Matula Thoughts September 5, 2014

Michigan Urology Family

Seasons, health care goals, required reading, truth & proverbs.

1. The writer Gertrude Stein once said: “A rose is a rose is a rose.” This summer has been replete with many roses but, with all due respect to Stein, if you look closely enough none is exactly the same as another. An equivalent generalization might be: “A year is a year is a year.” Although we begin the Earth calendar year of 12 months and 365 plus days on January 1 we also begin it at other times for specific purposes. Our fiscal year as well as the residency-training year start on July 1. The medical school students’ first year began just last month on August 3 with the White Coat Ceremony on a Sunday afternoon in Hill Auditorium. In the presence of their families and friends each student crossed the stage, announced his or her name, and received a short white coat and a stethoscope. We have been organizing the stethoscope presentations for the past ten years as a gift from the clinical departments and several benefactors in our community to the tune of more than $250,000 over the decade. Just as the stethoscope is a symbol for the practice of medicine, their presentation to the incoming medical students is a symbol of commitment of the clinical teachers and community to the education of the next generation of physicians. As the new students settle into their routines yet another type of year, the university academic year, began a few days ago on September 1 and with it now underway we find Quentin Clemens, Khaled Hafez, Brent Hollenbeck, and John Park promoted to professor and Jeff Montgomery to associate professor. These men are the best of the best in their areas of practice and scholarship. We welcome two new colleagues to our faculty: Jim Dupree who completed a Male Reproductive Medicine and Surgery Fellowship at Baylor College of Medicine and Nick Warner who finished a Trauma Reconstructive Fellowship at the Detroit Medical Center.

[White Coat Ceremony Hill Auditorium August 3, 2014. The cloaking of first year medical student Andrew Kozminski by his father Mike (Nesbit 1989) and brothers Michael (PGY 5) and David (UMMS class of 2016).]

2. The White Coat Ceremony marks the starting point for a life of medical education. Medical school graduation, usually four years later, is a major milestone along the pathway of lifelong learning that necessarily follows. Completion of residency training and its fellowship extensions are other occasions for celebration, these periods typically exceeding the four years of medical school. Specialty board certification a few years after formal training ends is an essential checkpoint for independent practice of urology, but now we find the concepts of “lifelong certification” and “re-certification” have turned into systematic “maintenance of certification.” You might question the point of all this – what are the goals of medical education, residency training, and certification in the first place? The answer to these questions requires historical framing and a belief in the balance of public policy and the right of a profession to set its own standards. Ultimately, however, they beg larger questions: what are the goals of healthcare and how do we best accomplish them? We touched on these issues briefly last month, considering healthcare metaphorically as necessary “attendence at the service stations of life”, to use Horace Davenport’s metaphor. The questions just raised are deep and essential – not just for those of us engaged in the processes of medical education, healthcare, and research. These issues are central to our work and lives, and they compel much of the attention of this communication we call “Matula Thoughts.” As a basis for further considerations I’d like to call your attention to a new book by Danielle Allen, called Our Declaration. This should be required reading for everyone. It is a deep, but very smooth dive into the 1337 words of the Declaration of Independence. Professor Allen will give you a new understanding of the ideas of liberty and equality relating directly to our immediate daily concerns of health care, professional standards, and public policy. The book came out right around Independence Day and I only just recently finished it, but will be coming back to it again in future “Matula Thoughts.”

3. Ed Tank (Nesbit 1971) is a great role model for me with the idea of keeping a book, a real book, on your person when travelling about so you can always have something to read worthy of your time. I recall him in years past carrying around substantial hard-bound volumes to read at spare moments. My wife Martha, on the other hand, carries an iPad with its library of books weighing only a couple of ounces, but my preference is for slim paperbacks or little hard cover books that fit into a sport coat pocket. Coming back from the AUA in Orlando, with a side trip to Memphis, I carried Tolstoy’s The Death of Ivan Ilych. This little paperback is part of a series called The Art of the Novella by Melville House. The book, with its new translation by Ian Dreiblatt, caught my eye at our new bookstore, Literati, in downtown Ann Arbor so I picked it up and took it along on a few previous trips, until its time to be read came up on that journey.                                           [Ed  & Rosalie Tank, with the late Lowell King on right]

  [Literati Bookstore, Ann Arbor]

4. The story is simple. Ivan Ilych, a fictional 45-year old successful Russian attorney died in St. Petersburg on February 4, 1882. Discovering that fact in the newspaper the next day at work, his colleagues commented on Ivan’s demise with varying degrees of sympathy. Tolstoy then recounts the life of the man, gradually revealing ironies of Ivan Ilych’s career, marriage, and friendships, all viewed at first impression as conventionally successful. The illness that caused his death dated to an injury sustained two years earlier when Ivan Ilych struck his side as he fell off a ladder. He had been trying, at the moment, “to show the uncomprehending upholsterer how he wanted the drapes hung” in his stylish new home. Dull discomfort in the left flank gradually increased after the injury, leading to pain. Consulting physicians offered varying opinions and “a urine test” was mentioned, although Tolstoy gave no results. Malaise, cachexia, and intolerable pain ensued over the next two years. Finally Ivan Ilych became confined to his couch for weeks until his end came. Whether intended or not, this story is an accurate and brutal depiction of death from an untreated kidney cancer that had likely ruptured.

5. Tolstoy (1828-1910) was either anatomically confused or mischievous in explaining how the physicians considered Ivan Ilych’s illness a matter of the appendix or kidney, even though the left side was clearly specified. The term “floating kidney” was added to the diagnostic mix. We must take into account the state of medical knowledge and urology in particular during the later years of Tolstoy’s life. Emotionally, however, Tolstoy had perfect pitch. His portrayal of physical deterioration, the anguish of impeding death, as well as the complex and often insincere responses of family and friends, was terribly convincing. The gradual unraveling of Ivan Ilych’s pretension, self-delusion, and dignity embittered his final days as he recoiled from attempted acts of kindness. Ivan Ilych offered a number of Joycean internal riffs, but produced no grand Shakespearean soliloquies although he surely came to question who he was, indeed he wondered “what he did wrong” to incur his horrible fate. He tortured himself in the final weeks searching his memories to comprehend how the life that he had believed so sweet could turn into an irreversible nightmare, until he suddenly realized: “There is no explanation!” His story, though, is an exaggerated version of everyone’s story. Who we are, to ourselves and to those around us, is a story of many versions. From Ivan Ilych we see that even who we think we are is, to some degree, a self-delusion.

6. Tolstoy targeted our imagined personal exceptionality While acknowledging that we know all men are mortal and that each of us is a member of mankind sharing the same fate, we nonetheless individually carry the delusion through most of our lives that the mortality proposition doesn’t quite include “me.” Our personal exceptionality is both true and not true. While we each are unique and indelible to ourselves, none of us is uniquely exempt from that ultimate prescription of mortality. The same holds true for Stein’s rose. How Tolstoy came to the beliefs he had in 1886, at age 58 when he wrote the story of Ivan Ilych, can perhaps be discovered though his semi-autobiographical fiction and the serious biographical work that has accumulated. Interestingly, if you go to the web site worldcat.org/identities/Iccn-n79-68416/ you find a publication time line that shows the yearly volume of publications by Tolstoy and about Tolstoy. Notably, the two categories are approaching parity, indicating that people today read almost as much about him as by him. For a student described by his teachers as “both unable and unwilling to learn” Tolstoy turned out pretty well as a mature literary figure, although using our modern vocabulary of political correctness he would be branded as “disruptive.” This adjective is widely overused today in its negative connotation, even though we recognize value to “disruption” in the scientific, technological, and business worlds. Politically and culturally, Tolstoy’s disruptions improved mankind and his reach is still growing. If you re-read Ivan Ilych that reach will grow a little more, and so might you. Were Tolstoy still alive, he would have celebrated his 186^th birthday last week.

[Tolstoy, disruptive author]

[worldcat.org/identities/Iccn-n79-68416/]

7. The chances for a patient with kidney cancer have improved vastly since the fictional death of Ivan Ilych. One hundred years later by the time of my residency and early years of practice, the miracles of diagnostic imaging, anesthesia, plus efficacious operative techniques in the hands of well-trained surgeons the outlook for patients with kidney cancer had improved markedly, yet another quantum leap was soon to follow. As junior staff person at Walter Reed Army Medical Center in the early 1980s I met another young urologist, Marston Linehan, who had just taken the urology position at the National Cancer Institute. In the years since then he has practically written the book on kidney cancer, elucidating the various metabolic pathways that cause it, classifying its genetic types, and discovering targeted treatments. I have several close friends alive and well today due to the combination of Marston’s discoveries and superb surgeons. I recently wrote to Marston about Ivan Ilych and found that he, of course, had read it years ago. The book is short and well worth re-reading even if you too had encountered it years ago. It slips easily into your pocket, or you can go the route of Kindles, smart phones, and iPads if they are your preferred media tools. Marston Linehan, M.D. is still Chief of Urologic Surgery and the Urologic Oncology Branch, Center for Cancer Research, at the National Cancer Institute, National Institutes of Health in Bethesda, Maryland. He and his team identified the critical genes responsible for von Hippel-Lindau Disease, clear cell renal carcinoma, hereditary papillary renal carcinoma, chromophobe renal carcinoma, among others. Marston’s work has led to understanding of the genetic events associated with the initiation and progression of urologic malignancies thereby enabling successful therapeutic strategies. He visited us here in Ann Arbor last autumn.

[Marston Linehan]

8. We conveniently divide writing into fiction and nonfiction. The boundary is important to us as physicians and scientists, because truth is a presumption of our work. Trust underpins everything in medicine and science. When dishonesty, in the form of false reporting, lies, or plagiarism are discovered trust is lost. The adage “trust, but verify” is useful although in the helter skelter of clinical work or the fast-moving world of modern scholarship, every detail cannot be quickly verified. When a colleague tells you that a patient’s creatinine in 1.0, you trust that report and make assumptions and critical decisions based on that “fact.” Honesty is essential, whereas accuracy is an aspirational trait that must be honed. Don Coffey, great role model of critical thinking for many of us, carried the idea of truth a step further when he said: “You need to know the difference between facts and true facts.” Tolerant of human frailty, but evangelical regarding the pursuit of excellence, Don also once said to me “Anybody can make a mistake, but it shouldn’t become ‘a way of life.” The rich vocabulary of integrity indicates its centrality to the human condition. An old proverb says “truth is the daughter of time.” Lincoln said: “No man has a good enough memory to be a successful liar.” Frankfurt, the esteemed philosopher at Princeton, wrote: “Any society that manages to be even minimally functional must have, it seems to me, a robust appreciation of the endlessly protean utility of truth.” Furthermore he said: “It seems even more clear to me that higher levels of civilization must depend even more heavily on a conscientious respect for the importance of honesty and clarity in reporting the facts, and a stubborn concern for accuracy in determining what the facts are.” I have been astonished on rare occasions to find blatant plagiarism in my role as a journal reviewer from people who clearly “should know better.” How I deal publically with these rare birds in academia has been a dilemma. Do I call them out, do I attempt to educate them, or do I remain within the comfortable anonymity of the peer review process? What should be my obligations towards honoring someone else’s dishonesty? On the other hand, when does academic sloppiness slip into convenient plagiarism? I don’t have good answers for these questions.

[Don Coffey, Professor of Urology, Johns Hopkins]

9. Scientists cannot be dismissive of fiction, however, because good fiction is an exercise of human imagination that illuminates a “real world” of facts and true facts. This brings us to the almost paradoxical consideration that there can be truth in fiction, insofar as a story is authentic. The world imagined in a writer’s mind, stripped clean of distracting elements and illuminated with precision, may give a more precise picture of reality than might otherwise be observed in the “real world.” This is the beauty and utility of story-telling. Ivan Ilych serves us well, illustrating the rough natural history of unattended kidney cancer, the definition of a “well-lived” life, and ultimately the individual comprehension and social indignities of death. Yet just as reality can be better understood through fiction, fiction can be double-edged and distort reality. This thought brings us to the uncomfortable question that naturally arises from Ivan Ilych’s story: When does belief in our own narrative stray into fiction? The fictional death of Ivan Ilych is a reasonably authentic depiction not only for a death from uncontrolled renal cell carcinoma, but more so for an end of life in general. In the grand scheme of life, a death is a death is a death. Yet death is usually only a footnote to the unique opportunities and accomplishments of each life, with the roses enjoyed along the way. Our faculty and their teams in the Uro-Oncology division (three of whom were just promoted academically as mentioned earlier) deal with death more than the rest of us in the department, they being more so attendants at the later service stations of life. Yet each of us, at the personal level, will stop at those stations. The most important estate each of us leaves behind, after that last station, aside from family and friends, will ultimately be our work and our integrity. After all, while roses are seasonal and variable, truth is the legitimate daughter of time.

   [Rose garden of Bob and Mary Lichty, Waterloo, Iowa]

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

David Bloom