Michigan Urology Family

Noise, imagination, reality, Nobel thoughts, & wisdom

12 items plus illustrations, 15 minute read (3386 words)

1.     November 7 is here with a bang. Many of us wonder how the 11^th month arrived so quickly, but here it is and Thanksgiving is just around the corner. Our PGY1s must be especially thankful to be reminded that their internship is nearly halfway complete since their steep learning curves probably eclipsed all sense of time and space, but even those of us further along on the learning curve (that asymptotic curve of mastery we mentioned last month) are surprised to find calendar year 2014 drawing to a close so swiftly. The daily noise of work and life overwhelms the limited bandwidth of most humans and dampens the sense of passing time. The world is noisy and in a historical sense this particular day was as noisy and random as most. For example in 1492 a meteorite with the oldest known date of impact struck the Earth thunderously around noon in a wheat field outside the village of Ensisheim, Alsace, France. This inexplicable phenomenon certainly altered the usual sense of order for those who saw or heard it – although the conventional wisdom of wise people then and now is the expectation that “stuff happens” in life. Still, we all like explanations; astronomy and other sciences have since cleared up the mystery of Ensisheim and the offending 250-pound chondrite space rock now sits on display in the town hall. In 1786, more pleasantly on this day, the Stoughton Musical Society, was founded, becoming the first musical organization in the U.S.A.. In a hail of gunfire on this day in 1908 Butch Cassidy and the Sundance Kid were killed in San Vicente, Bolivia. In 1940 on November 7 in the state of Washington, the original Tacoma Narrows Bridge,  noisily collapsed in a windstorm. This day in 1944 was politically significant because Franklin D. Roosevelt was elected to his fourth term as President of the United States of America. Coincidentally, his wife Eleanor Roosevelt died exactly 18 years later on November 7, 1962.

2.     Roosevelt quotes. Earlier this autumn you may have seen the amazing Ken Burns Roosevelt documentary aired on PBS. Two enduring quotes came from these remarkably similar and dissimilar distant cousins. Teddy said “speak softly, and carry a big stick” at the Minnesota State Fair on September 2, 1901 four days before the assassination of President William McKinley that thereby thrust Theodore Roosevelt into the presidency. Roosevelt had mentioned the phrase in an earlier letter (January 26, 1900), attributing it to a West African proverb, but his final version became a fitting encapsulation of TR himself as seen above in the 1904 political cartoon by William Allen Rogers. The most memorable quote of Franklin Delano Roosevelt came on March 4, 1933 in his first inaugural speech: “So, first of all, let me assert my firm belief that the only thing we have to fear is fear itself – nameless, unreasoning, unjustified terror which paralyzes needed efforts to convert retreat into advance. In every dark hour of our national life a leadership of frankness and of vigor has met with that understanding and support of the people themselves which is essential to victory. And I am convinced that you will again give that support to leadership in these critical days.” In those very dark days of the Great Depression and American isolationism FDR’s words gave strength to a fearful nation.

Picture [FDR, his dog Fala and Ruthie Bie at Hill Top Cottage in Hyde Park, the better of two known pictures of the president in a wheel chair. Franklin Delano Roosevelt Library, Library ID 73113:61]

3.     Nesbit reunion notes. Last month in October we hosted the Nesbit Society Meeting here in Ann Arbor. On Thursday we heard excellent talks by Anne Pelletier-Cameron on synthetic midurethral sling failure, John Stoffel on detrusor sphincter dyssynergia in patients with neuropathic bladders, and Bahaa Malaeb on complex revisions in artificial sphincters. These were followed by first-rate case presentations to our Visiting Professor Victor Nitti of NYU by Miriam Hadj-Moussa, Michael Kozminski, Amy Li, and Yahir Santiago-Lastra. Victor, a thought leader in neuropelvic reconstructive urology, spoke about surgical correction of stress incontinence from the perspective of a seasoned surgeon in an evidence-based world. The residents then took our guest to dinner and no doubt peppered him with questions. On Friday John Bacon spoke movingly about Bo Schembechler and the “lasting lessons” of his legendary career that affected the character and lives of the many people he impacted. We then heard from our own faculty: John Hollingsworth on metabolic stones, Ted Skoleras on prostate cancer survivorship, and Todd Morgan on liquid biopsies for genomic profiling of advanced prostate cancer. Dr. Nitti returned to the podium with a clear and instructive keynote lecture on bladder emptying problems. Surendra Kumar discussed radiation therapies for high risk prostate cancer. Julian Wan, our Nesbit Society President, gave an entertaining and wide-ranging talk “Why we won’t cure cancer in your lifetime.” Quentin Clemens presented an update on his extensive and well-funded pelvic pain research network, John Park spoke about his extraordinary Disorders of Sex Development Program and Clinic here at Michigan, Jim Dupree spoke about hypogonadism and the reproductive-aged male, and I gave a brief update on the state of the department. At the business meeting Ann Oldendorf presided over the business meeting and concluded her splendid service to the Nesbit Society.

[John Stoffel, Yahir Santiago-Lastra, Victor Nitti, Linda Ng]

[Nesbit Society at Michigan League]

[Day 2 of the Nesbit – in the Michigan League]

[Halftime show at The Big House from Sincock Suite]

4.     Award & victory. At the Nesbit Society reunion dinner at Barton Hills Brent Hollenbeck was surprised when his name was called out to receive the John Konnak Award. [Picture at the dinner: DABloom, Betty Konnak, Brent Hollenbeck, Julian Wan, Ann Oldendorf] We had good representation from past classes of Michigan and Nesbit alumni at the dinner. Saturday featured the Nesbit tailgate and the Michigan Penn State football game. The halftime show in the dark was an amazing experience for the 113,085 in attendance. A 18-13 victory over Penn State lifted spirits, as it has been a rough year for Michigan football, but win or lose Brady Hoke is a wonderful man and a fine coach who, if given the chance, will bring the scoreboards back in our favor and meanwhile serve as a first rate mentor and leader for student athletes.

5.     Fiction. The human element has a distinguishing feature of a boundless territory of imagination that is essential to our lives in the “real world.” In the pages of What’s New/Matula Thoughts this past September we considered a short story, The Death of Ivan Ilych, as a case report of untreated renal cell carcinoma. Coincidentally a few weeks later I read a book review of Atul Gawande’s newest book Being Mortal, and the reviewer Janet Maslin [NYT October 17, 2014] and I’ll quote her since I’ve not yet read the book. “Atul Gawande’s Being Mortal: Medicine and What Matters in the End introduces its author as a myopically confident medical student whose seminar in doctor-patient interaction spent an hour on Tolstoy’s novella The Death of Ivan Ilych. As a young man he was not ready to understand the title character’s loneliness, suffering, and desire to be pitied. He saw medical compassion as a given and Ivan Ilych’s condition as something modern medicine could probably cure. He and his fellow students cared about acquiring knowledge and competence. They did not see mortality as part of the medical equation.” Well said. As a medical student and resident x2 I don’t think I really “got it” either. But the story of Ivan Ilych, and likely many other stories lurking in subconscious memory banks helped nurture the first glimmers of eventual wisdom. Truth and fiction are inextricably enmeshed in each other, and the value of the latter in understanding the former is continuously astonishing. Scientists and physicians in particular are well-served by a robust amount of “fiction” in their reading repertoire. The truths discovered in the stories we read – truths often strongly linked to health and disease – bring us closer to wisdom, the elusive Higgs boson of our intellect (if you pardon this metaphor).

6.     Nobel illuminations. Peter Higgs (pictured) was prominent among the physicists who in 1964 proposed the concept of a new elementary particle that became known as the Higgs boson, in the Standard Model of Physics. It took many decades and complex experimental facilities to actually find this elusive particle that had only been dreamt of in the imaginations of Higgs and a few other physicists long before it was actually observed. Higgs won the Nobel Prize in Physics for this work back in December, 2013. This year’s physics award went to Isamu Akasaki, Hiroshi Amano, and Shuji Nakamura, who recognized that gallium nitride in a laser could produce a blue LED light and by adding aluminum and indium they were the first to create efficient white LED light. One winner of this year’s Nobel Chemistry Award was Eric Betzig, who had grown up in Ann Arbor and is now at the Howard Hughes Janelia Campus in Virginia. His work has taken optical microscopy to the nanometer and biologic real-time levels of living tissues. Illumination of different kind comes from another Nobelist, the great Peruvian writer Mario Vargas Llosa, in the extraordinary Nobel Lecture “In Praise of Reading and Fiction,” when he won the 2010 Prize for Literature. Recalling his childhood and the impact of learning to read, he wrote: “Reading changed dreams into life and life into dreams and placed the universe of literature within the reach of the boy I once was.” The social instability of his native Peru made the matter of politics acutely relevant to his life as he noted in his lecture: “Without fictions we would be less aware of the importance of freedom in making life livable, of the hell it turns into when it is trampled underfoot by a tyrant, an ideology, or a religion … Good literature erects bridges between different peoples, and by having us enjoy, suffer, or feel surprise, unites us beneath the languages, beliefs, habits, customs, and prejudices that separate us.” In less than 40 pages, Vargas Llosa makes an eloquent case for his compelling belief that language and the stories and literature it produced humanized us humans and allowed us to invent the “autonomous individual,” disengaged from tribes, clans, and nations, and capable of devising science, art, and freedom. [Mario Vargas Llosa. In Praise of Reading and Fiction. Transl. E. Grossman. Farrar, Strauss and Giroux. NY. 2011]

[Vargas Llosa]

7.     Ouroboros. The ouroboros is an ancient symbol depicting the place of the human element in space and time. The figure of a serpent devouring its own tail has been labeled by its Greek term ouroboros, which had piqued my curiosity when I watched the TED talk of Martin Rees (mentioned here in Matula Thoughts last month) and then the word came up again in Julian Wan’s engaging talk at the Nesbit Society meeting – “Why we won’t cure cancer in our lifetime.” The roots of the symbol trace back in turn to ancient Egypt, Plato, Norse mythology, alchemy, and Carl Jung. The prominent German chemist August Kekulé (1829-1896) attributed his discovery of the structure of benzene to a eureka moment in 1872 when he dozed off in front of the fireplace and saw the elements of the benzene ring assembling themselves in an ouroboros. I asked our illustrator, David Heskett, to render a modern version, urologically centric, that I enclose herein. Viewing the figure of snake,  or dragon in some representations,  from the tiniest beginning in a counterclockwise fashion, you can imagine the progression in scale from somewhere around the Higgs Boson with the tiniest bits of energy and matter developing into the cosmos at a far grander scale with us mere humans near the middle.

[Ouroboros per David Heskett]

8.     Data and decisions. At our recent HSR symposium, the role of “big data” in health care was covered thoroughly by an excellent cadre of speakers. We still have CDs available if you are interested. At our Health Services Research Symposium our friend and UMMS alumnus Jack Peirce had insightful questions for the speakers at every session. Jack (shown above) has had a long interest in medical decision-making and wrote a compelling article on the topic around 20 years ago and the matter of deciphering useful information from all the noise around us. His paper described how in the early days of radar technology during WWII, radar operators struggled to detect meaningful signal from the noise. This led to the “receiver operating characteristic (ROC) curve” later introduced into clinical medicine in the 1960’s by Lusted. [Peirce JC, Cornell RG. Integrating stratum-specific likelihood ratios with the analysis of ROC curves. In Medical Decision Making. Hanley & Belfus, Inc. Philadelphia. 1993.] I came to know Jack through our Nesbit Society member Clair Cox, of the same medical school class (UMMS 1958) and former Chair of Urology at the University of Tennessee. Clair, by the way, couldn’t make it for this year’s Nesbit meeting but had come to Ann Arbor with his wife Clarice, son Kevin, and grandson Ben for the Minnesota game, wherein we glumly received a negative signal of a 30 to 14 defeat.

9.    Medicine’s essential transactions. This month we begin anew the important annual cycle of interviews for residency candidates. The medical students we pick will finish our urology residency program in 2020 and their fellowships in 2022, 2023, or 2024. That is, to say, they will begin practicing urology on their own around 10 years from now. The world and the world of health care will be different for them than it is today, although the central dynamic of health care, the doctor-patient relationship, will probably be much the same. A patient will ask a doctor (or other provider) to take responsibility for their health care. Michigan’s late and great physiologist Horace Davenport characterized this work as “the service station of life.” This has been an essential transaction for millennia, and is not likely to disappear or be replaced by data and computers. My point of view as a patient is probably not much different than that of any other patient (and we are all patients one way or another, at one time or another); as a patient I want expertise, kindness, and convenience – in that order, although I want all three. Nonetheless aspects and expectations of the essential transaction are changing. We must find ways to be better, safer, and leaner in the delivery of health care. Now we might use the terms “healthcare” instead of medicine and “healthcare provider” instead of doctor. Technology has become a dominating force in modern medicine. Furthermore, some aspects of healthcare are easily commoditized and do not need that essential transaction between a professional and a patient. The role of the computer in healthcare is rising – but computers even with artificial intelligence (AI) are unlikely to have “minds” that can truly understand wisdom. That is, like our new smart phones, they may act smartly but they are not conscious. AI may yield smartness and decisiveness based on analysis of data, but not wisdom and truth.

10.    Noise. This term is most often employed for its acoustic meaning, specifically with reference to “unwanted sounds.” Yet noise is not necessarily unwanted, we have white noise or comfort noise. Noise can in fact describe any sound. Noise is not only acoustic, it may also be optical, describing a poor quality in digital photography. The valuation of a sound as wanted or unwanted is a reflection of our opinions, and it is not difficult to understand how even an unwanted sound or noise can be useful in some way. More fundamentally noise connotes any perturbation of time and space. A search for wisdom and truth must begin, therefore, with a consideration of noise because information is noise that makes some sense to us. Information that conveys useful information about the world is called knowledge. Models, constructs of reality built from knowledge, are described by our colleague Scott Page as logically consistent metaphors. Reality cannot be understood perfectly by any single model, but a number of models will likely give a closer view of the truth. Thus the Standard Model of Physics may help us understand space and time but not Butch Cassidy, Peruvian politics, or renal carcinoma. As better models are constructed, networks of models, although fraught with bigger data, theoretically will offer an even more realistic vision of reality. It is the perpetual optimism of the human condition that these intellectual efforts will bring us to the wisdom and truth our species seems to crave.

11.    Courtship. As the educational year for our residents nears the half way mark we are already well into the process of finding their successors for internship or the PGY 1 year (first postgraduate year after medical school). Selecting from 340 applicants we will interview about 60 and just last week interviewed the first 32 over two days and one dinner evening at Gary Faerber and Kathy Cooney’s home. Each year we see higher and higher exam scores and this year pushed the upper limits even higher. These were astonishing individuals of diverse life experiences, some incredible personal challenges, widely varied educational backgrounds, and language capabilities from Mandarin, Russian, Cantonese, Spanish, Sign, Arabic, or Gujarati. Practically any of them would be superb residents here at Michigan but we can only have four. The interview process (expensive for them and expensive for us) allows these fourth year medical students to evaluate and rank us just as we do them, so this is a process of sophisticated courtship. Their selections and ours determine the career-defining stage of their education so while this process is very important to our department of urology, the process is absolutely critical to each of the candidates for a position in our class of 2020.

[Ted Lee PGY 1 and candidates at breakfast the day after interviews]

12.    Final thoughts. I try to discipline Matula Thoughts to 10 items, but today couldn’t bear to leave out the residency applicants we saw last week. These individuals (and I mean everyone who interviewed with us last week) are the “smart creatives” who will define the next generation of urology and the world around urology. The term “smart creatives” comes from another book I just read, and in fact discussed with the applicants. Written by Google’s former CEO Eric Schmidt and VP for Products Jonathan Rosenberg the book is called How Google Works. It is quite informative about the unique Google culture and well worth your attention. I took much from it but have only one main objection and that came as I read the conclusion in which the authors offer their absolute faith that information (data) will solve virtually all of the big problems facing mankind. I believe that data can help solve many problems, but data is most likely to help find the low-hanging fruits of technology that will benefit largely those of us on the right side of the upper end of the bi-modal economic distribution of mankind’s wealth. However the essential needs of mankind, the loftier aspirations will not, in my opinion, be so smugly solved. The issues of poverty, human rights, universal education, safety, global disaster, food security, climate change, war, epidemics, or mankind’s penchant for extremism and other “isms” are a few examples. We could add meteoric calamity to the list since Ensisheim’s big brother is likely to show up some day. Until we achieve some multi-continental governance that is wise, fair, and enforceable no amount of data or technology will create a world where diverse people can live safely, happily, and creatively to build an even better world for their children. Google may help, but it is hardly going to get us to the answer. Although, by the way, why can’t Google build us a decent electronic medical record that could truly improve patient care, “meaningful use”, and also the lives and quality of work of health care workers. After all, no one else has come anywhere close (ok – maybe our own CareWeb and CCC forms of electronic medical records came close, but federal regulations forced us to discard them). Enough said for now.

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

David A. Bloom