Matula Thoughts August 7, 2015

Fair weather, formicidae, fables, and funambulism

3415 words

 

 1.   Brehm

August in Ann Arbor with long days of sunlight, warm breezes, and summer clothing is especially sweet by contrast to our winter days. Thanks to generous rains filling our rivers and refreshing the ground water Ann Arbor’s August is immersed in green. [Above: view from the roof of the Brehm Tower of Kellogg Eye Center. Below: kayaks by the Huron]

Kayaks

Birds, cicadas, tree frogs, and lightning bugs create accidental symphonies of sound and light in my neighborhood. Summertime in the Northern Hemisphere brings a measure of balance, relaxation, and sunny public spaces. Vacation allows time to recharge and summer in Ann Arbor is pretty much as good as it gets for doing that.

Golf

[Michigan Stadium from Ann Arbor Golf Outing]

August in parts of Europe is almost entirely set aside as vacation time for many workers, whereas in North America “work-life balance” is stricter with a week or two of vacation, plus the long weekends of Memorial Day, Fourth of July, and Labor Day. These thoughts remind me of an animated cartoon that I loved as a kid called the Grasshopper and the Ants, an ancient fable of Aesop recast by a young Walt Disney in 1934 in The Silly Symphony (you can find it on YouTube – it runs 8 minutes).

220px-The_Grasshopper_and_the_Ants

The gist of the story was that a grasshopper had fun and played all summer, while the neighboring ants aligned industriously to work throughout the sunny days storing up food and preparing for winter. When winter came, the cold and hungry grasshopper realized his sorry situation and came begging to the ants for food and shelter. According to Disney’s version, after a momentary reprimand the ants kindly took in the pitiful grasshopper who then entertained them with his fiddle over the winter. In the Aesopian corpus this story is The Cicada and the Ant (classified as Perry 373). The simplistic moral to the story is a useful lesson for children, but humans, unlike ants, need vacations; motivations in the human sphere differ from those in ant land.

 

2.   Screen shot 2015-07-18 at 9.09.21 AM

[EOW by DAB 2002]  

Ants and humans, E.O. Wilson teaches us, are among the very rare eusocial species on Earth. These colonial animals live in multi-generational groups where most individuals cooperate to advance the public good and to perpetuate the species into the next generation. In effect, their colonies are superorganisms that transcend  individual biologic lives and create civilizations turned over to successive generations. The meaning of individual lives, then, is simply to be found in their contribution to their tomorrow and the tomorrows of their successors. Ants accomplish this work by communicating via pheromones, chemical signals that Wilson and his collaborators elucidated. Pheromones, added to genetic and epigenetic capabilities, vastly enhance the ability of eusocial organisms to deal with and transmit information. The human luck of spoken and written language allows us to process information (sensory, narrative, and numeric), work cooperatively, and create new information that we deploy and pass along to successive generations. The cultural and scientific ways of thinking that emerged from language have produced creativity that has changed the Earth. Whereas internal motivation and environmental pressures inspire personal creativity, it is largely personal and political freedom that allows its dissemination, thereby expanding civilization intellectually and materially.

Tai Che 2

It is a beautiful thing to see people acting in harmonious synchrony. This picture I took outside the de Young Museum in San Francisco this spring shows a display of T’ai chi (太極拳), a Chinese martial art practiced for its health effects, focusing the mind for mental calm and clarity. No pheromones or visible rewards motivate this alignment, the motivation is internal. T’ai chi is lovely to watch, the harmony and synchrony registering pleasurably in the hardwiring of our brains. This is the stuff of art, the deliberate work of other people that we admire and that sometimes astonishes us. You can find beauty in a myriad of other aligned performances. The Stanley Cup playoffs are one example of exquisite and harmonious alignment of teams. Surgical procedures may fall into this realm; it’s interesting that in Great Britain the operating room is referred to as the surgical theatre. When synchrony is harshly enforced, however, as in the dark vision of industrialism depicted by the Diego Rivera murals in Detroit or the failed experiments of communism, alignment is not so pretty. 

 

3.  Diego Rivera

The cartoonish stereotype of disheartened industrial assembly line workers in the Rivera murals has been reinforced by generations of business schools and accounting management ideology. The belief was that managers should determine work-flow methodology and set production targets as if assembly lines were machines to be sped up or slowed down as managers deemed necessary. This is the essence of accounting-based management. The Toyota Process System, now embraced world-wide by forward-looking businesses as lean process methodology, turns this paradigm around, having shown that where workers are empowered to think, innovate, and take pride in their work, better products, greater efficiency, and customer satisfaction will result. Ironically, Toyota’s innovation was initiated over 60 years ago when the company’s founder visited Ford’s massive River Rouge plant just as Japan was rebuilding its industrial base after WWII. Where the American managers saw one thing in the Ford assembly line, the Japanese leaders saw something completely different. The following quote explaining “What Toyota saw at the Rouge” comes from an excellent book called Profit Beyond Measure, by H. Thomas Johnson and Anders Bröms: “When Eiji Toyoda told Philip Caldwell that Toyota had discovered the secret to success at the Rouge, his comment implied that what Toyota had perceived about operations at the Rouge was very different than what Caldwell and his Ford colleagues or their counterparts in the other Big Three auto companies had seen. For one thing, it seems that Toyota people did not view low cost at the Rouge in terms of its scale, its throughput, or its managers’ effort to impose external targets for speed and cost on workers in the plant. Instead, they seemed to perceive a holistic pattern permeating every minute particular of the system. On one level, the pattern that caught Toyota’s attention was the overall continuous flow of work in the Rouge as a whole. But at a much deeper level, they observed that work flowed continuously through each part of the system – literally through each individual work station – at the same rate that finished units flowed off the line.” (Caldwell was President of Ford at the time.) Toyoda saw an organic self-learning system in the assembly line, where expertise at work stations is continuously harvested by motivated workers to improve work flow and product. Jeanne Kin and Jack Billi floated this book to my attention a few years ago and it continues to strongly impact my view of organizational systems.

 

4.   Just as modern industry is embracing the concepts of Toyota Lean Processes, health care systems in their frenzy to cut costs while complying with increasingly onerous regulation are oddly embracing the failed experiments of management accounting that impose cost and throughput targets on health care providers. Data (numeric information) should inform decisions whenever possible, but it cannot be the sole driver of key operational choices. All data must be viewed as suspect for, after all, the numeric information we produce for ourselves is merely an artifact of human invention: numbers and their manipulation may or may not reflect reality accurately. Intense focus on data tends to obliterate stories (narrative information). Truth is elusive and while stories can be just as false or misleading as data can be wrong or misinterpreted, when stories resonate with truth, prove to be genuine, or otherwise offer value they get repeated and stick around. While the accounting mentality examines data for consistency and at its best extracts useful stories from data, the scientific mentality examines and hypothesizes stories and then seeks data to support the story and create a better one. Accounting is a matter of numbers, but science is ultimately a matter of stories. The human brain is hard-wired to relate to meaningful stories, and those ancient ones that endure, such as The Iliad, The Odyssey, and the Bible, endure because they give artful evidence of larger truths, exemplary behavior, or experiences that we keep repeating. Some stories are extremely succinct, but have enough truth that we keep repeating them like: Pythagoras’s story that for a right-sided triangle the area of the square on the side opposite the right angle equals the sum of the areas of the squares of the other two sides. Another durable story is that the area within a circle is its radius squared times an irrational number called pi.One might argue that by its very substance this story is irrational, but it sure seems to have held up through time. A newer story tells of the ultimate connection of light, matter, and energy, that is, is e=mc2. These stories seem to be true and have found their Darwinian niche in the human narrative.

 

5.   We are indoctrinated by stories since childhood. Fables, short stories with moral lessons, typically feature animals with human qualities. Aesop, supposedly a slave in ancient Greece (620-560 BC) a generation after Pythagoras and a century prior to Hippocrates, is the fabulist best known in the Western world. It is an astonishing demonstration of Darwinian durability that his fables have been repeated to children in most languages for well over 2500 years. Ben Perry, the 20th century authority on Aesop, indexed and edited Aesop’s stories for the Loeb Classical Library in 1952. One of the half dozen fables dealing with health care is The Old Woman and the Thieving Physician. This may have been added to the Aesop corpus rather than an original of the actual fabulist. The tale involves an elderly lady with sore eyes who asks a physician to cure her from anticipated blindness, but her deal was that payment had to await cure. The doctor made repeated house calls to apply salves and with each visit stole anything he could take away from the house. Once the cure was competed the woman refused payment saying that her sight seemed to be worse than ever since she now couldn’t see or find any of her household property. This characterization of the dishonest physician was number 57 of the Perry Index.

 

6.   Ben Perry was born in 1852 in Fayette Ohio and received his B.A. in 1915 from the University of Michigan and a Ph.D from Princeton in 1919. His early academic posts took him to Urbana Ohio University, Dartmouth, Western Reserve, and then, for the bulk of his career from 1924-1960 at the University of Illinois. He returned to Michigan as visiting professor in 1967 and died back in Urbana, Illinois in 1968. Perry concentrated his work in two minor genres, the fable and the ancient novel. The Perry Index includes all fables related to, ascribed to, or connected to Aesop and goes from #1 The Eagle and the Fox to #584The River-fish and the Sea-fish.  In addition, the Extended Perry Index goes from #585 Sick Lion, Fox and Bear to #725 Fish from Frying Pan into Coals. Curiously Aesop offered tales of all sorts of creatures and many occupations, but only the occasional doctor’s story in addition to the ophthalmologic case: #7 Cat as Physician and the Hens,  #114 The Physician at the Funeral, # 170 Physician and Sick Man,  #187 The Wolf as Physician, or #289 The Frog Physician, and #317The Unskilled Physician. Some of these were matters of impersonations while others like #57 above were character studies of the profession. Perry #427 was the classic Fox and Hedgehog story, resurrected for our time by Isaiah Berlin.

 

7.   The Art Fair is a special time in Ann Arbor. I lived here for about 10 years before I ever walked around in it – summertime is busy for those who take care of children, pediatric urologists included. In 1997 we started the John Duckett Lecture in Pediatric Urology, in honor of a colleague and a friend of Michigan Urology who had passed away that year. The idea was that this would take place on the Friday morning of the Art Fair, and we would close up most of our clinical and research work for the day. Our staff would simultaneously have Staff Education Day in the morning and the afternoon free for the Art Fair or whatever, as their annual birthday present. Over the years we have expanded the intellectual part of our Art Fair week with the Chang Lecture on Art and Medicine Chang on the Thursday and usually added a Lapides Lecture to the Friday session. This year we asked one person, Pierre Mouriquand from Lyon France, to do both the Chang and Duckett Lectures. In effect this was asking Pierre to walk a tightrope between two intellectual towers, and he navigated the line beautifully.  As a great pediatric urologist and a painter of substance and daily practice, he is well qualified on both fronts. The Chang Lecture consisted of Pierre’s story Slowly down the Rhône: the River and its Artists. He produced a magnificent talk bringing together not only art and medicine, but also geography.

Screen Shot 2015-07-20 at 7.40.50 AM

His Duckett Lecture was Understanding the Growth of the Genital Tubercle: Why it is relevant for the Hypospadiologist.  Here he showed his mastery of the field with a brilliant update on embryology and challenging thoughts on surgical reconstruction of difficult dysfunctional anatomy. He fielded a series of case presentations from residents and later in the day attended our Disorders of Sex Development (DSD) team meeting and lunch, where he challenged the modern terminology and presented some videos that showed new concepts in reconstruction. In the evening at dinner our residents and the pediatric urology team got to know Pierre and his wife Jessica mixing technical talk, health systems discussions, and seeing how a couple successfully navigates the challenging world of life, family, and academic medicine. 

Pierre & Jessica

Regarding this first academic event of the new season of residency training (also called Graduate Medical Education or GME) I need to invoke a sports metaphor and say that “Pierre hit it out of the park.” Events like these fulfill the essential duty of the university: sharpening inquisitiveness, disseminating ideas, widening cosmopolitanism, and educating our successors.

 

8.   Chang Lecture on Art and Medicine 2016. Our speaker next year will be Don Nakayama, former chair of the Surgery Department at West Virginia. He wrote an interesting article in Pharos last year on the Diego Rivera murals at the Detroit Institute of Arts. [The Pharos 77: 8, 2014] Perceptively, he recognized that the so-called Surgery Panel on the South Wall was not a depiction of “brain surgery” as art historians have claimed, but rather an illustration of an orchiectomy, a procedure much more attuned to Rivera’s view of the Rouge Plant workers. It is a great testimony to the vision of Edsel Ford to have brought Rivera, arguably the world’s best muralist of the time and an ardent communist, to Detroit to produce the work in 1932. Things didn’t go so well later in New York City when Rivera tried to repeat the experiment with the Rockefellers, but that’s another story.

Orch

[Lower right mural on the South Wall: the orchiectomy]

Caleb Nelson will be doing the Duckett Lecture and Bart Grossman will be doing the Lapides Lecture next year for an all-Nesbit Line up on that Friday of the 2016 Art Fair.

 

9.   Little Red Hen  Disney’s Silly Symphonies also included The Wise Little Hen, a version of a Russian folk tale more popularly known as The Little Red Hen. The nugget of the story was that the hen finds a grain of wheat and asks the other animals on the farm to help plant, grow, and harvest it. None chose to help, but after she harvests the wheat she asks again for help threshing, milling, and baking, but none step forward. After the bread is done, she asks who should help eat it – and of course everybody volunteers. The hen, however, says sorry “if any would not work, neither should he eat.” (The Wise Little Hen  included the debut of Donald Duck.) President Ronald Reagan referred to this story in 1976, citing a politicized version  in which the farmer chastised the hen for being unfair. After the hen was forced to share her bread, she lost the incentive to work and the entire barnyard suffered. This twist on the story made it a cautionary tale slamming the welfare state. While the story teaches children the importance of doing their part in terms of the daily work of the community it lacks the complexity of reality. Modern society is far more complicated than a barnyard and the line between personal responsibility and public beneficence (i.e. government) is tricky to arbitrate. Furthermore, many in society experience tragic bad luck beyond their control or are unable to assume personal responsibility. Reagan’s farmer had the un-antlike characteristic of compassion, a human quality that must have long-preceded even our biblical days. A society has to nurture personal freedom, creativity, and individual responsibility if it is to be successful, but without kindness and compassion a civilization is not a human one. After all, when Disney anthropomorphized his ants he gave them not just language, but also compassion.

Where do we draw the lines regarding personal freedom and such things as immunization mandates, smoking, drug use, obesity, and dangerous behavior? Should motorcyclists have to wear helmets? How do we provide health care to the indigent and incapable? How do we create health care equality and affordability? These questions ultimately get arbitrated in the political arenas regionally and nationally, generation after generation. Our nation walks on a tightrope between the cartoonish ideologies of the welfare state and what some might call individualism, capturing the beliefs of libertarianism, laissez-faire capitalism, and ethical egoism. Obviously neither the welfare state nor any “ism” has it right – the best path for a just, creative, and cosmopolitan civilization is a path in between the cartoons. The bad news of today (and maybe this is the bad news for every human era) is that cartoonish people find their ways to leadership and compel the rest of us along irrational paths that threaten  the future we want to turn over to our next generation. All citizens need to step up their understanding of the issues of public policy and health care as well as involving themselves in its regional and national discussions. We can no longer let politicians, accountants, and pundits alone shape the critical decisions.

 

10.  Funambulism. On this day, August 7, in 1974 a 24-year old Frenchman named Philippe Petit walked across a high wire he had rigged between the Twin Towers of the World Trade Center. He actually crossed the wire 8 times, performing for 45 minutes to the amazement of on-lookers in the towers. He must have looked like an  ant to those on the ground, and vice versa. Petit’s funambulism represents a perfection of self-alignment in terms of balance that few can achieve, yet it is also an astonishing display of self-confidence, clandestine preparation, and admirable civil-disobedience. Curiously funambulism defines tightrope walking and a show of mental agility interchangeably. Few can deny that serious tightrope walking is as much a matter of mental as physical agility and you have to admire the internal drive that motivated Petit to accomplish this heroic feat. That was art.

Pettit

Postscript: With the start of August we saw the retirement of Jack Cichon, our departmental administrator, and Malissa Eversole is now steadily in place on the job. Jack managed the business and operational affairs of Michigan Urology for 20 years with great loyalty, integrity, and (at some challenging times) extraordinary courage under pressure. He becomes an honorary member of the Nesbit Society and we hope to continue to see him in the course of our departmental events, noting his broadened smile of relief from the administrative pressures of the University of Michigan Medical School and Health System that he served so admirably.   

Cichon 2015

Thanks for spending time with What’s New and Matula Thoughts.

David A. Bloom, MD

Department of Urology, University of Michigan Medical School

Ann Arbor

 

Matula Thoughts July 3, 2015

 

Matula Thoughts July 3, 2015

Independence, PGY1s, peonies, & art.

3673 words

 

©Photo. R.M.N. / R.-G. OjŽda

©Photo. R.M.N. / R.-G. OjŽda

Wash Monument

1.     It’s July and peasants farm and shear sheep outside the protective walls of a castle in the beautiful panel of the renowned 15th century illustrated manuscript, Très Riches Heures du Duc de Berry. Life was safer within the castle walls than outside them. The authority in charge of the castle and grounds was a nobleman governing locally on behalf of a distant ruler and the governance was absolute. Many Julys have come and gone since the Duke of Berry (600 Julys since 1415) and government has become more representative throughout much of today’s world for villagers, city folk, and the rest of us who perform the daily work of civilization. The relationship between the authority we call government and “the people” has evolved based on principles extending back to the Magna Carta 800 years ago (June 15, 1215) and even before.

Magna Carta

[Magna Carta Brit. Lib. 4000 or so words in Latin on sheepskin]

The principles of authority for the United States of America are seated in the Declaration of Independence, adopted by the Continental Congress on July 4, 1776. If you’ve not read the book published last year by Danielle Allen, Our Declaration, you should do so this summer. It is an amazing study and quite readable. As discussed previously on these pages of What’s New and Matula Thoughts, Our Declaration will give you, among many other things, a more sophisticated sense of the idea of equality than you likely now have.

declaration-of-independence

[1337 well-crafted words]

When the three Limbourg brothers of Nijmegen produced the “very richly decorated book of hours” for the Duke of Berry, the Duke probably felt little sense of equality with his workers. In some parts of today’s world things remain little different than in the days of the Très Riches Heures when dukes and kings had total unchecked authority over their subjects. Such nations are rarely successful in terms of aggregate innovation, intellectual contribution, education, environmental stewardship, industrial production, or social justice. Conversely, most modern nations today enjoy a shared belief that all people are equal before the law. In these places where the ideas of representative government, equality, personal liberty, and cosmopolitanism take hold, the potential of the human factor is unleashed and creativity emerges on a large scale. History shows that, when people have freedom to achieve their potentials, individual happiness and general human progress are served far better than when the state or crown decides what’s best for its people. Tomorrow we celebrate that particular success of government by the people, for the people, and of the people in our nation. Yet, these aspirational ideals remain under challenge not only by human imperfections in their implementation, but also by today’s iterations of tribalism, despotism, human subjugation, sectarianism, extremism, and war. The divergent symbolism of a castle and protective walls on one hand, and our iconic monument of an open society is striking.

 

2.     With July comes a new class of interns (PGY1s, residents) and fellows. I’ve enjoyed being a part of this cycle for many years. Our careers flip by in the blink of an eye and I myself was at that early stage of medical education not so long ago. Although relatively clueless back then, I had the ambition of becoming a credible children’s surgeon of one sort or another. With influences like Judah Folkman, Rick Fonkalsrud, Bill Longmire, Don Skinner, Will Goodwin, Joe Kaufman, and Rick Ehrlich, I was inspired to push ahead toward that ambition, but felt a long way from my goal and quite distant from a place in the “establishment” of pediatric surgery and urology. A year in London following the footsteps of David Innes Williams gained me a slight bit of early credibility in addition to lifelong friends in urology – Robert and Anita Morgan, John Fitzpatrick, and Christopher Woodhouse. A couple in the Royal Shakespeare Company, Mike Williams and his wife Judi, further broadened my perspective on the world, and I often think back to Mike’s description of their work as that of “travelling players.” This metaphor applies to us in academic medicine – we are travelling salesmen indeed, going here and there to sell our ideas, observations, clinical experiences, and research findings at national meetings and during visiting professorships. On my return from London I experienced an incomparable month with Hardy Hendren in Boston, filling a notebook equivalent to the size as that from 11 months in London. During that stay I further was schooled in gracious hospitality by Mike and Connie Mitchell and John and Fiona Heaney. Wonderful reminiscences and the start of deep friendships. Our residents and fellows are now assembling their own stories of educational experiences, no doubt as rich and meaningful to them.

 

3.     Most people at certain times of their lives entertain the nagging question of the meaning of life. The question comes up in good times or bad, in the midst of crises, or even randomly. It is too big a question to answer in a general sense and certainly beyond the reach of these small essays. Maybe it’s a silly question, a human conceit, for in the grand scheme of things it could be argued that the meaning of geology, for example, is of no less significance as a question. In the specific personal sense many people find life’s greatest meaning lies in the ways they individually make their lives useful to others. In this sense, then, the meaning of life is simply its public relevance. This might well be Darwin’s ultimate revelation: a life’s meaning is found in its specific relevance today and in its more general relevance to the tomorrow of future generations. The desire to do things for other people is deeply established in our genes and has been reinforced by millennia of human culture. Not only do we seek to have meaning individually to others and to our society, but we are compelled to construct a world where our generation’s children can create their own meaningful lives. It probably seemed easier for the kings, queens, and noblemen in the days of the Duke de Berry. They were born into a world where their meaning (in terms of the faulty surrogate of their self-importance) was pre-ordained, but that world didn’t offer much of a chance for anyone else, hardly a sustainable Darwinian scenario. Self-importance is a biologic necessity, but its socially-acceptable expressions occur across a spectrum with Mother Teresas on one end and Donald Trumps at the other.   Off that spectrum, deranged and delusional self-importance leads to shootings, bombings, and beheadings – public slaughterings designed to induce terror and 15 minutes of “fame” that in fact become horrendous perpetual shame for the perp. Random tragedy still stalks us and may never disappear, but our responses as a society are sometimes great and inspiring, as we witnessed in Charleston SC one week ago today.

AME Church

[Emanuel AME Church, Calhoun St. Charleston SC. June 30, 2015. DAB]

In spite of the personal good fortune of many of us today, our gift of freedom has not been making the world a better place uniformly. One bit of evidence that it’s not: the UN released figures last month showing that 60 million people, half of them children, are fleeing chaotic lands looking for safety, food, and asylum. This is a staggering and unprecedented number. It is mentally incomprehensible. Another bit of evidence: Pope Francis’s recent encyclical Laudato Si, warns that our failure of planetary stewardship has left even larger numbers of mankind living in piles of filth and at risk from effects of deleterious climate change. An article about this 192-page document said: “Pope Francis unmasks himself not only as a very green pontiff, but also as a total policy wonk.” [Faiola, Boorstein, Mooney. National Post (Toronto) June 19, 2015. A11]

 

4.     Last season’s interns are now seasoned house officers (PGY2s). They have performed admirably and are well on their way to becoming excellent urologists. Just as we will make them better, they will make us better. We look forward to their full-bore immersion in urology starting now.

PGY1s 2014 copy

[PGY2s:Ted Lee, Ella Doerge, Parth Shah, Zach Koloff]

Our new interns (PGY1s), mentioned here last month, have just come on board. When I started in that same position at UCLA on July 1, 1971, I stepped right into the game of hospital medicine, taking orders from the higher level residents, watching them and the attendings at work, and anxiously taking call, hopeful that a disaster wouldn’t blow up around me. The world has changed and now we give the new medical school graduates days of preparation for the complex systems of healthcare, the explicit and implicit expectations of their daily work, the hierarchy of graduate medical education, and the local idiosyncrasies of the University of Michigan (e.g. when we put on gowns and gloves in the OR the left hand is always gloved first). Only after a deliberate program of “in-boarding” do our new interns step into the real-time practice of clinical medicine. We hope the new members of our urology family will embrace our sense of mission and values. We hope they will pick up the professionalism of our faculty, staff, and their senior residents and fellows. We hope they will learn the histories of our department and institution and become inspired by those stories. We hope they will learn their craft and become superior in providing our essential deliverable: kind and excellent patient centered care, thoroughly integrated with innovation and education at all levels. The fact is, looking at our finishing chief residents and fellows this year, Michigan urology trainees are superior and we expect them to get even better throughout their careers.

 

5.     While governments, in many nations, have become more representative and recognize that they exist for the people they represent, one unintended, but inevitable consequence is that they become self-righteous. Authority corrupts itself. This happens today no less than it did for any of the Dukes of Berry and their counterparts over the past millennia. We should be wary that self-righteousness of large organizations is a feature of all self-organizing systems. This propensity is seen in the reordering of our haphazard health care system, for example in the ill-conceived HITECH Act that forced the jettisoning of perfectly good electronic medical record systems in favor of a few clunky propriety systems that satisfied arcane details of the law including the mandated “meaningful use.” We also see this in the overwrought “Time-Outs” in the operating rooms that default individual responsibility to a team check-list. (As a pilot in training, when I was a resident, the checklist was the responsibility of the pilot and co-pilot, not a formulaic team exercise of everyone on the airfield.) I thoroughly believe that health care, surgery most especially, is a team activity and that rigid hierarchy is not conducive to a highly performing team. However, rote adherence to a formulaic “Time-Out” for all operative procedures is equally counterproductive. We hope that the next generation of physicians, especially the urologists we educate, will not be taken in by regulatory self-righteousness of third party payers, national professional boards, state boards, and hospital systems so as to believe that the practice of medicine is a checklist, patients are clients, that a patient’s story is a dot phrase or series of templates, and that time-outs do not obviate Murphy’s rule. No check-list or algorithm can substitute for individual sensibility (and anxiety) of the operating surgeon. The formulaic and monitored checklist ritual, in fact, defuses the sensibility. Finally we pray that the ancient Hippocratic idea of listening to and looking at the patient (and the patient’s family) is where medical practice must begin and end – not with the computer and electronic health care record.

 

6.     Visiting professors challenge us with new ideas and perspectives. They offer our residents and fellows a more cosmopolitan view of the world of urology, and visitors take away strong impressions of the Michigan Urology Family. The same happens when we visit other institutions and see how their residents learn. I was recently at the University of Toronto as Bob Jeffs visiting professor at the time for their fellowship graduation and was duly inspired by the faculty, residents, fellows, nurses, and systems that Marty Koyle and his team have developed at Sick Kids’ Hospital. They have some great innovations that might fit us well. The children’s hospital is vibrant, welcoming, and user friendly.

Sick Kids fellows

[At Toronto Sick Kids: Kakan Odeh, Keith Lawson, Frank Penna, Paul Bowlin, DAB, Marty Koyle, Joanna Dos Santos]

Sick Kids

[Toronto Sick Kids Atrium & lobby from urology & surgery floor]

In Ann Arbor we recently hosted visiting professor Tim O’Brien from Guy’s Hospital in London and he gave a wonderful talk on his work ranging from bladder cancer to retroperitoneal fibrosis. He explained that he has given up doing clinical trials due to the overbearing regulatory paperwork and processes involved in setting them up and implementing them in Great Britain. Tim used a phrase that “the many were controlling the few” in the quagmire of clinical trial regulation. This is the opposite of the Duke de Berry’s situation where the few controlled the many and it begs the question: What is sovereign in a society and what is the source of its laws? It seems right that the people in a society should ultimately be sovereign and that the source of its laws should derive from cosmopolitan human reason and experience. Rules, however, should not be so oppressive as to impede the function and flourishing of the workers. A sheep cannot be sheared well and efficiently by a committee, nor can a bus be driven by a team representing all the diverse interests of the stakeholders of the passengers, neighborhoods of passage, and owners of the bus. Society has to trust its workers to a great extent, knowing that some mistakes will be made and accidents will happen, although minimized by means of education, training, sensible rules, and systems. It seems that clinical trials, and perhaps much of modern medicine driven by HITECH mandates, ICD-10, and other regulatory burdens is not flourishing. Anyway, Tim gave us a terrific visit and showed that we share many regulatory impediments with the U.K.

Tim O'Brien

[David Miller, Tim O’Brien, Kurshid Ghani at Grand Rounds in Sheldon Auditorium]

 

 

7.     Chiefs dinner Chief residents’ dinner. Our residents go from newly minted graduates of medical school to skilled genitourinary surgeons and excellent clinicians in a matter of 5 or so years. In that time we, as faculty, work with them initially as teachers, but increasingly as colleagues during the progression of their training. It is said that it takes around 10,000 hours of practice to become proficient at chess, golf, piloting, piano, or other specific tasks. The evolution of graduate medical education in urology to a 5-year program points to a gestational period of around 20,000 hours to achieve competency as a genitourinary surgeon. Our expectation at Michigan, however, goes beyond mere competency. We have a strong track record of producing not just urologists but the leaders and the best in urology, and this year I believe we did it again. Our yearly graduation dinner (pictured above) for the completing residents and fellows is a signature event in our calendar. We held it at the University of Michigan Art Museum for the first time this year. As intently as we work with our residents throughout the years of their training, the narratives of their lives, as told so excellently this year by their fourth year colleagues, Amy Li, Miriam Hadj-Moussa, and Rebekah Beach offered entirely new perspectives on our chiefs – Noah Canvasser, Casey Dauw, and Joanne Lundgren. We heard “the rest of the story” for these three who have come a long way from novice PGY1s. They have withstood the intense pressures of high-stakes clinical work in the ORs and at the bedsides. They have studied hard to compete in a rarified intellectual environment of high stakes exams. And they have solved problems for patients and eased their anxieties in the high stakes of urological disease and disability. Still, their learning and practice must continue, and the stakes only get greater as our graduates advance in their careers, but they have given us confidence that they will become the leaders and the best of urologists and physicians. Our graduating fellows, a notch higher on the learning ladder, have been equally superb and have now become truly independent: Lindsey Cox, Sara Lenherr, and Paul Womble.  The art gallery was an appropriate place to celebrate this milestone with them and their families. The Shirley Chang Gallery in the Art Museum is an especially lovely space to stroll and reflect.

 

8.     The four “Rs.” The world provides as many opportunities to stroll and reflect as individual imaginations allow. A few years ago our friend Bill and Kathleen Turner (Bill was chair at the Medical University of South Carolina as well as Secretary-Treasurer and then President of the American Urological Association) a few years back took us to Mepkin Abbey in South Carolina where a dozen or so Cistercian monks have developed a community with open gates for visitors to come stroll and reflect.

Mepkin

The unofficial motto of the abbey is: read, reflect, respond, and rest. Reading intends the sense of thoughtful examination of the world around us visually, literally, auditorily, and emotionally. You don’t have to go to exotic abbeys and other places to perform the four “Rs.” Here at home you can reflect in places like the Shirley Change Gallery and in May and June, you can wander in the University of Michigan Peony Gardens. These were designed and established in 1922 with many of the original plants donated by William Upjohn, an 1875 graduate of our medical school. The collection consists mainly of one species, Paeonia lactiflora, blooming in pinks, whites, and red. The peony is named after Paeon, a pupil of the Greek god of medicine Asclepius. When the teacher became dangerously jealous as his student began to outshine him, Zeus intervened to save Paeon by turning him into the flower. Thus you might argue that the peony symbolizes education’s ultimate aim – the success of producing students who outshine their teachers. The root of the peony is a common ingredient of traditional Chinese, Japanese, and Korean medicine. Indiana has made this its state flower.

Peonies Yun_Shouping Freer

[Peonies by Chinese artist Yun Shouping, 17th century. Freer Gallery]

Peony gardens

[UM Peony Garden, June 7, 2015]

 

9.     Hippocrates allegedly said: Life is short, and Art long; the crisis fleeting; experience perilous, and decision difficult. According to the way I read this enduring aphorism and the way it is punctuated, the fleetingness of life and durability of art are linked as one thought. Life creates art, but art transcends life, and being passed across generations epigenetically, art changes life by enhancing it, inspiring it, or altering its perceptions. My late aunt Evelyn Brodzinski, a painter throughout her life and a student of visual arts, once said in reply to my question as to what, actually, constitutes art “Art is anything that is choice.” In the process of creation, selection, and omission of material and information people produce content that, presumably, had some meaning to the artist. Craving meaning in our lives, we find value in inspecting the visual, literary, or musical content that had meaning for their creators. When we started the Chang Lecture on Art & Medicine in 2007, in honor of the Chang family of artists & urologists, we hoped to offer a yearly lecture that would link the 2 essential human interests of art and medicine in some way. The choices thus made by our lecturers over the years have been amazing, and last year’s lecture by James Ravin, ophthalmologist and author of the book, The Artist’s Eye, was superb. I eagerly anticipate this year’s talk by Pierre Mouriquand who is both a pediatric urologist and an accomplished artist.

 

The Chang Lecture, targeted to a general audience, has attracted growing number of friends and members of our community. “Public goods” of our university such as the Chang Lecture and the Peony Gardens are part of the social compact between the University of Michigan and its community.

Chang 2013

 

Chang 2014

[Top: Chang Lecture 2013; bottom: Hamilton Chang, James Ravin, Dr. Cheng-Yang Chang]

 

Tom & Sharon 2013 copy

[Tom & Sharon Shumaker, loyal Chang Lecture attendees. Tom passed away in January this year.]

 

10.    Universities are the single institutions of civilization that exist for tomorrow. At the individual level they provide a framework for individuals to find their specific relevance as well as to understand the cosmopolitan nature of the world and their responsibility in it. In the larger perspective they create new knowledge through inquiry and research to provide the ideas and technology of the future. It is no accident that the largest piece of most great universities has become the health care enterprise. This is totally appropriate since health care is a dominant part of the GDP, it ultimately affects everyone, and economically it employs 1 in every 6 citizens. The bedrock of the best medical school departments consists of its faculty and the glue to secure the best of the best is the endowed professorship. Last month we held a lovely ceremony in which we turned over three existing endowed professorships to three faculty members who will carry the names of the professorships along with their titles: Khaled Hafez the George Valassis Professor, Ganesh Palapattu the George and Sandra Valassis Professor, and Julian Wan the Reed Nesbit Professor. They are superb surgeons, noteworthy thinkers, and astute clinicians. The endowed professorships allow them a little independence from the daily pressures of clinical effort and funded research.  These three are smart and kind people of the highest order and I’m lucky to call them colleagues and friends. They epitomize the cosmopolitan nature of our department, medical school, and university. Cosmopolitanism is a term I’ve come to appreciate through the work of Kwame Appiah (another author for your reading list!) and it consists of the belief that all of us human beings belong to a single global community with shared values and principles. Julian, Khaled, and Ganesh will be teaching our next generation of physicians and producing useful new knowledge in the milieu of our essential deliverable: kind and excellent clinical care. Someday, their successors – the future Valassis and Nesbit chairs – will be doing the same in the world of tomorrow that we may hardly be able to predict, but that we have thus prepared for amply.

Triple prof

[Julian Wan, Khaled Hafez, Ganesh Palapattu]

 

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

David A. Bloom