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/
What’s New August 2, 2013
A monthly communication to the faculty, residents, staff, and friends of the University of Michigan Urology Family.
21 Items, 1 Web Link, 15 Minutes
1. August greetings – urologists and friends. Last month we celebrated the Fourth of July, in commemoration of the Declaration of Independence adopted by the Continental Congress on that date in 1776. This document was a formal explanation of the reasons that the Congress had voted on July 2 to declare independence from Great Britain, at that point more than a year after the Revolutionary War had actually begun. Thomas Jefferson led a committee that composed the original draft that Congress ratified on the Fourth. (That manuscript, however, was lost and we have only the derivative copies remaining to inspect.) The night of the Fourth somewhere around 200 copies were published and distributed as the Dunlop Broadside (picture on left above). John Hancock’s signature and the others were not present, and the document was witnessed only by the patriot leader and secretary of the Congress Charles Thomson. (26 Broadsides are known to exist – the sole Big Ten copy is at the Lilly Library at Indiana University.) My point today is that this date in 1776, August 2, is the specific date the Declaration signing was completed by the key participants (picture on right above). So perhaps today is our nation’s actual birthday.
2. The document consists of 1337 words, counting the header but excluding the ultimate signatures and their state names. The second sentence is one of the best-known sentences in the English language, yet oddly it was very infrequently referenced for the next four score and seven years until Abraham Lincoln picked up on that sentence in his Gettysburg Address, a document of only about 270 words, a fifth the size of the Declaration. That essential sentence of 1776 is: We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.
3. That sentence has become a defining statement on human rights and transcends not just the principles of our Constitution and its Bill of Rights, but all nations and peoples. This belief is a fundamental principle of health care and the social justice that underlies it. Every life matters. It matters not only to the life of its owner, but to the lives of the rest of us. The illness of others affects the healthy ethically, socially, and economically. Furthermore, the reality of the human condition is that no one is consistently well for a lifetime. This innate belief is what brought many of us into the world of health care, although politics, economics, regulatory nonsense, industry, and avarice corrode that innate belief on a daily basis. From that sentence we need to somehow construct a path to a basic sustainable safety net for health care with a robust mix of governmental and private sector suppliers. The actual term health care must encompass its delivery systems, educational networks, and research programs. Some parts of health care are so clearly in the public interest (such as pre-natal & obstetric care, childcare, immunizations, communicable disease education & research, emergency care) – just like national defense, public education, and homeland security – that they are best guaranteed by society. Parts of health care that are straightforward commodities may also be more conveniently provided in the free market. If you need a school physical exam or immunizations, why not go to Walgreens, CVS, or a UM walk-in clinic and pay a fee if you prefer not to go to a public health clinic (shouldn’t we have these – or contract them out to hospitals??) or a VA (why shouldn’t the VA offer some basic general health commodities to the public?). It makes no sense to dole these necessary commodities out via an insurance-based paradigm with third parties doing paper work, arbitrating “prior authorizations” and wasting time and money with administrative overhead and paperwork. The free market generally works well for commodities, although critical health care commodities also need a “public option.” There, I’ve said it – the highly politicized term that Democrats and Republications have batted back and forth over their party lines. Anyway, that sentence of 1776, largely attributed to Jefferson, is a hell of a sentence.
4. Sentences are the building blocks of communication, however the rise of abbreviated electronic communication has put the well-constructed sentence at risk. A journalist named Verlyn Klinkenborg wrote a piece in the New York Times called “The decline and fall of the English major” (June 22) in which he laments the inability of so many literate adults to “distribute their thinking in the kinds of sentences that have a merit, even a literary merit, of their own.” A subsequent letter to the editor stated: “I think of it as a translation problem. Those who can translate their knowledge and understanding into meaningful sentences have a decided personal advantage.” (Betty Sugarman. NYT Friday June 28, 2013).
5. Two individuals who changed the course of history in the 20th century found their careers jump-started by their “personal advantage” of extraordinary communication skills. Winston Churchill as a young man was a skilled journalist who quickly achieved widespread recognition and as a young soldier Dwight Eisenhower’s effectiveness in written communications on behalf of a more senior officer raised his credibility in the U.S. Army. In this day of 140 character tweets and truncated electronic texting, the rarity of sentences with clarity, integrity, and eloquence makes them especially prized and effective. This is a skill well worth honing for residents, faculty, nurses, PAs, MAs, researchers, and staff. None of us is likely to surpass Jefferson in the Declaration, Lincoln in the Gettysburg, Churchill in the “Never give in” speech or Eisenhower in his D-day address. Those men turned out sentences that were noble, genuine, and stirring. For us, though, clarity is at least a good start, as we aim for excellence on our own more parochial turfs.
6. The D-Day speech in 1944 and the Military-Industrial Complex speech in 1961 were, perhaps, the most famous addresses of Eisenhower, however one other great speech worth noting for us in the health care world was his talk to the American Society of Newspaper Editors on April 16, 1953 at the Statler Hotel in Washington, DC. The following phrase is as true today as was 60 years ago when he gave it just after the death of Joseph Stalin in dismay of the waste of the Cold War. “Every gun that is made, every warship launched, every rocket fired signifies in the final sense, a theft from those who hunger and are not fed, those who are cold and are not clothed. This world in arms is not spending money alone. It is spending the sweat of its laborers, the genius of its scientists, the hopes of its children. This is not a way of life at all in any true sense. Under the clouds of war, it is humanity hanging on a cross of iron.” In a real sense this is true of the health care dollars spent for CEO corporate jets, HIPPA compliance, the so-called “meaningful use” mandates of the electronic health record legislation, Medicare/Medicaid fraud, unnecessary procedures and testing, in addition to the trillion dollars annually of general waste in healthcare.
7. Aside from the Fourth of July, last month was a rich time for Michigan Urology in terms of education, academic events and culture. As our completing chief residents and fellows headed off to the rest of their lives and careers, our 4 new PGY1s and 4 new fellows started work. The PGY1s: Neel Gowdar, Amy Luckenbaugh, James Tracey, Yooni Yi) have been sending me weekly commentaries on their experiences, which so closely parallel those I had in July of 1971 in Los Angeles. The basic challenges of learning the new language and work culture of a field, along with techniques, analytic skills, systems, and hitherto undeveloped hierarchy sense are being overcome rapidly, case by case and day by day. By the way, their sentences are pretty good so far. Our fellows old and new: Abdulrahman Al Ruwally – new in Endourology, Nina Casanova – new Pediatrics fellow, Chad Ellimoottil – new in Health Services Research, Sara Lenherr – NPR, Lindsey Menchen – new in NPR, Florian Schroeck – Oncology, Anne Suskind – NPR, Paul Womble – new in Oncology.
8. In the midst of the sweltering Art Fair, we hosted the 7th Chang Lecture on Art and Medicine. Dr. Richard Prager gave a brilliant talk about the legendary Bethune Murals, once owned and displayed here at UM in the hospitals, but disappeared during loan to the United Sates Army in the 1960s. The murals depicted the ravages of TB, as experienced by Norman Bethune, a rather oddball thoracic surgeon, who produced the work while he was a patient in the Adirondack Mountains at the Trudeau Sanitarium. Bethune found other causes to champion in his life including the Loyalist Forces of the Spanish Civil War and the Chinese Communist Part of Mao Zendong. Rich Prager linked his study of Bethune and the murals, to deeper considerations of the role of art as an expression of the human condition.
9. Ford Auditorium was as full as I’ve ever seen it and Rich hit a home run with his talk. Dr. Chang, his sons Ted and Hamilton, and sister Syauchen Baker were on hand for the event. Dr. Chang was Michigan’s first pediatric urologist having come here from Taiwan to train under the legendary Reed Nesbit. This association was a consequence of Nesbit’s clinical care, at the behest of the State Department, for Chiang Kai-shek (the 20th-century Chinese political and military leader, known in Mandarin Chinese as Jiang Jieshi (蔣介石) or Jiang Zhongzheng (蔣中正).
10. Why should we, the University of Michigan Department of Urology, organize a lecture on Art and Medicine? The first answer is the Chang family where art and medicine converged so harmoniously. Dr. Chang’s father was a premier artist in China in the days leading up to WWII. The revolution led by Mao split the nation, and Chang Ku-nien the artist sided with Chiang Kai-shek in the retreat to Taiwan. Much of the work of Chang Ku-nien, who is known as a preserver and transformer of the traditional style of literati (scholar-artist) painting, is now in our UM Art Museum. It is worth a visit to the Shirley Chang Wing at our Art Museum to find your own personal convergence of art and medicine. The second answer is that art and medicine are two of the oldest, most essential, and inseparable aspects of the human condition; naturally we have a stake in their exploration.
11. Some of our audience at the Chang Lecture: Frank Legacki, Alicia Torres, Sharon and Tom Shumaker.
12. The following day we saw our first visiting professors of the new academic (and coincidentally the new fiscal year FY 14). These were Tom Kolon of Philadelphia Children’s Hospital, George Drach of the University of Pennsylvania, and Wayland Hsaio of Emory. Tom spoke of undescended testis, George gave a terrific analysis of the impact of the new ACA legislation on Medicare and children’s services, and Wayland spoke of sperm preservation in children undergoing cancer therapy. Now that modern medicine is able to save many children with malignancies that not long ago were fatal, we should be able to find a way for them to achieve liberty and the pursuit of happiness in terms of fertility. All talks were well-constructed and inspiring. Our residents gave some excellent case presentations. Simultaneously during that Friday morning our staff underwent a morning training session. Their “visiting professor” was Brian Blasko, motivational trainer and consultant. Brian led the staff thru 4 hours of discussion and lecture on personal and organizational growth. His talk I’m told was entertaining and insightful. The staff was very appreciative of having this opportunity, not to mention they (except for a skeleton crew to man the phones, deal with the consults and staff the inpatient care) had the afternoon free for the art fairs, as our departmental gesture of an annual “birthday present” for all.
George Drach. Tom Kolon, Kate Kraft, & Wayland Hsaio.
13. Let me go back to art for a few moments. John Trumbull (1756-1843), an American artist born in Connecticut and son of the state’s governor, lost the use of an eye after a childhood accident. The handicap may have influenced his artistic career, but it didn’t preclude service in the Revolutionary War where his sketches of the British fortifications at Bunker Hill helped our cause. Following the war Trumbull studied in London under Benjamin West, but was imprisoned there for seven months in 1780 by the British in retaliation for the capture and execution in America of the British spy John Andre. After release and further study and work in London and Paris, Trumbull returned to the US for a distinguished career in painting. Undoubtedly, you have seen some of his work, including the famous “Declaration of Independence” picture he produced in 1817-19, with some help from Thomas Jefferson. The painting, placed in the Rotunda of Congress in 1826, depicts the drafting of the Declaration of Independence. Of course, as is true with many great historical paintings, the depiction is largely imaginary. We know there was no such actual moment when everyone saw and then signed the Declaration at once. All those people were not in the room (Independence Hall in Philadelphia where the Second Continental Congress met) at the same time.
14. Jefferson may have helped Trumbull construct the scene 41 years after the fact, but if his memory is like mine you should expect some plasticity of the recollection. You see in the center a 5-man drafting committee presenting their work to the Continental Congress. The painting shows 42 of the 56 signers, but Trumbull was unable to find likenesses of everyone and rather than “fake the faces” he chose to add some participants in the debate leading up to the Declaration, but who did not actually sign the document. This included John Dickinson who declined to sign the document, and Benjamin Harrison V for whom Trumbull could find no portrait (no iPhones then) but painted the son Benjamin Harrison VI who was known to resemble the dad.
15. During the Art Fair I walked around for a bit with Tom Kolon and Wayland Hsaio. It was hot so I bought us some iced tea and Arnold Palmers from a stand in front of the Michigan League Building (itself a building of great art). I paid for the beverages with my favorite paper currency – two dollar bills, nice pieces of portable art and history. The front part (obverse) has a portrait of Thomas Jefferson. The backside (reverse) has an engraving of a modified version of the Trumbull painting.
16. The engraving differs from the Trumbull original in expected and unexpected ways. As you might expect, the original was “cropped” to best fit the format of the two-dollar bill so the four farthest figures on the left and the two on the right were omitted (Left: George Wythe, William Whipple, Josiah Bartlett, and Thomas Lynch; Right: Thomas McKean and Philip Livingston). Oddly, for no good reason, the engraver also omitted George Walton, seated in the back well to the left of midline and marked by my notation as “missing.” Even more strangely, the engravers added two individuals who remain unidentified, they are indicated by my question marks. They look curiously like Waldo.
17. Returning to urology, let me take you further back in time 2500 years ago to the Hippocratic Oath in which the author made a singular exclusion of one specific type of medical practice to be left to “specialists.” This was the matter of cutting for bladder stone, something that was to be deferred to ”specialists in that art.” In that sense, lithotomists (urologists, today) were a unique type of practitioner with extraordinary skills. Throughout history they have been the Waldos of the medical professions, numerically uncommon and mostly hard to spot, leaving precious little of a paper trail. Urologists today are still not even one percent of the health care work force, but are still essential and hopefully easier to find. These are the practitioners we train at Michigan Urology where the old Hippocratic idea that our work is an art has validity to me. As I said in my introduction to Rich Prager at the Chang Lecture – art can inspire us and great art usually does. When a task – any art, any performance – is accomplished with extraordinary skill, beauty, & grace we take special notice sometimes to the point of exhilaration and inspiration. In urology that art may be found in diagnostic acumen, surgical dexterity, or in acts of kindness. Art must remain an essential part of our work.
18. So in my view no boundary exists between art and medicine. The two are as connected as you chose to believe and they are both essential to our aspirations of life, liberty, and the pursuit of happiness (if I can draw upon that great sentence once more). As this new academic season of 2014 gets underway, we will continue to practice urology, teach urology, and study urology with as much art and expertise as we can muster one patient at a time, one resident at a time, and one question at a time. We will find some moments of exhilaration and inspiration, as we navigate uncertain terrain hampered by bad legislation, industrial profiteering, relentless economic pressure, and suboptimal leadership, mine included. Still, we intend to be successful in all three missions and expect next year to produce an 8th Chang Lecture and an 18th season of Duckett-Lapides-Art Fair Professorships, each as worthy as we experienced last month here in Ann Arbor.
19. Two substantial administrative appointments involve our faculty. Cheryl Lee will serve in the Dean’s Office as Director for Continuous Professional Development starting September 1. Alon Weizer has taken on the position of Medical Director of the Cancer Center Ambulatory Care Unit (CCACU) effective June 17.
20. Yesterday one of our joint faculty members Maha Hussain, Professor of Internal Medicine and Professor of Urology, was appointed as the first Cis Maisel Professor of Oncology. Having a named professorship is a great honor and we congratulate Maha on her achievement.
21. Last month our internal weekly “What’s New” profiled Gary Faerber (Associate Chair for Research and the Edward J. McGuire Research Professor), John Wei (Director of Communications, Marketing, and Networks and Professor of Urology) and an update on the Pediatric Urology Division directed by John Park. Website: http://www.med.umich.edu/urology/about/MonthlyNewsletter.html.
Best wishes, and thanks for spending time on “What’s New” this first August weekend of 2013.
David A. Bloom, M.D.
The Jack Lapides Professor and Chair
Department of Urology