The University of Michigan Department of Urology
3875 Taubman Center, 1500 E. Medical Center Drive, SPC 5330, Ann Arbor, Michigan 48109-5330
What’s New October 4, 2013
A monthly communication to the faculty, residents, staff, and friends of the University of Michigan Urology Family.
Michigan Traditions – Kindness, heart, healthcare, kudos,
and other news.
22 Items, 2 Web Links, 12 Minutes
Autumn is at hand, with a solid football season in play and our Nesbit Alumni weekend coming up. The department is doing well as this new fiscal year has begun and our calendar year starts to enter the home stretch. It was a busy summer and a crazy September given the apparent usual Mott effect of added patients. In the middle of the month I drove into Kerrytown for a cup of coffee with colleagues and after parking I dutifully was putting coins into the meter when a car paused alongside me and the driver opened the window to tell me: “It’s Sunday, you don’t need to feed the meter.” It was a nice and random act of kindness. His heart was in the right place and it made me think of a book I read during my mini-sabbatical (Skip Campbell gave it to me, undoubtedly because he thought I could use the lesson and I truly did need it). The book was “The Power of Kindness” by Piero Ferrucci and was an easy read yet powerful and incisive. It pointed out that for most of us our heart is in the right place (anatomically and socially), although our self-absorbed lives and necessarily selfish interests often tune it out of our standard operating systems. Ferrucci’s lesson in kindness is an important “app” that we all need to install and refresh.
2. We had a retreat last month, the second in 2013, but this was entirely run by our younger faculty. The retreat was called “Marketing, Branding and Social Media at Michigan.” The faculty in charge assembled a great lineup of presenters and the keynote speaker was Ari Weinzweig on “Zingerman’s Community of Businesses: 3 Decades of Making a Difference.” The Zingerman’s Family of Businesses is a huge local success story, with a sustainable business plan, a culture of customer service raised to a whole new level, superb employee engagement, and a thoughtful holistic and precise strategy. We have much to learn from Ari. Coming soon as a result of this dialogue is a new and much improved website for our department.
Ari Weinzweig, Julian Wan, and Kate Kraft [Photo by Gary Faerber]
3. Our PGY-1s are well immersed in their first step of residency training going from their undifferentiated pluripotent stem cell state as new medical school graduates on a journey of specialization into urologists over the next 5 or more years. We hope this differentiation into specialists won’t impact their lifelong expression of kindness and curiosity although we know this happens to some specialists (rarely urologists). Our PGY-1s will finish in 2018, the 99th year of Michigan Urology, by my measure from the time Hugh Cabot brought modern urology to Michigan. The tradition from Hugh Cabot and his trainee Reed Nesbit is long and great. With the Nesbit Society annual meeting approaching this is a good time to mention that we are putting the production of the next edition of our departmental history on the front burner.
4. Imagine my surprise the other week when I was looking through Science magazine and I found a picture of Scott Tomlins, our joint faculty member with the Department of Pathology. It was not so long ago that Scott was one of our Michigan MD – PhD students considering residency choices. He picked well, selecting UM Pathology and his work with Arul Chinnaiyan, also a joint member of our department. Their team made a big discovery a few years ago, related to two normal human genes. One gene called TMPRSS2 is normally turned on in the prostate, while another called ERG is normally turned off. When, abnormally, the two genes fuse – something that the team found happens in about half of all prostate cancers – ERG becomes turned on and this drives cancer formation. From this observation, they have developed a urine test that can detect a product of this gene fusion. [Science 341:973, 2013] Potentially, targeted therapy could follow.
Scott Tomlins with AAAS CEO Alan Leshner [From Science: 341:973, 2013]
5. Nesbit Alumni Refresher. A new cohort of residents has stepped into the long maize and blue line of the Michigan Urology family that actually began under Hugh Cabot when he brought Reed Nesbit and Charles Huggins to Ann Arbor. Cabot was busy, building the Michigan surgery department, the new hospital, and being dean in his first 6 years, and didn’t step into urology GME until 1926. Formal residency training began under Nesbit and it is for him that our urology alumni group is named. We currently have 279 members consisting of 176 active members, 34 senior members, 32 UM Urology faculty, 15 joint faculty, 8 fellows, 20 residents, and 4 associate members. Whereas meetings used to occur on alternate years, now they take place yearly and our 28th one is coming up. The meeting is not just a scientific one, but a social one as well. The social aspect is essential. Residency and fellowship training constitute the longest and most intense single educational interlude anyone will likely experience and it tends to bind most participants together tightly. If careers and families inevitably create some drift of individuals, the Nesbit Society affords opportunity for reunion and reconciliation during careers and after them. Officers this year→ President Julian Wan [Nesbit 1990], Secretary/Treasurer Ann Oldendorf [Nesbit 1992], and three Directors David Bloom, Surendra Kumar [Nesbit 1981], and Dana Ohl [Nesbit 1987].
6. I was out of town for the Dean’s State of the School talk last month and went to the web site to see it. [http://medicine.umich.edu/medschool/about/news/view-dean-woolliscroft%E2%80%99s-2013-state-school-address] Dean Woolliscroft spoke of the challenges we face in this new resource constrained era of academic medicine. This is the 4th era for our Medical School, the first being the period of focus on medical student education (1850-WWII), the second was the period of federal investment in research (WWII-1965), the third period was shaped by the expansion of clinical federal funding from Medicare and Medicaid in 1965. This new era is one of resource constraint related to slowing of federal support of research and clinical care, increased regulatory constraints, and competitive pressure from aggregating large systems. One could argue that this is an era of mission equilibration as the dominant federal funds that support research, clinical care, and education seem to be shrinking significantly (era 4). Perhaps this became most evident with the world economic crisis of 2008. Research (era 2) and clinical care (era 3) come into balance not only with each other but with the basic unfunded educational part of our mission that started in era 1. The Dean nonetheless painted an optimist picture of Michigan’s future based on our collective engagement, citizenship, and collaboration to preserve our mission and existence in the new era.
7. Medicare and Medicaid Update. We had talked about this before, but it’s time for a refresher. These entities came out of the Social Security Amendments of 1965, a bill signed by LBJ on July 20 as part of his Great Society era, an important testimony to the power of kindness of a nation. The AMA opposed the legislation until it was enacted and then cooperated in the implementation. The law basically consisted of 2 amendments to the 1935 Social Security Act. Title XVIII was Medicare – consisting of Part A which provided hospital insurance for the aged and Part B which provided supplementary medical insurance. Since then Medicare has acquired a Part C (Medicare Advantage which was formerly known as Medicare + Choice) and Part D (a prescription drug coverage). Title XIX was Medicaid – providing for the states to finance health care for individuals at or close to the public assistance level with federal matching funds.
8. Medicare is a federal insurance program mainly for people over 65 and Medical bills are paid from trust funds that those covered have paid into. It also serves younger people with specific disabilities, particularly end stage renal disease and ALS. Patients pay part of costs through deductibles for hospital and other costs. Small monthly premiums are required for non-hospital coverage. Medicare is basically the same everywhere in the United States and is run by the Centers for Medicare & Medicaid Services. Part A is funded for by a portion of Social Security tax. It helps pay for inpatient hospital care, skilled nursing care, hospice care, and other services.
9. Medicaid is a federal-state means-tested assistance program and medical bills are paid from federal, state and local tax funds. Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States. It serves low-income people of every age and is managed by the states. Patients usually pay no part of costs for covered medical expenses. It varies from state to state and is run by state and local governments within federal guidelines. Each state has broad leeway to determine eligibility and states are not required to participate in the program, although currently all do. Medicaid recipients must be U.S. citizens or legal permanent residents, and may include low-income adults, their children, and people with certain disabilities. Medicaid payments assist nearly 60% of all nursing home residents and 37% of all childbirths. In 2008, Medicaid provided health coverage and services to approximately 49 million low-income children, pregnant women, elderly people, and disabled people. In 2009 Medicaid provided health care for approximately 50.1 million Americans and about one of every five persons in the U.S., were enrolled in Medicaid for at least one month that year. The Children’s Health Insurance Program (CHIP) provides coverage to 8 million children in families with incomes too high to qualify for Medicaid, but can’t afford private coverage. Supplemental Security Income (SSI) disability benefits are for adults or children with a disability who qualify for income, resource and living arrangement requirements. Although the standards for determining disability are the same as for Social Security Disability Income (SSDI), people are not required to have paid Social Security taxes to qualify for SSI; once they qualify for SSI, they are also eligible for Medicaid.
10. The Affordable Care Act Update. In case you forgot, the ACA, passed into law March 23, 2010, sets out comprehensive changes that are already underway but go into high gear in 2014. In summary, in 2010 a Patient’s Bill of Rights went into effect to protect patients from abuses of the insurance industry and additionally many cost-free preventive services were offered. Other consumer protections included elimination of lifelong limits on coverage, prohibition of rescinding coverage, prohibition of denial of coverage to children with “pre-existing conditions”, and help with appeals of corporate decisions. Small business tax credits became effective in a first phase. New incentives were created to rebuild the primary care workforce. States were offered matching funds to cover more people on Medicaid. In 2011 Medicare patients were slated to get certain preventive services for free and receive 50% discounts on brand name drugs in the Medicare “donut hole.” In 2012 value-based purchasing, linking payment to quality outcomes, was established in traditional Medicare. Accountable Care Organizations (ACOs) began to form that year and standardized billing requirements were initiated. Federal health programs were required to collect and report disparities-related data. In 2013 new funding was provided to state Medicaid programs that cover preventive services at little or no cost. The law established a national pilot program to encourage payment bundling. Open enrollment in the Health Insurance Marketplace was set to begin October 1 of this year (three days ago) and will go to March of 2014.
11. One key goal of the ACA was to fix the unconscionable problem we had in this country of 47 million uninsured people. The latest estimates I’ve seen are that in spite of this gargantuan law, the number of uninsured will only drop to 31 million. In 2014 new consumer protections will be put in place including prohibition of discrimination due to “pre-existing conditions”, elimination of annual limits on coverage, and ensuring coverage for patients in clinical trials. Quality improvement and cost reduction factors in the 2014 step include tax credits for people with income between 100% and 400% of the poverty line who are not eligible for other affordable coverage. A Health Insurance Marketplace should be available in 2014 and the small business tax credit second phase will be implemented: for qualified small businesses and small non-profit organizations the credit is up to 50% of the employer’s contribution to provide health insurance for employees and there is also up to a 35% credit for small non-profit organizations. Access to affordable care will be promoted in two ways. One: increasing access to Medicaid – Americans who earn less than 133% of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid; states will receive 100% federal funding for the first three years to support this expanded coverage, phasing to 90% federal funding in subsequent years. Two: under the law, most individuals who can afford it will be required to obtain basic health insurance coverage or pay a fee to help offset the costs of caring for uninsured Americans. If affordable coverage is not available to an individual, he or she will be eligible for an exemption.
12. In 2015 it is intended that physicians will be paid (from Medicare and Medicaid) based on value not volume. A new provision will tie physician payments to the quality of care they provide. Physicians will see their payments modified so that those who provide “higher value” care will receive higher payments than those who provide “lower quality” care. This will be a fascinating experiment, although not one that I think should be run without far better understanding of what “higher value care” means and detailed analysis of the effect on health care at the individual level and the health care market. We certainly need to reform the American health care enterprise, but this sector of our national economy employs one in six people and affects the care of everyone so experimental solutions should be applied with great caution and prudence. The risk to the nation’s health care and the economy as a whole is massive. We can’t afford to continue on the previous trajectory, but we also can’t afford to crash.
13. Last month I spoke of the loss of KAL 007 due to a trigger happy, nervous, and unkind Soviet military pilot. This catastrophe took down one of our Michigan Nesbit alumni, Larry McDonald, who had been a passenger on that ill-fated commercial flight. Coincidentally on this day in 2001 another commercial flight, Siberian Airlines 1812, crashed into the Black Sea, killing all 78 people on board (12 crew, estimated 66 passengers). Since this was just a month after September 11, terrorism was suspected. The plane, a Tupolev Tu-154, was enroute from Novosibirsk to Tel Aviv. The CIA reported that the crash was due to an errant S-200 surface to air missile fired by Ukrainian Air Defense Forces from the Crimean coast likely by some other nervous character with a firing switch. Russia denied that possibility.
14. Comments from Dick Lyons, a great name in the history of urology and a colleague of Nesbit and Lapides. Dick is retired in Napa, in his mid 90’s and is a faithful reader of “What’s New.” Responding to last month’s edition and the McDonalds he said: “I knew Harold Sr. better than most. One day on a visit on the way back from AAGUS, we had a long talk and I asked him how many TURs he would do in a day during the War when he was almost alone in town. He operated standing, by the way. He said ‘Eight or ten.’ He must have been a whizz, doing that many a day, and he had only a single resident, usually from the islands below. I asked how he slept, and he didn’t understand the question. My point was to do that many and not have a troublesome bleed seemed miraculous to me. No room for skepticism. The man was better than good. He always was sad and disturbed about not being in the AAGUS. But it seemed clear why. In any discussion, Harold would stand up and tell all that he had already mastered the subject in question, and he was correct and honest. I would have loved to partake of his knowledge and experience. But the egos got their wishes and kept him out. It’s tough to always be one-upped by someone who had really done it and I decided to test him. I had a urethral caruncle or was it a partial prolapse, in a black youngster…So I gave him call, asking what he would do. Wonder of wonders, he said ‘I don’t know. Never had one’ I told him that I, in the office simply strangled it with a tie, and it dropped off in a day or two-just common sense of course. But now I knew without doubt that Harold was an honest man. He admitted he didn’t know everything and I [therefore found that] had that rarity, a wonderful, exciting, probing, curious, older friend. There’s more to his story, for this was a lively family, at the least. He died of a broken heart … That is another heart rending story.”
15. Things aren’t always right. Sometimes, if you will forgive an anatomic pun, the heart is aberrantly in the “right” place, that is on the right side. Situs inversus was first reported in 1788 when students at the Hunterian School of Medicine showed their teacher, Matthew Baillie, a cadaver with the liver on the left side and heart on the right. Baille, a nephew of John & William Hunter, was a physician at St. George’s Hospital and specialist in morbid anatomy. He died of TB in 1823. Carl Zimmer wrote an interesting report on this historic moment. [Carl Zimmer, Growing Left, Growing Right. NYT June 4, 2013] Actually, Leonardo da Vinci (1452-1519) had observed and drew dextrocardia much earlier but didn’t “report” his finding publically. The Baille story is even more interesting due to the investigative skills of Wendy Moore, author of The Knife Man, a great biography of John Hunter, the founder of scientific surgery. Baille kept most of Hunter’s notes after his death and is believed to have plagiarized so much from his uncle’s prodigious work that Baille burned the notes late in his life to hide the plagiarism. The observation of dextrocaria, however, seems to have been legitimately that of Baille.
16. Situs inversus refresher. This is autosomal recessive, although it can be X-linked and there is a 5 –10% prevalence of congenital heart disease in individuals with situs inversus totalis, most commonly transposition of the great vessels. (Curiously the incidence of congenital heart disease is 95% in situs inversus with levocardia.) Individuals with primary ciliary dyskinesia have a 50% chance of developing situs inversus and when they do this is called Kartagener Syndrome. In the absence of congenital heart defects, most individuals with situs inversus who do not have Kartagener Syndrome are phenotypically normal (about 1 in 12,000) and can lead normal healthy lives. One example is Randy Foye an American professional basketball player currently of the Denver Nuggets of the NBA who has situs inversus with apparently no functional significance. He played collegiately at Villanova University and was selected in the 2006 NBA Draft by the Boston Celtics, immediately traded to the Portland Trail Blazers, and later traded to the Minnesota Timberwolves. He was just 30 years old at the end of last month and seems to have done pretty well in spite of his anomaly. We have full confidence that Foye and his similar anatomically distinct brethren are kind by default since their hearts are always in the right place.
17. Since we have been discussing puns and anatomy I can’t let the day go by without mentioning that it caught my eye that Oct-4 is the term for a transcription factor that is initially active in the oocyte but remains active in embryos throughout the preimplantation period. Oct-4 expression is associated with an undifferentiated phenotype and tumors. Oct-4 can combine with Sox2, so that these two proteins bind DNA together. Sox 2 is important to us urologists because it is actually SRY (sex determining region Y)-box 2, a transcription factor essential for maintaining self-renewal, pluripotency, of undifferentiated embryonic stem cells. The Sox family of transcription factors plays key roles in many stages of mammalian development. Sox2 maintains embryonic and neural stem cells and may be critical for induced pluripotency, an emerging area of regenerative medicine. Mouse embryos that are Oct-4-deficient lose pluripotency and differentiate into trophectoderm. Therefore, the level of Oct-4 expression in mice is vital for regulating pluripotency and early cell differentiation since one of its main functions is to keep the embryo from differentiating. So much for the interwoven story of mice and men, for now.
18. The 3rd Annual James E. Montie Visiting Professorship was held on September 20 with W. Marston Linehan, MD, Chief of Urologic Oncology Surgery and the Urologic Oncology Branch at the National Cancer Institute in Bethesda. Marston gave a great talk on “Targeting the Genetic Basis of Kidney Cancer, a Metabolic Disease.” His extraordinary life’s work at the NCI has revolutionized our understanding of kidney cancer with its variants and pathogenesis. I have several great friends who have benefited enormously from Marston’s work.
Marston Linehan lecturing [photo by Todd Morgan]
VHL Family Alliance Benefit Dinner honoring Jim Montie [photo by Todd Morgan]
19. New faculty have joined the Urology Department. Mike Kozminski [Nesbit Alumni 1989] will be working part-time with us here in Ann Arbor and Chelsea in the general urology clinic while he still maintains a practice at Phoenix Urology of St. Joseph, Missouri. He has four sons. Michael is a third-year resident here, Christopher escaped the medical world and is a comedic writer in Chicago, David is in our Medical School, and Andrew is at Northwestern senior pre-med. Khurshid Ghani just completed a fellowship in Robotic Surgery at the Vattikuti Urology Institute at Henry Ford Hospital with Mani Menon. He will be seeing patients at the Ann Arbor VA. Daniela Wittmann, a social worker in our department, recently received her PhD from Michigan State University and now holds an appointment on our faculty as an Assistant Professor. Welcome and congratulations!
20. Congratulations to Susanne Quallich (along with Cynthia Arslanian-Engoren) for winning 1st Prize Poster on “Chronic Testicular Pain: An Integrative Literature Review” at the 2013 UMHS Nursing Poster Session held last month. Also John Wei will be honored later this month by the Medical School with the Dean’s Award for Clinical and Health Services Research. Julian Wan is beginning his term as Chair of the American Academy of Pediatrics Section on Urology and was just named as one of the editors of the Journal of Urology.
21. Our Taubman II Ambulatory Care Unit has had two terrific leaders. Jerilyn Latini got it up and running very successfully at the start, and since she left John Stoffel has continued the pattern of excellence and leadership. Earlier this week he held a mini-retreat and gave an update on the ACU and his compelling vision. The ACU saw about 13,000 patients last year and its 34 FTEs support 20 providers. Four key metrics for the ACU are the current areas of focus. The first is a matter of accessibility – trying to get at least 80% of new patient visits to occur within 4 weeks. The second is moving the patient into a room within 15 minutes (this metric is identified on our gemba walk by little racing cars on the visual board). We have been quite successful. Metric #3 is that of having visits completed in 60 minutes (90 minutes for our NPR patients. Previously we had about 80% success in this, although the challenges of MiChart have dropped this to around 50% for now. The final metrics are related to having nursing calls answered live and all problems addressed within 24 hours.
Malissa Eversole, John Stoffel, and Connie Standiford
Early audience attendees
22. Last month our internal weekly “What’s New” profiled Brent Hollenbeck with updates as the Associate Chair for Research; Fellows Abdulrahman Al-Ruwaily, Chad Ellimoottil, and Sara Lenherr from Health Services Research; and an update from Jeff Montgomery head of urology at the VA including comments of Khurshid Ghani. Website: http://www.med.umich.edu/urology/about/MonthlyNewsletter.html.
Best wishes, thanks for spending time on “What’s New” this weekend, and we look forward to seeing many of you at the Nesbit Society meeting. If you can’t make it this year, consider joining us in 2014.
David A. Bloom, M.D.
The Jack Lapides Professor and Chair
Department of Urology