Eric Kim, MD:
Eric Kim, I'm chief of Urology at University of Nevada Reno. Just moved here from St. Louis, was at WashU in St. Louis for a long time, which is where I had the very good fortune of training under Dr. Bullock, befriending Dr. Bullock, and also helping take care of Dr. Bullock.
Arnold Bullock, MD:
I'm Arnold Bullock. I am a urologist who did medical school training at Hopkins. I came to Washington University for my residency training. Beginning in 1987 is when I came to WashU for my residency training under Dr. Catalona. And I've been in practice here since 1993. The Alan A. and Edith L. Wolf Distinguished Professor of Urology, mostly based on work on disparity issues in prostate cancer treatment and diagnosis and my work on erectile dysfunction and penile implants. So those are my two areas of specialty practice.
I have the good fortune of having trained Eric Kim, amongst other partners, and every year we have three or four trainees, and in every few years you have one that just stands above the rest. We have really good residents here at Washington University, but every once in a while, there's a resident that really goes over and above and is special. And that's Dr. Kim. And I can tell you that when I found out, when I was tracking my PSA going up, because it had been pretty stable in the range of 1.0. And then 1.8 and 2.6 and then maybe 3.1, and then it jumps to 5.0, and repeat was 4.5 or so. And I'm like, "Oh wow, crap. I've been smelling the prostate smoke for too much."
And so Eric Kim had this great study where they're trying to use, I don't know if I should announce, but they were trying to look at MRIs and see if there's other ways to evaluate an MRI to increase the accuracy of an MRI. And so I called Eric and got into the MRI study, and unfortunately my MRI showed a lesion that was a PI-RAD 4. But on talking with the radiologist, he said if the lesion was larger, it probably would have counted as a PI-RAD 5. It was only 0.6 CCs in volume. And so the next step become pretty automatic.
Eric Kim, MD:
No, and I think that was an important point. And we don't know where the research is headed. I think the future is more radiomics to get more information out of the MRI than we do currently. But until then you rely on your radiologist to tell you how suspicious or concerning it looks. And luckily it was organ confined, but it really was an angry looking tumor. The ADC map did not look good. A lot of diffusion restriction, a very dense nodule in the peripheral zone. So biopsy was the obvious thing to do.
Arnold Bullock, MD:
Yes, no doubt that I needed a biopsy. And fortunately we can do MRI directed biopsies here at Washington University. And the biopsy results, being on the other side is so funny, it's so different. You're going to sleep, you're like, "All these people in the OR that I know are going to be looking at my tush." And so it's so different being on the other side. But the biopsy was really, it was one of those ones where, dang, I'm stuck because there was cancer that was Gleason 3+4. The lesion on MRI is in the right posterior medial zone, but the biopsy always is peculiar because the MRI lesion is positive for Gleason 3+4, but so are the random lesions from those two same zones.
And so you say, "Well, the random zones could really just be sampling and extension of that same lesion." But unfortunately there was another lesion at the right base and the one on the left side that was two millimeters of Gleason 3+3. So you have the lesion at the right posterior part of the prostate that's seen on the MRI, and then these two distant insignificant 3-3's. But the lesion is only 0.6 CCs.
Eric Kim, MD:
Yeah, the Gleason 7 spots are essentially microscopic, right?
Arnold Bullock, MD:
Right.
Eric Kim, MD:
They're not seen on MRI, and lucky for you, there's so many men out there that maybe have gotten the wrong information about PSA screening and how helpful or useful it can be, especially for a high-risk individual, family history, African-American race, any genetic germline mutation. But lucky for you, you caught it super early. There was the one nodule that was still very small organ-confined, but there were these other small satellite microscopic spots that it could have been, I don't know, years before you really dove into it if you didn't know better.
Arnold Bullock, MD:
But you think about it, there's something that's suspicious or concerning, which is the steady rise in the PSA. The Baltimore Longitudinal Trial says your PSA gets to the point over three years where it's tracking 0.7, 0.8 per year, that's pretty suspicious. But at the end of the day, I have a lesion that's pretty small on MRI, and still most of my cancer is Gleason 3-3. So I'm thinking I have a Gleason 3 and a component of 4, 40% 4 in one of the spots though. But still, I'm only looking at a 4-millimeter lesion, and 40% is a Gleason 4. So in a sense, one millimeter of a Gleason 4 in each one of these cores is the way I'm thinking about it. This is still a tiny tumor. I could watch this for a while. In fact, Eric and I were talking about, why don't you just freeze the right posterior zone? Why don't you just freeze it or radio frequency or do any of these targeting tools that we now have and target just that one site? That probably would do.
Eric Kim, MD:
That's exactly what we talked about because focal therapy, if you use it as an adjunctive to active surveillance, you could treat the dominant nodule, and then you're monitoring the other ones. It's not like we're going to tell you to move to Montana and never get an MRI again. We treat the bad one and watch it. And that's not, I think, crazy in today's day and age for a lot of men out there.
Arnold Bullock, MD:
So the one thing to be cautious of though is when's the last time you sent someone to focal therapy at 61, 62 years of age? And so why do for yourself something that you don't routinely do? There's a reason why you don't routinely do this. Maybe a guy 69, 72 other medical problems, I'm like, "Dude, if I was you, I'd just freeze the thing. And if we control it for another six years until you're 78, you're already headed toward dialysis. You already had a heart attack."
Eric Kim, MD:
Yeah. Oh, for sure.
Arnold Bullock, MD:
"Reasonably in your lifespan, sir, this is going to be of no consequence." But I don't have such a thing. At the time I was picking this up, I was starting to exercise more. I joined a boot camp. I was doing a cycling class for an hour three times a week. And I'm thinking, even though my family history is terrible in the sense that my father died at 47 and his father currently died at 51, I don't know what my risk of prostate cancer is in my family. And so I just know I'm a black man who smells a lot of prostate smoke. And so it's interesting. That must play a role. Really, I'm thinking that it plays a role.
So I was really at a quandary. I saw one of my best friends who's also one of the best radiation oncologists here, and he said, "Well, maybe I could brach you, do brachytherapy and control it with brachy." But if I did that, I really don't want to use hormone therapy. Hormone therapy for two years, wow, that would destroy everything I'm working on right now. So I was at a crossroads. I don't want to watch it. That's too risky. I would do brachy, but not if I have to take the hormone therapy, so I needed more inflammation. And that's where Decipher comes in.
Eric Kim, MD:
I think that's a perfect segue for Decipher provides totally independent information. Unlike some of the other tests that incorporate clinical information, Decipher stands alone. So you can add it to the data you already have and say, "Well, we have some check boxes in the we-can-watch-it section, and we have check boxes in the we-shouldn't-watch-it section." In Decipher, you can treat the same way. Where do you end up with check boxes? Does it tip the scales towards saying, "Hey, we really need to consider treatment?" Or is active surveillance or modified active surveillance not crazy in this person's case? And Decipher, again, I'm sure we talk it about all the time, but it was originally designed as a gene profile to predict metastasis. So in my mind, I always think of it as the best tool we have presently to tell you what's the biology of the cancer and how likely is it that this tumor could spin off something that metastasizes. And so it goes from zero to one, zero being lowest, one being highest. And so anything above 0.65, anything over 0.6 really is considered high risk that it could metastasize.
Arnold Bullock, MD:
And I agree with that. I'm able to speak both as a patient and as a prostate cancer specialist for many years. And that's the problem with some of the other tests. What they're doing is interpreting all of the data put together for me, but I don't want anyone to interpret that for me. I'd like to have all these independent factors, and I can plug them into any nomogram that I want. But the beauty of some of these tests, and there's only a few, is where it doesn't ask if you're black or white. It doesn't ask if you're young or old. It doesn't want to know your PSA. It doesn't tell you about previous biopsies.
It's just give me the data. Just tell me what the genetics suggest because that should be an independent variable. If you try to play a trick and send it on a woman and says, well, "You've got an 80% chance of having prostate cancer," then you say, "Well, there's something wrong with this test." But the genetics should be reliable to help you as the deciding factor, having already considered all the other factors. Because if they're considering it for you, that's not as useful for me.
Eric Kim, MD:
You can really end up double counting. If it already incorporated Gleason score and you're already looking at this Gleason score, then you're weighting the Gleason score more than the genomic information.
Arnold Bullock, MD:
That's right.
Eric Kim, MD:
So I think that's why Decipher, in my mind, is so useful. But then for you, Dr. Bullock, that Decipher came back relatively high.
Arnold Bullock, MD:
My Decipher score came back very high, but what did I just say? I just looked it up earlier, 0.78. So a 0.78 Decipher score very quickly gave me information that told me what I thought I needed to do. Because I can't keep sitting on a prostate cancer knowing that the risk of having high grade disease would be that high or the risk of potential metastasis by monitoring. What the Decipher suggested to me is that I could have other areas of Gleason 4, or the Gleason 4 seen in those random cores, I'm thinking all these cores could be hitting that 0.6 CC lesion, i.e. 1/10th of a teaspoon. But that lesion, instead of being 0.6, could have been 1.9 because the random samples are also hitting it. So technically the random samples are done with some spacing between them. The MRI may lead you to believe that you only have 0.6 CCs of a tumor, but really, in fact, you have a tumor that could be three or four times larger. And the only way you know is by having your prostate in a bucket and letting them look at it.
Eric Kim, MD:
And I think MR has really been adopted quickly by patients' urologists everywhere, but MRI is not the end-all-be-all. It's not a perfect test by any means. And so I think adding the MRI information and the Decipher together like you're getting at, Dr. Bullock, that's really where you start to get a better holistic sense of the patient's prostate cancer. You then obviously have to put that in the context of their health. Like you, you're trim, fit, good-looking, we got to treat you aggressively. But again, that Decipher rounds out your understanding of that cancer as best as you can with today's technology. And without having the whole prostate in your hands yet, it gives you as much information as you can have to be armed to make the best decision for you, both the clinician and the patient, I think.
And then the other point that I was going to bring up, Dr. Bullock, was Decipher has built a lot of data in all of these clinical spaces. So like you were saying earlier, in the Gleason 7, so intermediate risk group, when you're deciding on radiation, it seems that those with high Deciphers really benefit from hormones with the radiation. Radiation therapy doesn't do as good of a job. And so with the high Decipher, it also tells you, like you said, do you want hormones and radiation for your definitive treatment, or do you want surgery as your definitive treatment? Whereas if you're a low Decipher, you could say, "Well honestly, I could do radiation monotherapy. Surgery is obviously still gold standard, but maybe focal therapy is not wrong."
Arnold Bullock, MD:
That's right. So for me, that was a clear-cut decision. And I think part of it is you have to have this in the back of your head before you get the test, and then hopefully you make that decision and you stick to your decision. And the decision therefore would be brachytherapy, for me brachy, aiming knowing where we would want to target more along with two years of hormone ablation therapy or just taking the prostate out. And I already decided that if I would have to take two years or even one year of ADT, no, I'd rather just take it out, as long as I had a good surgeon to take it out. So I think you got to make sure you have a good surgeon, otherwise you just might as well get the brachy.
So once I had that, it actually made the decisions and all of this discomfort of, dang, what do I do? What do I do? You could sit on it. Maybe we're over-treating prostate cancer. No one says I got a PSA of 5. There are some people that say, "Well, why don't you just wait until your PSA is 8 or 10?" But you can have horrible cancer with a PSA of 6 and practically have no cancer with a PSA of 12. So you cannot use a 40-year-old test to make a decision in present day. You can't do that. Not with all of these data options out here, all these new biomarkers. But I think once you have cancer, the Decipher is the best test. The other test is just predictive of your risk of cancer realistically, whereas the Decipher it telling you actually about the cancer you have. It really is the standard.
So it worked for me because on removal of the prostate, 20% involvement of my prostate with cancer, not just some 0.6 CCs, 20% replacement with cancer, and 20% of it was pattern 4. So it was not just in one isolated spot.
Eric Kim, MD:
And I think that's where you're probably right that the systematic samples, the random samples from that region geographically within the prostate probably did have 7 in it because our understanding of prostate cancer, it's still evolving, but it really does seem to be like planets and moons. It's not just one discrete tumor like a clear cell RCC. The prostate tumor has these small foci of microscopic cancer that are surrounding the actual dominant tumor.
Arnold Bullock, MD:
I always think of it like Minesweeper.
Eric Kim, MD:
You think that there is a large region of that prostate that had 3+4 in it.
Arnold Bullock, MD:
It's not just one circle. You can't predict the shape of it, and nor does it have to be continuous.
Eric Kim, MD:
And that's where, I think actually, and this has been published on, MRI fools people. Because what is the abnormality that's visible or obvious to the human eye is different than what is objectively abnormal. And so you may just see on the MRI one tumor spot, but if you actually take the raw radiology data, the raw MRI data, there's actually abnormalities as a halo around that discrete tumor.
Arnold Bullock, MD:
That's right. So there has to be some margin between pure cancer and pure normal. And the question is how far is that marginal zone, and when you sample it, are you sampling more toward the negative or more toward the positive? And so the biopsy is the definitive way to make the diagnosis, but we have people who get on active surveillance for Gleason 3+3 and two cores, one millimeter each core. There's still, until better things come out, probably a need for a second biopsy, at least a biopsy done transperineal or transrectal to get better cores, under sedation is what I mean, because that first biopsy can miss a cancer.
I tell people all the time, it's like the balloon analogy at the circus. You could win a big doll. The next time you might throw 10 darts and hit no balloon. There is a reason for a second biopsy, in my opinion. But I do think that the new technology, when you combine multiple biomarkers and you put them together, it gives you way more information where you could reasonably eliminate some people from a biopsy. And you could tell other ones, "Dude, you need a second biopsy. You might need a third biopsy." But again, you can't base it on PSA because that's 40 years old looking for one protein.
Eric Kim, MD:
I think that's a really good point too, that for active surveillance, our definition of active surveillance are changing. Low volume 3+4 is not crazy to consider active surveillance, but we should really do it in a rational, thoughtful way. And so someone with a disgusting MRI with a PI-RAD 5 lesion that's really big, and even if the biopsy comes back 3+3, like you said, that may have been a sampling error. Maybe we need to re-biopsy before we even consider active surveillance for that guy. Or similarly or conversely, someone comes back with 3+3, the Decipher is low, you can say, "Hey, look, I know I did a really good biopsy. I took 20 cores. I spaced them out really well. This is low volume 6 or sure, and it's also genomically low risk. Let's watch this, guy." And if he's 73 and not fit and trim and sexy like you, then maybe that guy you say, "I don't know if we need to do a confirmatory biopsy this year, Mr. Smith. Maybe we can wait until next year."
Arnold Bullock, MD:
We have all of these tools. And the Decipher is just one of the essential tools that could be used in conjunction and with pretty high accuracy. You can look a person in the eye and say, "Sir, you could reasonably be on active surveillance." And I say, I'd change it. 10 years ago, we probably said you could be on active surveillance or you could take it out, you could radiate it, you could do any of these. But nowadays, I phrase it differently. I have some men, I say, "Not only would you be on this, but you should be on this."
If you said, "Dr. Bullock, I want you to take my prostate out. My daddy died of prostate cancer," I'd be like, "Yep, I bet. Yeah, yeah, yeah, that's true. You do have prostate cancer, but I don't really think I'm going to take your prostate out." I'm just going to flat out say I wouldn't do it. You have a PSA of six, you have a low Decipher score, your MRI doesn't show anything. Your free to total PSA is 27%. You have one of these other urine tests that's low or an ISO, a different blood test that's low, dude, you got a lot of feathers in the hat that says that you don't have to do this. At least you don't have to do it right now. You're concerned? Come back in six months, we'll do another type of biomarker. You come back in another year. If you really want, we'll do a second biopsy.
But it's hard to justify doing that today. There are a lot of people with prostate cancer. The question is, as we get better and better at picking it up, if all of a sudden people start getting PET scans all over the world for some reason, we will pick up stuff that a 1.5 sonometer renal mass in an 83-year-old guy who fell down the steps. Maybe we shouldn't have known about that.
Eric Kim, MD:
Maybe ignorance is better in that context, right?
Arnold Bullock, MD:
As I was saying, I was doing boot camp before my prostate surgery. So I do it on December 26th when my kids can all be in town. I told them over Thanksgiving and do it December the 26th. You know what I did on December the 27th and December the 28th and 29th? I went home on 27th. Every night my kids were in town for the next four days, we'd go eat at a different fine (dining) restaurant. And so that's what we did. We'd go and with my kids every day for the next five days until they all take off back out of town. And so January the 15th, MLK weekend, I go visit my mom in Savannah. You know what I do the next seven days? I take flight lessons again. And so I renew my pilot's license. I didn't fly solo. Let me just say. I didn't do any solo flights. I was with an instructor, but I had to climb up on the wing to check the gas tank. No problem.
And so I did wear a pad, a thin panty liner. You get 30 panty liners for 10 bucks. And if you position it right, especially the one with the wings, if you strain or you move a different way, or more importantly, you lean back to the back seat to talk to your grandbaby, they're going to make you spot a little bit. But I bet by January 1st, I'm back in boot camp and no pads. And so my result has been just spectacular. I feel like I'm all the way back in every respect, except I got this black line over my belly button that I can't wear no Speedo drawers like on an Italian cruise ship. That's the only problem. You know what I mean?
But aside from that, it's all good. So I do a lot of community screenings. Every month I'm at some church or some health fair, and so I must get my PSA checked every two, three months. Because whenever I'm there, it adds to our numbers for how successful our screening was. So I just put my arm out and check my PSA again. And mine has been, you not only want a low PSA, it's preferred to have an undetectable PSA, less than 0.01. And so mine has been good. It's the only test that I've done. I don't routinely do anything other than PSA in my own patients if it's truly undetectable.
Eric Kim, MD:
How often do you have your patients check it? Is it every three months? Every six months?
Arnold Bullock, MD:
So mine is different. So I check my patients at the six-week visit, I want it to be undetectable. If there's a positive margin on any adverse pathology, then we check it every three months for at least the first year. But if the margins are negative, we check it at the six-week visit, I check it four months after that, which would be the six-month visit, and then I check it every six months. And I tell them to check it at least every six months for the first three years. And if it truly is undetectable and they want to go to once a year, sure. Because how many people go from a 0.02 to a 0.30 after three years where it's undetectable? And if it does happen, it doesn't happen between year three and four.
Eric Kim, MD:
You don't go to a real number that quickly. And again, I think that's where we have to demystify PSA both on the front end and the back end. It's a blood test. Check it often. What are you hurting by getting it more often?
Arnold Bullock, MD:
That's right.
Eric Kim, MD:
It's more information.
Arnold Bullock, MD:
$25. It's free at a health fair. Go help out the health fair. Join your local community prostate cancer support group. We have one of the best support groups in St. Louis. It's called the Empowerment Network, started by Mellvi Shahid and Isadore Wayne, and they have nothing to do with medicine. They just didn't have any African-American men to talk to. Most cities have a support group, and if they don't, look up ZERO. There's national support groups. We have members of the Empowerment Network in St. Louis who don't live in St. Louis. There's all of these advocacy groups that really, even if you have the most wonderful outcome, you could serve a purpose by talking to other people who didn't have quite the same outcome or who are facing a little bit of recurrent PSA. It's amazing the impact you can have on other people. That's why these support groups are very useful, to see a whole group of brothers, brothers meaning all races, and they're doing great.
So I think that even if you do have a good outcome, it's incumbent upon you to reach back and show your support to those people about to go through the same thing you did. I ended up seeing a radiation oncologist. Now, do I think a radiation oncologist could tell me something other than what I knew? Nope. But do I think it was extremely helpful to see somebody I trust and get another opinion and be sure that I'm not being biased in my own head as to what I should do? Absolutely. And do I think it was a good visit? And when I see this radiation oncologist, good friend of mine, she's like, "You know what? I'm going to see you like a regular patient." So I show up at 5:00, has her staff to stay late. Person does this whole intro, asked me about just the whole psych evaluation, the whole review of system evaluation, gets me in the office. "So we got to feel your prostate." "Say what?"
But the point is you don't want to treat anybody you don't know better than the people you treat that you do know. That doesn't make sense. You did some work on someone's house, and you'd rather fix the kitchen on someone you don't know better than the people you do know. Well, yeah, he's not going to bother. He's not that particular. And so I think that that's the thing with Eric. I know that Eric would do his absolute best with me. But truth be told, Dr. Kim is going to do his absolute best for anybody. Someone comes and says, "Well, I'm the president of such and such corporate St. Louis," he'd be like in the back of his head, "What does that make any difference than the dude that just left who got to call a taxi?"
So we look for morals in our doctors, and that does come across in the way we talk to people, the way we respect them. We try to see them where they are. But my true advice is we have to tell all the people that you have prostate cancer. I know when I first was diagnosed, I was like, "I'm not going to tell anybody. I'm not going to tell anybody. I don't want anybody to know." Then I said, "Well, that's wrong because I'm part of this Empowerment Network where we get volunteers to tell the truth, and that would be horrible." What if it came out that I had prostate cancer and I didn't tell anybody? That wouldn't be right. But amazingly, when you have something yourself, it's amazing how you think different than when you're just a treater. There's a benefit in me doing this. And there's a benefit in everyone with cancer telling other people so that your children know, your nephews know, your cousins know and know their risk.
Eric Kim, MD:
Obviously, I don't have the professional experience or personal experience you do, Dr. Bullock, so I'm coming from a different place, a less insightful place. But the three things that really ring out to me are you got to trust your doctor. So if you see someone and you get just a spidey sense that, "Hey, I don't really jive with this person. I don't think we're on the same wavelength," see somebody else. It's America. You can shop at Target, you can shop at Menards, just go somewhere else. There's no commitment you have necessarily to a physician that you don't get along with, that you don't trust. And then I think what you said, Dr. Bullock, was great. It never hurts to get more information. So getting another opinion from a radiation oncologist or another urologist or urologic surgeon is not a bad thing.
And anyone who's offended by you getting another opinion, they're the short-sighted one. No one should be upset at you that you're gathering more data and more information for yourself. We would all want that for ourselves. We would want that for our families. Here we're actually starting a true multidisciplinary clinic where one of the radiation oncologists that specialize in prostate cancer and I see patients on the same day in the same clinic space, and a couple of the patients we've actually seen together at the same time, and just have more of a discussion. It's a three-way conversation about here's some expertise, and what questions do you have that are pertinent to your life and your lifestyle and your priorities going forward?
Arnold Bullock, MD:
Second opinions, this is the thing, it is amazing how different someone who comes in to plaster your wall is, and you think that there's not the same degree of difference between doctors and surgeons, you're fooling yourself. It is always appalling sometimes to see people who come in for a penile implant, let's say. And I say, "Oh, so you had your prostate removed? How long ago?" "Four years ago." I said, "Well, what was your PSA?" "Oh, my PSA was four and a half." "Oh, was it really bad to see it to give you a number?" Yeah, they said it was 3.3, And I could watch it, but they said, who watches cancer?" And then you see the pathologists like, oh man, this is terrible. This was terrible. There's no way possible this guy should have had his prostate removed. They didn't get a second opinion. Crazy.
But technically the doctor said that I could watch it. They did. They said, "Well, you can take it out. That's the most definitive thing. That's what most people do. You can radiate it, but then you got to get two years of hormone therapy." Now, hormone therapy is like somebody taking your nuts off. Or believe it or not, there's some people just watch it. But the way they said it is framed that you think you're crazy if you watch it. So even though they threw out that you could watch it, and they asked the wife, "Did he say you could watch it?" "Yeah, he said we could watch it." But you know that's not accurate the way it was presented.
Eric Kim, MD:
And you said it earlier really well, that active surveillance is evolving. There's more and more people that are going on to active surveillance. I think patients are a little bit more aware and savvy, but physicians have also changed. And a lot of it is just how you counsel the patient. Right, Dr. Bullock?
Arnold Bullock, MD:
Yeah.
Eric Kim, MD:
It's how you lay out the information, and then going back to the top of our discussion, that's where I think Decipher is really helpful. If you have a patient that you know in your mind really should be prioritizing the active surveillance but maybe they're a little bit more anxious or nervous and you get that Decipher that comes back low risk, that may be the tiebreaker that gets them to do what you know is in their best interest.
Arnold Bullock, MD:
Certainly active surveillance. But again, this is where second opinions come in. And I always ask patients who come in for a second opinion and say, "Have you had any of the tests beyond just the PSA, the MRI, and the biopsy?" "No, doctor, that's all we have done." Now sometimes a person has Gleason 4-4, but then you wonder, have you had a bone scan or a PET scan? On the other hand, someone has 3-3 and four cores. Technically it doesn't meet the six strict criteria, but that's evolving, like you say. You need other opinions, and there's no harm in another opinion. I'm always amazed. I always tell people, I had this Porsche after my kids all graduated from college. I'm thinking next year instead of college tuition, I'm going to buy me this used Porsche, buy this Porsche. Porsche gets wrecked. Do you know they made me take that Porsche to three Porsche dealers, and then they were going to put it on a truck and take it to Peoria before they totaled it?
Eric Kim, MD:
Wow.
Arnold Bullock, MD:
And I always ask people, "Imagine you have a Buick in a big accident. They don't settle for one claim. That's for your Buick. Now you got to have half your liver cut out, and you went to see somebody that your next door neighbor who's a landscaper gave you. That's crazy. That's crazy as can be." They say, "Well, no, no, they gave me the name of a good doctor. Everybody knows this doctor." "Yeah, that's because he's a clown in the doctor's room." You know what I mean? That don't make him a good surgeon, you mean?
Eric Kim, MD:
Yeah, that's right.
Arnold Bullock, MD:
You got to have a second opinion. Well, my word is I'm glad that Dr. Kim was my doctor, and I'm glad that we used all of these tools to give me more definition. One, so I could make the right decision. And two, so I would be very comfortable before and after with the decision I made. It's a lot of patients and the doctors need to be comfortable that we are doing the right thing. And sometimes additional tests like the Decipher gives you that level of comfort and accuracy.
Eric Kim, MD:
I guess my only last thoughts are really appreciate you doing this, Dr. Bullock. I know you have such a unique vantage point that I think your voice is incredibly powerful when speaking to patients and physicians. And for you to be willing to share personal information in order to get that message across, I think, speaks volumes of your character. And then the other thing is just, man, I feel so privileged to have trained at WashU under Dr. Bullock. The life lessons and lessons in medicine that I've learned from you are things I keep with me every day.
Arnold Bullock, MD:
Well, thank you, Dr. Kim. You really make it worthwhile to keep teaching because you're able to carry on good patient care, and it makes my career really worth it.