Michigan Urology Family

The Shannon number & retrograde thoughts

1. May greetings from Michigan Urology. We are getting very close to fiscal year 2014 when many of the changes in health care due to the Affordable Care Act will be set into motion. Even without this act, American health care has been changing substantially due to the effects of the mandated electronic medical record, soaring costs, coalescing health care organizations, expensive new technology and drugs, escalating regulation and bureaucracy, as well as a new consumerism.  That last item, new consumerism, is the result of many influences of social media and 21^st century human psychology expressed in direct-to-consumer advertising (for prescription drugs, specific bits of medical technology, individual heath care entities) as well as optimized web-based search engines. Little of this is good for the care of patients, the care of populations, the rational use of health care dollars, the profession of medicine, or health care education.
2. At serious risk is the academic health care organization such as ours.  Our niche is precarious and there is little positive transformative change on the horizon. I expect some academic places will fail to negotiate that impending cliff, but I hope Michigan Urology will do as we have done in the past – that is to continue “to lead and be among the best.”  That will take transformative change from within our organization, emanating from our smart, creative, and engaged workforce of faculty, residents, health care providers, staff, researchers, alumni, and friends of the department. That change will also test the limits of our philanthropic base (good as it is) and our ability to generate a positive financial margin in the constrained fiscal years ahead.  But, I believe in the power of human imagination, especially in our department.
3. Let me call your attention to the recent 97^th anniversary of the birth of Claude Shannon (April 30, 1916 – February 24, 2001), the source of the concept of the Shannon number. Shannon, considered the father of information theory, was a Michigan Man. He was born in Petoskey in 1916, graduated from Gaylord High School in 1932, and got his B.S. in mathematics and electrical engineering from The University of Michigan in 1932. He traveled to MIT for a Ph.D. in mathematics in 1940 and then went to work at the famed Princeton Institute for Advanced Study. During WWII he worked at Bell Laboratories on matters of importance to the war effort, including cryptography. Shannon worked side by side with some of the best minds in 20^th century science and had an enormous influence in creating the modern world of communications.
   
4. A paper he wrote in 1950, “Programming a computer for playing chess”, is the source for the concept of the Shannon number. This represents the number of different possibilities in chess, that is the number of different possible games of chess. The number is said to be 10 to the 10 to the 50^th power (10^{10 to the 50th}).  I couldn’t put this into Microsoft PowerPoint as I can’t figure out how to do a double superscript. Anyway, it’s a huge number. Now, somewhere I’ve read that the number of atoms in the observable universe is 10⁸⁷.  Whether these numbers are precisely true or not, they provide a great metaphor for the idea that human imagination (even just the tiny example of chess!) is far greater (numerically) than physical reality (particles in the universe).  Consider the thought that if chess offers such great possibility, what about language – and which language? What about basketball games? What about musical compositions? Human imagination is a whole different dimension beyond the three that we normally consider traveling through time and space. Human imagination is infinite.
5. We had a faculty retreat late in April that centered around an analysis of our Urology Department’s clinical footprint.  Michigan Urology began and flourished in a public medical school that was created to teach the next generation of physicians for what was then, in 1850, a young state in a growing nation. Since then it has gotten more complex to produce that next generation of practitioners, going from a mere 2 years of classroom instruction in 1850, to 4 years of medical school that included laboratory investigations plus bedside instruction by 1890. Now 120 years later those 4 years of medical school are only a prelude to the residency and fellowship training that can add up to another 10 years of clinical and research experience to produce that finished product of “the next generation of medical professional.” Some medical schools, such as the University of Iowa that I just visited, have broadened their educational portfolio to include Physician Assistants (PAs) in the medical school cohort, resulting in a very high quality PA. At a place such as ours, it seems right to have such an ambitious educational portfolio, that is to want to produce the leaders and best of all important parts of the health care work force. We also must come to understand that in health care there is no such thing as a “finished educational product.” We and those we have trained must always be watching, learning, and changing. Of course, that’s hardly a new idea – people have been talking about the “practice of medicine” for hundreds of years.
6. All this is to say that the point of my mini-sabbatical studies, the point of my “A3 analysis” with its sequelae that will unfold, and the point of the faculty retreat is that in this world of rapid change we need to understand the potential of the Shannon number and imagine a different future for the way we deliver, teach, and investigate health and health care. In concrete terms, the A3 analysis leads to the conclusion that we must understand, deconstruct, and reconstruct our clinical operations with a “value-stream” mentality. Everything we do (all of our clinical processes and “products” such as the patient’s call to the call center, the new patient visit, the diagnostic procedure, the inpatient experience, the clinical trials, patient educational materials, etc.) need to be inspected, recrafted for better value to the individual patient, recrafted for better value to the other customers, made leaner, and thoroughly integrated with innovation and education. This work will be best performed by those closest to each product and process. The possibilities are endless as Claude Shannon might have predicted. Although we are already late in the game in starting this, our first step is the engagement of the work force of Michigan urology and the belief in one unifying simple essential deliverable.
7. Above all our analyses, mission statements, visions, goals, plans, and strategies I found from the discussions with faculty and staff, and from the A3 analysis, one single unifying idea. You might call this our essential deliverable. This is why we come to work each day, it is what the public expects first and foremost, and it is most likely a very central aspiration of most of us in the department whether clerk, MA, nurse, PA, NP, administrative assistant, physician, resident, fellow, statistician, or researcher. I believe the essential deliverable of the University of Michigan Department of Urology and its faculty and staff individually is KIND AND EXCELLENT PATIENT-CENTERED CARE THOROUGHLY INTEGRATED WITH INNOVATION AND EDUCATION AT ALL LEVELS.  If we get this right, everything else will follow.
8. Two books I read on my mini-sabbatical caught my attention. “Intuition in Medicine” is a rather dense read and it sent me back to the dictionary many times. The author, an MD and Ph.D. named Hillel Braude gets into the mechanisms of reasoning, namely induction, deduction, and a process he calls abduction. The other book, called “Justice for Hedgehogs” (by Ronald Dworkin) intrigued me because I’ve long liked the idea that people tend to be either foxes or hedgehogs in terms of their reasoning as to how the world works. The idea was popularized by the great thinker Isaiah Berlin, who attributes it to a thinker from ancient Greece.
9. Braude’s book had one great take-away concept for me, although that may not have been his central intention with the book. He introduced the idea of statistical physiognomy. Physiognomy is the archaic idea of looking at a person’s face and discerning their character. It is roughly analogous to phrenology whereby a physician could feel the shape of someone’s skull to diagnosis their illness. According to Braude statistical physiognomy is the implication that numeric data can be a surrogate for the actual patient. This is even worse than the classic metaphor of mistaking an actual patient for the disease.  The idea to me is that physicians first and foremost should look at, see, and talk to the patient. This was the concept that Michael Foucault called the “clinical gaze.” We should not confuse the patient for his or her disease. We cannot mistake a patient for a lab test. And today most especially we must not let ourselves substitute the computer screen and electronic medical record with the human being under our care.
10. The author of “Justice for Hedgehogs”, Ronald Dworkin, was Professor of Law and Philosophy at NYU, but died just this past February. This is an amazing piece of work that focuses, as a hedgehog must, on one big thing. That big thing is something that concerns us centrally as physicians, but even more so it concerns us as generic human beings. The thing is simply and hugely “value.” The value that we seek in life encompasses truth, meaning, morality, justice, goodness, and freedom, to name some essential attributes. Morals are principles or habits that relate to right or wrong conduct that should be consistent. EO Wilson writes of the “biology of morality,” expressing the idea that these principles are built into us.  Whether built into us by means of evolutionary natural selection or breathed in at the time of Creation, is a metaphysical matter.  Physicians are assumed to have a strong moral sense, although we see it expressed in some degree of spectrum. Ethics are specific rules of conduct, that are defined according to some consensus and may differ for different groups. Thus the Hippocratic Oath outlines a set of 8 ethical rules for physicians. Maritime captains will share a somewhat different code of ethics.
11. Dworkin, a legal scholar at heart, takes a very broad view of justice and links it fundamentally to something to which we all aspire – living a good and meaningful life. This is surely served well by that essential deliverable we discussed earlier. A phrase toward the end of Justice for Hedgehogs ties it all together well.
12. Dworkin’s phrase. “But remember finally the truth as well as its corruption. The justice we have imagined begins in what seems an unchallengeable proposition: that government must treat those under its dominion with equal concern & respect. That justice does not threaten it expands – our liberty. It does not trade freedom for equality or the other way around. It does not cripple enterprise for the sake of cheats. It favors neither big nor small government but only just government. It is drawn from dignity & aims at dignity.  It makes it easier & more likely for each of us to live a good life well. Remember too that the stakes are more than mortal. Without dignity our lives are only blinks of duration. But if we manage to live a good life well, we create something more. We write a subscript to our mortality. We make our lives tiny diamonds in the cosmic sands.”
    
13. The months fly by.  The current academic season is winding down as our chief residents prepare for their next steps and our incoming PGY1s prepare for “internship.”  Residents and fellows are the reason we exist as a department of urology – specifically, we are here to create the next generation of leaders in urology.  The context, milieu, or substrate for that education, however, is clinical care – which becomes the moral trump card for everything else on our plates at any moment. The best education requires the best clinical care – clinical care that is innovative if not at the cutting edge, clinical care that is safe, clinical care that is efficient, clinical care that is patient-centered, and clinical care that is kind.
14. When the resident applicants come by in the late autumn for their interviews, I have been giving them a little slide talk about urology and the history of our department. The other day I was thinking about our “expectations” for residents and thought I’d add those thoughts to the slide show. What do I look for, and try to predict from their applications and interviews? It really came down to 5 things: character, drive, intellect, sociability, and productivity. As I made the slide it occurred to me that we expect no less of ourselves as faculty and clinical providers, research staff, and administrative staff.
15. Our future as a department will largely depend on the intellectual and clinical productivity of our faculty in addition to the industry and success of our residents. I’ve been thinking about this a lot. My job is to optimize these things in an environment that is neither predictable nor even conducive to our work and ambitions. As a department, as a Faculty Group Practice, as a medical school and as a health system we try to learn from the best practices of our peers, from the academic community and from the business world. Amidst the cacophony of catch phrases of the day, we find some enduring concepts of value such as continuous quality improvement, lean process thinking, Gemba walks, SWOT analysis (strengths, weaknesses, opportunities, threats), and elimination of waste.
16. David Spahlinger at our FGP retreat showed a TED Talk by Simon Sinek, and Fritz Seyferth at our 2012 urology retreat showed an excerpt from the film “Emperors’ Club.” These clips inspired me as they pulled my focus from the immediate and pressing issues of the moment to the submerged considerations of meaning and deep value in life. Modern daily life, especially in an academic health center, is complex and intense. But at the end of the day how do we integrate these central three things that ultimately matter most: a.) finding meaning in our lives, b.) supporting ourselves and families (– for most of us this means getting a paycheck), and c.) enjoying the day while planning for the future?
17. Some of our best faculty have been asking the big “whys” of their careers and moved to other opportunities that we couldn’t match.  Ken Pienta is our most recent loss. While his primary appointment was in the Department of Internal Medicine, he had a joint appointment in the Department of Urology and in many ways was the intellectual epicenter of our uro-oncology research for more than 15 years. He has joined Johns Hopkins, which has enjoyed intellectual enrichment from its start – after all of its first 8 faculty in its medical school in 1893, 4 came from the University of Michigan. So Ken continues that great tradition of keeping that fine medical school in the game!
18. From Ken. ”I am currently the Donald S. Coffey Professor of Urology and Professor of Oncology and Pharmacology and Molecular Sciences.  I serve as the Director of Research for the Brady Urological Institute at Johns Hopkins University.  My laboratory will continue to be involved in research to develop new therapies for prostate cancer through defining the tumor life-cycle utilizing ecological principles. We will especially be emphasizing the study of disseminated tumor cells as an invasive species to bone, and why they become dormant as well as start to proliferate in some patients.”
    
19. Ken’s new position is attached to the name of his beloved mentor, the inestimable Don Coffey who directed the urology research laboratories at Johns Hopkins. Don was a visitor here to Ann Arbor on a number of occasions and I especially recall one cold evening after a lecture and dinner when he and I drove to Borders Bookstore so I could get him a copy of E.O. Wilson’s mind-bending book “Consilience.” Both Wilson and Coffey have bent my mind most wonderfully. After conversations with them my head sometimes has felt a little soggy, as if edematous after over use, just as my inner ear feels after too much loud noise (Dads’ weekends at Indiana University with the Delta Gamma daughters visiting fraternity parties – my advice to the next generation of dads: carry ear plugs.)
    
20. I love this quote from Northrup Frye: “the human word is the power that orders our chaos.”  Words are more than just the tools of our communication, they shape our thought. One of my favorite words, retrograde, links astronomy and urology. Retrograde is a word of distinguished provenance having early been used, if not invented, by William Shakespeare who used it first in Hamlet (1599-1602) when Claudius tries to dissuade his nephew (and step-son) the prince from returning to school in Wittenberg, saying of that intent: ”It is most retrograde to our desire  –And we beseech you, bend you to remain –Here in the cheer and comfort of our eye…”  Later, in All’s Well that Ends Well (1604-1605), Helena says “When he was retrograde, I think, rather.”  Although a less memorable quote, Helena’s comment still gives a full sense of the term.
21. Astronomy as a field also uses the term, most usually in relation to orbiting planets and their moons. Thus eight planets in our solar system orbit the sun in one direction called “prograde” (counterclockwise as viewed from the pole star, Polaris), while Venus and Uranus have retrograde orbits. Medicine did not embrace the term “retrograde” until after 1906 when Voelcker and von Lichtenburg described a happy marriage between Mr. Roentgen’s pictures and urology as they passed a cystoscope into the bladder, catheterized a ureter, and injected a contrast agent so as to “shoot” a retrograde pyelogram and visualize the upper urinary tract. When, exactly, “retrograde” was actually applied to this technique is a matter of further study for me.
22. I bring this matter of words up, because of the use of the word “terror” recently, particularly in relation to the Boston Marathon tragedy of April 15.  Geopolitics and terrorist activities have brought the idea to the public that this tragedy was “an act of terror.” That term was first out of the gate in news reports and it may be coupled with this event throughout our attempts to bring the perpetrators to justice and thereafter in the historical accounts. The use of the terrorism card did allow full weight of federal resources (the FBI and federal attorney jurisdiction) to come into play, resources that undoubtedly are necessary to deal effectively with any crime on such a large scale.  In reality, though, the disruption of the marathon was fundamentally a matter of mass assault, battery, and murder. No political excuse can be accepted. No excuse of mental illness can be accepted. No excuse of cultural alienation can be accepted. These were petty hooligans who resented the good fortune and happiness of other people. Bomb-building allowed these small-time closet thugs to achieve 15 minutes of notoriety in the news media of the day, at outrageous cost to hundreds of people they never knew. This behavior is not compatible with civilized people, it is not compatible with civilization. It is retrograde.
23. Health care is in the midst of a storm of epic proportion, although perhaps this will come to be viewed as a period of creative destruction. The meteoric effects of the federally mandated electronic health record may prove to benefit the greater good of mankind someday, although they mainly now seem to be benefiting the specific good of a few companies whose products (literally) fit the legislated bill of “meaningful use.”  I’ll leave retrograde thoughts to your imagination here.
24. Most destruction is not creative. Now that we are in tornado season it’s wise to keep an eye out the window or on the media for bad winds and tipping points. On this day in 1999 a portion of Oklahoma City was devastated by an F5 tornado, killing forty-five people, injuring 665, and causing $1 billion in damage. The tornado produced the highest wind speed ever recorded, measured at 301 +/- 20 mph (484 +/- 32 km/h) and was one of 66 in the 1999 Oklahoma tornado outbreak that included the picture shown below on the same day near Anadarko. Storms of epic proportions are freak anomalies of the atmosphere, just like the retrograde anomalies of human behavior that created the tragedy we saw in Boston last month. As we study these anomalies imaginatively and robustly, we should come to understand them and predict them better in the future.
    
25. Facebook & Blog. A reminder that we now have a Facebook page, called (as you might have guessed) Matula Thoughts. We will try to post something relevant to Michigan Urology several times a week and would be grateful for any observations or pictures that you (Nesbit alumni, friends of the department, staff, health care providers, researchers, residents, faculty, or colleagues) would be kind enough to send me for inclusion. This blog will be the site for the global “What’s New” we send out at the beginning of each month, usually around the first Friday. Of course, comments regarding these present Matula Thoughts, will be gratefully received.

Best wishes, and thanks for spending time on “What’s New” this weekend. I hope to see many of our friends & alumni on Sunday at the Nesbit Reception in San Diego and will give you an update on that next month.

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