What’s New April 5, 2013

Michigan Urology Family 

Looking at things – asteroids, racehorses, A3s, and other matters.

1. I’m very glad to be back to work after my mini-sabbatical. What was I doing during this hiatus from day-to-day tasks? Mainly I was focused on an analysis of what I think is an existential threat to our department, specifically a gap between our current clinical footprint today and where our clinical footprint needs to be to serve the needs and aspirations of our department. The time away from our front office allowed me to take a 30,000-foot view of Michigan Urology. Plus I was able to read and think deeply, as well as to reflect and set a course for the balance of my term as chair. I’m appreciative to John Wei and our two other associate chairs Gary Faerber and Stuart Wolf as well as my pediatric urology colleagues who covered for me. I last had a mini-sabbatical at home in 2000, just before my 7 year interlude as Associate Dean. This time I went to Charleston, SC for 2 months. A friend visiting asked me: “What do you want to accomplish?” My answer: “Three things. One, I want to complete my A3 analysis of the departmental gap I’ve been worrying about. Two, read deeply, and three, come back with new energy and ideas obtained from one and two.” One small product of the time away had been this blog which will house our monthly “What’s New” broadcasts and offer a chance for your comments. On the table you can see the A3s in preparation –> 
2. Michigan Urology is centered on a four-part mission that we have been fine-tuning for a good number of years.  We recently hammered out a new version of our mission statement that considers the key components of education, clinical care, discovery, and leadership. Of course once we assume the responsibility for clinical care it then becomes the moral trump card that can displace any of the other parts of the mission at any given moment or day. The essential deliverable of our mission thus becomes patient care – kind and excellent patient care, integrated with innovation and education at all levels.
3. The A3 analysis is a method from the Toyota Production System that I learned at our Lean Training here at UM and at the Lean Enterprise Institute in Cambridge, MA last summer when I attended with John Park. As a health system, as a Faculty Group Practice, and as a department we have been heavily engaged in these ideas and methods. The A3 (named for a size of paper on which one executes the problem solving) is an excellent method of analysis that is just as suitable to health care and academia as it has been for manufacturing industries. My A3 is titled: “Our clinical footprint is falling short of our needs and aspirations as a department of urology.” My reading list evolved into a talk for our Senior Clinical Management (SCM) Group and the A3 Report will be the subject of our Faculty Retreat on April 26. If you are interested let me know and I’ll send you a copy of the SCM talk. The A3 turned out to be one primary A3 and four separate “baby A3s.”
4. History has much to teach us, it is sometimes greatly entertaining and stimulating, and it can be reassuring. For example, we have confidence in today (April 5, 2013) and the week ahead because history allows us to guess that a hurricane, devastating earthquake, or catastrophic meteor impact are unlikely. The guessing is not random, it is a matter of prediction or forecasting that depends upon data, analysis, and intuition. Of course we recall the recent hurricanes Sandy, Irene and Katrina, or winter storm Nemo, none of which came out of the blue – all were predicted reasonably well. However, this week and indeed the next few months should be free from hurricane anxiety. Charleston was hit by a devastating intraplate earthquake August 31, 1886 of an estimated 7.3 magnitude. History and science allow us to predict that a large magnitude earthquake is a 1-in-600 year event for Charleston (although a 1-in-30 year event for Anchorage, AK). Nearly everyone knows about the meteor impact that wiped out the dinosaurs and the 1908 meteor that flattened a forest 2/3 the size of Rhode Island in Tunguska, Siberia. Yet the world was surprised just six weeks ago on February 15 when astronomers were tracking a known asteroid called “2012 DA 142” (the size of a football field and a half) as it was about to pass within 17,100 miles of Earth. The surprise was that unexpectedly from another direction a different unknown asteroid (the size of a bus) slammed into our atmosphere (thus becoming a meteor) and exploded over Chelyabinsk, Siberia injuring over 1200 people. (Why Siberia so often? Is it just big, or unlucky, or both?) So, while history can give us some predictive confidence in the future, prediction is not necessarily reality or truth.
5. Of course, from catastrophe and destruction come novelty, innovation, and evolution.  An alleged meteor (10 kilometer or 6.2 miles in diameter traveling 30 km/sec) impacted off the Yucatan peninsula 65 million years ago) and caused a mass extinction that knocked off the dinosaurs giving evolutionary opportunity to small mammals, then larger ones including primates.  A few primates expanded the use of tools, communication, and imagination far beyond their predecessors and here we are. The artwork of our earliest forefathers, dating back nearly 30,000 years, is astonishing. The horse illustration shown above from the Cave de Chauvet, of which I’ve spoken here before, is a prime example. What was the ancient artist trying to communicate? To my eye it seems to be horses in motion, although the artist was clever enough to achieve that sense without showing the legs of the horses. Horse racing is a beautiful thing and an evocative image. Organized horse races might have been a wild dream for some of those cave dwellers – the idea of controlling wild horses and holding a race must have been a wild fantasy at first, but it soon became reality soon after the first horses were domesticated.  Imagination, innovation, team play, and leadership over the millennia that followed brought that dream and hundreds of thousands of other fantasies to fruition.
6. The silver lining of the great meteor and mass extinction took more time to play out than you and I have at hand so in our short-term view a big meteor slam would be very bad news. Extending the possibilities of natural disaster a bit more, one could argue that the seeds of our potential destruction could come not just from out of nowhere (asteroids) or from within (earthquakes). Equally destructive disaster can come laterally from our atmosphere (hurricanes, tornados, and tropical storms).  In an analogy for Michigan Urology the asteroids might be the world and national socioeconomic threats, perhaps even reflecting the sequelae of climate change. The earthquakes might be internal disruptions and instabilities arising in our university and health system. The atmospherics could be construed as turbulences within our department. If our powers of forecasting and prediction were better for asteroid impacts, earthquakes, or the weather we could take that information to the bank and craft strategies and tactics to protect ourselves. If my own predictive powers were better I could guarantee protection of our mission.
7. Most mission statements throughout our medical school and health system are tripartite, beginning with our founding educational mission as a university and as a medical school. Of course great education must begin with self-education and discovery, thus discovery and research are surely part of our mission. Furthermore, unlike many other types of education, medical education cannot be separated from its practice. Within only 19 years of its founding, the University of Michigan Medical School realized that it needed a hospital to stay ahead in the game of medical education. Thus UM became the first university to own and operate a hospital, which has today become a multi-billion dollar health system. Medical education at Michigan began with a single “product” of the MD,  but it soon came to include residency education that today is the career-defining element of medical education. While we have around 650 students in our medical school we have over 1100 residents and fellows training in our health system at any given moment.  Somewhere along the line, UM picked up the slogan “leaders and the best.” This is really more than a slogan, it is a fact attested to by our history and our present belief in our medical students, residents, and faculty today.  So it seemed proper and fitting to add leadership to our mission statement as a fourth attribute.
8. Leadership implies a contest or race, something of interest to our species since our earliest days. Of course we can never know anything of the life of that artist in the cave in what is now southern France, but he had a sharp eye and keen talent. This next painting shown is a detail is from a work by George Stubbs in 1765 of the horse Gimcrack on Newmarket Heath. Stubbs was then considered the greatest painter of horses. In the century after Stubbs, the understanding and representation of equine motion was no different, as this second race scene, by an artist named Charles Newdigate, shows (courtesy of the Edmondston-Alston House, Charleston, SC).         
9. While our senses are pretty good at showing us how the world works, they are not perfect. Technology has given us more information. For example, Steve and Faith Brown, UM Fans extraordinaire, gave me an amazing book on the eye and art that got me thinking about art and illusion (“The Artist’s Eyes” by MF Marmor and JG Ravin). This led me to recall the groundbreaking photographic studies of motion by Eadweard Muybridge (1830-1904). Until his stop-action photos of a horse running, we humans had absolutely no idea how horses actually ran. Their gallop was too fast for our brains to sort out the position of their feet at any instant and at that airborne moment in particular.  Stubbs, Newdigate, and the rest of us consistently imagined the airborne moment inaccurately with the horse’s front legs extended forward and rear legs extended backwards. In 1872 Muybridge settled a bet for Leland Stanford and came upon the truth.
10. Muybridge was born in Kingston-upon-Thames in England and emigrated to San Francisco, still the Gold Rush Capital, in 1855 becoming a successful bookseller. By 1867 he had become a successful photographer. In 1872 the former governor of the state, Leland Stanford, asked Muybridge to help him settle the question of whether all 4 feet of a horse were simultaneously off the ground while galloping. Stanford believed in the controversial idea that horses were capable of “unsupported transit.” The resulting photographic series of Stanford’s horse, Occident, not only proved the contention of unsupported transit, but also showed that at the unsupported moment during gallop all four legs were collected under the body rather than extended ahead of and behind the body as had been commonly represented in art. Stubbs and Newdigate’s work was terrific for their times, but artists can do better today, in terms of accuracy and representation of reality.
11. Things that we have accepted and that worked well enough in the past, can be improved. In the world of health care many things must be improved as they no longer fit the changing world. How can we better understand patient care in terms of value stream analysis? What are the essential transactions of health care delivery and how can we improve them?  How do we standardize our clinical transactions without losing the professionalism of medicine and commoditizing the doctor-patient relationship? How do we better understand our other customers of health care – those parties beyond the patient such as the referring physician, the patient’s family, the third party payers, the patient’s employers? How do we eliminate waste? How do we make each and every clinical product rewarding to the patient, consistent and efficient? (What do I mean by clinical products?  These include that very central and essential interaction after the doctor closes the exam room door to talk to and examine the patient, but also informational web sites, the conversations with the call center, the check-in process, diagnostic procedures, operative procedures, consultations with colleagues, the consoling of a family, etc., etc.)  These matters need our immediate attention. Our clinical products are not as good as we have thought they are. Our attention, already spread thin, is being squandered by political-federal shenanigans, wasteful electronic medical records, bureaucratic claims processing, and the heavy footprint of corporate medicine among other ills.  We must reconstruct healthcare nationally – but that remains to be seen and is beyond my job description.  We can, however, reconstruct it locally in our own department.
12. Let’s take, for example, the new patient visit and deconstruct it so as to reconstruct it. We have each developed and individually come to cherish patterns of clinical performance based on our teachers, role models, and personal experiences. But how sure are we that our performances and systems are equally cherished by patients. How consistent and efficient are we? What worked well enough in the past is unlikely to be the best in show of the future. So for the new patient visit, what are the 5 (let me pick arbitrary boundaries) initial greetings and ice breakers that patents value most? What is the typical “structure” of a new patient visit, what are its elements?  How can you be assured consistently, that patients have their questions addressed and fears allayed? What is the amount of “speaking time” that patients need in a typical visit – have you thought about that and how can you consistently create that? How do you structure your recommendations and plan? How do you hand off the patients to medical assistants, residents, nurses, or check-out clerks? What about the summary letter – does it clearly serve the needs of patient and referral physician, or is it an ugly, lengthy and formulaic computer-driven piece of epic nonsense? However, you answer these questions, it is beyond doubt that we can improve our game, make it more valuable, kind and consistent for patients, and eliminate waste.
13. Life is short and we want to spend it valuably. This is as true for providers as it is for patients, and of course all providers at some times will become patients. In health care we want to do things well, efficiently, and valuably. Yet value is something that is ultimately very personal. Value is in the eye of the beholder. Economic value is a measure of benefit from a good or a service. (This is not the same as price.) More broadly value can mean a fair equivalent, it can mean the perception of relative worth or importance, it can be a numerical value, or it can be a human value. Personal and cultural values are more difficult to define. Personal values inform our individual sense of what is good, useful, helpful, important, or desirable. In the aggregate of a team, community, or society a set of values emerges to allow a collective sense of what is good, useful, helpful, important, or desirable.  Value theory distinguishes moral goods from natural goods (such as physical materials). When we ask “what does the patient value?” we ask a complex question, but it is the central question.
14. Health care is in the midst of a period of creative destruction. The meteoric effect of the federally mandated electronic health record may prove to benefit the greater good of mankind someday, although it mainly now seems to be benefitting the specific good of  a few corporations. We are still recovering from the steep initial drop in clinical productivity and are learning to practice within the rigid burdens of the new systems. The present creative destruction, however, extends far beyond the electronic record with other powerful acronymic meteors such as the SGR, GDP, ACO, along with manpower concerns, millions of new “covered lives”, millions still uncovered, unfunded mandates, the crime of health-care forced personal bankruptcies, impoverished states, national deficit, and the impotence of partisan gridlock. Whew! There’s a lot on our health care plate. Our best response is really not a matter of stepping up our game, rather one of changing our game. I hope my A3, the A3s that follow, social media integration now in the works, as well some experiments to retool our clinical products will give us a leg up (like all 4 legs of the racehorse Occident) in this new world that’s upon us now.
15. Department notes. I returned to the front office of  a changed Michigan Urology. John Wei has done a yeoman’s job of dealing with the daily work. We did experience a big loss as our esteemed professor, Jill Macoska, answered the call of the University of Massachusetts to move her laboratory to Boston and assume the Alton J. Brann Endowed Chair as Professor of Biological Sciences. This is a huge and well-deserved honor for her and, of course as Bo Schembechler would have said: Jill will always be a Michigan Woman.
    
16. More department notes. Last week Visiting Professor Dr. Rosalyn Adam, Associate Professor of Surgery, Associate Director of Urology Research from Harvard Medical School/Children’s Hospital Boston gave a great talk at Grand Rounds on “Signaling Networks in the Bladder: Implications for Cancer and Benign Disease.”  Last month our internal weekly “What’s New” profiled Gary Faerber, Associate Chair for Education; an update from Stuart Wolf and Quentin Clemens on the recent Urology Joint Advocacy Conference (JAC) in Washington, DC; Division of Endourology and Stone Disease update; and John Stoffel in the Division of Neurourology and Pelvic Reconstructive Surgery. Website: http://www.med.umich.edu/urology/about/MonthlyNewsletter.html.
17. Even more department notes. In the spirit of change we are putting a toe into the social media world and we now have a Facebook page “Matula Thoughts” and we will be putting versions of the monthly What’s New here on this blog: matulathoughts.org.

Best wishes and thanks for spending time on “What’s New” this weekend, and welcome to the MatulaThoughts Blog. I am grateful that others beyond my immediate team and family are willing to slog through these monthly “What’s New” essays. Naturally, my intent is to keep them interesting and your thoughts are welcomed.

David A. Bloom