Back on the road to contagious hospitals

Matula Thoughts 1 May 2020
2430 words


Back on the road to contagious hospitals

“Reading gives us someplace to go when we have to stay where we are.”
Mason Cooley, American aphorist, 1927-2002.


[UH & UMMS Early spring 2020 on the road from old AA train station to main campus of Michigan Medicine.]

One.

Back on the road. May is usually a sweet spot in the calendar, but not so sweet around the world this year. Some random mistakes in the RNA sequences of a single common virus created a new version that has wrecked worldwide havoc on health, hospitals, and economies. Normally in May, memories and anticipations run strong, for it is a particularly sensual time of the year when colors, smells, tastes, sounds, seem to have especially bright notes after winter dormancy has lifted in the northern hemisphere. That sense of memory and anticipation is reflected in William Carlos Williams’s curious piece, Spring and All [By the road to the contagious hospital], written by the New Jersey physician and published in 1923. The title has long intrigued me and the content continues to puzzle me. Williams was a doctor in New Jersey, who wrote in his spare time. He was an excellent physician, my friend Joan Chiaviello Flanigan recalls from his care for her family when she was a child.

The odd free verse poem of Williams is deliberately mal-organized into 27 sections (identified by Roman enumeration I through XXVII, minus the missing number VII), with random prose interludes of commentary, “chapters,” and unidentified “footnotes” interspersed throughout it. An upside-down Chapter XIII follows a normally-oriented Chapter 19 in the unspecified introduction to the poem. Most verbal images precede spring and are neither attractive or cheering. Spring and All, both poem and its world, is very much upside down and disordered, until XXII and the Red Wheel Barrow that helps set things right. [Below: the confusing “Chapter XIII.”]

 

Little did we expect, just a year ago writing here about Williams, that we would actually be back on the road to contagious hospitals this May in 2020. Luckily, the Michigan Medicine field hospital at the athletic complex did not require deployment several weeks ago because social distancing and personal hygiene flattened our covid19 curve enough to preclude the new contagious hospital in Ann Arbor – at least for now. Given the widely disseminated knowledge of historians and scientists, it is incredible that we were surprised (again) by a terrible infectious pandemic.

Two.

Contagious diseases worried the University of Michigan Medical School in 1897 when it converted a small laundry shack behind the Homeopathic Hospital into a Contagious Ward for diphtheria, smallpox, and scarlet fever, diseases barely mentioned in medical schools today. In 1914 the city of Ann Arbor, still recalling a 1908 smallpox epidemic, gave the university $25,000 for a new Contagious Disease Hospital with 24-beds in an isolated area, well to the east of the larger hospital grouping. The civic contribution was as much a matter of self-protection than generous philanthropy, although the two attitudes are not unrelated, for philanthropy after all is a self-protective attribute of humanity at the species level. [Below: Michigan’s Contagious Hospital 100 years ago. Bentley Library.]

Williams wrote Spring and All [By the road to the contagious hospital] at an exuberant time for the University of Michigan and its Medical School. Urologist Hugh Cabot, recently appointed dean (in 1921), was building a great medical faculty and new hospital. Michigan’s  contagious hospital of that time is now long gone and the idea of contagious hospitals had all but disappeared in Ann Arbor and around the world, until this past winter. Some modern hospitals, such as our new Mott Children’s Hospital have been built for contingencies of terrible new epidemic possibilities such as SARS and Ebola, as well as resurgences of ancient ones like measles – perplexing and only understandable because of persistent human folly. Contagious hospitals revived in Wuhan and Manhattan this winter, although they seem to be more contagious dormitories rather than hospitals as we now think of them.

Three.

A May birthday. One birthday to recall this month is that of Dorothy Mary Crowfoot Hodgkin, born on 12 May 1910 in Cairo, Egypt. I first became interested in Hodgkin when I saw a painting of her at the National Portrait Museum in London, last winter during a visit for the wedding of the daughter of my good friends from our training years in London, Robert and Anita Morgan. The painting was prominently displayed and instantly attractive, but a mistake in the label next to it caught my attention.

Dorothy was the oldest of three daughters of John Winter Crowfoot, a civil servant in the Ministry of Education, and his wife Grace Mary Hood. Living and working in Egypt for many years, the family returned to their native England each summer in the hot months and during one of those summers WWI began. In that August of 1914 the parents left their girls with paternal grandparents near Worthing to return to Egypt, where father could continue work.

After the war, the reunited Crowfoots relocated to Sudan where Mr. Crowfoot was put in charge of national education and archeology, until 1926. The girls attended local schools in Sudan and Dorothy became fascinated by archeology and the mosaic tiles in Byzantine-era churches. She also developed an interest in chemistry and her mother, a botanist, gave her a book on x-ray crystallography for her 16th birthday. Dorothy combined her interests by drawing pictures of mosaic patterns and doing chemical analyses of the tile cubes, called tessera. At age 18 she returned to England to study chemistry at Somerville College, Oxford, and received first-class honors in 1932, proceeding then to Newnham College, Cambridge for Ph.D. studies.

Dorothy worked with John Desmond Bernal on applications of x-ray crystallography to protein analytics and their work on the structure of pepsin turned out to be the first biological crystallographic analysis. Dorothy obtained her Ph.D. in 1937 for work on sterol structure and she held a post as Oxford’s first fellow and tutor in chemistry until 1977. In 1964 Hodgkin won the Nobel Prize in Chemistry. [Below: Hodgkin’s model of penicillin. Science Museum London, Science and Society Picture Library.]

Molecular model of Penicillin by Dorothy Hodgkin, c.1945.

One of her students, a young woman named Margaret Roberts at Oxford from 1943 through 1947, wrote a dissertation on the x-ray diffraction of the antibiotic gramicidin that led to a good job in industrial chemistry but Roberts turned to politics around 1950, married Dennis Thatcher in 1951, and qualified as a barrister in 1953. In 1959, then Margaret Thatcher, she was elected member of Parliament, rising to Prime Minister in 1979. In her office at 10 Downing Street Thatcher displayed a portrait of her former teacher. Hodgkin, however, was a life-long supporter of the Labour Party. [Below: Hodgkin legend with corrected name of artist. National Portrait Gallery London, December, 2019.]


The mistake that caught my eye at the National Portrait Gallery was in the adjacent description of painting and artist, Maggi Hambling, where her first name was written “Maggie,” but someone (I’d imagined it might have been the offended artist herself) crossed out the final “e” with what seemed to be a pencil. No matter, the museum is now closed down for a lengthy renovation and time will likely heal this minor error.

Four.

Among the many innovative changes Ganesh Palapattu has brought to the Department of Urology is the broadening of the weekly grand rounds conferences to periodic wider learning experiences that extend beyond world of urology, that he calls “Teach us something.” A session of this nature in late February featured Professor James Kibbie, Chair of the University of Michigan Organ Department who taught us something in the School of Public Health (SPH) where one of the 16 pipe organs of the University of Michigan temporarily resides. In late February Professor Kibbie spoke on “Bach and the Organ,” and treated our faculty and residents to three beautiful pieces (played on the James Walgreen Létourneau Organ on loan to the SPH) from the 270 surviving organ compositions of Bach. [Above: Professor Kibbie at urology grand rounds.]

Kibbie has been collaborating with computational faculty to understand the science behind Bach’s music and a recent grant from Barbara Sloat allowed him to record all of the Bach organ works, all 270 pieces, performing them on instruments of Bach’s era located mainly in Germany. These works are available to the public through the University of Michigan. [From Prof. Kibbie: “If you want to add the URL for the university’s website with the free downloads of my Bach recordings, it’s http://www.blockmrecords.org/bach.”%5D


[Above: Kibbie, Vesna Ivanĉić, Sam Kaffenberger.]
The pipe organ, complex and large, manipulates forced air through many ingenious pipes. Mistakes are inevitable in all spontaneous performances and Professor Kibbie explained how organ recitals are particularly susceptible, having three keyboards, multiple stops, layers of foot pedals, hundreds or more pipes, and up to 100,000 parts. Paired with the human factor, pipe organs offer countless opportunities for performance variations and transcription errors. Of course, Professor Kibbie’s ear can register musical mistakes that fly by most of us with untrained attention.

Everyone makes mistakes from the moment they arise in the morning, whether squeezing out too much or too little toothpaste, rolling through a stop sign on the way to work, or parking too close to an adjacent car – the possibilities are myriad although most are inconsequential. Error is something we understand in clinical work. Medical mistakes may be transcribing errors when writing (now, typing) patient stories, missing veins on blood draws, or making erroneous clinical decisions. To err is human, to err consequentially is unfortunate.

Algorithms promise perfection, if we are naïve enough to forget that they are written by humans. Whereas a piano played spontaneously offers novel idiosyncratic momentary interpretations, innovations, or mistakes that combine to make each performance unique – and mistakes are nearly inevitable –  a programmed piano (player piano) is free of performance interpretation and variation. The standardization (assumed to be error-free, but any algorithm is only as good as its author) brings freedom from the anxiety and art of human performance.



Five.

A scarlet tanager showed up in our old neighborhood last May around this time. My neighbor, Mike Hommel, called to alert me one Friday afternoon when I was indoors on the computer working on the Urology Department history. Mike is a great naturalist who can spot morels on the ground and birds in the trees better than anyone I know and that day, specifically 10 May 2019, he spotted this little fellow, tired and resting after a long flight from somewhere in the south. The splash of color is amazing and has served its evolutionary purposes well. This little guy was not too concerned by our attention as it shifted trees periodically and hopped to the ground to feed from time-to-time.

Had William Carlos Williams spotted a scarlet tanager on his road to the contagious hospital, the poem would probably have been much different. (Such are the contingencies of life.) Piranga olivacea used to be categorized in the bird family Thraupidae within the Passeriformes family (the perching birds with one backward and three forward toes) but DNA studies have reclassified them to the cardinal family (Cardinalidae). When I was younger the Linnaean binomial classification held little interest for me, but my perspective has changed. I looked for the tanager the next day, but he had moved on. A number of deer, however inspected me carefully. They used to drive us crazy, eating everything we planted, and either we would shoo them away or our dog, Molly, would give chase. By May, 2019, Molly’s arthritis had erased her interest defending the property and at that point the property seemed to belong more to the deer than to Molly or us, which was just as well for we had sold the house to downsize in downtown Ann Arbor.

Other hopeful signs of spring popped up last month, oblivious of the prevailing RNA threat to humans. [Above and below: early April 2020, Ann Arbor Water Hill area.]

[Above: pond in West Park. Below: new normal – outdoor picnic tables at Zingerman’s replaced by spaced waiting areas for take-out orders.]

 


Postscript.

Disruption. Is clinical medicine a performance art, as aspired to by professionals since Hippocratic times, or is it becoming an algorithmic practice? Professor Kibbie provoked this question. The doctor-patient relationship has been disrupted by the “encounter” framed by the electronic health record (EHR) format, that is the ubiquitous EHR-directed patient “encounters” have replaced the narratives my generation was taught to elicit. We used to initiate evaluation of patients using the so-called SOAP notes (subjective, objective, assessment, and plan) that align with the medical gaze – Sherlockian/Oslerian scrutiny by a trained observer. 

A “chief complaint” was a story that could be boiled down to a phrase, but narrative demanded more and gave the chief complaint context. Shoulder pain could be a malignant metastasis or a rotator cuff injury and it was important to know if the injury was life-style related, due to occupation, or traumatic; the story behind the pain, its comorbidities and social determinants, are no less relevant than the pain itself. Abstraction of a patient’s story to a drop-down phrase or an ICD-10 numeric diagnostic code is a poor substitute for conversation, medical gaze, and narrative. We should resist this terrible trend as best we can and create EHRs that support narrative inquiry and medical gaze rather than commoditize encounters.

One hundred years ago, Hugh Cabot got off the train from Boston at the old Ann Arbor station (shown at the top) and initiated the first century of Michigan Urology, not knowing that he would have little more than a decade to do it. Medical care had its disrupters back then, new technology, burgeoning subspecialties, and novel models of practice. Some tension existed between the old and the new approach to disease. Classical Oslerian ideas are routed in the bedside medical gaze and dialogue with the patient to understand and explain the problem. The new scientific approach sought to understand disease based on facts derived in research laboratories, other sources of verifiable data, or from the patient as a virtual laboratory. Clever clinicians recognize it is not a matter of one or the other, patients deserve both approaches. Brutal realities of a post-covid19 world will favor the curt, transactional, commodity aspects of health care. Role models in fiction and fact such as Sherlock Holmes and William Osler, and new analyses such as The Good Doctor – Why Medical Uncertainty Matters, a book out soon by Kenneth Brigham and Michael Johns, help navigate this new era of disruption.

[Below: sign of spring, late April, near Barton Pond.]



Thanks for reading Matula Thoughts of May, 2020.
David A. Bloom, University of Michigan Department of Urology

April, perhaps the cruelest month

WN/MT 3 April 2020
2356 words

This April, perhaps the cruelest month



One.

April, was the original title of this painting by American impressionist Frederick Childe Hassam, a century ago, in 1920. It was an optimistic time when the world was rebounding from years when the thin veneer of civilization seemed to be wearing away with war and influenza. The pendulum of events changed for the better and, in Ann Arbor, Hugh Cabot started up a century of modern urology at the University of Michigan.

It is a mystery what drove Hassam, just then, to go back to his very beginnings with this work. Maybe the emergence of the world from the edge of catastrophe just then was a factor. He renamed his painting, Green Gown, the woman in green being Rosa Delia Hawthorne, Hassam’s mother, depicted in an April a half century earlier when three months pregnant with Frederick (born October 17, 1859 in the family home in Dorchester, Massachusetts). [Above: April, Courtesy, Gibbes Art Museum.] The gorgeous composition shows Hassam’s imagination of his mother at 27 years of age, reclining pensively on a settee, as if considering her next 6 months of confinement or the joys and trials of parenthood. A daffodil arrangement in the right foreground reinforces the time of year in the original title. Yet it was an odd concept for a painting, with the artist picturing his mother in the first trimester of pregnancy with him, at his actual beginning. This was a curious contrast to Whistler’s famous consideration of his own much older mother a half century earlier.

Hassam’s painting is a suitable introduction to April, the beginning of spring in the northern hemisphere, when showers anticipate May flowers, as the saying goes. Another painting by Hassam, The Avenue in the Rain (in the White House Collection) depicts Fifth Avenue in NY around the time of WWI and perhaps during some April showers. This was one of 30 paintings in Hassam’s Flag Series.



Hassam purchased a home in 1919 in East Hampton where he most likely painted April the following year and would live another 15 years, dying in East Hampton at a respectable 75. The country was in a patriotic mood in April, 1920, with the Great War and recent influenza epidemic no longer existential threats, but the national optimism eclipsed any prudent attention and resources to prepare for the next iterations of existential threats. This April, normally a time for beginnings, existential threats are back at civilization’s door. [Above: The Avenue in the Rain. Hassam, 1917. White House Collection, since the Kennedy Administration. Below: Oval Office 2009, photo by Pete Souza with the president and the picture on the wall.]





Two.

A century is a convenient milestone, although most humans fall short of this in their life spans. The modern average of “three score and ten” or so, however, is ample time to leave something behind, if one is fortunate, in good works, successors, and kindness. Octogenarians, septuagenarians, and centenarians are rarities, the products of good genes and lucky circumstances. The U.S has 80,000 centenarians, the U.N. estimates 343,000 worldwide in 2012 and projects 3.2 million by 2050.

A century is an extreme stretch for a single human, few make it that long, but human collectives – nations, organizations, corporations, and other teams – are not limited biologically and for them a century is a useful ruler to measure accomplishments and create historical narratives. So, consider medical practice and urology in April 1920, in particular, when the grim experiences of war and influenza were fading from memory, although some lessons learned were working their way into civilian health care. The growing scientific knowledge base of medicine and its burgeoning subspecialties by 1920 had rendered medical school alone insufficient training for the new generation of medical practitioners; internships and residency programs were producing a new world of graduate medical education that became the career-defining element of medical training.

This centennial year of urology at the University of Michigan is an opportunity to understand our organizational corporate past and some of the many stories relevant to Michigan Urology. Additionally, the centennial is a chance to personally reconcile with our roots in healthcare and at the University.

With the present world turned upside down by Covid19, the AUA in Washington, DC and Sunday Nesbit reception are cancelled, but we look forward to the autumn and September 24-26 with the Nesbit alumni reunion here in Ann Arbor, featuring guest speaker alumni Carol Bennett, Barry Kogan, Ananias Diokno, Carl Smith, Curtis Nickel, Mitch Albom, and Sherman Silber, among others. The first of our two books on Michigan Urology will soon be available (and also online via Michigan Publishing), this being Urology at Michigan – The Origin Story, tracing the development of genitourinary surgery, the University of Michigan, its Medical School, and the introduction of modern urology to Ann Arbor by Hugh Cabot. Book two will cover the first hundred years of urology at Michigan, year by year, expanding on the Konnak and Pardanani text that Jim Montie commissioned 20 years ago. We hope to finish this in the next year.

This April 2020 it’s natural to pause for a moment and consider what urology practice and education were like 100 years ago. Cystoscopy, a new skill of the late 19th century, required special instruments and novel expertise that defined urology and fueled its early creative burst. A new breed of surgeons picked up cystoscopy, improved the technology, gained insight into genitourinary dysfunction, and created miracles of minimally-invasive therapy. Nonoperative and open solutions to urinary problems expanded urology, after it was so-named in 1902. Urology came together as an open organization in 1910, created rational training programs for young physicians, and formed its own journal in 1917. Little of this progress translated to the battlefields of WWI, but the civilian progress accelerated after its conclusion, although barely in time to be applied in the next war.


Three. 

 

In April, 1920, the Cabots were adjusting to their new lives in Ann Arbor. Hugh was busy as chair of the Surgery Department and the sole urologist at the University of Michigan. Cabot’s two competitors in Ann Arbor, still calling themselves genitourinary surgeons, had left the university to practice a few blocks away at St. Joseph’s Mercy Hospital and neither they nor Cabot had any interest in collegial relationship. The University Hospital complex was physically constrained and outdated, pale in comparison to the facilities Cabot left behind in Boston, but a quantum leap from the 2,500-bed hospital he had commanded in France on the Western Front of the Great War.

The Cabot family was living temporarily in the President’s House, having cajoled the Regents into its use pending the anticipated summer arrival of incoming President Burton. Anxiety was growing within the university administration as it tried to coordinate renovations demanded by the Burtons and uncertainty over the Cabot’s plans. At work, Cabot had to manage the teaching and clinical responsibilities of his small Surgery Department, deploying the full-time compensation model. To grow his small and inbred Surgery Department Cabot leveraged his military connections to bring two essential additions to Michigan that year, Frederick Coller and John Alexander.


Four.

Just about halfway between the start of the Michigan Urology centenary and now, I began my era of training. It was 1971 and urology was at a watershed. It sat between an era of board-certified urologists with life-long certification working in individual or small practices and the present era of urologists with contingent re-certification working in large practices or multispecialty health systems. In 1971 fiberoptic cystoscopy had only recently replaced first generation cystoscopes, illuminated by distal mignon lamps of Edisonian technology; transurethral surgery was one of surgery’s rare minimally-invasive operative procedures; major open reconstructive urologic procedures were available at only a few centers; the intravenous pyelogram and retrograde injection studies were the main imaging modalities (ultrasonography was in its primitive stages); and training programs were mostly small and weakly standardized. That year, Jack Lapides Section Head of Michigan Urology from 1968 through 1983, introduced his strongly disparaged idea of clean intermittent catheterization.

Meaningful visual cystoscopic acuity for old-time urologists required much skill, art, and experience. For learners, peeping over the shoulder of  cystoscopists (whenever they decided to let learners have a look), the opportunity was fleeting. This scenario earned Jack Lapides his covert nickname, Black Jack: for he was known to temporarily disconnect the light cord (by stealth of hand) before letting the learner look through the scope and asking what they saw. [Below, Jack Lapides photo by DAB.]



Lapides had been a loyal and productive lieutenant to Reed Nesbit for some 20 years. When Reed was aiming toward retirement in 1967, Jack no doubt felt inclined to take over the leadership of the small section. The two urologists seemed to have gotten along well professionally, although there was no doubt as to who was in charge and it didn’t seem that a strong friendship existed outside the workplace. Lapides had been running his own separate and independent residency program at Wayne County Hospital, graduating a single chief each year whereas at this point the UM program was finishing 2-3 per year.

Karl Montague (UMMS 1968), visited by us last autumn at the Cleveland Clinic, recalled his experience as a junior medical student rotating on urology. Karl had been focused on a career in cardiology, primed in that direction by an NIH fellowship in Basel, Switzerland. Urology at the University of Michigan was then a mandatory clinical rotation and Montague recalls some of Lapides’ pedagogical antics (at the VA):

“Dr. Lapides was demonstrating cystoscopy to a group of us medical students in our third year. Of course, this was before the time of video teaching and the learner had to peer over the shoulder of the teacher who had positioned the scope over a landmark view of anatomy or pathology, while the patient was under anesthesia as happened to be the case that day. So Dr. Lapides had the first student in turn to look in the scope and asked: ‘Do you see the verumontanum?’ The student, after a few awkward moments said ‘Yes’ and Lapides checked the position and asked the next student, who again agreed. When it was my turn, I looked and looked and finally said ‘No.’ It turned out that the Professor was holding the scope in the middle of the full bladder, nowhere near the veru. He seemed to like me after that day and later in the rotation asked my career plans. I told him it was cardiology. He said: ‘Think about urology, and if it interests you, come back and talk to me.'”

Montague did give some thought to urology and that changed his career arc and life. It was a clever and kind approach on the part of Lapides, kinder than the anecdotal “Black Jack” stories. [Below, Montague in his office at Cleveland Clinic, autumn 2019.]




Five.

Kindness & Kurt Vonnegut Jr. (November 22, 1922 – April 11, 2007). The Vonnegut books I read in college, medical school, and during residency offered great escape from study with humor, satire, and surreptitious insight into the thing we call, the human condition. More than appreciated at the time, Vonnegut expanded my sensitivities to the comorbidities of life, environmental deterioration, and the quality of kindness. Cat’s Cradle (1963), iconic book, offered very short chapters that fit my short extracurricular attention span. [Above: “Two Young Women Seated playing cat’s cradle.” Suzuki Harunobu, ca. 1765. Wikipedia.] Slaughterhouse-Five (1969, film 1972) didn’t mean so much to me then, but years later hearing a beautifully performed audiobook, I felt its powerful impact, reflecting Vonnegut’s lived experiences as a prisoner of war in the Allied firebombing of Dresden. Even though I served in a peacetime Army for four years after my residency training, I had gained enough maturity, experience, and knowledge to appreciate that mind-bending book. 

Vonnegut told stories of contrived odd characters and places. While exaggerated and even preposterous, he resonated with the best and worst of human attributes. God Bless You Mr. Rosewater (1965) only came recently to me, as I was tracking a quote that reflects Vonnegut’s dark humor and the hope that underlies his satire. The quote came from an anticipated baptismal greeting:

“Hello babies.

Welcome to Earth.

It’s hot in the summer & cold in the winter.

It’s round & wet & crowded.

On the outside, babies, you’ve got 100 years here.

There’s only one rule that I know of, babies –

God damn it, you’ve got to be kind.”

T.S. Eliot once called April “the cruelest month” so it seems fitting to conclude now with thoughts of kindness, a trait that seems to come naturally to some people, but most of us have to work at it, balancing it against our selfish particularities. Kindness is a very human trait, the very basis of civilization, although many other creatures evidence kindness in numerous ways. Kindness is, no doubt, tied into mirror neurons, oxytocin, and other incredible biologic inventions that we are dimly aware of at best. Motherhood is the ultimate expression of kindness, perhaps that was on Hassam’s mind to some extent in April, 1920.

 

Postscript.

With few centurions living today, only historians can tell us much about what daily life was like during the big influenza epidemic of 1918-1920 that ended around the time Michigan Urology’s first century began. And, of course, one hundred years from today, will many people fully understand the anxieties, terrors, and tragedies of the present moment in time.

Kindness is always at risk in the busy workplaces of healthcare, and this will be especially tested in this current pandemic threat (Coronavirus 19), that has taken civilization by surprise. We are too often surprised by infectious diseases, whether cyclic or novel and while our immune systems may be surprised, our brains have no excuse. Here is an amateur historian’s list of the last big pandemics:

HIV/AIDS rising from 1976 to 1981 and peaking 2005-2012, killing 36 million

Influenza H3N2 1968 killing 1 million

Influenza H2N2 1956-58 killing 2 million

Influenza H1N1 1918-1920 killing 20-50 million

Sixth cholera pandemic 1910-1911, killing somewhat under 1 million, estimated.

Influenza H3N8 1889 – 1890 killing 1 million

Third cholera pandemic 1852-1860 killing 1 million

Black Death (bubonic) 1346-1353 killing upwards of 200 million

The Plague of Justinian (bubonic) 541-543 killing up to 25 million

[Above: Red Cross volunteers assembling gauze face masks at Camp Devens, MA, 1918.] 

Thanks for reading Matula Thoughts this April, 2020. It will be a rough month.

David A. Bloom
Department of Urology
University of Michigan

March thoughts, idle and otherwise

WN/MT 6 March 2020

March thoughts, idle & otherwise
2102 words

 

One.

Be cautious in mid-March, the spirit of Julius Caesar warns. It’s not idle advice, for Caesar must have had a tin ear to the political dissent building up around him, or else the mantle of authority made him feel unassailable until he was terminally disabused of that conceit on the Ides of March 15 in 44 BCE. A coin issued by Brutus two years after Caesar’s assassination (shown above) celebrated the would-be king’s downfall. Before the Ides of March became notorious, that day in the Roman calendar was reserved for religious observances and settling of debts. It so happens that the big settling of debts in American society two millennia later has been displaced a full month in the calendar to April 15 for taxpayers like me and businesses not clever enough to find the loopholes. [Above: Eid Mar coin reverse, the tail side. Below: Wikipedia, The Tusculum likeness of Julius Caesar, photographer Gautier Poupeau.]

No one wants to be overly superstitious, but it is wise to venture forth with a measure of caution not only on the Ides of March but every day, monitoring your physical and political environments, on the lookout for “hungry looking” Brutuses and watching for reckless scooters, distracted walkers or drivers, rising seas, hurricanes, fires, blizzards, tornados, or merely uncovered sneezes and coughs. (By the way, why is it socially accepted that we expect ourselves or others to cover coughs or sneezes only when “feeling sick” with a fever? Why doesn’t every adult carry a handkerchief or tissue to cover every cough or sneeze – especially in these coronavirus times ?!)

Ancient Roman days were counted differently than they are now, with three named points each month: the Nones in the early month, the Ides in mid-month, and the Kalends on the first of the next month. Assassination perp Brutus issued the coin in the fall of 42 BC, and that Eid Mar denarius shows a “freedom cap” positioned between two daggers.

The denarius was the standard coin in the Roman Empire from 267 BC until replaced by the antoninianus in the mid-3rd century AD, the coin of Galen’s day. The silver in the coin was initially worth about a day’s wages for skilled laborers at that time in Rome, today that equivalent amount of silver is less than $4. Emperor Nero, about 100 years after Caesar’s assassination, began to debase the coin, substituting cheap metal for the silver, until hardly any silver was left by the end of its use. The Eid Mar value, however, has greatly appreciated – a single coin recently fetching 325,000 Swiss francs ($332,583) at auction on Oct. 6, 2016.

[Above: Eid Mar coin obverse – the head side with Brutus. Below: Silver content debasement by year of Roman Empire denarius and its successors, 11 BC to 250 AD. Wikipedia: Data from Walker, D.R. (1976-78), The Metrology of the Roman Silver Coinage. Parts I to III. Nicolas Perrault III.]

 

Two.

Coffee Houses. My youngest daughter and her husband, both academics, do much of their work in coffee houses, as do many of their generation. Before computers and the internet, coffee houses were places to meet and converse. Now, it’s more common to see people with ear buds in place and eyes focused on their work on laptops and (annoyingly) on phones.

The coffee house of Edward Lloyd on Tower Street in London around 1686 was the room where it happened that marine insurance blossomed and grew into an essential component of modern business and life. Insurance was a necessary ingredient in the emergence of the limited liability company, that is, the modern corporation underpinning modern capitalism. Coffee houses have been important social hubs for over 300 years in Western Society and the tea customs in Asia have been around much longer. The Cosy Corner Tea Shop of Mrs. Hugh Cabot opened in Ann Arbor 1923 and became a small part of the Michigan Urology story, with its own backstory of how social changes and the Great War changed expectations for one faculty wife. Coffee and tea houses today serve as primary places to plug into earpieces and computers so as to disconnect from people and immediate scenes around you and leap into distant people, scenes, and your own imagination. Oddly, socialization and social media are not very compatible.

The Coffee House, in the winter of 1905/1906, a painting by Alson Skinner Clark (1876-1949), shows the State Street Bridge amidst smoke, fog, and early “skyscrapers” over an icy river. You can barely identify the actual coffee house. [Above: Institute of Art, Chicago.] The title suggests Clark either painted the scene in real time (en plein air) or recalled it from his time in the neighborhood, although he was also an accomplished photographer and may have used that medium to help fashion the painting. The view is not vastly different a century later, the high rises are higher and more numerous, the horsepower of street transportation has increased (without much increase in the transit time per mile), and the price of a cup of coffee has gone up. That same neighborhood these days contains at least several Starbucks and other coffee houses. [Below: State Street Bridge in early spring 2019 during AUA national meeting.]

 

Three.

Coffee beans. I can’t spend too long in coffee houses without recalling the great Danish story teller Karen Blixen, known more widely by her pen name, Isak Dinesen. Out of Africa in 1937, described her years in British East Africa (modern-day Kenya) between December 1913 and August 1931. She initially tried to raise cattle, but switched to growing coffee beans although that, too, proved difficult. The soil and high elevation were not perfectly conductive, East African conflicts in First World War interfered with supplies and equipment, and ultimately the Great Depression made the business untenable. Having run through her family’s money, Blixen returned to her family home in Denmark to write. Her work there proved far more successful and enduring than the Karen Coffee Company and she became a world celebrity, dying in 1962 at age 77. Orson Wells planned a film anthology of her work, but never completed it, producing only The Immortal Story (1968). Babette’s Feast (1987) became an extraordinary black and white film of a somber isolated Scandinavian village and Out of Africa (1985) was gorgeously filmed in color featuring Meryl Streep and Robert Redford. Last autumn, while at the terrific CopMich meeting organized by Dana Ohl and Jens Sønksen, I spent an afternoon at the Blixen family home in Rungstedlund. [Above: Photo by Sophus Juncker-Jensen (1859-1940) taken in 1913 shortly before Blixen’s departure for Africa. Below: Karen Blixen’s home, Rungstedlund, 2019.]

The Isak Dinesen quote that comes to mind after an hour or so in a coffee house is from Seven Gothic Tales:

“What is man, when you come to think upon him, but a minutely set, ingenious machine for turning, with infinite artfulness, the red wine of Shiraz into urine.”

Unpleasantly, the name Karen, like many other terms on social media, has become a derogatory meme. [Below: Wikipedia: Baroness Karen von Blixen-Finecke at Kastrup Airport CPH, Copenhagen 1957-11-02.]

 

Four.

A book on urine. In 1917, when Karen Blixen was cultivating coffee by day and telling stories to her friends at night and Michigan Urology founder Hugh Cabot was serving on the Western Front for the British Expeditionary Forces during WWI, Arthur Robertson Cushny, former University of Michigan professor from 1893 to 1905, was working at University College London when he published Secretion of the Urine, a book explaining the machinery and infinite artfulness of urine production. [Above: Cushny, Wellcome Museum. Below: title page.]

Cushny took uroscopy to a new level of detail. Uroscopy began in ancient times with basic sensory evaluation of urine (color, odor, taste, etc.). Medieval uromancy offered speculative linkage of urine findings to diagnosis, and microscopic evaluation later opened new levels of visual detail. Chemical and microbial analysis, using 19th century tools and technology, provided meaningful therapeutic opportunities, but Cushny’s book of 1917, Secretion of the Urine, explained how urine was formed in health and disease, by filtration at the glomerulus and reabsorption/secretion along the renal tubules.

Arthur Cushny (1866-1926) had come to the Medical School in Ann Arbor to replace John Jacob Abel, a UM graduate from 1883 who had returned to Ann Arbor in 1891 to teach, pursue research, and create the world’s first department of pharmacology. Abel transformed the formal and ancient lectures on materia medica and toxicology into pharmacology instruction with demonstrations applicable to clinical practice of his time. Johns Hopkins lured him away in 1893, but that opened the door for Cushny to replace him as chair. Dean Victor Vaughan found Cushny in Berne, investigating the problem of death from chloroform anesthesia and developing methods of titrating the delivery. Cushny was an effective teacher and a productive researcher in Ann Arbor, but returned to Europe for an attractive job as chair of pharmacology at University College London in 1905 and in 1918 returned to his native Scotland as chair in Edinburgh, where he died in 1926. Secretion of Urine was a major contribution to physiology and urology. [Cushny AR. The Secretion of the Urine. London, Longmans, Green, 1917.]

 

Five.

You are what you eat, like most aphorisms, contains truth and hyperbole. It extends easily to other bodily inputs such as you are what you drink. [Above: The Cook, Guiseppe Arcimboldo 1570. National Museum, Sweden.] Last month’s suggestion, that you are what you read, regarding on The Crisis periodical, fortifies a parallel claim for mental nutrition, which came to mind again in another magazine that compels interest, The Economist. A recent piece in the recurring essay entitled “Johnson” (after Samuel Johnson, of dictionary fame), combined the recent custom of selecting “words of the year” and the phenomenon of adverse climate change. “Johnson” offered a number of candidates for word of the year, noting that according to the Dutch dictionary Van Dale, Dutch-speaking Belgiums voted for winkelhieren, a term for “buying locally,” as the 2019 word of the year. [Economist Jan 4, 2020, p. 62.]

Ann Arbor offers excellent examples for buying locally including Zingerman’s and Kerrytown markets for food and stuff, Literati for books, or Camera Mall for photographic things. Amazon is convenient, luring, and addictive but it robs from local communities (livelihoods and taxes). Plus, given the packaging and reported 30% return rate, that particular limited liability corporation accelerates planetary degradation. Perhaps a community becomes what it buys. If people buy mainly from Amazon, they will be an Amazon community as local businesses recede like the glaciers – not such an attractive possibility.

 

Postscript x 2: peas and war.

Gastronomic identity. In 1826 Anthelme Brillat-Savarin wrote, in Physiologie du Gout, ou Méditations de Gastronomie Transcendante: “Dis-moi ce que tu manges, je te dirai que tu es.” [Tell me what you eat and I will tell you what you are]. In 1940, Victor Lindlahr, nutritionist and enthusiast of the so-called catabolic diet, wrote a book You are what you eat: how to win and keep health with diet. In strict chemical and physiologic terms, it’s hard to deny that fact, although it’s nice to believe the human sum is actually greater than the sum of its nutritional parts, as the Italian painter Guiseppe Arcimboldo (1527-1593) hinted in his arresting works, such as Vertumnus. [Above: Emperor Rudolph II as Vertumnus, Roman god of seasons. c. 1590, Guiseppe Arcimboldo. Skokloster Castle, Sweden.]

The Battle of Columbus. Just around this time of year, in 1916 (March 9), Francisco “Pancho” Villa’s División del Norte raided the small border town of Columbus, NM and retreated back to Mexico. United States President Woodrow Wilson, while holding the U.S. back from the Great War in Europe (that Hugh Cabot entered as a volunteer with the British Expeditionary Forces) eagerly sent 4,800 U.S. troops led by General John Pershing over the U.S./Mexican border to capture Villa. [Above: Unmindful of the Ides, U.S. troops crossed into Mexico in March 1916 in pursuit of Pancho Villa. Photo courtesy U.S. Army Military History Institute.] The 9-month punitive incursion south of the border failed to capture Villa, but it did recruit University of Michigan Ph.D. Paul de Kruif, who joined as a private. The campaign ended in January 1917, without achieving its objective. Pershing claimed the effort a success, even though it seemed that the U.S. soldiers were the main parties punished. de Kruif went on to join the WWI effort after the U.S. officially entered the conflict, serving in the Sanitary Corps as a lieutenant and then captain before returning to Michigan for a short time. His next job was at the Rockefeller Institute until he was fired, rendering him the freedom to become a medical journalist and collaborator in 1926 with Sinclair Lewis in Arrowsmith.

 

Thanks for looking at this month’s communication from the University of Michigan Department of Urology. What’s New is the email version and matulathoughts.org is the web-based version.

David A. Bloom

Matula Thoughts February 7, 2020

Matula Thoughts 7 February 2020 Leaps, literacy, & opinions 2142 words One. Leap Year. A celestial accounting anomaly this month on Saturday February 29 will have only minor impact on people’s lives and world economies. The extra business day, when … Continue reading

2020 – a new blank slate

Matula Thoughts 3 January 2020

A new blank slate

2376 words

One.

 

Tabula Rasa 2020.

Optimists begin New Years with clean slates. Most people negotiate internal tension between optimism and pessimism, but the sense of opportunity that comes with a new year generally tilts the balance toward optimism and the chance to start anew with mistakes and sins of the past perhaps forgotten, if not forgiven. The blank slate, though, is only a metaphor; each year ahead will build on stories of the past – history – and the contingencies of immediate moments. [Above: Blank wax tablet.Wikipedia.]

The new year, next decade, and century ahead for Michigan Urology, may be shaped by the century that unfurled after Hugh Cabot came to Ann Arbor late in 1919, but the critical determinants of the future will be the ingenuity, industry, and success of our educational programs, research, and clinical delivery. The idea that the essential deliverable of academic medicine is patient care, while not historically prominent, is absolutely clear today. That essential deliverable, as we have said in our department of urology for some years, is kind and excellent clinical care, thoroughly integrated with education and innovation. With that, as the “North Star,” navigation becomes simple.

The Latin phrase tabula rasa originates from blank slates or waxed tablets that, after erasure of chalk or melting the wax, are available for fresh notation. Aristotle was one of the early thinkers who likened the mind to a clean writing slate and Avicenna, Thomas Aquinas, and John Locke, among many others, expanded the idea until modern neurobiology brought science to the matter. Metaphors are merely tools for thinking and communication, not absolute “true facts” that Don Coffey sought to recognize amidst the litter of contemporary information. Steven Pinker’s book of 2002,Blank Slate: The Modern Denial of Human Nature, calls out the metaphor and explains that human behavior is not constructed on a blank slate, or tabula rasa, but is heavily programed. [See Pinker’s TED Talks 2008 and 2019.]

Blank Slate is also the clever name for an Ann Arbor Ice cream shop, the actual ice cream serving as a medium for an ingenious palate of flavors. Ice cream, one of the great inventions of humankind, is a delight in any season, although winter demand slackens enough for the Creamery to close up for the coldest months (above at Liberty and S. First Streets). Having borrowed the metaphor for this monthly message, I was duty bound to ask (and receive) permission from Michigan grad Janice Sigler who opened Blank Slate in July, 2014, with her husband.

 

Two.

January 1920 was an optimistic time for Hugh Cabot in Ann Arbor at a high point of his career. Modern Urology, his noteworthy 1918 textbook, capped his 15 year rise to central authority in the field. An early volunteer for the European conflict, well before American entry made it a world war, Cabot commanded a 2,500-bed general hospital on the Western Front by war’s end. His return to Boston at the end of January 1919 was front-page news in the Boston Herald, although not without glitches. Cabot’s team of doctors and nurses was blocked from leaving the train at the Boston station where a reception was waiting for them. A military authority ordered the ensemble to remain on the train and continue on the train to Camp Devon, Massachusetts and then New York City for official discharge of duties. After discussion Cabot declined the order and the entire medical team disembarked from the train to join the waiting reception and then dispersed into the crowd to resume civilian life. [Below: Boston Herald. Front page. “Harvard Surgical Unit held prisoners by error on arrival in Boston.” January 31, 1919.]

As Cabot resumed civilian life the world seemed enroute to a better future in terms of public health, geopolitics, economics, technology, and art. The devastating Great Influenza Epidemic was over, but other pandemics followed. Geopolitical solutions to WWI would pave the way to WWII and later conflicts. The economic world collapsed in less than a decade. Rapid advances of technology that seemed so wonderful in the early 20thcentury proved two-sided by century-end with antibiotic resistant bacteria threatening food safety, robots displacing jobs, computer malware holding businesses and cities hostage, identity theft via internet, and social media manipulation of public elections. The public eagerly embraces Orwellian Big Brother – reassuringly renamed Alexa, Hey Google, and Siri – with ubiquitous cameras on streets and in homes paving the way to authoritarian control of society through artificial intelligence.

 

Three.

The “blank slate” of the new year, brings to mind resolutions and the human itch for personal mastery of something – work, play, family, or hobby. Just as they were once inspired, Bach and Casals are posthumously inspiring future composers and musicians today. The cello suites have had a remarkable 300-year journey since Bach started writing them as exercises for his young wife in 1717. Casals discovered the largely-forgotten music in a shop in 1890 and mastered its performance by 1896 when he became principal cellist in Barcelona at the Gran Teatre del Liceu. [Below: Title page of Anna Magdalena Bach‘s manuscript: Suites á Violoncello Solo Senza Basso. Wikipedia.]

Casals had ups and downs, like everyone, but the worst immobilized him for two weeks in 1939 when he didn’t leave his room in Paris, exhausted from recording the six Bach suites (Casals hated the recording process) and despairing over Franco’s take-over of Spain. Casals was thoroughly burned out, although the favored terminology of the time described him as emotionally exhausted and depressed. Thankfully, he rebounded and his career reached new heights. Nearly 20 years later, at age 80, he married 20-year-old Marta Montañez y Martinez, dismissing concerns over their age discrepancy: “I look at it this way: if she dies, she dies!” [Cesare Civetta. Mar 14, 2018. “Pablo Casals sacrificed his career to protest Franco.” https://CesareCivetta.com/blog] [Below: From Encyclopaedia Britannica, Pablo Casals, 1965. Erich Auerbach, photograph, Hulton Archive/Getty Images.]

The inspiration of the suites lives on: Yo-Yo Ma was inspired by Bach’s cello suites at age 4 and today, at 64, travels six continents to perform all six suites in single sittings at 36 locations.

Combustion control has been a defining feature of our species beginning around campfires for comfort, cooking, and conversation. Heat may erase tabula rasas, but metaphoric self-combustion in modern society seems a new thing. It is not clear when burnout is a “legitimate” dysfunction or an extension of quotidian fatigue? That state of reduced personal efficacy, emotional exhaustion, and depersonalization describes the condition today called burnout, that suddenly, it seems, has become epidemic in many professions, including health care. Conferences, surveys, and editorials proliferate and  medicalize the matter. The Lancet offered a useful perspective in an editorial, Physician burnout: the need to rehumanise health systems. The wording is counterintuitive – the “rehumanization” of human health care. [The Lancet. 394: 1591, 2019.]

 

Four.

So how is it that health care became “dehumanized”– that very suggestion seems to be an oxymoron, a contradiction in terms, as René Magritte cleverly depicted in his surreal paintings such as the 1953 Wonders of Nature (©René Magritte). The dehumanization phenomenon in medicine seems linked to the systematization, corporatization, and commoditization of healthcare. Systems are necessary in modern healthcare, of course, but the displacement of what historically was called the doctor-patient relationship with checklists, guidelines, and clinical pathways distracts from the human element. The EHR-directed patient “encounters” have largely replaced the narratives of the human conditions wrapped-up in taking “the history.”. Corporate medicine is quickly replacing small practices and bringing with it tainted ideas of business management, specifically the failed ideas of Taylorism, managerial accounting, and the North Star of shareholder value.

The idea of the limited liability corporation has largely built the modern world, as human society has given corporations many special rights such as limited liability, free speech, and some special benefits that ordinary people cannot have. (Back around 2003 Julian Wan gave me a book that explains this – The Company – A Short History of a Revolutionary Idea, by John Micklethwait and Adrian Wooldridge.) Undeclared but implicit in that Victorian innovation is a social contract that businesses exist not merely for shareholder value, but more broadly for stakeholder value – jobs, employees, benefits, suppliers, community – and for value to society-at-large, the most important stakeholder of all.

It is natural that some parts of health care are legitimate commodities, functioning optimally in a market-based economy without the necessity of an intermediary professional agent. Examples are many – flu shots, over-the counter medications, food supplements, and countless others. Other healthcare functions are complex, multilayered, and highly professional, such as renal transplantation, mental health treatment, and management of malignancy. In between these extremes are the essential transactions of visits to physicians, dental care, emergency department visits, orthopaedic care, periodic eye care, and treatment of urologic conditions – these are a mix of commodity and profession. The arbitrage of those two elements of society is an endless conversation.

The extension of personal mastery in one’s subject of choice, whether by New Year Resolution or not, is self-vaccination against burnout. The enhanced personal well-being can re-humanize your medical workplace in more ways than this essay can explain. Recently, up in Flint at the Hamilton Community Health Center, Mike Giacalone, Jr., the Chief Medical Officer, was explaining Hamilton to interviewing journalists and said that for the Flint patients, “every visit is not just a medical visit, but equally so a social, economic, and behavioral visit as well.” While particularly relevant in Flint, this should be a universal aspiration in health care. The medical gaze should try to “take it all in” and triage the needs of a patient and family as best possible, in spite of the rigidity of the EHR- constrained medical encounter programmed around a chief complaint.

 

Five.

Media and messages. Whether the medium is ice cream, canvas, blank paper, musical instrument, computer screen, stage, construction site, clinic room, operating room, or learner – artistry can be performed.

Everyone is a lifelong learner, but the health care field demands special attention. Undergraduates and beginning medical students are the most impressionable blank slates and for that reason the responsibility of role models, teachers, and mentors is perhaps the greatest for them among the learners we teach. For many of the younger set their first experiences seeing a physician, nurse, or physician’s assistant at work (sometimes in instances of personal care of a UTI, stone, or surgical correction) imprints and fosters a lifelong pursuit. Whenever possible, these opportunities for shadowing or introductory teaching should be embraced. Residency training, however, is the most critical blank slate of all in medicine, fashioning the knowledge, skills, artistry, and professionalism for a career. [Images above & below from “the internet.”]

Blank slates are opportunities, but risk erasure of the past although that is necessary with wax tablets and chalkboards. Parchment and paper were a big improvement allowing durable manuscripts and books, still at risk from fire (accidental or intentional) or other forms of destruction or deterioration. The new world of digital information carried the conceit that humans could become “paperless”, but that is ultimately not only impractical but also a genuinely bad idea for free societies.

When governments, sectarian authorities, or corporatocracies control printing presses, airwaves, or other social media – society is captive to a few reigning opinions because inconvenient stories, opinions, ideas, or truths are conveniently avoided or erased. Clever memes and tweets easily subvert social groups and human ideals. One great feature of the human condition is the testing and synergism of opinions, ideas, and technologies that can build civilization for the greater good of mankind and sustainability of the planet. The central idea of free speech at the heart of civilization, is being sorely tested by the unexpected opportunities of modern technological social media.

From our parochial perspective in the art and business of health care, erasure of history is an especially unfortunate reality, but we see it with each change of technology in health records. The operative procedure notes and pathology reports from the earlier part of my career seem to have vanished with the paper records we utilized when I started here in Ann Arbor, as I have learned when trying to answer requests from people regarding, say, an exstrophy closure operative report in the 1940’s, a hospital course in the 1960’s, or thyroidectomy pathology findings from the 1970s. Those floppy discs we had in the 1980s and zip-drives of the 1990s are increasingly difficult to access as obsolete technologies disappear. No one today can ensure that the massive data in electronic records will be converted to the media of the future – it seems unlikely that the “data cloud” of 2020 will be maintained in a future data cloud or its equivalent of 2050.

When Ed McGuire brought me to Ann Arbor in 1984 my blank slates were 3×5 index cards and the newly launched Macintosh Computer. Our hospital then had separate inpatient and outpatient paper charts. The Surgery Department administrators cautioned me to not get used to my Apple Computer as UM was preparing to launch the Wang Computer System. I didn’t listen – but still have the cards (one for with every patient I saw at Michigan) and that original Macintosh (now a book end).

 

Postscript

Matula Thoughts analytics, 2019. We have no sense of the total readership of the monthly What’s New delivered by email, but the web version matulathoughts.org has levelled off at 3357 views and 2199 visitors from 78 countries as of 31 December 2019, down from 3458 views, 2226 visitors from 89 countries in 2018, probably due to personal retreat from the chair position of the Urology Department at the University of Michigan. This past year we shortened the essay from 10 to 5 numbered items and dropped the word count to 2000 or so, although still far less convenient than a 140-character microblog tweet.

This leveling-off of Matula Thoughts recalls the Hippocratic Aphorism: Art is long, life is short, opportunity fleeting, experience hazardous, and judgment difficult. Other interpretations of the Ancient Greek vary the nuance and words, but clearly this personal essay, the first Friday of each month, is anachronistic and risky in offering personal judgments and observations. Those facts are more than balanced by the personal delight in hearing back from a handful of readers each month, thus extending these essays to dialogue and conversation, challenging facts, pointing out errors, and teaching me. Comments last month were especially appreciated. For all these, thank you.

 

David A. Bloom

Department of Urology

University of Michigan, Ann Arbor

Mastery

Matula Thoughts December 6, 2019

Mastery

2473 words

 

One.

Master cellist Pablo Casals received the Presidential Medal of Freedom, on this December day in 1963, among the first cohort of recipients, in a bittersweet ceremony two weeks after President Kennedy’s assassination. Kennedy had come up with the idea for the award, but Lyndon Johnson presided at the event by default.

The Presidential Medal of Freedom was a successor to the Medal of Freedom that derived from Harry Truman’s Executive Order 9586 (signed July 6, 1945), establishing an award for notable civilian service during WWII. Over 20,000 such medals were given out, mainly by the secretaries of state, war, and navy up through 1961. Kennedy re-oriented the award with his Executive Order 11085 (signed February 22, 1963), broadening the name to Presidential Medal of Freedom and shifting its scope to include cultural achievements. Other awardees with Casals that evening December 6, 1963, were architect Ludwig Mies van der Rohe; painter Andrew Wyeth; singer Marian Anderson; writers E.B. White, Thornton Wilder, and Edmund Wilson; Rudolf Serkin pianist; Edwin Land inventor; Edward Steichen photographer; Clarence Randall businessman; educators Genevieve Caulfield, James Bryant Conant, Alexander Meiklejohn, and George Taylor, and others including John Enders for his vaccine work. It was quite a gathering. [Above: Casals at Carnegie Hall, 1917. Bain Collection, Library of Congress.]

Casals, one of the great cellists of all time, at age thirteen had found a tattered copy of obscure Bach unaccompanied cello suites in a Barcelona shop, mastered the six pieces, and took them to international attention that would inspire generations of cellists such as Yo-Yo Ma. On Wikipedia you can find audio clips of Casals playing parts of the First Cello Suite. The Casals entry from the same source offers a quote from George Carlin attributed to Casals, who when asked at age 93 why he continued to practice three hours a day replied, “I’m beginning to notice some improvement.” Fact or true fact, it’s a beautiful thought and one certainly in keeping with the artist’s persona.

 

Two.

Born in Catalonia Spain in 1876, Casals died in Puerto Rico in 1973. His life was one of mastery and professionalism, interrupted by a terribly low point around the time of the Spanish Civil War, when he was a refugee in France. Fleeing Franco’s efforts to liquidate political foes, Casals learned that he would have his arms cut off if he returned. Anguished over the fall of the Spanish Republic, distressed by it abandonment by democratic nations, fearful of his own safety in France as the Nazi’s rolled across Europe, and exhausted by demands of recording the Bach cello suites (the first recording made of them), Casals fell into a deep depression and didn’t leave his room in Paris for two weeks. Burned-out, as some people now would say, he eventually rallied and got back to his work. Much later Casals gave his memoirs to a writer, Albert E. Kahn, who published Joys and Sorrows: Pablo Casals, His Own Story in 1970.

Kahn, it should be noted, was nephew of the master industrial architect Alfred Kahn who worked with Hugh Cabot in Ann Arbor to plan and build Michigan’s acclaimed University Hospital in 1925. Kahn also designed Hill Auditorium, Clements Library, Angell Hall, Betsy Barbour Residence Hall, Burton Memorial Tower, Harlan Hatcher Library, Ruthven Museum, among other buildings on campus. Kahn’s son, Eddie, a contemporary surgical trainee with Nesbit under Cabot, became Michigan’s second neurosurgeon (after Max Peet). Sixty Kahn buildings are on the National Historic Register list, but it was the Clements Library in Ann Arbor for which Kahn wanted to be most remembered.

Stories of the Bach suites and Casals are interwoven by Eric Siblin in The Cello Suites (Grove Press, New York, 2009). Mastery is an aspirational trait that most people seek in one way or another, whether it be mastery of a skill or hobby, mastery of a job, or mastery of parenting. Kennedy’s idea for the Presidential Medal expanded a national honor related to war to the mastery of the constructive skills of civilization – the humanities. Kennedy’s empathy and respect for those arts reverberates today and marks him as a master statesman, no doubt imperfect as is anyone, but a master of the presidency. [Picture: Casals performing for the Kennedys at the White House, November, 1961.]

 

Three.

Kennedy had a special linkto the University of Michigan dating from his campaign speech on the steps of the Michigan Union at 2:00 AM on October 23, in 1960 when he proposed the idea of the Peace Corps. The national shock at his assassination only three years later was profound for most people, no matter how they had voted. [Above: Time cover from John F. Kennedy Library, Boston.]

At this time in 1963 the Section of Urology of the Department of Surgery at the University of Michigan was in the final stage of Reed Nesbit’s leadership. Nesbit’s mentor, Hugh Cabot, had been an undisputed master of the subject of modern urology in the early 20th century, while Nesbit subsequently became the undisputed master of many of its skills, most notably transurethral resection of the prostate. Nesbit was also a master educator, training at least 83 residents and additional fellows, although we are still trying to get a precise count (demonstrating once again how elusive true facts and actual history can be).

In December 1963, as Nesbit was winding up another good year as chief of urology at Michigan, he undoubtedly read of Casals and the other Presidential Medalists the following day in the Ann Arbor and national newspapers. The only other senior faculty member in the Section of Urology faculty with Nesbit in the Section of Urology in 1963 was Jack Lapides who was Chief of Urology at the VA and at Wayne County General Hospital (since 1950). Joe Cerny (N ’62) was a junior faculty member. Harry Lichtwardt had been Vice Chair of Urology at Wayne County General Hospital, since 1951. The three new residents in 1963, halfway through their year at this time of the season were Dale Alkema, Larry McDonald, and Bernie Sloan, while the chief residents were Robert Bishop, Dewey Heetderks, and Harold McDonald. Nesbit was likely starting to think about his annual Christmas letter around this time. Meanwhile I was in my first year of college, oblivious to the field of urology and wondering if I would master anything at all.

The news cycle, one hundred years ago, centered around the daily papers with a 24-hour rhythmicity. The national news for December 6 contained little information that today’s newshounds would recognize, except perhaps for mention of the Warren Commission in the New York Times, an Oswald reference in the Ann Arbor News, and a Big 10 athletic scholarship limit reported in the Michigan Daily. [Thanks to Katie Baxter for finding these.]

The inaugural Presidential Medals of Freedom winners were not revealed to the public until the next day, December 7, in addition to other newsworthy items, including the 22nd anniversary of Pearl Harbor.

 

Four.

Senait Fisseha. Not every week does The Lancet feature an article on a Michigan faculty member, but that happened recently with a profile on Senait Fisseha, Clinical Professor of Obstetrics and Gynecology. [Lane R. Profile. Senait Fisseha: empowering women through reproductive health.The Lancet. 394:1405, 2019.]  Medical Director of the University Center for Reproductive Medicine in 2008, Director of the Division of Reproductive Endocrinology and Infertility in 2011, and creator of the University of Michigan Center for International Reproductive Health Training, Senait  has developed a partnership between Michigan and St. Paul’s Hospital Millennium Medical College in Addis Ababa, Ethiopia.

Another shout-out for The Lancet relates to Ella Doerge, who graduated from our program last year and is currently pursuing further training in a London fellowship with Tim O’Brien. She recently sent me the following comments and picture she took at The Lancet Library.

Hi Dr. Bloom,

Just dropping you a line to see how things are going back on the homefront in Michigan. I’m a month or so into working at my fellowship at Guy’s and am getting more and more familiarized with life in the UK, both in the health care system and in the city at large. While we share the English language with the English, there have been more differences in culture and conversational conventions than meet the eye that I’ve been uncovering. While it’s been good here, I think I’m irrevocably American, in mentality, how I prefer to practice medicine, and how I interact with my environment.

Anyway, I thought of you in particular a few weeks ago because I had the opportunity to spend a day with one of the lead editors of The Lancet. I got to peruse the library with volumes dating back to their first publications which I’m sure you would have found particularly interesting (photo attached). I also sat in on their weekly editorial board meeting with their editor-in-chief in which they made all the decisions for papers to include in the coming week’s issue.

 

[Above: Lancet Library; Below: Ella with Duncan Morhardt during their days at Michigan.]

 

Five.

Burnout is a hot topic. It rightly focuses attention on our students, residents, and colleagues who are struggling more than usual. It offers many opportunities for blame, administrative burden, the electronic record, mandatories, administrators in general, third party payers, regulations, fee-for-service systems, RVUs, corporate medicine, throughput demands, constrained schedule grids, and the gray days of winter. It provides new opportunities for talks, papers, and even jobs. But let’s not blame burnout, per se; many physicians lose a sense of the magic in their profession and others are truly overwhelmed by “TMI” and conflicting responsibilities. And, of course, some organizations provide poor workplaces.

Burnout cannot be detected by biomarkers and as of yet has no ICD 10 diagnostic code. Once it was considered a binary phenomenon – you either have it or don’t, just as Casals in his darkest days couldn’t leave his room to re-engage with the world. Individuals, at some point, may be overwhelmed by work and can’t continue it. Surveys and questionnaires (“instruments”) allegedly diagnose “degrees of burnout” which seems to have been externalized, from an internal or personal condition, to a workplace fault. No responsible leader can avoid discussing the topic and “measuring” their teams for it with further surveys, thereby adding counterproductively to the enlarging ambient administrative burden. By medicalizing burnout and viewing it as a “disease,” like a generalized form of carpal tunnel syndrome, we gas-light the matter, conveniently obscuring leadership a causal factor, but no matter how we frame it we, as leaders, are responsible for workplace conditions that heavily contribute to the condition.

It is unreasonable to expect successful people, even the masters of their arts to be “on fire” every day. Pablo Casals had days of tedium, frustration, annoyance, and – as is well documented – anger and embitterment over the political realities of his nation. His dysfunctional interlude in Paris was multifactorial in origin – the recording process was particularly alien and painful for him – but he rebounded. Could intrinsic motivationbe the converse of “burnout” or provide a “vaccination” against it? Daniel Pink’s book, Drive, caught my attention in my early days as chair and affected my world-view. I gave out numerous copies of it and had many productive discussions on it with executive coach David Bachrach and faculty colleagues. The ideas integrated beautifully with concepts of lean processes that Toyota, John Shook, and locally Jack Billi, Jeanne Kin, and Malissa Eversole have shown me. The key features of intrinsic drive,or self-motivation, that Pink teaches are purpose, mastery, and autonomy.

Purpose envelops healthcare professions, you shouldn’t have to look far to find it, although it can become obscured in crowded and tense modern workplaces. Mastery is a matter of training, life-long learning, and deepening maturation of perspective. Our residencies and fellowships get us started, our practice and continuing education hone our skills, and hard-won wisdom opens the door to mastery, which is never complete, as Pablo Casals lightly noted in 1964 when he said: “I’m beginning to notice some improvement.”

Autonomy is the challenge, in these times of complex health care teams. Of course, no person is an island – we are members of a deeply interwoven eusocial species and rely on others to bake our bread, brew our beer, and prepare our meats and tofu. Autonomy is relatively conditional. In rare instances, some people can effectively bully their way into great degrees of autonomy and achieve wonderful things, although usually with a personal toll – e.g. Steve Jobs. The challenge for leaders, whether at single unit levels or presiding at large systemic levels, is to understand and protect the autonomy needs of workers under their authority. The complex teams of modern medical practice preclude absolute autonomy of any one person. Everyone reports to someone from custodian to CEO, yet members of most teams function best when driven by their own intrinsic motivation rather than external carrots or sticks, targets or incentives; the challenge is unleashing that intrinsic motivation. When employees understand their contribution is valued, when they have freedom to improve that work, and when they feel fairly compensated, then intrinsic motivation can thrive – and that is the best inoculation against burnout.

 

Postscript.

Dick Dorr passed away last month. He was an iconic figure in Michigan Urology and a pillar of the community, leader of St. Joseph’s Mercy, and faculty member in the University of Michigan Department of Urology in his later career. Richard Paul Dorr was born 8/17/1936 in Saginaw and became a loyal Spartan at Michigan State prior to coming to the University of Michigan Medical School to obtain an MD in 1961. After surgical internship at Wayne County General Hospital he served as Captain in the U.S. Army Medical Corps and Commander of an Airborne Division Medical Company at Fort Benning, Georgia. Dick returned to Ann Arbor in 1964 for urology residency at the University of Michigan that began under Reed Nesbit and concluded under Jack Lapides in 1968, when he went across the street to St. Joe’s to begin urology practice and develop a superb team with Tim McHugh and Hugh Solomon. Dick served as chief of the medical staff from 1980-82. He became a member of the American College of Surgeons, in the tradition of Dr. Nesbit. A master of urology, and ever the student, Dick completed a fellowship in pediatric and reconstructive urology with the cutting-edge team at East Virginia Medical College in 1984. Following that he had important corporate roles in the St. Joe’s system before returning to fulltime practice in 1990 with Tim and Hugh. In the last six years of his career he worked at the University of Michigan Medical Center during the leadership period of Jim Montie. Dick died on 11/6/2019 and these pages cannot do justice to that master of urology. He is survived by two siblings, his wife Jane, and children Richard, Susan Dorr Goold (colleague in Internal Medicine here at UM), and Mark. Dick and Jane have five grandchildren, two step-grandchildren, and three great-grandchildren.

 

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

November one

DAB Matula Thoughts November 1, 2019

One hundred years of urology
2615 words

One.

The origin of urology at the University of Michigan centers around its first three urologists Hugh Cabot, Charles Huggins, and Reed Nesbit, each having enormous impact in their individual ways. Cabot’s impact was academic, clinical, and organizational. Huggins came to Michigan for what was then called “postgraduate training” under Cabot and was inspired to a career in urology that took him to the University of Chicago as chief of urology and eventually to a Nobel Prize. Nesbit, roommate of Huggins as trainees, became Cabot’s successor and a noteworthy urologist, whose clinical innovation, organization leadership, and education of future leaders of his century, had few equals.

The story of genitourinary surgery, of course, actually began much earlier, with pre-Hippocratic roots and slow evolution until the second half of the 19th century when health sciences, modern technology, and medical subspecialties emerged and revolutionized medical care. The University of Michigan story is entwined with those changes, as one of the earliest public universities and in 1869 it was the first university to own and operate a teaching hospital. By the early 20th century the University of Michigan Medical School was noteworthy among its peers in teaching and research, but lagged behind in the clinical arena, a fact that some viewed as due to its small-town location. After the 1902 neologism by Ramon Guiteras the term ii replaced that of genitourinary surgery, although not until many years later in Ann Arbor.

Exactly one hundred years ago, on November 1, 1919, the University of Michigan Medical School, although still stuck in educational and clinical paradigms of the previous century, was on the precipice of major change that would launch it into the major leagues of 20th century academic medicine. Dean Victor Vaughan, an immeasurable influence since his arrival in 1874 as one of Michigan’s first two Ph.D. candidates, had been distracted by duties in Washington during WWI and was reeling from the death of one of his sons who had been about to return home from his service in Europe on the Western Front. Vaughan had other national leadership responsibilities on his plate in addition to the war effort and his inattention to Michigan had left the Medical School without chairs for its two main departments – internal medicine and surgery. In Boston Hugh Cabot had recently returned home from 2.5 years of service overseas to find his private surgical and urologic practice “evaporated.” He discovered the Ann Arbor opportunity for a fulltime salaried job as chair of surgery and jumped at it. Beginning work on October 12, 1919, he initially stayed at the Michigan Union, but soon convinced the regents to allow him with his wife and four children to live in the unoccupied University’s President House until a new president was in place.

Cabot was a necessary change agent for the Medical School. He was a top-of-the-line international urologic celebrity even before his 1918 textbook Modern Urology. It is telling that his predecessors in genitourinary teaching and practice at Michigan, interim surgery chair Cyrenus Darling and clinical professor Ira Dean Loree, had been holding on to the older name for the field. Cabot was a self-declared urologist. A prolific speaker and writer, he was assiduous in connecting with new ideas, other specialties, and novel technologies. During the war he became a skillful administrator, ultimately rising to Commanding Officer (CO) of a British Expeditionary Force (BEF) hospital with over 2,000 beds near the front. While he would bring leadership and modernity to Ann Arbor, his brusque style had already created detractors on the national scene, as evident in files at the Bentley Library where a letter to Victor Vaughan from Bostonian Dr. Frederick Shattuck on September 30, 1919 commented:

“Dear Vaughan:
I am greatly interested in your capture of Hugh Cabot for whom I have high regard and much affection, not so much because he is a first cousin of my wife, though very much younger, as for himself and what he is. His departure will be a loss to me, personally, and I think a loss to this community; but the more I reflect on the matter the more I feel that he can render greater service, and thus derive greater satisfaction from life by accepting your offer. Like other strong, positive men, he has made enemies, but I think his capacity to deal with men developed markedly during his service as C.O. of Base Hospital No. 22, B.E.F. There were difficulties connected with that practice which do not appear upon the surface, and it is my belief that, taking all things into consideration, he handled the job extremely well…”

Shattuck concluded the note offering condolence to Vaughan on the recent loss of a son in Europe, referring to the actual moment Vaughan got the terrible news just about as he was to preside over a session of the AMA at its Atlantic City meeting that summer. Cabot also must have been at that meeting, according to the correspondence, and it is likely that it was when and where he first learned of the Ann Arbor job, perhaps directly from Vaughan (letter below).

 

Two.

The first century of urology in Ann Arbor: October 1919 to October 2020. Michigan Urology now entertains a year-long celebration of its centennial. Cabot introduced modern urology to the University of Michigan when he arrived on October 12, 1919, and began to build a formidable clinical engine. He recognized that clinical practice is the essential piece of the tripartite mission of academic medicine, providing the milieu for medical education, factory for new knowledge, and regional reference point for clinical expertise. The clinical milieu generates inquiry and provides a testing ground for the ideas and technology to improve healthcare, and it is the spiritual center of the organization. Clinical programs provide the essential deliverable of academic medical centers. The clinical enterprise is also the financial engine.

Since 1972, Michigan Urology has called its alumni group the Nesbit Society, not from ingratitude to Cabot, but out of respect to his trainee Reed M. Nesbit who became the first Section Head of Urology, after Cabot’s abrupt departure in February, 1930. Over the next 37 years Nesbit made Ann Arbor an epicenter for medical education and clinical innovation. Nesbit trained nearly 80 residents and fellows (we are still trying to determine the exact number), and an extraordinary number of them became leaders in academia and their communities. As a principal innovator and master of transurethral prostatectomy, Nesbit made Ann Arbor a destination for doctors wanting to learn the operation as well as for “patients in-the-know” to get treatment. A number of Cabot’s other clinical faculty also became internationally dominant figures in their newly evolving clinical arenas, of thoracic surgery, neurosurgery, and orthopaedics as well as general surgery, thus bringing the University of Michigan to the center stage of clinical medicine for the first time in its evolution. Nevertheless, Cabot’s vision of a synchronous multispecialty academic health system eluded the University because the hospital functions and professional units (the clinical faculty) were competitive rather than synchronized.

 

Three.

The Nesbit 2019 Scientific Day last month was packed: Peggy Pearle from UT Southwestern in Dallas (above, with Stu Wolf from Dell Medical School in Austin, and Rod Dunn from our Dow Health Services Division) was featured as our Nesbit Visiting Professor with one talk on controversies in medical management of stones as well as another on ureteroscopy; UM President Emeritus Jim Duderstadt discussed the unique impact of the University looking back and looking forward; Jim Cogswell of the School of Art and Design gave a multimedia presentation on the mysteries of dark matter; Dan Dierdorf UM offensive lineman from the famed 1969 team and famed sportscaster presented his Michigan Memories; Stuart Wolf our own star faculty alumnus described the Michigan lessons he is deploying at the new Dell Medical School in Austin, and our departmental leaders gave updates on their divisions including Program Director Kate Kraft and CopMich Co-chair Jens Sønksen. This writer presented Centennial Thoughts and Ganesh Palapattu gave the State of the Department address. We had many wonderful returning alumni and I wish I could have shown them all on these pages, but more pictures can be found on the Nesbit100.com website. I also wish we could have had our traditional alumni talks, but we deferred those for this special Centennial Program, save for Peter Fisher’s unique talk of his personal experience that was both terrifying and uplifting: Everyone should experience sudden cardiac death —- and live. [Below from the top: Dan Dierdorf, Pete Fisher between Will Roberts and Phil Sweetser, Ganesh & Manfred Stöhrer.]

Manfred Stöhrer from Germany, Jens Sønsken from Denmark, and Kash Siddiqi from the UAE travelled far for this meeting. Some of us had been with Jens just a few weeks earlier in Copenhagen, and our ties to him and his team in Copenhagen go back nearly 30 years. The association with Manfred is just as long, with strong ties through Ed McGuire (below) and myself. Our actual but geographically distant faculty included Sherman Silber, now adjunct professor from St. Louis (below with postdoc Yuting Fan – Fanny), and Brian Stork and Jessica Phelps of our Muskegon West Shore Urology practice.

We consider UMMS graduates, residency trainees and alumni, faculty, regional colleagues, and other friends of the Department of Urology as Nesbit Society members, and many joined us to enrich the meeting. Bruce Bracken, John Hall, Phil Sweetser, Betty Newsom, the Chang duo of Cheng-Yang and Ted, Mike Rashid, Dave Morris, the Taub duo of Marc and David, the Kozminski duo of Mike and Michael, C. Peter Fischer, Howard Usitalo, Stan Swierzewski, Charles Gershon, Charles Reynolds, Jay Hollander, Amy Li, Parth Shah, Hugh Solomon, Joanne Dale, George Schade, Noah Canvasser, Katy Konkle, Bert Chen, Tim Schuster, Craig Kozler with son Oliver, Pete Fisher with son Jake who was interviewing for medical school, Brian Lane, Herk Khaira, Atreya Dash, Ray Tan, Ron Suh, and Scott Gilbert. Rebekah Beach, Frank Begun, Tim Bradford, David Burks, Ward Gillett, David Harold, Will Johnston, Earl Koenig, Surendra Kumar, Amy Luckenbaugh, David Perlow, Paul Sonda, and Nick Styn. Ed Kleer and Elena Gimenez from St. Joseph’s Hospital. Samir Basata, Bob Isacksen, Andre King, David Lutchka, Konda Mouli, Eric Stockall, and David Wenzler. UMMS alumnus Richard Tsou came from Hawaii Pacific Health. Jim Peabody and Nesbit alum Hans Stricker from Henry Ford Health System. From East Lansing we were honored to have Shirley Harding from Michigan State and Nesbit alum Len Zuckerman and Sparrow Residents Margeaux Dennis, Eric McKeever, Andrew Schwinn, Alex Shannon, and Ross Voelker. David Miller won the Konnak Faculty Service Award.

The evening reception at Zingerman’s Greyline event space at the Marriott was terrific with Thad Polk and Red Berenson who offered stories of hockey and Putin. Next year’s meeting will conclude this year-long Centennial Celebration of Michigan Urology and will center around the Wisconsin football contest. The dates will be September 24-26, 2020.

 

Four.

The game. The tailgate at Nub Turner’s GTH Investments provided a more relaxed social gathering point than the scientific program of the previous day. With the concurrent Homecoming Weekend and Parent’s Weekend, Ann Arbor was hopping. The victory over Iowa was a modest win, and it was largely won by our defense. The B-52 flyover was a crowd-pleaser, and the Veteran of the Game was a UM graduate named Thomas Houdek (below).

Michigan Urology has many notable veterans, although none more distinguished than Edward J. McGuire, the man who succeeded Jack Lapides in 1983 and hired me in 1984. Courtesy of Julian Wan we sat in the Club seats with Khaled and Mary Ellen Hafez (below).

 

Five.

Seasonal note. Autumn is fishing season in academic medicine when senior medical students prowl the nation’s training programs for residency education to select where they hope to learn their lives’ work. This process of residency training, postgraduate medical education, was quite informal in Cabot’s time, a century ago – a sort of “arrange-it-yourself” process for periods of time from weeks to years in length. Now the process has been standardized and is regulated by professional organizations including the AUA, ABU, ABMS, and ACGME.

Training programs simultaneously audition medical students in clinical clerkships in summer and fall of the senior years and interview them formally in fall and winter. Each party then submits their “rank lists” to a national site and matches are made for urology residency training positions. The process of interviews, selection, and then the actual residency training of 5-8 years is delegated to the Program Director, a position that has grown increasingly complex over the years since the terms of Gary Faerber, Khaled Hafez, and now Kate Kraft. Selection, education, and supervision of residents requires a small village of helpers and Kate is assisted by Sapan Ambani and a team of committees. This year Michigan Urology had over 375 applicants, offered around 66 interviews, and will end up matching with four trainees who will begin their residency training next July 1. Michigan Urology matched five last year, one of whom will have an 8-year period that will include a substantial research component, and this is Joel Berends. Ganesh, Khaled, Kate, and Sapan plan to alternate 4 and 5 year classes.

 

Postscript.

Vaughan’s reply to Shattuck. Only two days after Shattuck’s revealing response to the dean’s reference inquiry, Vaughan replied:

“My dear Friend:-
I am fully aware of the fact that Dr. Hugh Cabot being as strong a man as he is has made enemies and their criticisms have not failed to reach my ear, at least some of them. However I believe in Dr. Hugh Cabot and am greatly pleased that the prospect lies before me of having him as my colleague in work which I believe to be of the greatest importance to the future of American medicine. I congratulate myself and my school upon being able to obtain his services.

I wish to thank you for your words of sympathy. I had five sons in the Army and it seemed that the good fortune of having all of them returned to us was about to be accomplished. My eldest son was Chief of the Medical Service in the Roosevelt Hospital at Chaumont during the entire period of the war. After the armistice he was detailed to work up typhoid fever in the American Expeditionary Force. He had collected all of his data and was on his way home when he was accidentally drowned in a small river in France. It is the first time that death has visited our family. Time alone will assuage the sorrow but words of sympathy from such a dear friend as you will do much to mitigate our sorrow. Yours sincerely, V.C. Vaughan” [letter below]

 

PPS

In little over a decade Cabot brought the University of Michigan Medical School into the top tier of academic health centers. He recognized that a superb, attractive, and financially robust clinical engine was at the center of medical academia and he delivered on that necessity. Yet he spent down political capital rather than building it and he had a tin ear for the faculty and staff he led; it was not quite like his successful, albeit shorter-lived, experience as commanding officer at the Western Front of WWI. His successors in urology at Michigan continued to build one of the finest urology programs in the world, and Cabot surely would have been astonished to see what it looked like 100 years after he first set foot in Ann Arbor as its one and only urologist. [Below: Faculty, residents, alumni, guests at Nesbit Society meeting 2019.]

We thank those who joined us for this kick off for our Urology Centennial Celebration and invite you and those who couldn’t make it this year to the conclusion in 2020, September 24-26.

Best wishes as we begin November, 2019.
David A. Bloom
University of Michigan, Department of Urology, Ann Arbor

A century and a millennium

DAB Matula Thoughts October 4, 2019

A century and a millennium

Michigan urology begins its centennial celebration
2087 words

One.

But first, consider what happened in 1623. Horace Davenport, the great American physiologist, University of Michigan educator, and de facto historian of the Medical School asked that question when he introduced physiology to a class of medical students. This story has been told here before, but it deserves repetition for each new generation of trainees as well as for the rest of us, who tend to forget Davenport’s lesson. The prize for the correct answer, Davenport said, would be an “A” for the class with no further expectations – no attendance, no labs, no homework, or exams.

The medical students scrambled with answers, all erroneous and some ridiculous, but no one came close to the correct one – the publication of Shakespeare’s First Folio in 1623. After the playwright died in 1616, friends collected his works, many printed in smaller books called quartos, and they published the First Folio, actually titled Mr. William Shakespeare’s Comedies, Histories, & Tragedies. This consisted of 38 plays and over 150 poems, in addition to Shakespeare’s portrait by Martin Droeshout, one of two authentic images of the author. Of the 750 copies printed, 223 survive and 82 are in the Folger Collection in Washington, DC.
Davenport’s point was that the practice of medicine doesn’t play out in isolation, it is part of the context of life, the unique circumstances of humanity with its individual stories, dramas, aspirations, co-morbidities, and accomplishments. William Shakespeare’s work encompassed the range and depth of the human condition more completely than any artist before or since.

Before learning physiology, much less practicing medicine, Davenport claimed, the human condition must be studied to the extent best possible by each of us although the “self-awareness” of humanity as a species can never be complete. Self-awareness requires some sense of time and place, and these senses are enhanced by knowledge of history. The history we each know may be reality or mythical, a distinction that good historians just as good scientists work to discern. The arts help navigate the ambiguities of that distinction.

 

Two.

And what happened in 1919? One hundred years ago, Hugh Cabot, Michigan’s first urologist and new chair of the surgery department arrived in Ann Arbor and performed his first operative procedures at the University of Michigan. Cabot’s first specific urologic cases in Ann Arbor have not yet been identified, but a letter in the papers of UM President HB Hutchins of 1919 explains the successful appendectomy on a patient known to and likely referred by Hutchins “in the Surgical Clinic October 13.” This was Cabot’s second day at work and he helpfully told Hutchins:

“Since the operation patient has progressed very satisfactorily and we see no reason why he should not make an uneventful recovery. Twenty-four hours later this case would have been a complicated one, and the prognosis would not have been as hopeful.”

The letter was typed on stationary that read: University of Michigan, Department of Surgery, University Hospital (nearly identical to what this senior author found on arrival to the Medical School and Hospital 65 years later, although the names were different). The faculty listed in 1919 were C.G. DARLING. M.D. GENERAL SURGERY; I.D. LOREE. M.D. GENITO-URINARY SURGERY, C.L. WASHBURN. M.D. ORTHOPEDIC SURGERY; AND C.J. LYONS. D.D.Sc. CONSULTING DENTIST.

Ira Dean Loree was Michigan’s principal genitourinary surgeon up until that time in the small Surgical Department, although his senior, CG Darling, also did work in that emerging subspecialty as well. If stationary is to reflect mindset, neither Darling nor Loree embraced the new terminology of urology, the neologism of Ramon Guiteras in play since the formation of the American Urological Association in 1902 (of which Cabot had been president in 1911) and embraced by Cabot in his influential textbook Modern Urology in 1918.

 

Three.

A thought experiment. Given that Hugh Cabot came to Ann Arbor and introduced modern urologic practice to the University of Michigan a century ago, we might reflect upon what happened a century before then, in 1819, when the fledgling University of Michigan was only two years old. Not much was actually going on educationally in its initial Detroit site then and no medical school existed in the territory of Michigan, which was not yet a state.

The year 1819 brought the first major peacetime financial crisis in the United States and the Tallmadge Amendment that was passed in the House of Representatives, but got lost the next year in the Missouri Compromise. The amendment would have prohibited slavery in the impending statehood of Missouri, but got traded away for the admission of Maine as a free state.
What about 1719, 300 years ago? The world was being mapped with increasing realism and imagination. Herman Moll’s “codfish map,” A New and Correct Map of the Whole World in London was a step along the way to visualization of the political and geographical reality of the planet. Also that year Robinson Crusoe, was published, arguably the first English novel, a fictional account of an actual event.

Slavery began in the American colonies a century earlier, it was in August 1619 according to the illuminating 1619 Project, a partnership of the Pulitzer Center and the New York Times. The Idea of America, an essay by Nikole Hannah-Jones, is informed and provocative. [NYT Magazine. August 18, 2019. The 1619 Project.]

Five hundred years back in time, on 20 September 1519, Portuguese explorer Ferdinand Magellan began his trip that would circumnavigate the planet, thereby quieting down the Flat Earth enthusiasts of the time, although that stubborn phenotype reappears in alternative forms, notably, the climate change deniers of today. Magellan had five ships, two more than Columbus, and carried supplies for 270 men and two years. In spite of mutiny, desertion, catastrophic storms, starvation, and raids from local natives, Magellan made it to the Philippines by March, 1521, where he was killed in battle by natives who resisted his offer of religious conversion. Other officers took charge and a single ship made it back to Spain on 6 September 1522. Leadership lessons still abound.

In 1419, during the Hundred Years War, France surrendered to Henry V and Normandy was re-annexed to England providing the nidus for Shakespeare’s great imaginative play 180 years later. Joan of Arc would have a fiery end in this town in 1431 and Charles VII, King of France, recaptured the city in 1449. A strong earthquake devastated the city of Ani in Armenia in 1319. A century earlier, in 1219, Genghis Khan sought advice on the Philosopher’s Stone from Qui Chuji (Taoist Master Changchun) and St. Francis of Assisi introduced Catholicism to Egypt during the Fifth Crusade. Navigation was improved in 1119 by Chinese author Zhu Yu who described the innovative use of magnetic compass and separate hull compartments in ships. Japanese statesman Fujiwara no Michinaga (966-1028) retired from public life in 1019 after installing his son as regent, but remained behind the scenes as Japan’s de facto ruler until his death nine years later. In spite of the coincidence of pronunciation, however, there is no way to connect Michinaga to our State of Michigan today in October, 2019, more specifically than as bookends to a millennium of human stories and progress.

The point to this thought experiment is that matters of immediate moments pale in the grand scheme of human centuries and glacial millennia. Nevertheless, those momentary and seasonal concerns constrain most human attention. Our lives are framed by the past and moments of grand inspiration transcend the mundane times. King Henry V’s exhortation to his troops at Agincourt, as imagined by the Bard of Stratford, is as inspiring as George Gipp’s softer “Win one for the Gipper” speech before Army played Notre Dame in 1928, and portrayed by Ronald Reagan in the classic film Knute Rockne, All American, in 1940.

 

Four.

Autumn in Ann Arbor brings the excitement of new students, football, and the academic season of meetings and visiting professors. Marty Koyle came from Toronto (with provenance from the Brigham, Dallas, UCLA, Denver, and Seattle) last month as our visiting professor in pediatric urology. Marty is a great clinician, surgeon, and educator, and he is one of the few urologists today with an active practice in pediatric renal transplantation (in addition to the astonishing John Barry). Over three days Marty interacted with faculty and residents, leaving an indelible imprint. Courtesy of Julian Wan, we repaid Marty and his wife Ellen in part with the Michigan Football experience, witnessing a close struggle to defeat Army. [Above: Army on the defensive; Below: Marty at the Pediatric Urology Conference.]

The tradition of visiting professors was indoctrinated at Michigan in the time of Cabot, who himself shuttled among peer institutions and brought the best experts to Ann Arbor faculty and students, notably with strong relationships between the Mayo Clinic and St. Bartholomew’s in London. Cabot’s successors, Frederick Coller, Reed Nesbit, Jack Lapides, Ed McGuire, and those who followed, maintained the important tradition to expose our learners to the best surgical educators and ideas. [Below: Puneet Sindhwani, Department of Urology and Transplantation Chair, University of Toledo with Marty Koyle after Grand Rounds.]

[Above: Tailgate at Zingermans.]
Athletic traditions have been closely entwined in the academic mission, offering counterbalance from book-learning and clinical medicine. Performances, great or aspiring to greatness, entertain and serve as rallying points for institutional spirit. Even back in Cabot’s time, important conversations and political alignments took place on the sidelines as the following letter shows – when Cabot followed up to Governor Green (1927-1930, Republican):

“You may remember at the time of the Wisconsin Football Game you were kind enough to suggest that I write you after election concerning certain matters of medical interest which we discussed that day. Now that this turmoil of election is over I am taking the liberty of complying with your suggestion. …”

This was hardly a rare follow-up to social encounters at Michigan games.

 

Five.

A century of urology followed at the University of Michigan after Cabot’s arrival, directly impacting hundreds of thousands of patients, more than ten thousand medical students, and hundreds of residents – who in turn impacted their share of patients and learners. In that century, two world wars and other conflicts were fought, two major economic collapses occurred, and climatic and geologic catastrophes pummeled the planet. In the grand scheme of things, the particular story of urology at Michigan may be small, but it is our history to know and tell. Furthermore, some of the myriad stories within the larger story are instructive, many are inspiring, others are sobering, and all should be examined in context.

Today, October 4, 2019, our current departmental faculty, residents, nurses, clinical teams, research teams, staff, and alumni are gathered for the Nesbit Society events, culminating with the Michigan-Iowa gridiron contest, where, no matter the outcome, important conversations and good fun will be had at the tailgates and on the sidelines.

 

Postscript.

October factoids. On 16 October 1901, shortly after moving into the White House, President Theodore Roosevelt invited his adviser and friend Booker T. Washington (below), to dine with him and his family, provoking an outpouring of condemnation from southern politicians and press. No other African American was invited to dinner at the White House for almost thirty years.

Sinclair Lewis, author of Arrowsmith, a book modeled on the University of Michigan Medical School in the early 1900s, suffered a terrible personal loss this month in 1944, when his first son was killed during efforts to rescue the Lost Battalion.

The 1st Battalion, 141st Infantry (36th Infantry Division, originally Texas National Guard) had been surrounded by German forces in the French Vosges Mountains on October 24, 1944, and attempts by other troops failed to extricate the men. The 442nd Regimental Combat Team, a segregated unit of Nisei (second-generation Japanese Americans), ultimately was successful after 5 days of battle and rescued 211 men by October 30, but suffered more than 800 casualties. For size and length of service the 442nd is the most decorated unit in U.S. military history. Above is Wells Lewis with father and stepmother Dorothy Parker in 1935 on way to accept Nobel Prize. The death of Wells in France took place only nine years later.

131st Field Artillery, 36th Infantry Division (Texas National Guard of the U.S. Army) who were survivors of the sunken USS Houston. They were captured by Japanese forces and taken to Java in March 1942 and then sent to Singapore and Burma where they worked on railway construction crews, as later depicted in the 1957 film The Bridge on the River Kwai. It was not until September of 1944 that it became known they were prisoners of war.

Thus went some highlights from the last century and the last millennium.

Thanks for reading Matula Thoughts.

 

David A. Bloom
University of Michigan, Department of Urology, Ann Arbor

Matula Thoughts September 6, 2019

Matula Thoughts September 6, 2019

Urology at Michigan is a century old
2411 words

 

One.

The origin of Michigan Urology. The state of Michigan and its sole university had no medical school when Moses Gunn (above) came to Ann Arbor in 1845. Gunn had heard rumors that a medical school might be formed in this small town and moved here after graduating from Geneva Medical College in New York. He came by train in mid-winter with a cadaver in a trunk and began practicing medicine, accruing surgical expertise, and teaching anatomy to aspiring students in the back room of his office.

Gregarious, talented, and confident, Gunn networked with Zina Pitcher and others interested in creating a medical school for the University of Michigan and within three years the school became a reality. Dr. Pitcher, leading the university board of regents, included Gunn among the five founding faculty of the medical school in 1848 and classes began in the fall term of 1850, after a building was constructed. Gunn taught anatomy and practiced a wide range of general surgery, perhaps best reflected in the textbook of his contemporary, Samuel David Gross, A System of Surgery, although that didn’t appear until 1859. Genitourinary surgery was then an important facet of general surgical practice and the first textbook Gross wrote earlier in 1851 was specifically on the topic of genitourinary surgery – A Practical Treatise on the Diseases and Injuries of the Urinary Bladder, the Prostate Gland, and the Urethra. Gunn undoubtedly was familiar with these books of his fellow academic surgeon, at some point in his career.

Genitourinary surgical disorders were necessarily taught and practiced at the University of Michigan since those early days of the medical school in Ann Arbor and Moses Gunn was the starting point, although the actual first moment is unknown. His operation on a man with “phymosis” in a surgical demonstration for medical students is the earliest example we have found of Gunn performing an ancient procedure necessary for men with symptomatic restriction of the preputial aperture. Nothing innovative was offered at that occasion, but it must have been a useful lesson for the medical students in 1866. Gunn by then had moved to Detroit to live and practice, believing Ann Arbor’s medical school should have been relocated there because of its hospitals and larger population. He returned to Ann Arbor, twice weekly by train, to teach by lecture and surgical demonstration, until gong to Chicago in 1867 as professor of surgery at Rush Medical School.

Procedures such as Gunn’s dorsal preputial slit or circumcision for phimosis, paraphimosis, or recurrent balanoposthitis, have been necessary since the earliest days of mankind. More complex interventions, such as lithotomy for bladder stones, had also been performed since well before the days of Hippocrates, who cautioned healers to leave “cutting for stone” to specialists of the time – namely itinerant lithotomists. They were itinerant for good reasons, they didn’t readily want to share their single skill and their clinical outcomes probably mandated short stays in any location. Little information about them exists, aside from Frere Jacques and the nursery rhyme that commemorates him two millennia after Hippocrates.

Genitourinary surgical practices muddled along with little change over the millennia until science and technology permitted innovations, safety, and better outcomes in the later 19th century. Moses Gunn, by then in Chicago, witnessed these changes amidst the emergence of a group of surgeons who incorporated new skills, instruments, and the novel tool of cystoscopy into their larger practices. Cyrenus Darling as Lecturer on Genito-urinary and Minor Surgery in 1902, and Ira Dean Loree as Lecturer in Genito-urinary Surgery in 1905 and Clinical Professor of Genitourinary Surgery in 1907 (both pictured below) were the first specifically-designated genitourinary practitioners and teachers at the University of Michigan.

[Above: Darling; below: Loree. Bentley Library]

 

Two.

Urology and the 20th century. Small clusters of genitourinary specialists accumulated in several locations in North America, notably Boston and New York. Ramon Guiteras in New York was one of these young men and in 1902 he came up with a new word to define the newly re-tooled specialty, partly to differentiate it from the empiric practice of venereology that had been part of the genitourinary domain. Urology, the new word, was not quite perfect semantically, but worked well enough and replaced the older terminology, more quickly in some places than here in Ann Arbor, where the Medical School and University Hospital job titles held on to genitourinary surgery. Both the school and the hospital needed to enter modernity and the new century, which had moved on since the fin de siècle of the 19th century.

Hugh Cabot, a young surgeon in Boston, was among the first to embrace the Guiteras neologism of urology, and his textbook in 1918, Modern Urology, was among the earliest to use the name in a title after the Guiteras text of 1908. A progressive in many ways, although startlingly biased in other dimensions. After more than two years on the Western Front during WWI, Cabot found private practice in Boston unfulfilling and was eager for a career change when he arrived in Ann Arbor around this time of year in 1919.

Cabot hit the University of Michigan like a hurricane and within a decade brought the modernity of urology to the medical school and the hospital. The amateur historian in each of us sometimes defaults to a “before and after” construct, and urology at the University of Michigan truly began when Cabot first arrived in Ann Arbor, in September, 1919. Michigan’s genitourinary surgeons, Darling and Loree, quickly recognized their incompatibility with the new boss and resigned from the medical school leaving Cabot, the urologist, their practices and teaching responsibilities.

 

Three.

Imagine that world of 1919: World War I was winding down and the Spanish flu was still ravaging North America and Europe. The Great War killed 17 million people, while the influenza epidemic killed 20 million, proving once again that humans don’t really need to kill each other off as other species can do so far more effectively. Prohibition and women’s suffrage were occupying much of the national political conversation. At the University of Michigan President Hutchins was ready to step down but the regents hadn’t found a replacement and the Medical School was at loose ends.

Victor Vaughan had been a transformational figure at Michigan since his starting days in 1874 and assumption of the medical school deanship in 1891. He became a national figure academically though his initial investigations and teaching in biochemistry, physiology, and bacteriology, followed by his medical service during the Spanish American War. The medical school, that Vaughan had effectively stewarded, shined in the 1910 Flexner Report but began to run down, especially during World War I as he spent time in Washington helping manage military medical affairs and was increasingly distracted from duties as dean. By 1919 the chairs of internal medicine and surgery remained vacant, in spite of modest efforts to fill them, and plans for a much-needed replacement university hospital were dormant. [Below: Vaughan portrait by Gari Melchers, also shown here last month.]

The year 1919 was one of deep loss for the Vaughan family, when one of their five sons perished by drowning just before returning from duty in France. Dean Vaughan was notified while in Atlantic City at a meeting of the American Medical Association in June and, after what must have been a horrible pause, collected himself enough to deliver concluding remarks for the session he was chairing at the moment.

[Class picture 1919]

In Ann Arbor, prior to Cabot, the teaching and practice of genitourinary surgery had been mostly in the hands of Ira Dean Loree, a respected member of the community and one of the 20 local citizens behind the creation of Barton Hills Country Club, that opened in 1919 with its Donald Ross golf course. Loree, Vaughan, and Darling are seen in the UMMS class picture (above) at the end of the 1919 spring term, unaware that Hugh Cabot was about to disrupt their lives. As summer came to an end, Vaughan was resuming life back in Ann Arbor still faced with the two open chairmanships and the deteriorating clinical and educational physical infrastructure of the Medical School. Meanwhile, in Boston, Cabot had returned from duty in France but was frustrated on resumption of his clinical practice. At some time around then, Cabot learned of a unique opportunity in Ann Arbor, and he jumped at it. He had not been on anybody’s radar screen of candidates at that time. Vaughan, in fact, quietly favored his internal faculty candidates Carl Huber and Frederick Novy, according to a personal letter to one of the Vaughan sons in the autumn of 1918.

 

 

Four.

Cabot’s decade in Ann Arbor began with a first visit in September, 1919. He came by train and stayed at the new Michigan Union, where Vaughan and President Hutchins housed their major recruits. The first visit impressed the Michigan leadership and impressed Cabot as well, who saw the Medical School as a perfect canvas for his bold ideas that fused the provision of just and medical care to a democratic society, emerging subspecialties, brisk incorporation of new technologies, multi-specialty group practice, and clinical education from full-time salaried academic clinicians. Cabot was an excellent educator, a powerful administrator, a world-renown urologist, and an effective politician who usually got his way. He came to Michigan as professor and chair of surgery, following Gunn and de Nancrede, but unlike them built a powerful surgical faculty known not only for teaching, but also for academic productivity and clinical excellence. He was also predominantly a urologist. Cabot recruited and developed a robust cadre of young faculty, especially distinguished in the surgical fields with Max Peet, John Alexander, Frederick Coller, Charles Huggins, Reed Nesbit, and others who enriched and dominated their emerging subspecialties, winning accolades up to and including the Nobel Prize.

Within a year and a half from his start, Cabot became dean of the Medical School where his accomplishments were extraordinary. While managing day-to-day functions of the medical school and continuing to grow his voice in urology, he presided over the dissolution of the Homeopathic College, the construction of a new University Hospital (the fourth iteration of our hospital since 1869), and the deployment of the first world class cadre of clinical faculty at the University of Michigan.

We intend to elaborate on this story in two parts to mark our centennial. The first part, The Origin of Michigan Urology, will be in print later this autumn and will tell the story of our field and our university up to (and through) the Cabot era. The next part, The First Century of Michigan Urology, will cover the ensuing 100 years up through 2020 and we project its completion in two years as the story evolves. It was a remarkable century.

 

Five.

Fast forward over an astonishing 100 years from Cabot’s arrival in 1919 to last month in Copenhagen and the CopMich Urologic Symposium. Dana Ohl and Jens Sønksen began a collaboration two decades ago that culminated in this biennial event alternating between Ann Arbor and Copenhagen, where Jens is chair of the surgery department. This Third CopMich Urology Symposium was held west of Copenhagen at the lovely Hotel Hesselet in Nyborg on the seaside of the “Great Belt” a wide strait between Copenhagen and Jutland, connected by the magnificent Øresund Bridge. The three-day symposium (above) covered reproductive urology, urologic oncology, pediatric urology, stone disease, pelvic floor and pain, patient information, psychosexual health, telemedicine, and an amazing new generation of research projects mentored by Dana Ohl and Jens Sønksen. From this collaboration, nearly 100 peer-reviewed publications have resulted. [Below: a.) Jens, Diana Christensen, Christian Jensen; b.) Anne Cameron, John Wei, Mikkel Fode; c.) Helle Harnish, Nis Nørgaard, Yazan Rawashdeh.]

Danish and Michigan faculty produced a superb collection of talks over the 2.5 days and planning is already underway to return this symposium to Ann Arbor in 2021 was given the chance to give one talk about anything I wanted, in addition to assignments of more usual urologic topics. Reverberating from the dozen years of Chang Lectures on Art and Medicine we concluded in Ann Arbor last year, I returned to that theme to talk about the role of art in dealing with the “TMI” (too much information) of our medical world. Our arts compress, abstract, or replicate things artists find beautiful, meaningful, or otherwise worthy and those windows onto the world help the rest of us expand our own windows. Matula Thoughts, What’s New, and CopMich last month provide opportunities to delve into these matters, not from any learned perspective as an art historian, but only from the simpler framework of a citizen and physician deluged by the constant typhoon of TMI. [Below: a.) Mette Schmidt, Cea Munter, Klara Ternov, Marie Erickson; b.) Jens, Hans Jørgen Kirkeby, & Dana; c.) Ganesh Palapattu.]

[Below top: Maiken Bjerggard “Queen of Jutland”, Erik Hansen, Pernille Kingo, Anna Keller. Bottom: CopMich ensemble 2019]a

 

 

Postscript.

This is hurricane or typhoon season for much of the world. Cabot may have hit Michigan metaphorically like a hurricane in 1919, but real mega-storms regularly challenge eastern and south central states at this time of year and today Hurricane Dorian is running itself down after a week of devastation and terror. The Waffle House Index comes to mind. This informal metric was conceived of in 2011 after the Joplin tornado when FEMA noticed that two Waffle House restaurants in Joplin stayed open during the storm, eliciting the idea of a measure of community robustness – that is, its ability to function in the face of overwhelming forces. This “index” abstracts from all the noise (all the overwhelming “information” of the hurricane and its effects) some measure of community functionality. The Waffle House, unlike most other restaurants and businesses that close when environmental conditions deteriorate, is reputed to do its best to remain functional for its communities, following the lead of the first responders, police departments, fire stations, and hospitals. The Waffle Health Index, unlike abstruse statistical measures, is simple, understandable, and meaningful to most people. An abstraction of regional disaster to a useful metaphor, or a meme, that brings some clarity to mass confusion and facilitates useful response.

One could hope for similar indicators of biodiversity, local or global environmental integrity, generalized human well-being, or academic health center viability, to give clear appraisals of complex conditions as a basis for appropriate responses. The individual biologic response to threat may be prompt, as we recoil from fire, but the systemic response of the human species to impending disaster is woefully inadequate.

 

September & centennial greetings,

David A. Bloom
University of Michigan, Department of Urology, Ann Arbor

Matula Thoughts August 2, 2019. Impressions

Matula Thoughts

August 2, 2019

Impressions & metaphors:

Thoughts from a UMMS faculty member
2224 words/20 minutes

 

One.

As a medical student, my first impressions of children’s surgery imprinted on my brain much like a duckling gets imprinted when it initially sees its mother, or whatever creature first walks by. I went to UCLA for surgery residency in 1971 and then to London for a year in 1976 to learn from David Innes Williams, a founder of pediatric urology (above, Shaftesbury Hospital, 1976). The experience was rich. At first I was as an observer and later served as a registrar, the UK version of my status in the U.S. Mr. Williams was the consummate professional and his attitude was reciprocated by patients, trainees, and staff. My first impression of “DI,” as we called him, was one of the perfect English gentlemen, with unparalleled expertise and skill in one’s field. I noticed that even the poorest families coming to see him dressed for the occasion, the men often wearing a coat and tie, and the children well-scrubbed up and disciplined. Formality was echoed by kind and polite staff (Sister Fay and Sister Val) and by Mr. Williams himself who invariably offered a proper English greeting.

Mr. Williams was always addressed as “MR. WILLIAMS”– the appropriate title for a surgeon in the British world of medicine since the days of King Henry VIII who chartered the Barber Surgeons Guild in 1544. The physicians (internists) had been chartered in 1522 and were addressed as “Doctor” and the surgeons, a very distinct class of practitioners were “Mr” back then and remain Mr. to this day. Additional medical customs and traditions persisted in the National Health System and when I was a clueless young American, a colleague then ahead of me in training, Mr. Robert Morgan, took me under his wing and kept me out of trouble. Just as British ways sometimes confused foreigners like me and American ways tended to befuddle the British who, for example, couldn’t understand why Henry Kissinger came to be addressed as Doctor.

I returned to London in 1986, as a young UM faculty member on leave under Ed McGuire, to serve as a locum tenens for several months. Sir David Innes Williams (above, recently knighted) had retired from a large administrative post in the National Health System (NHS) and his successor Phillip Ransley was the sole pediatric urologist in London. American colleagues were taking sequential turns filling the spot that soon became formalized with a second NHS pediatric urologist, who turned out to be Patrick Duffy, the registrar working with me those months in 1986. I was self-conscious to be sitting in the same chair and at the same desk Mr. Williams had used to see patients, but I seemed to be tolerated by staff and patients.

In the decade between my times working for the NHS, the dress code and sense of formality of the clinic visits had relaxed. Families were more causal in dress, perhaps reflecting acceleration in the pace of life, only occasionally putting on their Sunday best for clinic visits, more likely quickly assembled from work and school to rush to Great Ormond Street Hospital by tube, bus, or cab (rarely by car, because where could they park?). Nevertheless, greetings were not rushed, but rather were moments of catching one’s breath on both sides of the table, with casual inspection, mutual taking measure, and kind acknowledgements. Those first impressions the parents and children have of the physician/health care provider are lasting.

 

Two.

Life is a social business and medical practice and education are especially social. That’s why we have frequent visiting professorships, like the Duckett Lecture last month, with Chester Koh from Baylor. Chester spoke on medical devices and discussed cases with residents, who also observed his professionalism and communication skills.

[Above: Pediatric uroradiology conference with Chester; Below: Kate Kraft, Chester, John Park.]

The first words patient hear often set the stage for their entire relationship with a health care provider. It is no surprise that one of the more offensive introductory phrases patients report is: “Why are you here?” Clinicians never intend any offense, and I myself may have cluelessly used those words in past days, trying to figure out the needs of a patient. Health care providers have many pressures for excellence, self-education, relevance, academic productivity, and equanimity. Furthermore, they are belabored by systemic pressures that are, perhaps, the greatest drivers of professional burnout: organizational metrics, throughput demands, rigid schedules, mandatory web-learning programs (fire safety, compliance, “high reliability training,” new chaperone rules, opioid regulations, and other modules every year). Electronic health record systems set the stage – demanding entry of a chief complaint at the outset of each “encounter.”

To many patients, however, that first question, Why are you here, is a slap in the face, interpreted by some as an accusation (“why are you wasting my time?”) or is evidence of an unread letter of referral or poor preparation. Patients may be anxious, looking for reassurance, expertise, and kindness. Parents with sick children will be especially distressed and for them, “Why are you here?” is a poor choice of the starting position for the physician or provider. If you put yourself in the place of the mother in Gari Melchers’ painting after the hassle and expense of getting to the clinic with your baby, you might not respond favorably to that question. If the provider was, perhaps, “burned-out” from a busy clinic schedule, the electronic health record, systemic mandatory demands, and short ancillary staffing, it is very likely that the mother with the sick baby was equally stressed, if not more so.

[Mother and Child. Gari Melchers. C, 1906. Institute of Art. Chicago.]

 

Three.

White Coat Ceremony. The stethoscope, invented in 1816 by René Laënnec in Paris, is not just an effective tool for auscultation, it is an equally effective metaphor for listening, which is itself a metaphor for seeing, hearing, or otherwise sensing the needs of a patient and family. [Below: Laënnec, National Library of Medicine. Below: Laennec’s 1819 monograph.]

Laënnec died of cavitating tuberculosis at age 45 on August 13, 1826 in Kerlouanec, leaving a wife but no children. [Ariel Roguin. René Theophile Hyacinthe Laënnec (1781-1826): the man behind the stethoscope. Clin Med Res. 4(3):230-235, 2006.]

The meme of the physician as a listener and observer is worth preserving, especially in this day of corporate medicine and formulaic encounters based on electronic medical record work flow. To institutionalize this idea of listening, our medical school began giving all entering medical students top-of-the-line stethoscopes on their first day of school at the White Coat Ceremony on 2004. The instruments were gifts from the clinical departments and some friends of the medical school interested in the actual and metaphoric listening skills of our “next generation” of physicians. Some of the best listeners in health care are themselves hearing-impaired and have trained themselves to go beyond casual vocal encounter with patients to discriminating perception of their patients with all senses.

[Above & below: UM White Coat Ceremony July 27, 2019.]

White Coat Ceremonies date back only to 1989 when, at the University of Chicago, a professor complained that first-year students “were showing up in shorts and baseball caps … where the patients are pouring their hearts out.” Dean of Students Norma Wagoner responded by starting a ceremony where students were supplied with white coats and instructed: “for any session where we have patients present, we expect you to look like professionals, wear the white coat, and behave appropriately.” [Peter M. Warren. “For new medical students, white coats are a warmup. Los Angeles Times. October 18, 1999.]

In 1993 Dean Linda Lewis at Columbia University College of Physicians and Surgeons, joined with the Arnold P. Gold Foundation to sponsor a white coat ceremony that is mirrored in medical, dental, and osteopathic schools today, among many other health professional schools. (Today, many of these medical schools bear the new names of their modern benefactors.) The white coat as a uniform of a health care provider is importantly a symbol of personal hygiene and responsibility. [Below: White Coat Syndrome, 2008, by Pat Curry, RN.]

The matula was the most prominent symbol of the medical profession for 650 years, as evidenced in art of the times, until Laënnec’s stethoscope in 1816 and the white coat even more recently. What the prominent symbols of the healing professions will be a century from now remains to be seen, but with luck regarding human destiny they won’t revert to the Aesculapian staff and matula.

 

Four.

The moral universe. The compelling imagery of a moral universe is a comforting metaphor. In 1958 Dr. Martin Luther King wrote “Let us realize the arc of the moral universe is long, but it bends toward justice,” in The Gospel Messenger, noting it to be a known aphorism. He used it again in 1964 for commencement exercises at Wesleyan University. The phrase has a deep history, traceable to 1853 and “A Collection of Ten Sermons of Religion” by Theodore Parker, Unitarian minister, American transcendalist, and abolitionist. A book in 1918, “Readings from Great Authors,” quoted Parker. A columnist in the Cleveland Plain Dealer reiterated the phrase, but omitted the word “moral” in 1932. The phrase has been since repeated on many occasions such as in a 1940 New Year version by Rabbi Jacob Kohn in Los Angeles: “Our faith is kept alive by the knowledge, founded on long experience, that the arc of history is long and bends toward justice.” President Obama used the phrase and credited Dr. King in 2009. [Above: Chagall Windows. Art Institute of Chicago.] Whereas some things in life are described as “soul-crushing,” this phrase is soul-compelling.

The physical universe and the universe created by the collective brains of Homo sapiens overlap and the human one increasingly changes the other, at least for the present in the Anthropocene moment. The change is simultaneously creative and destruction – think Mona Lisa or the miracles of contemporary health care versus genocide and environmental deterioration. But if we accept the fact that the human universe is ours to create, then we must recognize that it is (it should be or it can be) a moral universe, thus validating the aspiration of King and those who came before and after him with this belief.

The idea of a universe is a human construction and belief in a moral universe is a particularly human invention. Not eager to invite liturgical criticism, few can deny that Homo sapiens has built extensively around concepts of spiritual faith. But such is the nature of our species to imagine, discover, plan, and pass the information we find and create along to successive generations. In that sense, it is up to us to build that moral universe within the gargantuan amoral physical universe around us.

 

Five.

Ann Arbor August. In much of the northern hemisphere, August is a time for vacation, although the modern workplace of 52 weeks and 365 days per year, and 24 hours per day, requires some people at work every minute such that August is no longer a month of universal leisure time. I recall that when the yearly calendar was unveiled to my surgical internship group at UCLA in July, 1971, the first vacation assignment (namely July), went to the most hyperactive of our class, who was expecting to dive immediately into the world of operating rooms, intensive care units, conferences, and clinics.

That intern was very displeased at being told to “stand down” for his first month. The rest of us, I suspect, would have been more accommodating. In the end, he accommodated just fine, and over the course of a distinguished career, Ron Busuttil ended up as chair of the surgical department at UCLA himself. Summer or winter today, the life of a resident provides more downtime and one expects that our new PGY1s will have time for the pleasures of Michigan this month and next.

The Ann Arbor Farmers’ Market (above), operating since 1919, is a lovely feature of our community – a perfect example of Adam Smith’s second-best quotation (a favorite of John Wei):

“It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own self-interest. We address ourselves not to their humanity but to their self-love, and never talk to them of our own necessities, but of their advantages.”

[Below: top, local farm sales; local idiosyncrasy – Wolf Man; bottom, Sweet Dirt – Melissa Richard’s Ann Arbor ice cream]

 

Michigan Urology has its own centennial this year. We begin this celebration next month, 100 years after Hugh Cabot came to Ann Arbor, recruited by Dean Victor Vaughan, and will conclude it in the autumn of 2020, to coincide with Cabot’s first academic year at the University of Michigan. Cabot brought modern urology to Michigan in the multiple dimensions of clinical care, education, research, and the international stage.

 

Postscript

Gari Melchers (1860-1932), whose Mother and Child was shown earlier, originally from Detroit, was awarded an LL.D. from UM in 1913. His impression of Victor Vaughan was presented to the university in 1916.

Melchers’s Theodore Roosevelt, originally in the Detroit Freer Collection, is now at the Smithsonian Freer-Sackler Galleries. [Donaldson BM. An Appreciation of Gari Melchers (1860-1932). Michigan Alumnus, Quarterly Review. 1934. P. 506-511.]

As you enjoy August we prepare for the Michigan Urology Centennial, marking the start of modern urology in Ann Arbor under Hugh Cabot.

 

• Centennial Celebration launch, Nesbit Society Annual meeting October 3-5, 2019, Ann Arbor.
• AUA Nesbit Society reception May 17, 2020, Washington, DC.
• Centennial Gala Celebration. Nesbit Society Annual Meeting, September 24-26, 2020, Ann Arbor.

David A. Bloom
University of Michigan, Department of Urology, Ann Arbor