The University of Michigan Department of Urology

3875 Taubman Center, 1500 E. Medical Center Drive, SPC 5330, Ann Arbor, Michigan 48109-5330

Academic Office:  (734) 232-4943   FAX: (734) 936-8037   www.urology.med.umich.edu    https://matulathoughts.org/

1.

National holidays are treasured interruptions of the work cycle and the Fourth of July is a favorite of mine. Granted that the fireworks, lawn mower accidents, trampoline injuries, and water sports traumas put an extra burden on our emergency departments and personnel on call, I still enjoy the long weekend and chance to think about the luck of our national circumstance. I’m neither a political scientist nor professor of law, but even pediatric urologists can have (should have) political opinions and appreciations.

2. When the status quo of colonial America was disrupted by a critical mass of disaffected individuals, that diverse and feisty group somehow came together around a set of principles and rules that was larger than their individual selfish interests, yet still served those interests, for the most part. Those principles and rules have held up well for 237 years, requiring tweaking by only 27 amendments (the first 10 comprise the “Bill of Rights”) from 1791 through 1992 and one terrible civil war to correct a grievous error of political compromise in the writing of the Constitution, namely the acceptance of slavery. The resulting rules and principles, along with the public acceptance of them, are largely the reasons we don’t behave as a nation like Syria, Argentina, North Korea, or many other nations you might name (not that we are perfect as a nation). So, happy Fourth of July to all of us. (Painting by Archibald MacNeal Willard c. 1875. “The Spirit of ’76. Location: Abbott Hall, Marblehead, MA)

3. What will the future hold for us and other nations? Can we go for another 237 years? This matter of contingency and possibility depends on far more things than I can understand, but whatever plays out will follow a Darwinian path that some might call survival of the fittest.  This, of course, requires military fitness, but that by itself alone works only in the short run as demonstrated in ancient Egypt, Rome, the lands of Genghis Khan, the Spanish Armada, the Third Reich, etc. A national military needs to be balanced by a civilian representative government to best serve its citizens and stakeholders, including its neighbors. Citizens must have education and opportunity within a stable and fair environment. Somehow, we have managed to get this fairly right in the United States, and we hope the model is gaining worldwide traction.

4. Darwin is credited with understanding how a multitude of tiny variations tweak the descendants of a species over time so that some descendants better fit a future environment that is prospectively unknown. Conventional wisdom is that these tweaks are genetic mistakes.  In reality, however, they are hardly mistakes but intentional programmatic gambles on the future. Nature tries to provide a diversified portfolio of options for each tomorrow. The source of that intent is our greatest mystery. Scientific inquiry, mankind’s useful tool for comprehending the world, has proven the opinion of James Ussher in 1650, namely that the world most likely began in 4004 BC, was somewhat off target.  Everyone is entitled to his or her opinions and we have to credit Ussher for trying to be as precise as he could using the best evidence he had available. Better evidence today tells us that the known universe dates back to some sort of big bang 13.792 billion years ago. Since then the world on any given day has been a matter of contingency and possibility, driven by and resulting in neverending change.

5. Contingency, a noun, is a rather ephemeral (transitory) concept. Like happiness it describes a state of being, but the particular state depends on other things happening or having happened. A contingency may be an event that is neither certain to occur, nor certain to not occur. It depends on some thing. Possibility is an essential part of human happiness. More fundamentally, it is the reason the world exists, starting with some fundamental energy that led to space, time, and matter. For us, in our narrow playground of human interest, the possibilities that human imagination has created are what allows us to control parts of the world and procure better futures for ourselves and our children. Humans turn imagination into reality. That imagination may be small and immediate, or it can be grand and play out over years or generations. We talked about how imagination extends reality two months back in the discussion of Claude Shannon. Dreams and fiction can quickly transform into truth. Look at what a century of science, technology, ingenuity, industry, and government did to the fantasies of Jules Verne.

6. I’ve strayed far from my field and department, so forgive this riff on the Fourth. We are now entering a new fiscal year, approaching a new academic year, and are stepping into a new era of health care in the USA. The world of academic medicine is contingent on the expansive and expensive new possibilities of health care, the changing world economy, and the emerging realities of recent governmental legislation. The world in which our trainees will practice is rapidly taking shape and it will be quite different from that we have known.

7. Our new PGY1s are in action and our new chief residents are on the home stretch, finalizing their plans for next year.  The training cycle for our immediate residents is 5-6 years, but many (last year all of them) take additional training in terms of fellowships to prepare for the contingencies of tomorrow’s urology. It’s interesting to me that we are producing only a few more finished urologists per year in this country as were produced when I completed my training. Many people today argue that we should be producing many more, considering the evolving demographics of the world. Yet, in my years of evaluating electronic billing records for the ABU certification and recertification candidates, I found this country seems to have plenty of urologic manpower for the actual urological surgical “work” in terms of operative cases that require a well-trained urologist. What keeps our 14,000 or so practicing urologists in the USA busy and compensated is largely the office work and small cases that fill their days. So thus we seem to have a conflict between the needs of the public, the free market, and the needs of a profession.

8. 

Cicada mania is sweeping the East Coast with Brood II of the 17-year swarm popping up. It is a great curiosity of biology and example of contingency and possibility that some species have 17-year cycles and others have 13-year cycles.  For some Darwinian reasons the eggs they lay and grubs they become stay underground for these cycles and then appear in such abundance that they overwhelm the unprepared predators for enough cicadas to mate and deposit enough eggs sufficient to keep their game going. I remember the last major Michigan cicada brood swarm in 2004. The tree in our back yard, where I photographed this fellow back then, is gone since we had to chop it down when our deck was replaced. It seemed useful to turn the tree into logs that kept our home warmer for a few winters, although that process moved carbon from our back yard to your atmosphere. The yard was a noisy place in the summer of 2004 and those strange creatures with red eyes were all over the place. That Michigan cicada cohort, Brood X, will be back in 2021.

9. Michigan Urology was different back in our last cicada year. We were smaller, having grown from a little division of the Surgery Department just a few years earlier when we gained departmental status under Jim Montie in 2001. When the brood hatches next it will occur in 2021 – the world will be even more greatly changed. By then the Accountable Care Organization model may be gone and MiChart may be recalled as an awkward federally mediated experiment of the past. I bet a few oddballs like me will still be using 3×5 cards and some sort of pencil or ink to keep track of their patients in addition to the next generation electronic health record (EHR) that possibly may be wonderful and intuitive allowing deep archiving, prompt communication at a national level, and full storytelling in a limited number of optical fields.  Electricity, however, will be more expensive and likely less reliable.

10. Is Moore really less? Moore’s law is the observation that, over the course of computing hardware history, the number of transistors on integrated circuits doubles every two years. Derivative from that is the idea that computing systems get equivalently smaller and cheaper in that interval. However, the smaller and cheaper idea may work at the end user level, but the large data bank farms with their requisite temperature control systems seem to more than offset the elegant capacity, tiny size, and minimal energy needs of your smartphone.  By 2030 Planet Earth will have enormous energy hunger and we will be close to tapping out known oil and gas reserves, plus we will probably have “fracked” everything frackable.

11. Part of my gripe with the expensive, primitive, and encumbering electronic record system we were forced to buy and implement (for quarter of a billion dollars here at UM) is that it is not easy to find the story of a patient. Many visual screens disperse the parts of the story so no single optical field is likely to capture the key elements to understand it quickly. The “filtering” systems can create individual idiosyncratic overviews, but no useful generalization has been found for the 2000 practitioners at UM. It is largely left to each of the 2000 to figure it out themselves. I have found the company unhelpful with my implementation. The expensive and plentiful subcontractors we employed a year ago were clueless regarding the needs of our clinicians’ workflows. To add insult to injury we found that the system we purchased couldn’t “talk to” the same company’s system in Kalamazoo, where some members of our department also see patients (“that would require a special upgrade” – but wasn’t such broad inter hospital communication one of the main points of the federal EHR regulation?). Many of us wondered how it could be that very obvious and basic problems we encountered in our EHR implementation that affected daily workflow, patient convenience, and physician efficiency were not experienced by other health systems that purchased the same system. Obviously they were, but any learning that must have occurred was not translated to us in Ann Arbor. We were told that such things were “proprietary.” Anyway, time to stop griping, today’s EHR is what it is. Our workflow, at least mine and much of what I see in our department and others, is noticeably slower, more painful, and more distant from the actual patient.

12. I recently got a new car. A Ford product from Joe Sesi. The cost was pretty much the same as the cost per physician of the mandated EHR. However, my car is not just an amazing manufactured product that also contains a huge amount of software and complex, yet interactive, electronic systems. Customer service, from Darin Ballenger the salesman, Joe Sesi the dealer, and Ford nationally (by direct phone line to a person) is terrific and ongoing. Anything I need help with in terms of the car mechanically, its software, or my understanding of its operation is readily available from any or all three of those resources from the source. Ford gets it.

13. Workflow is important in health care. If it is efficient, lean, and value-stream oriented it is most likely to give satisfaction to all stakeholders and less prone to error.  As human beings imperfection is part of our reality – to deny this is to step away from reality. Yet, as good and conscientious health care providers (or citizens, for that matter), we want to minimize errors, especially grievous ones.

14. It is a naïve supposition to assume that any electronic medical record can or should capture all of the myriad facets and transactions in the work flow of health care. An interesting paper in the Journal of the American College of Surgeons (“30-day outcomes support surgical safety checklists” by Bliss, Ross-Richardson, Sanzari et al JACS 215:766, 2012) illustrates this point. The authors arranged for surgical cases to be monitored for “safety-compromising events.” In 73 surgical cases they observed 511 such events. My point is that those 73 cases must have also included literally thousands of other “events”, transactions, or interactions that went well. Many interactions between patient and someone in the health care system are routine and some are very complex. However, it is the nature of health care that even routine transactions such as moving or positioning a patient, afford opportunities for error or damage. No system, EHR, or checklist can shelter a physician from the ultimate professional responsibility and perpetual anxiety to “first do no harm.” I fear, however, that a generation of commoditized health care providers will come to believe they are so sheltered from that personal responsibility if they follow guidelines, observe checklists, and dutifully type in their parts of the EHR.

15. We once criticized physicians (often ourselves) who got so wrapped up in numbers and systems that they began to mistake lab tests or pathologies for actual patients. Thus a resident in clinic might go from “a small renal mass” in one room, to a “high PSA” in another, and then take a consult for a case of “unexplained hematuria.” This could be called a matter of statistical physiognomy in which clinical data replaces the “face of a patient.” Today’s new iteration of this error is the substitution of the computer screen for the actual patient, an error we might call “LED physiognomy” or the “meaningful use avatar.” I believe Michigan Urology residents, faculty, and Nesbit alumni graduates will not fall easily into that trap. What distinguished Cabot, Nesbit, Lapides, and our faculty and trainees who followed, was their ability to see beyond the limitations of their colleagues, economics, and systems of their times so as to deliver innovative urologic care, thoroughly integrated with education and scholarship. Statistical and LED physiognomies are the false deities of our era. They may be alluring traps for some medical geeks, but they are certainly bogus.

16. 

Our graduating chief residents Ray Tan, Jon Ellison, George Schade, and Gareth Warren with Lora Allen who was recognized by the residents for doing a great job as residency coordinator.

As I looked at our graduating class of 4 residents and 1 fellow during the dinner we held for them at the Michigan Union last month I saw the best of the best of the next generation of urologists, who will lead the way in our field with the tri-part mission implicit in our art and science. That is to a.) care for patients kindly, well, and innovatively; b.) integrate education thoroughly throughout that care, thus training the next generation of physicians; and c.) expanding the conceptual basis of our field including the systems of health care delivery. Michigan did it well for this class just as has been the case for a long line of classes back to 1926.

17. Michigan Men’s Football is one of our key funding vehicles for prostate cancer research. This idea derived from Jim Montie and Dave Brandon and is dependent on the generosity and enthusiasm of the football coaching staff and our participants.  We had a terrific two days in June with 58 participants and some 21 coaching staff. We will have room for twice as many participants next year and hope many of our readers will either participate or generously send someone out on the turf.

18. 

The McGuire Professorship was inaugurated in June and Gary Faerber was installed as its first recipient. Pictured above from the ceremony are Brian and Mary Campbell with Gary.  Brian and Mary among a number of other friends, faculty, and Nesbit alumni helped fund this professorship.  Gary was trained by Ed, had been our Residency Program Director for 10 years, and is Associate Chair for Education. He is a “urologist’s urologist” and is always among the first to take on another patient in need and add to his clinic or OR schedule without so much as a grumble. Ed McGuire’s mark on Michigan Urology is indelible. He was a perfect and most worthy successor to Jack Lapides and impacted a generation of residents and fellows, thousands of patients, and the basics of urologic knowledge.  Ed retired last month and is now an Active Emeritus Professor.  Ed has held the Reed Nesbit Professorship and we will ask the Regents if it may go to Julian Wan, one of Ed’s early residents, and much like Ed and Gary, a versatile “stand-up” urologist, an innovative thinker, and an essential citizen of our department.

19. Last month we wrote about the importance of medical journals insofar as they take new ideas, vet them through the process of peer review, and publish them for inspection. The peer review part requires thoughtful and generous peers to review submissions, and in this respect some of our faculty really excel. Bill Steers, the Editor of the Journal of Urology, recently sent me a note telling me that 5 of our faculty were among the handful of reviewers honored this year by the “Best Reviewer” Award. I am in awe of these five, who accept and review, with clarity and promptness, a large number of manuscripts each year. My hat is off to Quentin Clemens, John Hollingsworth, Kate Kraft, David Miller, and Julian Wan.

20. Last month our internal weekly “What’s New” profiled Khaled Hafez in the Division of Endourology, Corey Longley the development officer for urology, and an update on the Neurourology and Pelvic Reconstructive Surgery Division directed by Quentin Clemens. Website: http://www.med.umich.edu/urology/about/MonthlyNewsletter.html.

21. This will be our seventh year for the Chang Lecture on Art and Medicine in which we honor the extraordinary Chang family who link Chinese art and Michigan Urology.  Dr. Richard Prager, Professor of Cardiac Surgery and Head of the Section of Adult Cardiac Surgery at the U of M, will present “Art as an Expression of the Human Condition” on Thursday, July 18 at 5:00 PM in the Ford Auditorium of the University Hospital.  We hope to see many of you there and a reception will follow. Friday, July 19 is the Duckett/Lapides Lectureships from 9:00 AM-12:30 PM in the MCHC Auditorium. The visiting professors are Dr. Thomas Kolon, Associate Professor of Urology in Surgery from the Children’s Hospital of Philadelphia (Duckett) on “Cryptorchidism and Germ Cell Preservation” and Dr. Wayland Hsiao, Assistant Professor of Urology at Emory University School of Medicine (Lapides) on “After childhood fertility preservation, what are the state-of-the-art options.”

22. While the faculty and residents are at the lectureship the staff will have their annual training and education day from 8:00 AM to Noon at the BSRB. We welcome back Brian Blasko, a highly motivated, nationally known speaker and trainer, who will present The Car Key Factor in Creating Your Comfort Zone With Communication.  The afternoon is free to enjoy the Art Fair as our annual “birthday” present to our staff (recognizing that a few will have to stay behind to cover phones and emergencies).

Best wishes, have a wonderful 4^th of July holiday, and thanks for spending time on What’s New this week.

David A. Bloom, M.D.

The Jack Lapides Professor and Chair

Department of Urology

TEL: 734-232-4943

Email: dabloom@umich.edu