcomes of surgery have evolved a lot particularly in Italy because I have to tell you that with respect to the US where there is uh which is very nice I I love to see that there is a trend towards uh um standardization of every surgery in the way that is a deliverable transferable to the residents and the clinical fellows as as fast as you can so you don't you you don't you do not make the surgery very very complex with lots of details but you simplify the surgery so that even a fellow a resident of the 10 cases has reached at the same level that you have in in Italy we are more artistical we we put more details maybe in our surgeries so that we have some masters at the fantastic level they have like continents and erective function rates which are amazing and I I can tell you that their data are not invented uh they correspond to the truth so they are very very competitive with everything but also at a lower level you you already have some kind of you know good good uh proficiency for example uh you you know what I'm talking about the results in terms of continents rate to a two year follow-up in the PACE 8 trial randomized control trial uh in the control arm of uh surgery are kind of unreal for for an Italian perspective because uh you have 50 percent of the patient in continent after surgery at the two year follow-up for sure this will be statistically significantly different today in continents that you have after radiotherapy but I can tell you that to look for an institution or a surgeon in Italy uh having 50 percent of in continents two years after the percentectomy in Italy it's very very complex because continents uh is not any more an issue we we often say we have some patient that remains in continent most likely more likely they are obese old or with locally advanced disease or big big process but if you exclude this kind of patient the recovery of continents after robotic prostatectomy nowadays it's it's reality I I usually stay to my patient in the clinic that within two months after the procedure they they they they they can't forget about the pads and actually I'm I'm kind of gambling for every single one but it's not far from the reality at the end of the day yeah I mean I can see potency is another issue yeah yeah I mean I think part of that is a like what I call it in my hands argument that like you see someone it's like the data says this but in my hands uh the toxicity is that and I I don't know I have a hard time with that even with radiation oncologist uh similarly it's like oh well I never have bleeding I never have this I never have that and I think you know I I sent you a post that I've written it was you know a data driven look at prostate cancer treatment toxicity and I I've studied this pretty in depth and I think if you put it all together so that why we're brittle about discussion about radiation toxicity versus prostateectomy is perhaps this is an American thing I I don't know I've never practiced anywhere else but I see the notes from neurology and what they say and what we see and what the data says and I don't think it corresponds and uh I think we get our toxicity oversold and prostateectomy toxicity undersold and I told you a little bit about this like this nerve sparing nerve sparing surgery what that what I call tumor sparing surgery because it's it's just making your margins slimmer and the the rates increase and the patients are under this specific impression that this is just you know this is going to save this this function I think we're brittle also because we don't get to see patients upfront uh the statistics say about 40 to 50 percent of patients with prostate cancer don't see radiation oncologists so which patients are we getting you know are we getting the patients that are really sick or have problems that are geared up to have problems um why shouldn't they get to see radiation oncologists uh you know Australia mandates it and Americans are not very good with federal federal mandates and telling a surgeon what to do uh from the federal level probably would make people uncomfortable but I don't know I think it's part of multidisciplinary care like you you said you guys do a tumor board um which is good for every patient we don't we don't do it for every patient in America but I think you know radiation oncology in America has the capacity to see more consults that they don't treat um and that way we get to talk together or it like I have partners my in my practice we have urology up huge urology group 30 40 docs and like I'd love to see the patients together urology um I see them we figure things out in a week or two you know uh but it doesn't happen and we're also sort of a specialty under siege in America you can see radiation oncologists are very defensive we have a lot of reimbursement issues we have a lot of coding changes our volumes are down uh we feel that the media reports our toxicities and doesn't report our successes there's a study in the New York Times showing pretty much a hundred percent of New York Times articles over the last 20 years are negative about radiation even though we've done great things in this specialty um so that's you know that's why we're brittle about this and I think uh you know the uh the other chairman from Cleveland mentioned uh the comparison articles between prosthetectomy and radiation and gosh we always get upset at those because it's all selection but that's how we see it at least so I I want you to understand like some of we talked about to some phone this this rage that we had against this paper it built up for many reasons yeah no for for sure you're right that there is uh there are some issues uh also in Italy for radiation oncology for example uh I can tell you that in the most important residency program about radiotherapy radiational oncology in Italy in the last years last two years uh we have so many a very high percentage of uh unassigned uh uh places spots yeah unmatched we have a big problem with that a few years ago for several years yeah if you go to the European academic uh your European association of urology meeting you have very robust studies favoring radiotherapy for many many this is uh including you know in just in the urology field bladder cancer uh kidney cancer now is getting more and more popular with the SBRT prosthet cancer uh you you you you you you very well know that for locally advanced disease and oligometastatic disease by the moment we you know surgery disappeared as an indication from our guidelines so we have very popular a nice moment a nice momentum for radiation oncology with the paradox of uh no no younger colleagues no younger uh medical doctors considering to match for our radiation oncology in Brazil uh that's hard to hear I mean that's tough because we we suffered that a little bit but yeah because america is so desirable people will switch specialties just to take a spot so they don't go unassigned in everything and we end up telling our yeah I can tell you that the matching the last matching was on 2025 in november and uh the the the closest most important resiliency programs to verona are in padua embracia zero and zero so this is this is honestly speaking uh the the the the numbers spokes by by themselves and the the other point is that as you were saying even a few but I'm happy for this honestly speaking because we collaborate a lot with our local radiation oncologists we have a very good uh collaboration relationships we we we we run for every single patient when you have an indication to treatment of the um of the primary cancer for prostate we we run at the MDT together and the general decision the decision which is kind of shared is that if the patient is pretty young i'm telling you 65 or 70 years old the patient with a very very long like expectancy feeling we tend to use surgery as a local treatment because the likelihood of a complication if the prostate stays there it's higher with longer survivors this is this is another important point that i that i can tell you as a urologist i i noticed that sometimes you have the disaster the urological disaster which is maybe occurring 12 years after their radiation and and this is an ingredient important to be considered in the counseling of our patient and this is one of the phrases the conclusions that we also included in our paper so for long survivors unless you you you you improve the machines and the precision of the of the of the radiations that that in in a so so nicely so good that you can ensure that you will not have any longer term complication i we usually in our NDT tend to favor surgery towards versus radiotherapy for for younger patients and that's why we still have biocid cohorts if we compare how a patient's yeah i mean i i think you know it sounds like you have some radiation colleagues that still exist in area have them look at the dose symmetry of these patients have them look at the treatment plans i'm curious because i i told you and when my criticisms is that you you broke it down by dose by absolute dose that's not useful for a radiational oncologist i know that's not it's the fractional dose that matters and i'd like to see you know the rectal dose i'd like to see the bladder dose yeah unfortunately this is an issue big issue of the paper even if the data collection was prospective because the enrollment was prospective yeah from the first day to the to the last day of the year of enrollment building up the anonymous is the history the past history of the patient was a retrospective so some patient had many data other patient they didn't bring many details about the radiation treatment they received so we had to kind of keep it simple the data set had to be kept simple and some some day days were missing which are sometimes most of the times the most important for you as a radiation oncologist well tell you have have a few can give me a call or email me and we can try to do something together to try to work on the quality if there's a quality issue there there's really great programs there's great people and places to learn from so what switching to gears what do you think of x or twitter as a platform for scientific discussion thank you for the question i can tell you that i i registered myself to twitter when i landed in Cleveland i told myself you know i'm out of theater everyone is using i want to go i want to dive into this and i started following prominent urologist prominent researchers scientists and actually it was very nice for me because when i when i was just logging in i was reading important paper published important news and i had the opportunity to post some some of my papers some of my surgical videos and i can tell that it was invited to some international meetings just because i became popular for something for even very famous urologist you know i remember when i was invited at the a o a meeting for for for a board talking about complex kidney surgery or what a kidney surgery and it was very nice for me because i said to myself look at the power of this free tool that we have and i was liking a lot i've been in in the last two years i noticed that some algorithms changed a lot and i i noticed a crime of it was it's not very active anymore but the the publication the post about the year at eight study made the exception and the fantastic discussion started unfortunately the wording by most of the people was not perfect the same people that were not so elegant on twitter sent some letter to the editor uh where the tones and the wordings are completely different yeah because you have to go through peer review and you know can't can't have your insults or bad wordings published in a in a in a nice journal yeah yeah i mean i i i talked with some of my friends about this there's a way you speak as a keyboard warrior when you don't know somebody you write that angry letter or rangy angry tweet i i you know i've done that a bit in the past i i've kind of been chased off of social media for other reasons and it's by my own people you know it's more about radiation oncologist and astral and and so i i was sympathetic to you because we can disagree of a science or policy or economics or reimbursements or philosophy of treatment but it so quickly turns into personal deligitimization yeah and i you know i i feel like i'm kind of like i have a voice i'm not like de platformer cancelled but i'm kind of exiled from the society um and and i just don't like that like debate my ideas don't call me a bad doctor debate my ideas in my positions don't question my motives um that's sort of how i feel and i saw that and that's why although that paper created a visceral you know feeling in me i also had you know some anger initially with the infographic and the paper but my thing is like the best way to like communicate is to communicate like i reached out to you i found john linkedin sent you a message a sent you my phone number um and we talked and i i feel like this is how we get you know get to a point of uh we may not agree with each other completely but we'll understand where each other is coming from i get the sense that some of your attackers don't want conciliation that that's my my promise it doesn't sound like they want it like you took the grab yeah yeah you're right because they they they they went on anyway uh even if we're giving a reply or we're trying to solve uh the issue they were raising they were going on so that's that's what they were look they were looking for a target and and this is pretty fascinating on one side for me because we don't we never talk together we we didn't know each other it was like you know i was insulting uh one of my former best friend that now uh you know engaged with my wife and so i uh doing something as a target but at least i am in confidence within i instead in this case was like most of the people the the rudest one never talked to me didn't know about me obviously as as the first name of the paper even if i was just in front of a concertion of uh important urologist in italy i became the target and uh it's yeah it's tough because it's it's easy to get in touch with people like they could have gotten in touch with was a focal therapy rather than a radiation therapy against very very specific targets yeah yeah um you know and i i think like had we you know could we have had a summit could we have had four or five with bust on a zoom call and talk this out um rather than doing it the way we could have and you know it it's really the cascade of this is certainly interesting i mean uh the the the editor of the journal one of the editors journals that one of these people is tagging uh the Cleveland clinic CEO in a tweet yeah um i don't i don't understand like how that makes any sense um it's it's it's completely uh without any any kind of sense honestly because exactly at that point uh i was not anymore the sole target but other targets came out just because they were reposting the post or supporting the fact that sometimes we have some patience after radiation therapy with some urological complication obviously most of the things they were urologist for sure because they they leave the same kind of uh reality that we see and maybe they they like me they have a bias at the view because they only see half uh of the sky just one of the sky just one flip of the coin but just because they were kind of supporting they became at another target and they were same way insulted or yeah the example you're you are you are providing is it's maybe the most embarrassing one which was tagging the CEO and the chairman of Cleveland Clinic just because one of the employees of Cleveland Clinic was come on guys it's uh yeah you know we haven't you either use names uh i will use the name of one doc uh a martycheon from ucla uh who i thought was the radiation oncologist that provided the most balanced uh an informative critique his messages were professional inside of you know uh thoughtful he he's also an editor of one of the family of journals uh involved i know him personally i talked him a little bit last night um but i just thought like if the communication was like his communication i think we get somewhere we actually get to a point of understanding and learning um and the search for truth right like to do not be a pie in the sky or idyllic about this but that this is what this is this is the search for truth like how can we discuss uncertainty which is essentially the lack of the denominator without panicking or attacking each other yeah yeah yeah for example one of the paradoxes was that there was a radiation oncologist calling for um turning down collaboration etc and and after this um they were going on with insulting where is the multidisciplinary where is the collaboration it's it's it's it's it's uh uh at the at the certain point you realize that uh such a repressed anger is hiding the the the feeling the desire that you have that that this multidisciplinary should be unilateral so it's like uh uh me myself as a urologist if i see a prostate cancer patient amenable of uh treatment of the primary tumor i have to refer to you uh to to to for radiotherapy and that's it yeah and the message is like this that multidisciplinary is okay when it's unilateral which is not it's not the best word we want to leave in right right i mean i i you know i i have a guy right now who's who's 47 with with intermediate wrist prostate cancer and tell a guy in aid surgery in aid surgery yeah this is what i would do he says is i sent him a surgeon saw him back again he's like i don't want surgery i sent him back again i sent him to another search comes back doesn't want surgery straighten him okay okay but you know i'm comfortable with this but i did my part and i think like that that's a little bit what we are hoping to get more from urologists yeah but this this makes you a very nice uh colleague and radiation oncologist i i have in mind a clinical case that i saw in Rome it was 47 at the first radiation and it had three a total of three radiation because there there is a colleague of yours in Rome which is pretty artistic but be be such integralistic with the radiation oncology as exaggerated i think i would say because this young man because he's a young man will suffer from some toxicity from all this race received and probably at 47 a nice nurse pairing uh surgery would have been or a phototherapy even a phototherapy is the first one uh would have been maybe better for him to reduce i have my concerns with vocal therapy but yeah yeah okay me either but i always think to my with myself what i would do i'm probably brachimotated because my mother and my grandmother had breast cancer i i still didn't go through um testing genetic testing but i'm pretty convinced that will be brachimotated so i'm sometimes say i sit down and i think about myself what i would do if i i'm the diagnosed with with prostate cancer and probably i don't know uh i would go through phototherapy and that's okay i mean that's that's not a real thing we have to we have to speak about that in a certain way i think the ncc does a good job but i i don't think and again it's not the special i shouldn't say special but certain specialists in my area don't do as good of a job of defining the issues with that um so you know i want to just think about like the strongest reaction of the paper what it wasn't about what it said but what it threatened so what do you think it what do you think it threatened and what what's like that the upshot of this this whole thing because the paper itself if you read it in isolation there's one error with the 1200 patients there's the to me you guys didn't push the fact there's no denominator other than that i can't call for a retraction of this paper yeah i don't know why yeah maybe it's the first time i i read the a call for retraction but actually it was a call it was a call from for retraction by after you people honestly speaking and one of this and his gore is like uh very very very active on social media against everyone against referees during soccer matches for mistakes against the politics the president of the united states the politics in russia Brexit and also urologist but i discovered it was existing since a couple of days but it's very very active to it probably as a need for for shouting against people for you know digiting on the phone i don't know why that's something worth of being started maybe yeah yeah and i i i don't do it anymore i um i try to keep my political views in my smaller circles even even in smaller circles like ash and i like to talk about this stuff the idea of putting it online for the world to see is it's not for me it's it's not comfortable for me um so you know i think science wise i think you know there's going to be letters like i think we had a little little disagreement on this like to me once the paper is done nobody reads the letters anymore you guys and you're in your out of your towers in your offices maybe you guys read them but the real world to move on and um i'm a community doc i stay up to date i have eight or nine partners in radiation oncology in my practice i don't think one of them has heard about this maybe one um and so like the actual reality of how much x is like the very online versus like you know i could probably query ten of my community radiation oncology friends and maybe you know to have heard of it you know of what's going on so i think it's it's less you you felt the rage in the pain but it's very visceral to you and real to you and for the people that were on the other side again we we have our reasons for being brittle but the reality is like i have great colleagues i have great urology colleagues uh they're going to send me patients i'm going to send the young ones back um i want them to send me more patients early you know i i'd rather talk to them and at least tell them what about what i tell my patients is the biggest toxicity of prostate cancer treatment is decision regret that's the worst thing and what i want to do is avoid that you know there are some publications about also the seasonal regrets after surgery which is sometimes very high 60 percent uh the worst of him was urology paper i remember that and i always think about that um that's why we try to to select the patients at the best uh you have to set the person the use you have to set the the expectations that is the most important thing if you set the expectations um an explanation uh given before surgery is unavoided explanation that you have to give after surgery and this is correct yeah that that is true for every every single treatment that we counsel our patient for which is very important this is also very important i i i perform a lot of microinvasive surgical techniques for for bph for example this is another one uh if you set the expectation that the maximum urinary flow rate would be improved uh at the at the level of your adolescents plus you maintain the ejaculation that is far from the reality you have to set the proper expectation so maximum urinary flow rate would be slightly improved maybe the irritative symptoms would be uh softened a little bit you maintain the ejaculation if you are young you have a bridging therapy to bring you a little bit older yeah set setting the expectation is the most important point you know i think that's that's there yeah i think we we got to do a better job of that in general so to move away from all this i heard in the phone you have you have a daughter how many kids do you have two uh one is five years old one is ten years old uh two daughters i'm fighting in him family the only man also uh the dog is is the is the female so i'm the only one you are the only man in the house that i have a six-year-old daughter and five-year-old son and uh they are they are my world uh along with my wife of course my wife is my world she she listened so i got to make sure i said that um but yeah if you're ever in the Midwest or if i'm back in Italy i hope to be so i would love to meet you you know you have my contacts um yeah definitely it would be very nice you were so kind with me uh very inspired the illuminated the colleague i have to say thank you thank you thank you thank you not the only to be honest to not the only one among radiation oncologist because i i received the nice messages and the private messaging uh by other redonks but you were very very kind thank you yeah now i i thank you for saying that i think i think the most of us are the community redonks we we're we're nice folks we we like to work with you guys we we want what's best for our patients we want to stay busy we want to um but we we like for i don't i'm getting upset you know i don't get him so i just want to take good airbations have good colleagues so we'll have a great rest of the day um and uh let's let's uh let's catch up soon and i i hope we can collaborate maybe not you and me necessarily the academic community with radiation oncology and urology to try to get a better understanding of this you know post-treatment toxicity the reality rather than uh something that's thought to be made up by either side and i i think we can get there yeah yeah yeah thank thank you very much for for the opportunity of chatting with you and uh and get into a little bit deeper on this publication all right have a great rest of the thanks for listening if you liked our show please subscribe and leave us a rating we hope you're having a great day and look forward to seeing you again soon