DAB What’s New/Matula Thoughts June 3, 2016
Periodic explanation: What’s New is a weekly email communication from the University of Michigan Department of Urology. Most Fridays it is distributed internally to faculty, residents, and staff, dealing with operational specifics, personnel, and programs of the department, but on the first Friday of the month it is general in scope as “a chair’s perspectives” and is distributed more widely to alumni and friends of the department. The website (blog) version is matulathoughts.org.
One. Springtime & Montie. Spring declared itself in Ann Arbor early last month when flowers, shrubs, and trees began to wake up from the winter, while many Michigan urologists headed out to San Diego for the national meeting of the American Urological Association. There Jim Montie received the Lifetime Achievement Award, a distinguished honor for a great career.
[Picture above: NCRC trees waking up near the Keller Laboratory; below: kudos to Jim Montie]
Michigan Urology owes much to Jim who took the helm during a turbulent era of our Section of Urology in the Department of Surgery in 1997. He stabilized our unit without disturbing its essential deliverable of kind and excellent patient-centered care while standing solidly for the other key parts of our academic mission, education, and research. Jim led our Section of Urology to departmental status and became inaugural chair in 2001. As a world-class clinician and surgeon his reputation is unsurpassed. Jim’s foresight in recognizing the potential for health services research in urology and his courage in “betting the farm” on it within our new department led to our key position in academic urology today. This is a good year for Montie awards, as Jim will also be receiving the UM 2016 MICHR Distinguished Clinical and Translational Research Mentor Award.
Above you see Jim in an older picture with his own mentor, Ralph Straffon (Nesbit 1959), another great Michigan Urologist. Ralph, also honored by the AUA during his lifetime, became President of the American College of Surgeons and led the Cleveland Clinic to its excellence.
Two. AUA & Nesbit. The national meeting of the American Urological Association is an annual ritual that mixes science, technology, networking, and reunions to the general advantage of our field of urology and to the public it serves. Our Department of Urology figured prominently at the meeting this year with over 120 presentations by faculty, residents, and fellows. Additional work produced by our Nesbit alumni at large and former students nearly doubled that number. The MUSIC reception on Saturday highlighted productive collaborations of urologists throughout Michigan and regionally that have measurably improved urologic practice. Envisioned by Montie and led in turn by John Wei, Brent Hollenbeck, David Miller, and now Khurshid Ghani, the collaborative is an international model for medical practice improvement, centered where it should be centered – at the professional level. This lean process approach has been generously funded by Blue Cross/Blue Shield of Michigan.
[MUSIC Collaborators: Khurshid Guru of Roswell Park, DAB, Jim Peabody of Henry Ford, Ahmed Aly of Roswell Park]
Our Nesbit Reception on Sunday evening hosted 130 alumni, faculty, residents, and friends of Michigan Urology from Sapporo, Japan to Copenhagen, Denmark. We additionally were pleased to see chairs from other departments of urology in this country including Joel Nelson from Pittsburgh, Mani Menon from Henry Ford Hospital, Marty Sanda from Emory, and Tom Stringer from Gainesville, Florida (former chair). Three father-son urology pairs attended our event – Ian & Robert McLaren, Len (Nesbit 1980) & Jack Zuckerman (currently at Portsmouth Naval Hospital), and Mike and Michael Kozminski (Nesbit 1989, 2016). In spirit we thought of Carl Van Appledorn (Nesbit 1972 who passed away last month) and his son Scott, a urologist in practice in Kirkland, Washington. Another urology family attended the Nesbit reception – Kate Kraft and her uncle Kersten Kraft (a urologist trained at Stanford and in practice in the San Jose area). Kersten coincidentally is a relative of Norm Hodgson (Nesbit 1958), a great pediatric urology pioneer who practiced in Milwaukee. Other UM Michigan urology pairs, not in San Diego this year, include Cheng-Yang and Ted Chang (Nesbit 1967 & 1996), Marc & David Taub (Nesbit 1971 & 2006), the late L. Paul Sonda II & his son Paul Sonda III (Paul II finished urology under Lapides at Wayne County Hospital in 1962, Paul III Nesbit 1978), and of course Reed Nesbit and son-in-law Roy Correa (Nesbit 1965).
[Above: Bob & Ian McLaren, below: Len & Jack Zuckerman]
[Above: Tim Miller (London, UK), Jens Sönksen (Nesbit 1996), Jim Dupree (faculty), Dana Ohl (Nesbit 1987).
Below: Miriam Hadj-Moussa (Nesbit 2016), Quentin Clemens (Nesbit 2000), Lindsey Cox (Nesbit 2015), Irene Makovey (Cleveland Clinic), Yahir Santiago-Lastra (fellow, Nesbit 2016)]
Three. Corrections & kudos. Like me, you are likely deluged by email, electronic feeds, newsletters, and blogs so you necessarily pick and choose what you attend to with the slow thinking part of your brain (to use terminology of Daniel Kahneman – Thinking, Fast and Slow, 2011). I am thankful that this monthly column, What’s New/Matula Thoughts, has found a loyal readership to inspect these words in detail and catch me up for inaccurate claims. My friend John Barry is one of those who keep me on my toes. After my mention of Joe Murray in our March edition (with reference to the history of human renal transplantation and my old teacher Will Goodwin), John referred me to a historical paper in the Journal of Urology he authored with Joe Murray in 2006 [Barry & Murray. The first renal transplants. J. Urol. 176:888, 2006]
Reading this paper I learned that the first human kidney transplantation was performed in 1933 by Yu Yu Voronoy in the Ukraine, although the outcome was not good. Other attempts followed in Boston, Chicago, and Paris, but the first long term success was achieved by Joe Murray along with Hartwell Harrison and their team in Boston in 1954. Total body irradiation improved subsequent results, followed by pharmacological immunosuppression. Goodwin was the first to use glucocorticoids to reverse rejection. The transplantation story is clearly more complicated than I thought.
[Two notable urologists: Parry & Barry]
John Barry (R) is shown above with Bill Parry (L), one of the great statesmen and historians of urology. Bill Parry had a distinguished urologic career in Oklahoma. Many paths in the history of worldwide urology trace back to Michigan and accordingly Bill credits William Valk (Nesbit 1943) for significant mentorship. Valk went on from Michigan to become Chair of Urology at the University of Kansas and served as President of the American Board of Urology. I recall Valk’s name from correspondence at the time I was getting my board certification. Valk spent six years in Ann Arbor amidst the heyday of BPH as the index disease of urology and TURP was its signature procedure. Reed Nesbit and Ann Arbor were the international epicenter of prostate expertise. Things change in medicine and the TURP is giving way to other modalities (including the histotripsy method of Will Roberts and his team). Renal transplantation, once a core part of urology’s domain, remains so only at a few centers today including UCLA and Portland, Oregon where John Barry, former chair, is a rare urologist with a strong presence in that realm.
[Pythagoras, contemplating his idea: by Peter Fischli & David Weiss, Swiss artists recently exhibited at the Guggenheim]
History. Written history is ultimately a matter of finding clarity from evidence and out of critical analysis of anecdotal stories. New information improves the historical interpretation of events and is an important part of ongoing scholarly investigation that sharpens the rigor and truth of any field. Knowing the past adds meaning to today and gives perspective to the challenges of tomorrow.
Mathematics, for example, is best understood from the perspective of the stories of people, from Pythagoras, to Euclid, to Newton, to Fermat, etc. Whether Newton’s apple was a real event, a thought experiment, or a wild speculation may never be known unless some evidence turns up from a discovered letter, a diary, genetic evidence of an apple orchard at the site of Newton’s garden, or a time machine. The story of urology is also incomplete, but is rapidly evolving from the days of Hippocrates’ admonition against cutting for stone to the latest chapter of robotic prostatectomy. All stories bear re-inspection and who, after all, is better equipped to do the scholarly inspection than those participants with knowledge of each story? Historical inquiry is a fundamental part of the scholarship of all disciplines.
Five. Change is in the air. A recent paper called Injurious Inequalities, by David Rosner of Columbia University, caught my attention with the statement: The close relationship between a nation’s physical health and its economic and political health has been a central tenant of statecraft since the rise of the mercantile economy in the 18th century. [D. Rosner. Milbank Quarterly 94:47, 2016] On more levels than easily counted, politics and health are closely linked. Today’s public is uneasy and change is in the air. Of course change is what elections are about, but this time the issues and consequences of their resolution seem more substantive. Change was in the air around the time of the Arab Spring, yet humanity doesn’t seem to have benefited from the resulting change. Certainly the sum total of human happiness is no greater since that springtime. Stability may not be relished by the populace, but it seems preferable to unbounded terrorism, genocide, massive waves of immigration, and erosion of national borders.
When I was a youngster, learning to spell, the rumor on the streets of my pre-adolescent peers was that the longest word in the English language was antidisestablishmentarianism. Being a nerd back then, it was somewhat of a rite of passage to know that fact and to be able to spell the word. Probably our language has longer words and, anyway, nerds today define themselves digitally. Antidisestablishmentarians seem to be a rare breed currently, or perhaps disestablishmentarians are barking louder today in political conversation directed at taking down establishments, an ambition that seems rather anti- conservative.
Antidisestablishmentarianism has roots in 19th century Britain, developing as a political position opposing liberal proposals to disestablish the Church of England as state church for England, Ireland, and Wales. The word now refers to any general opposition to those who would disestablish government, public programs, or other established parts of society.
Six. Germinal ideas. Sometimes disestablishmentarianism is the right thing. Recently these pages discussed Holmes, Semmelweis, and Lister with reference to the germ theory, an essential building block in the modern conceptual basis of health care. Many authorities of the time not only were nonbelievers, but became vehement antisepsis-deniers. Amazingly, incomplete appreciation of the reality of germ theory is still evident in the under-utilization of genuine handwashing, covering coughs, or sneezing into handkerchiefs. The setting for Semmelweis, at the University of Vienna, is an illuminating case study. The late Sherwin Nuland, surgeon and faculty member at Yale and friend to many here at the University of Michigan wrote about this in his introduction to a modern translation of Semmelweis’s book.
“The University of Vienna, most particularly its medical school, was a hotbed of revolutionary activity. The uprisings of 1848 were strongly supported by the younger faculty members, largely because the university was under stifling control of government ministries. Some of the major positions at the school were held by professors who were old in years and who owed their power to close connections with those very same bureaucrats. They became arrayed against the younger faculty whose liberal policies and new ideas in research and pathophysiology they opposed.” [Nuland in Etiology, Concept and Prophylaxis of Childbed Fever by Semmelweis. Classics of Medicine Library. Birmingham, 1981. P. xvi.]
The ideas of Semmelweis, embraced by only a few of his mentors and colleagues, were perceived by the establishment as threatening. Nuland frames this as a conflict between “the flow of true understanding of pathophysiology versus the fuzzy theoretics of nonscientific medicine.” The younger crowd in Vienna embraced the new idea that puerperal fever was transmissible. Semmelweis made the proper and seminal distinction that childbed fever is a transmissible but not a contagious disease.
Semmelweis had been an upstart outsider in the eyes of established senior colleagues who controlled appointments and when his appointment as assistant in obstetrics expired in March of 1849 it was not renewed. Younger colleagues (Rokitansky, Skoda, and Hebra) spoke on for his idea and ultimately coaxed the authorities to allow Semmelweis to speak about his work and urged Semmelweis to give a talk at the Vienna Medical Society. This happened on 15 May 1850, although Semmelweis didn’t submit written remarks. Accordingly the speech, first public record of his idea, was only recorded as an abstract in the minutes of the society. Nonetheless Semmelweis must have been somewhat persuasive and he was offered a minor clinical appointment. This must have offended him, however, and he abandoned Vienna and his supporters abruptly in October of 1850. The Etiology was not published until 1860 and Semmelweis died in 1865.
Poppy fields. One free afternoon during a recent meeting in Texas, Martha, Linda Shortliffe, and I visited the LBJ Ranch north of San Antonio and west of Austin. Remembering the LBJ presidency, but hardly a student of the era, I was surprised to realize the shortness of LBJ’s terms, somewhat over 400 days in total, and equally surprised to learn that Johnson spent a quarter of that time at his ranch, requiring a large entourage of support. A poppy field nearby (shown above) caught our “fast-brain attentions” and we pulled over for slow-brain inspection. I recalled two other poppy fields. One, you too might remember, was in The Wizard of Oz by L. Frank Baum. The original text in 1900 portrayed the vapors from the poppy field as enticing fatal sleep – and only narrowly did Dorothy and her companions escape.
In the 1939 film the 5 travelers were lulled into temporary sleep that allowed nasty flying monkeys to carry them off to the Wicked Witch of the West.
The other poppy field I recalled was real in Normandy, France in 2010. Intending to visit the famous beaches and other sites of WWII, we came across a large poppy field on the mainland from which I first viewed Mont Sainte-Michel, floating a short distance offshore. The Normandy poppies although sparser than we would see in Texas 6 years later were equally stunning. [I took the picture, below, with my Blackberry camera phone, which could hold little more than a few dozen pictures].
Field notes: The poppy is a flowering plant in the Papaveraceae family according to the binomial system of Linneaus, who was far better known for his botanic studies than for his short career as a proto-urologist in early 18th century Stockholm .
[Robert Berks sculpture of Linnaeus, Chicago Botanic Garden. Taken May 23, 2009]
The species, aptly named Papaver somniferous, is the source for well-known medicinal and “recreational” alkaloids, in particular opium and morphine. Poppy seeds, edible and tasty, lack the narcotic factor and are also a source of poppy seed oil. The poppy fields of Flanders became terrible places of trench warfare during WWI and perhaps for that reason poppies, like rosemary, are a symbol of remembrance around Memorial Day.
Eight. Memorial Day & sad transitions.
Earlier this week (May 30) we paused at Memorial Day. You may recall that Memorial Day was first celebrated in 1868 as Decoration Day in memory of soldiers who died in the Civil War, although it was only celebrated in the north until 1890. After WWI the holiday honored the memory of all Americans who died in wars, and in a cosmopolitan sense it also reminds me of anyone who dies in service to their fellow man or those who die from the disservice of their fellows. Memorial Day reminds me, too, of the waste of war, some wars being sadly virtuous while others are failures of diplomacy and excesses of greed, tribalism, and stupidity.
The federal holiday was traditionally celebrated on May 30, whatever day of the week that happened to be. In 1968 the Uniform Holidays Bill created 3-day holiday weekends, with the last Monday of May assigned to Memorial Day.
Most acutely, Memorial Day reminds me of friends gone by such as Carl Van Appledorn (Nesbit 1972) last month, and last year Gordon McLorie, Tom Shumaker, Bill Steers, and Adrian Wheat, a career Army surgeon and expert on Civil War medicine.
[Above: Joe Cerny, Carl, Cheng-Yang Chang. Below Gordon, Tom & Sharon Shumaker, Bill Steers, Adrian Wheat]
Nine. Good transitions. This year 4 anchors of the Urology Department are moving on to great new phases of their careers.
Gary Faerber is in Salt Lake City with a terrific urology team at the University of Utah where his wife Kathy Cooney is the new chair of internal medicine at the University of Utah. Gary will be returning to us for quarterly clinics at our Hamilton FQHC in Flint.
Cheryl Lee will become chair of urology at Ohio State, an opportunity not only for a new challenge, but also a chance to get her family in the same city as her husband’s twin and his family. She will be a loss not only for us in the Urology Department, but also for our Dean’s Office where she has been managing the Office of Career Development for the Medical School.
Our irreplaceable Ann Oldendorf is retiring. No one can sort out a complex UTI or deal with complex neurourological dysfunction such as seen with interstitial cystitis with more expertise, patience, and kindness than Ann. Our PA Gayle Adams will be picking up some of that work, but Ann was a unique talent.
Stuart Wolf will be moving to Austin, Texas, and we have had a long “heads-up’, as this has been a planned family transition. He will be in on the organizational stages of a new medical school as Associate Chair for Clinical Integration and Operations of the Department of Surgery and Perioperative Care at the Dell Medical School of the University of Texas at Austin.
Austin, Columbus, and Salt Lake City are lucky to get these extraordinary medical talents and superb Michigan people. We will be honoring all 4 faculty at the autumn Nesbit Society Dinner here in Ann Arbor, and hope for a large turnout of alumni and friends.
Ten. Graduation, JOW, & predictions.
Medical school graduation last month in Ann Arbor featured our former dean, Jim Woolliscroft as speaker. You can see a video clip of the lovely event. Jim’s speech offered 7 lessons for the graduates that are well-worth repeating:
- Recognize and respect your good fortune that medicine is an inherently meaningful profession.
- Patients are not clients – you are not service providers but professionals who share an ancient responsibility to those you serve.
- Yours is a healing profession, not primarily a curing profession. Cure is not always possible, but your presence can be valued just as much.
- Recognize the individuality of patients. The experiences, comorbidities, and expectations of each is unique. (Jim recalled a patient who taught him that no single patient has, for example, a 20% chance of an outcome or complication – for that patient the chance is zero or 100%).
- Making the correct diagnosis is important – don’t jump to conclusions based on what you are familiar with or what’s in your toolkit.
- Maintain curiosity and awe of the infinite variety of the human condition. From here on, your patients and your colleagues will be your teachers.
- Take care of yourself and your relationships. Make time to reflect.
I especially liked Jim’s fourth lesson and the predictive bearing of statistics on the individual patient. Yogi Berra, in better words than mine, said that predictions are unpredictable. Four years ago, when we were in the midst of another presidential election season, change was also in the air and predictions were no better then than they are today. Jim’s next three points, culminating with reflection, will help your inquiry and critical thinking lead you out of the poppy fields to the right choices of antidisestablishment or disestablishment.
[Taken from my TV October 22, 2012]
If anyone had asked a year ago for predictions of probable high profile medical topics one year hence (i.e., now) Flint, Michigan and the Zika virus would not been at the top of any lists. Yet these topics figure prominently today’s nightly news, daily papers, and top medical journals. Zika, a Flavivirus that injects a single RNA strand into the host cells, was recently discovered to cause acute myelitis, Guillain-Barre, macular atrophy, and microcephaly, for a start. A bite from an infected mosquito (daytime active Aedes aegypti or A. albopictus) gives you a one in five chance of getting the viral infection with headaches, maculopapular rash, fever, malaise, conjunctivitis, and joint or back pains. (Yes, that’s only a 20% chance, but when it’s you that gets the bite it’s all or nothing.) Vaccines are on the way, but until then all you can prescribe is rest and symptomatic treatment. Zika is also spread from mother to fetus, as well as sexually.
As for water security – a single April issue of The Lancet contained articles on toxic water in Flint [The Lancet 387:1499, 2016] and Bangladesh [The Lancet 387:1484, 2016]. These stories are neither random nor coincidental, but part of the growing collective evidence of environmental deterioration and climatic instability. Such issues occupy some of our attention today, but will likely dominate much of the attention of our successors.
So what might we predict for the hot topics one year hence? I would put a major bet down that climatic heat will be a key feature of some of them.
Meanwhile, to help cope with daily change and challenges, good advice comes from the display labeled HOW TO WORK BETTER at the Guggenheim Museum in the exhibit mentioned above by Swiss Artists Peter Fischli & David Weiss.
DO ONE THING AT A TIME
KNOW THE PROBLEM
LEARN TO LISTEN
LEARN TO ASK QUESTIONS
DISTINGUISH SENSE FROM NONSENSE
ACCEPT CHANGE AS INEVITABLE
SAY IT SIMPLE
[Texas Hill Country poppy field. Linda Shortliffe, 2016]
Postscript: July 21 (Thursday at 5PM) Chang lecture on Art & Medicine: Don Nakayama, pediatric surgeon, will speak about his unexpected discovery in the Diego Rivera Murals. July 22 9 AM Duckett Lecture in pediatric urology – Caleb Nelson and Lapides Lecture – Bart Grossman.
David A. Bloom
University of Michigan, Department of Urology, Ann Arbor