Quixotic Thoughts January 3, 2014

1. A new January and 2014 are at hand and given general and personal good fortune for you and I, along with the Urology Department, a good year lies ahead in spite of great change swirling around us. The year began with the thrilling Winter Hockey Classic in Michigan Stadium between the Red Wings and Maples Leafs. The same day we saw health care extended to millions of “uninsured” and elimination of the odious pre-existing illness restrictions and life-time limits on benefits. Few can deny these important public goods, but the collateral damage of the legislative and regulatory context of these changes is significant. While we cannot cling to the past, not all that is new turns out for the greater good. Rather than massive shifts in the superstructures of health care, we should recapitulate the Darwinian methodology of creating optimum adaptive phenotypes for the future. That is, we need to create new (experimental) clinical, educational, and research models in the hope that some of these might best fit the immediate but unexpected environments of tomorrow.

2. The 16th century Spanish writer, Miguel de Cervantes Saavedra, said in his book Don Quixote: “To imagine that things in life are always to remain as they are is to indulge in an idle dream.” [Part 2 Chapter LIII] He mischievously added: “It would appear, rather, that everything moves in a circle, that is to say, around and around: spring follows summer, summer the harvest season, harvest autumn, autumn winter, and winter spring; and thus does time continue to turn like a never-ceasing wheel.” Cervantes surely knew that as seasons cycled regularly, even in his retrograde version, no two successive ones were identical.

3. Change was exemplified on this particular day (January 3) in many years past. In 1496 on January 3, for example, Leonardo tested a flying machine, but lacking an aluminum internal combustion engine, the deep mechanical expertise of the Wright brothers, and the winds of the outer banks he didn’t break the barrier of sustained heavier than air flight. Still, he was far ahead of his time and technology. Our national geography changed on this day in 1823 when Stephen Austin received a grant of land in Texas from Mexico and in 1959 when Alaska became the 49th state. And who could have predicted on this day in 1977 when Apple Computers was incorporated that the whimsically-named company would become one of the largest companies in the world (currently #15 by Forbes listing for 2013 and #1 by market capitalization in 2013 Q1 and Q3 – dropping to #2 in the second quarter of the year). We should also keep in mind that 2014 is a full century after the start of the ill-fated War intended to end all wars. Change is inexorable and although not all change is good, we need to not only survive change, but come out better at the end of it.

4. Last month’s story of the Halifax disaster elicited a comment from my friend and colleague David Diamond of Boston Children’s Hospital who noted that every year the City of Halifax sends his Children’s Hospital a splendid Christmas tree in thanks for the outpouring of support and volunteers that rushed to Nova Scotia after the horrendous explosion.

5. With Stu Wolf as Acting Chair of the Urology Department for the first quarter of 2014 we repeat last year’s very successful experiment with John Wei in charge. One of the fruits of my mini-sabbatical labor then was our departmental A3 and its derivative “baby A3s” that have benefited our departmental thinking and operations. John did a superb job in the front office and brought great ideas and analyses to the department, continuing to provide leadership and clear thinking. His quarter at the helm changed him and benefitted our department. Stu will likewise bring valuable new insights and ideas to our departmental table.  John Wei has taken over the weekly production of “What’s New” except for the larger broadcast on the first Friday of the month that Stu will produce as chair. I missed this ritual last year, so I will independently keep up the “Matula Thoughts” Blog. You will thus have two fabulous reading options for that first weekend of each month this winter. If you must choose just one, I recommend picking the “What’s New” of Stuart.

6.   Don Quixote 1605 I started to read Don Quixote a number of years ago out of curiosity and what I felt to be a need to be familiar with key parts of our literary heritage. My sally into the canon didn’t take me to the very end of the story, as the adventures of the deluded knight-errant, while initially amusing, became tedious. In short order the wanderings of the Don, Sancho, and Rocinante became supplanted by Urology Department promotion letters, recruitment, retentions, committees, Faculty Group Practice, patient care, and other day-to-day matters. Accordingly, the book (Modern Library, Samuel Putnam translation, 1998, over 1200 pages) found its way back to my shelves. (Picture: Title page first edition of Don Quixote Part 1, 1605)  Actually titled The Ingenious Gentleman Don Quixote of La Mancha, the text was a foundational work of modern Western literature. Published in two parts by Spanish author Miguel de Cervantes Saavedra in 1605 and 1615, the book tells the story of Alonso Quijano, an older member of the nobility who becomes so brainwashed by chivalric stories (the novels of his era) that he sets out to revive chivalry. The term chivalry comes from the obvious French word meaning “horse soldiery” and carrying with it characteristics of gallantry, training, service, and knightly virtues including courtesy, love, and honor. The Knight’s Code of Chivalry was a moral system requiring knights to protect those who were incapable of protecting themselves. These fundamental values emerged during the earliest human existences of small bands of hunters and gatherers. Over ensuing millennia these values were incorporated for larger society by religions. The Spanish and Portuguese knights’ codes of Cervantes’s era offered laymen’s versions that simultaneously supported the church and translated those values into the special obligations of a “profession.”

7. With the enlightenment it became clear (“self-evident” as said in the founding documents of the USA) to many thinkers and occasional leaders that a moral system with values such as those in the knights’ code was a duty of the state or government. Our Declaration of Independence, Constitution, and Bill of Rights took over from religions, knights, and philosophers. The essential values of life, liberty, the pursuit of happiness, and equality were stated well and eloquently in those documents, although our national execution has been imperfect and the prime fault at the start was the persistence of human slavery that took a civil war and a further century of countless injustices to start to set straight, although it still persists in this world. Social justice is elusive. Health care is intrinsic to any reasonable modern chivalric code. Our dilemma is how to get it right, how to find the right mix of federal, state, professional, and private sector contributions even as rapidly evolving technology heightens the complexity and costs of health care. The private sector of business and the health care professions together cannot fill all of the health care needs of the people of a nation. The government alone is also woefully inadequate. Furthermore an insurance paradigm makes no sense either as the dominant methodology of providing health care to a nation. Hundreds of billions of dollars, complex legislation/regulation, and incalculable political rhetoric are only making matters worse with a good solution further away from today.

8. Cost of Tech - JAMA copy Last October I mentioned an amazing crayon drawing made by a little girl as her sister sat on a doctor’s examining table. In the picture the patient, the mother and little baby on her lap, and the 7-year old artist were regarding the viewer in the best tradition of Vermeer. In contrast, the physician sat off to the left side, intently typing on a keyboard and looking at the computer screen. The accompanying article in JAMA was written by Elizabeth Toll, at Brown University, and the copyright for the illustration listed Dr. Tom Murphy (likely the physician so-depicted).  Both he and Dr. Toll kindly gave me permission to utilize the picture that I’ll show again. [The cost of technology. Toll. JAMA 307:2497-2498, 2012] The illustration shows how the electronic medical record, mandated in swift deployment by the unfortunate HITECH Act, has become for many of us, a surrogate for the patient. Technology has gone beyond enabling to distorting the practice of medicine. This is just one more threat to the idea of medical practice as a profession. Many social and regulatory pressures are forcing the commoditization of medical practice, with a misguided belief that technology will solve the problems. The ridiculous mandated complexity of ICD-10 is another related matter (see the article in New York Times Business Day by Andrew Pollack December 30, 2013” “Who knows the code for injury by Orca?”).

9. Medical practice is just one part of health care and even that part consists of many goods and services. Some parts of health care are best dealt with by society as commodities. For example, perinatal care, immunizations and dental cleaning. These all serve the public interest and can be delivered economically by a number of means. They can be delivered efficiently as public goods at free clinics. They can also be delivered very conveniently at drug stores, grocery stores, or in smartly-designed health care facilities (how I wish we were so “smartly-designed” at the University of Michigan). They can also be provided in professional offices. In an ideal free society, people generally have a choice as where to obtain these commodities, but in any case when people don’t have a reasonable choice the important commodities must somehow be provided.

10. Other professional activities are more complex, such as the sorting out of a specific health problem and finding a remedy. The remedy itself may require a complex orchestration of personnel and a complex performance of the manual (and now robotic) arts of surgery. A professional doctor-patient relationship lies at the heart of most of these amazing feats of modern healthcare. Even more complex, but something modern healthcare has not effectively solved, is the simultaneous management of the many interlocking illnesses we call co-morbidities. These involve numerous health care specialists and specialties, often in multiple separate health care systems, insurance programs, and states. The simplistic idea of a “medical home” cannot be legislated or mandated by regulation. Whether or not a single patient care relationship between healthcare professional and patient can remain at the center of modern health care is a very real question right now. The answer is “to be determined.”  If such a central relationship is replaced, we have to imagine what the world of health care will look like for us (as we ourselves and our families are patients) as well as what it will look like for those we serve on a daily basis.

11. The answer may be in front of us as we look at what health care is like for the many people who lack a primary care physician and get their care at urgent care facilities, from ad hoc specialists, emergency care centers, or forgo care in many instances. Is this a scenario we want to embrace? The choice will not be ours to make, as economic, social, and legislative forces are moving things in that direction. Primary care physicians are becoming harder to find, we know this acutely here at UM, even as new health care legislation forces the centrality of the primary care physician in the evolving superstructures of health care like the accountable care organization. The idea of a primary care person as a gatekeeper and coordinator in our indisputable world of specialty medicine may be outdated. The Norman Rockwell ideal of the GP is a lovely sentiment, but while it represented the world of 1940 in industrialized countries, it no longer fits today where the American Board of Medical Specialties certifies around 150 areas of specific medical practice. Even with my previous involvement with the ABMS I cannot name them all, and even have to think very slowly to come up with most of the names of the 24 primary member boards.

12. Professional activities, such as operative procedures, are becoming framed by guidelines, check lists, time-outs, mandated documentation, and other constraints. These formalities relegate those human performances to isolated “procedures” that neglect the totality of the patient and family.  I can’t really argue against guidelines, checklists, and documentation per se, but I believe that rigid incorporation of these things into “systems” should not replace the professionalism that must underlie the best surgical arenas. In the United Kingdom, these operative performances are described as occurring in the “surgical theatre.” The terminology is apt; great performances do not lend themselves to commoditization. Some readers might challenge these thoughts as quixotic, but I hope they are not. Humans are hard-wired to value excellence, and professionalism has passed the test of Darwinian endurance for at least two and a half millennia as evidenced in the Hippocratic Oath. The doctor –patient relationship underpins the health care that people value most, whether in our Taubman Urology Ambulatory Care Unit or in the landscapes of Africa where Doctors Without Borders tend the marginalized citizens of the world trying to survive wars, genocide, hunger, displacement, and natural disasters. We are not finished with wars and natural disasters, but should be smart enough to avoid them, minimize them, and contend with them better than we have up to now. WWI on a global scale was the result of political stupidity and human arrogance, the Halifax Disaster was a blunder of multiple human errors within the war, but the response to it revealed some of our best human virtues and behaviors.

Best wishes, and thanks for spending time on “Matula Thoughts.”

David Bloom