Matula Thoughts March 6, 2015

Matula Thoughts, 6 March 2015 

Seeing ourselves, health care, & other thoughts. 

3486 words


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1.    By March, winter has pretty much worn out its welcome in Ann Arbor. Strictly speaking it’s officially spring in 15 days, although it hasn’t been feeling that close. Nevertheless, we muster on contending with polar vortices by means of central heating, L.L. Bean fleece, March Madness and comfort food. On this particular day, March 6 in 1943, the Saturday Evening Post published Norman Rockwell’s illustration Freedom from Want. Although the illustration might have seemed more suitable for a Thanksgiving issue, the work was number three in his Four Freedoms series. Rockwell’s oil paintings were inspired by Franklin Delano Roosevelt’s 1941 Four Freedoms State of the Union Address. Rockwell actually started this particular painting in November 1942 depicting his friends and family at their Thanksgiving. The other end of the spectrum from Rockwell’s idyllic scene is the image evoked in a report I saw recently from the Bangweulu Wetlands in Zambia on the unintended use of mosquito nets for fishing where:  Out here on the endless swamps, a harsh truth has been passed down from generation to generation: There is no fear but the fear of hunger.  [Gettleman NYT Jan 25, 2015 p.1]  


2.    Freedom from want is a timely theme. During these cold wintry days, it is discomforting to cross paths with panhandlers on our streets. How do we each respond, knowing that many panhandlers have terrible life stories and are at their wits’ end without resources for the next meal or warm bed? (Yes, many of them are clever enough to make a living on the street and a few actually retreat to their own abodes to sleep at night). It is important to realize that most homeless people are not panhandlers and that not all panhandlers are homeless. Furthermore, mental illness is a pervasive condition among panhandlers and the homeless. Most experts on homelessness agree that handouts to panhandlers are not a good solution for homelessness, hunger, and mental illness; a set of community solutions is vastly preferable. University towns like Ann Arbor provide good environments for panhandlers who can turn streets full of students into their workplaces. Still, many of these people are truly homeless and hungry – so how do you and I face those who confront us directly with their need? It is a personal dilemma. I often point them to the Delonis Center, only a few blocks away as a resource that offers decent food, shelter, and a pathway out of homelessness. Many of us in the community support Delonis, but its capacity is stretched and some who need shelter and services are adverse to it for varied reasons. The failure of our society in the industrialized world of 2015 to provide food, security and decent shelter to all its citizens is troubling. Health care is as basic “a need” as food and shelter and most of those folks on the street are incapable of attending to their basic health needs. One measure of our humanity is the sense of empathy that allows us to see ourselves in the faces of the needy who confront us. The great religions value empathy, our most respected leaders throughout time displayed empathy, and mankind’s greatest thinkers argued for it, notably in my mind Adam Smith in his opening sentence of the Theory of Moral Sentiments. Yet, we must be constantly aware for ourselves as we gain privilege and power, that power diminishes empathy. When we lose the recognition that the homeless and the panhandlers are in a real sense our doppelgängers we lose much of our humanity.

3.    Homelessness and hunger are invisible to us most of the time in our busy lives in clinics and operating rooms, contending with hospital capacity issues, residency education, MiChart, RVUs, regulatory mandatories, grant deadlines, and the rest of the broth of clinical and academic medicine. A recent Lancet editorial [The Lancet 384:478, 2014] and series [Faizel, Geddes, Kushel The Lancet 384:1529, 2014 and Hwang & Burns  384:1541, 2014] dealt with homelessness, noting that on any night in the USA and Europe around 1 million people are homeless (median age is 50 years). And what about the Middle East, South America, Africa, and Asia? In our own Washtenaw County, the federally-mandated count on a cold day this January found 307 sheltered and 80 unsheltered homeless people. Of the 387 that day: 52 were children, 94 had severe mental illness, 44 had chronic substance abuse, and 34 were victims of domestic violence. Chronic homelessness accounted for 71 of the total and 29 of the 387 were military veterans. Homeless people, just like us luckier ones, may suffer from multiple morbidities, infectious and noninfectious, including all of the genitourinary disorders that we urologists manage. Yet, most of the homeless are well outside networks that feed into our health care system. The Affordable Care Act (ACA) made inroads into this underserved (or unserved) population, but better models and systems of health care are needed if we hope to truly mitigate freedom from want and provide basic humanitarian services fairly. At the personal level, it’s unrealistic to expect most of us in academic medicine to volunteer in soup kitchens or hand out blankets and socks on the streets. Clinical work is demanding and our environment heaps on additional burdens such that few of us work less than 80 hours a week. However, our community offers a variety of philanthropic opportunities that can use our dollars and leadership just as handily as direct labor. So if you feel some moral traction when you pass by a panhandler, rather than handing over cash (that may or may not be used well), look further (and point them to) resources in our community that help the homeless, hungry, and uncared for – the Delonis Center, the Packard Clinic, and others. If these resources are inadequate, help make them better.

4.    Steven Brill’s book called America’s Bitter Pill was a follow-up to the focused issue of Time magazine he wrote, and I discussed, 2 years ago in these columns. I read the book word-by-word, including the appendix and footnotes. Brill frames the story well and reasonably fairly. Replete with detail as to the historical background of healthcare economics in the USA, Brill takes the reader from March 2007 when the ACA started to take shape as an idea to a year ago in April 2014 when its implementation was in full swing. Much of American health care is the envy of the world, in terms of medical education, residency training, research, and innovation. Yet we are also rightly and severely faulted (often by ourselves) for failure to provide equitable care, for our costs, and for our results. Brill is a journalist and between his Time issue and his new book he experienced a catastrophic illness that gave greater nuance to his reporting. On April 4, 2014 he underwent repair of an expanding symptomatic aortic aneurysm at Cornell. He praised the doctors and the staff, but disparaged the administration of the hospital. His repair and 8 days in the hospital cost $197,000 – and he says it was worth every penny of it, to him. The politics and sausage-making deals with the hospital industry, insurance industry, pharmaceutical industry, and device industry are not pretty. The sausage, by the way, was pure pork. Effectually absent from the bargaining table (and thus on the menu) were the consumers, health care workers, health care scientists, and the educational community of healthcare. Representing the consumers (that is, the public who otherwise were never at the bargaining tables) was the basic structure of the ACA which was totally modeled on Romney Care and its triple intent. These three legs have been variously stated, but they boil down to these:

a.) expanding healthcare coverage throughout the nation;

b.) continuation of an “insurance-based” system that remains employer-funded, private pay funded, & government-funded; 

c.) abandoning the constraints of pre-existing exclusions & life-long limits of coverage.

Kicked down the road was the matter of cost, which inevitably will rise with expanded coverage, enormous subsidies, and corporate protections (future “give-backs” from industry notwithstanding). It was pure speculation to assume that costs will drop after ACA implementation due to less waste, electronic record implementation, bundling of services, improved safety, better “quality” and the “give-backs” of industry. Just about a year ago the federal exchange,, was resurrected (in large part with help from Google experts) after its disastrous initial launch. Given that healthcare has become such a massive part of our economy, no single fix, even as complex as the ACA is likely to solve the main problems. Furthermore in the unlikely event of totally disabling the ACA, the negative impact on health care and the larger economy would be unimaginable at this point. Inexplicably, Congress’s flawed 1997 Sustainable Growth Rate (SGR) law that linked Medicare’s relative value units (RVUs are measures of clinical work) to changes in national gross domestic product (GDP) was not addressed in the ACA. This law has now been “put off” by last-minute Congressional “fixes” 17 times. As for my position on these matters, I am a believer in social objectives of the triple intent that underlies RomneyCare, ObamaCare, the ACA, or whatever label you want to throw at it. Few reasonable people doubt that the pre-existing state of health care was unsustainable. Nevertheless, Brill’s book with its collection of leadership lapses, bungled technology deployment, management failures, turf battles, political grandstanding, closed-door deals, corporate greed, personal tragedies, and more, is not inspiring. The ACA may be ultimately so complex, so flawed, and as yet so indeterminate that it will prove to rival the injustice, personal pain, and unsustainable costs of the pre-existing state of heath care. Time will tell. I’ll give what I think is the bottom line on Brill’s book next month. Meanwhile, I believe the ACA’s main effects are here to stay for a while (we will learn what the Supreme Court thinks about the “four word mistake” in the law), but are not sustainable in the long run. The market, the academic community, and the government will inevitably float new ideas and experiments. Some may even be good.

5.    Ultimately, the idea of funding a nation’s health care mainly on an insurance model is not sensible. Basic health care is a human right; people need health care from before birth until death. Furthermore, universal health care is in the public interest – you don’t want people standing next to you on the street with active TB, influenza, measles, or smallpox. Nor do you want a suicidal driver to crash head-on into your car. We don’t need Emergency Departments overwhelmed by health care crises that could have been pre-empted by good preventative medicine and timely care of routine illnesses. We also need the next generation to be healthy in mind and body so as to improve our world and civilization (and fund social security!). Insurance, however, is a sensible way to fund big ticket and catastrophic expenses – such as ruptured aortic aneurysms, renal failure, liver transplantation, major trauma, or amyotrophic lateral sclerosis care to name a few terrible problems.  One experiment in health care delivery already underway is the Federally Qualified Health Center or FQHC.  We have discussed this in these columns and after a few years of preparation finally implemented involvement of our Department of Urology at the Hamilton FQHC in Flint.

6.    FQHC. In January John Wei held the first urology clinic at the Hamilton FQHC in Flint, in February John Stoffel held the second, and we intend to continue a monthly presence there. Hamilton’s facilities include a new user-friendly multi-specialty building just north of the city. Last year’s Hamilton budget was around $22 million, including its basic federal grant of $3.5 million, and it is very well run under the leadership of Michael Giacalone and Clarence Pierce. The following details may seem arcane, but are worth knowing. FQHC’s operate under the auspices of the Health Resources and Services Administration (HRSA). These grant-funded (330B) Health Centers satisfy the following requirements: they are in high need communities, are governed by community boards, offer comprehensive primary care with supporting services, provide services to everyone (with adjusted fees according to need), and meet government accountability requirements. Nationally in 2013 FQHCs served 21.7 million patients and provided 86 million visits. In addition, HRSA supervises two other types of Health Center programs. One is the non-grant supported “FQHC Look-Alike” that operates under Section 330 of the PHS Act. Washtenaw County was just approved for its first “look-alike” at the Packard Clinic. Look-alikes nationally served 1 million patients in 2013 with 4 million visits. The other alternative outpatient program functions under the Indian Self-Determination Act. Although insurance paradigms currently work well with FQHCs, it is the grant funding that provides the backbone.


 425px-Save_Freedom_of_Speech  save_freedom_worship  Freedom From Fear

7.    The other freedoms that FDR’s State of the Union addressed were: speech, worship, and fear. In that order those Rockwell illustrations were published in 1943 on February 20 and 27, and March 13 each accompanied by a matching essay. The FDR freedoms contrast and compare with the equalities articulated by Danielle Allen in her book Our Declaration, mentioned here last month. Allen makes the point that a just society cannot have freedom without a framework of equality. FDR’s freedoms are in themselves manifestations of equality throughout a society including basic human needs of food, shelter, health, and safety with the political freedoms of worship and speech. It is compelling that the final figure, Freedom from Fear, shows 2 parents concerned about their children’s future. [All paintings are at the Norman Rockwell Museum in Stockbridge, Massachusetts.] The future of our children is not only a fundamental human concern, but it is evident throughout much of the animal kingdom. I recall TV docu-drama years ago dealing with the Cuban missile crisis during the Kennedy presidential administration in which JFK summed up our ultimate mutual long-term interests with the Soviets in a phrase something like this: We all inhabit the same Earth, we breathe the same air, and cherish our children’s future. These sentiments derive from thinking of the Enlightenment, tenets of social justice expressed (although imperfectly) in some modern governments, and emerging belief in the necessity for planetary stewardship. Kennedy’s point: if two conflicting sides recognize the similarity of their human condition and ultimate aspirations, conflict can be mediated. This is the empathy of the doppelgänger. I’ve been unsuccessful so far in learning if this was an actual quote from Kennedy or part of the television script, but the words are good. Of course, as we are learning in the Mideast, barbarity and conflict endure when similarity of the human condition is not mutually recognized such as when one side claims divine advantage.

8.    The future of our children and the future of our planet have been best represented by universities for the past 600 years. Universities have been the only enduring heavy-hitters in the matters of educating our successors and expanding the knowledge base of humanity. To a great extent this mission developed accidentally and is fulfilled inadequately. Far from recognizing this essential role, most modern universities fret about rankings, reputations, endowment races, NIH market shares, applicant/acceptance ratios, athletic programs, profitable products, and so forth. We see few grand educational visions. We see little focus on creating a better planet tomorrow – better citizens, better workforce, better governments,  and better energy sources to allow 8 billion or more people to inhabit the same Earth, breath the same air, and give all children a decent chance for self-determined lives. 

9.   Senses. The idea that we, among many other biologic constructs, have 5 senses goes back to the time of Aristotle if not well before then. Hearing, touch, sight, taste, and smell comprise the classic senses, but the reality is more complex for most creatures with additional senses as proprioception, thirst, hunger, and magneto reception. Humans also have a unique sense of time. The human intellect can integrate and creatively imagine senses, such as when you read, dream, or think. Importantly for our species although perhaps not unique to us, is the sense of compassion as so well articulated by Adam Smith that I want to again bring forward. His book, The Theory of Moral Sentiments, in 1759  begins: How selfish soever man may be supposed, there are evidently some principles in his nature, which interest him in the fortune of others, and render their happiness necessary to him, though he derives nothing from it except the pleasure of seeing it. This sense of philanthropy (love of humanity) is a fundamental part of the human condition that has allowed us to build teams, societies, and civilizations in which we take care of ourselves, including the needy and the vulnerable, as well as to try to create a better tomorrow for our children and their successors. FDR’s Four Freedoms (etched into stone at the FDR monument in Washington, DC) extend Adam Smith’s optimism in mankind’s better nature.




10.   Faces – a big step in the world of surgery. Excluding the rare true doppelgängers, it is our faces that mainly set us apart. [Illustration: Dante Gabriel Rossetti – How They Met Themselves. Watercolor 1864. Fitzwilliam Museum] For higher orders of mammals facial recognition is the key identifying feature. The nuances of human expression are essential to conscious and subconscious communication. Darwin wrote a book on this topic in 1872 called The Expression of the Emotions in Man and Animals. Among all the equalities that modern civilization is built upon, the equality of human recognition is no less essential than any other. Seeing the faces of our fellow members of society is a requisite part of the equality of reciprocity in civilization. Facial expression is essential to full interactive participation in society, to understand intent, acceptance, irony, honesty, displeasure, and all the other nuances necessary to the normal daily give and take of citizens, neighbors, customers, and all stakeholders in modern life. To “lose face” is a basic human shame in the figurative sense, but a horrendous circumstance in the physical sense. Ten years ago the first face transplant was accomplished and a recent Lancet article reviewed the first 28 facial transplants done to date in this new surgical frontier.[Khalifian, Brazio, Mohan, et al. The Lancet 384:2153, 2014]

 The authors wrote:

Facial transplantation is a single operation that can restore aesthetic and functional characteristics of the native face by giving ultimate expression to Sir Harold Gillies’ principle of ‘replacing like with like’ … Unlike solid organ transplantation, which is potentially life-saving, facial transplantation is life-changing. The possible consequences of life-long immunosuppression in otherwise healthy individuals  – including cancer, metabolic disorders, opportunistic infections and death – must be carefully balanced to minimize risk and maximize benefit. Yet surgical innovation has outpaced the scientific community’s ability to fully address certain immunological and clinical challenges. Here, we review the immunological, neurological, and anatomical principles gleaned from the 9 years since the first facial transplantation with a discussion of ethical considerations, highlighting lessons learned from clinical experience.    

A few comments on this quotation. You see once again how surgical innovation outpaced knowledge in the so-called scientific community. Yet isn’t it a strange belief that the surgical community is “not scientific” – for what is science after all but matters of imagination, methodological experimentation, analysis, and new hypothesis? Gillies, by the way, was one of the great early pioneers of modern plastic surgery. The last phrase lessons learned from clinical experience is the essence of the rational practice of medicine and this applies equally in the unnecessarily separated domains of medicine and surgery. A cynic might argue that the 28 salvaged lives cannot justify the costs and risks involved. Wiser voices would counter while the dozens of steps on the moon hardly justified the costs and risks of the lunar program, the collective spinoffs to knowledge and technology were of immeasurably greater value. In a parallel way face transplants similarly extended the reach of medicine and philosophic understanding of the meaning of a face. What have been the big steps in genitourinary surgery? Cystoscopy, cystolithalopaxy, orchidopexy, hypospadias repair, closure of exstrophy, prostatectomy for benign disease, perineal prostatectomy for cancer, the use of bowel in urinary tract reconstruction, cystectomy and bladder substitution, TURP, renal transplantation, ESWL, the Mitrofanoff principle, minimally invasive urologic surgery, and nerve sparing retropubic prostatectomy come to mind. Certainly there are others and more importantly, there will be more. Some will come from here in Ann Arbor.


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A final comment. We will miss Michael Johns, who has been with us for much of the past year providing wisdom and effective leadership for our medical school and health system as Executive Vice President for Medical Affairs. We welcome his successor Marschall Runge.

[ President Mark Schlissel, Special Counsel to President Liz Barry , & Michael Johns]


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

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 David A. Bloom

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