DAB What’s New Aug 4, 2017
Summertime secular thoughts
Summertime. Summer is busy for children’s surgeons. Well in advance of the upcoming summer, as early as winter, families schedule elective surgery for their children. Aesthetically, summer began for me in May when peonies opened up in the Nichols Arboretum adjacent to Mott Children’s Hospital. Meteorologically, summer started at the northern hemisphere solstice when the Earth’s axial tilt toward the Sun peaks with its highest position in the sky at the north pole (12:24 AM EDT June 24 this year). By now we are in summer primetime having enjoyed Farmers’ Market, resident/fellow graduation at the Art Museum, Ann Arbor Summer Festival, fireflies, Top of the Park, chiefs’ roast, July 4 fireworks, Art Fair, Chang-Duckett-Lapides visiting professorships, Zingerman’s outdoors, and other seasonal pleasures counterbalancing our jobs. [Above: Art Fair – Matt Lee, Lindsey Herrel, Rita Jen. Photo by Ted Lee]
[Above: UM Peony Garden & Mott; below: Art Museum graduation dinner for chief residents and fellows.]
[Below: boating on Huron]
[Above: Summer Festival. Charles & Julie Ellis, Rhiannon Giddens; below: hotdog line in front of Human Genetics Department with Joette Goudie, Lisa Turek, Pattie Postel, Sandy Heskett, Maranda Valentine, Phoebe Hankins, Liz Daniels, Marlene Muscott, Amanda Thatcher, Shelby Chase.]
All jobs are performances, some more complex than others, but no matter what the work may be individuals can bring art and professionalism to any job. What inspires performance? Ultimately, it is a matter of internal drive, the personal motivation to go beyond mere competence to achieve one’s best, to find excellence, to bring art to tasks. In earlier agricultural and early industrial societies people either worked for themselves or had their work regulated by ancient “carrot and stick” motivations. Frederick Taylor’s influential monograph in 1911, The Principles of Scientific Management, argued that managers should coordinate workers by using data, leading to the idea of managerial accounting.
In the modern knowledge economy, internal motivation (see Daniel Pink, Drive) and lean process thinking (Johnson & Bröms, Profit Beyond Measure) seem better ways to understand, stimulate, regulate and standardize work, as well as satisfy stakeholder needs rather than using carrots and sticks. For the multi-pronged mix of clinical care, education, and discovery of academic medicine, internal motivation is the key to high performance, quality improvement, value, standardization, and job satisfaction, all with art that inspires further motivation. Carrots and sticks may have been useful motivational tools in commodity commerce, but don’t satisfy the health care market nor improve the genre of medical practice.
Graduating urologists step into their next career stages this month. Katy Konkle joined a practice in Pueblo, Colorado, Ian McLaren is with a 5 -person urology group in Wenatchee, Washington, Duncan Morhardt stays with us for a year of research prior to pediatric urology fellowship at Boston Children’s Hospital, and Ryan Swearingen enters a practice in Indiana.
The work of physicians changed since I took that same step in 1980, moving from residency at UCLA to a staff position at Walter Reed Army Medical Center in Washington DC. My practice, like that of any urologist then, was spent mainly one on one with patients in clinics, at bedsides, or in operating room teams. Today, however, clinicians spend as much time focused on computers and keyboards as directly interacting with patients. A recent paper in Health Affairs demonstrates the tyranny of the modern electronic medical record demanding equivalent parcels of physician time spent at computers as facing patients. [Ming Tai-Seale et. al. Electronic Health Record Logs indicate that physicians split time evenly between seeing patients and desktop medicine. Health Affairs. 36:655-662, 2017] Computer interfaces proliferate in operating rooms today, but remain more tools than tyrants, although the imagery is ironic.
[Above: Alon Weizer’s OR with Joe Bloom by the patient; Below: Dr. Weizer at controls.]
Eighty years ago, this month, the head of the Section of Urology at the University of Michigan in the Department of Surgery published an important paper in the New England Journal of Medicine. This fact is doubly curious because it was a surgical paper in a journal of medicine and Michigan is hardly in New England. That journal, the “journal of record” for historical and contemporary reasons, attracted the most important medical papers internationally, a reputation still largely intact although challenged by other world journals such as The Lancet, British Medical Journal, and the Journal of the American Medical Association. Reed Nesbit’s paper had global significance, as TURP became the gold-standard solution for the common curse of benign prostatic hypertrophy. The surgical procedure was as much art as skill and Nesbit was the go-to TURP artisan of the time, attracting trainees and visitors from around the world. The centennial of urology at the University of Michigan (1920-2020) is approaching and the changes in urology, some emanating from the University of Michigan over those 100 years, are astonishing to consider. More largely, the changes in healthcare itself are enormous, and much of the change is due to massive expansion of the federal role.
The role of government in the life, liberty, and pursuit of happiness of its citizens intensified in the USA midway in the span of academic urology at University of Michigan. The expanded role affected all aspects of medical practice, education, and research. Countless factors influenced and displayed this change, but two are particularly salient. One milestone was the new national attitude expressed in the Four Freedoms speech of Franklin Roosevelt (January 6, 1941), discussed previously here in Matula Thoughts [Jan 6, 2017 matulathoughts.org]. The Social Security Act of 1965 turned attitude into public policy, immersing government deeply in the healthcare of its people. Although strongly resisted at the time, few can deny that social security is an American core belief. While admittedly imperfect, Veterans Administration and Medicaid funding of healthcare, including skilled nursing facilities for the aged, infirm, and impoverished, provide social security necessary for the stability and ultimate productivity of the country. No rational person who has worked in a VA hospital, Federally Qualified Health Center (FQHC), or nursing home can argue that they are overfunded, although efficiency can always be improved.
Waste occurs in all human activities, it is a natural part of biology. Inefficiencies and mistakes are parts of normal life and learning, our challenge is to attend to them and learn from them. That’s why we inspect the work of our trainees, why we use “lean processes”, why we have morbidity and mortality conferences, why we perform root-cause analyses for errors, and so forth. We pay attention to waste on a daily basis in healthcare, although we could do better, recognizing that local attention to waste by workers in workplaces is the best way to improve products, satisfy customers, and create efficiencies. Centralization of waste reduction, or for that matter centralization of national economies, is a failed experiment amply demonstrated in 20th century authoritarian and communist nations. It also didn’t work so well when authoritarian industries and unions contested for control. Optimal workplaces rely on democratic ideas of liberty and equality, but not in trivial senses. For example, physicians and other health care providers have liberty of free expression like all other citizens, but in their professional roles they are not generally free to bring political or sectarian judgments to patients and their treatment.
America’s commitment to social security, a robust experiment in progress, is threatened. Without a commitment to social security, societies aren’t very nice and don’t look good at the street level, whether rural or urban. Medicaid and the VA provide food, shelter, healthcare, and a measure of security for at least one quarter of the population of the United States, but this massive safety net still misses millions of people, 24 million at the last count I heard. Consider the effect of going back before the Four Freedoms became a national belief, and absent the Social Security Act. The effect on the national economy would be negative, and the mere optics of streets, neighborhoods, cities, and rural communities would reflect an unkind and sad society. The population would be more grossly disparate economically than today and future society would likely be a contest between the lesser nature of mankind’s stone age phenotype against a necessarily Orwellian world.
Hawthorne. This month has its share of notable anniversaries, but one birthday that may not spring to many minds tomorrow, August 5, is that of Henry A. Landsberger, born August 5, 1926 in Dresden, Germany. A Kindertransport refugee at age 12 to England and later a Cornell Ph.D. graduate, this distinguished academic spent his career studying industrial and labor relations. His 1958 article described the “Hawthorne Effect”, the name of a town in Illinois.
The Western Electric factory (below) in Hawthorne conducted a study circa 1930 under sociologist Elton Mayo on the effect of physical environment and work conditions (lighting, rest breaks, work hours, etc.) on worker productivity. Mayo’s group originally concluded that attention to workplace conditions improved productivity, but Landsberger later deduced that it was the novelty of attention that produced higher productivity of the workers. This so-called observer effect, which proved temporary, continues to be debated today, although it is self-evident that the fact of observation is likely to affect performance.
Prior to Hawthorne, simplistic ideas of the ancient “carrot and stick” and the “scientific management” concepts of Frederick Taylor dominated discussions of labor and productivity. Currently, Toyota’s “lean process management” coupled with Daniel Pink’s observation that internal motivation is the best driver of productivity ring true to my experience, harmonize better with democratic societies, and give superior results. Still, the take-away from Hawthorne is that the act of measurement is likely to influence performance and results, in some ways a phenomenon akin to Schrodinger’s cat, in that the act of observation can be consequential to a given reality of the subject.
Whether you are an industrial engineer or an average citizen, there is little doubt of the observer effect relevance. This explains why people get on scales every day, count their steps, time their marathons, measure their RVUs, and test their cholesterol or blood sugar. Measurement matters to the human brain and subtle or gross changes in performance are likely to result. The more you examine something, the more you see in it and the more it changes, at least in your mind and imagination. Schrodinger’s cat, thus, has far more than 9 lives.
Universities are society’s best bet for creating a better tomorrow. Medical schools do their part, blending didactics and investigation in rich milieus of clinical practice to produce tomorrow’s physicians, but universities should be challenged to produce a larger part of the spectrum of healthcare workers, training medical assistants and physician assistants, for example, rather than relying on their education from a mix of proprietary schools and other facilities that lack the breadth, depth, and integration of academic medical centers in universities such as ours. A grander vision of health care education nationally would invigorate the medical work force and certain broaden the regional and societal impact of universities.
Few, if any, universities fulfill their educational missions fully. American universities evolved from colleges educating clergymen and civic leaders (Harvard 1636), to institutes training technical professionals (Rensselaer 1824), and research universities (University of Chicago 1890). Modern universities contain schools and colleges plus health systems, research institutes, technology transfer programs, athletic programs, art museums, libraries, performance schools, and a myriad of other things. However, universities need to more fully embrace their roles in educating tomorrow’s global citizens, building tomorrow’s workforces, and generally strengthening human society. As universities fail to step up to the challenge, what other entity in the world can we count on? Surely not “the market.” A controversial book, The Golden Passport: Harvard Business School, the Limits of Capitalism, and the Moral Failure of the MBA Elite by Duff McDonald, takes an iconic business school to task in this regard. Coincidentally I saw a review of this while re-reading Robert McNamara’s book, In Retrospect, wherein he described his experience in the same business school.
“After Berkeley, I attended Harvard Graduate School of Business Administration, soaking up the nuts-and-bolts skills I figured I would need to land a job. Many on the faculty appeared to believe that the purpose of business was solely to make money. But a handful of people, including Ross G. Walker, my financial controls professor and Edmund P. Learned, my marketing professor, took a broader view. They taught that business leaders had a duty to serve society as well as their shareholders, and that a company could drive for profits and at the same time meet social responsibilities. I think of this in a phrase Walker and Learned might have liked: ‘There is no contradiction between a soft heart and a hard head.’ That has been a guiding principle in my life.” [In Retrospect. P. 7]
Economic marketplaces test the principles and character of their workers, and time is the ultimate arbitrator of the testing. Many companies and individuals fail. Certain automobile companies, we have learned, systemically cheated with software programs to produce bogus favorable emissions results during testing or concealed critical safety issues. Health care is not immune to character corruption, with sad examples even in our institution and department, historically. Much like doping in sports, those who get away with cheating may win today, but the long-term consequences of discovery will likely be far more expensive than transient moments of glory, gold medals, or favorable earnings reports. Integrity and character matter. Cheaters steal from the rest of us and civilization is durable only if integrity and reasonable rules are embraced widely.
Sectarian vs. secular. These adjectives, although similar in sound, are antonyms, having opposite meanings. Sectarianism is behavior with ideological, regional, ethnic, partisan, political, or class-based motivation. Naturally everyone has distinct individual identities that reflect these underpinnings, but global citizenship requires that personal sectarianism does not pervert thinking, behavior, and socially-oriented decision-making. Global citizenship may seem an ephemeral idea and impractical aspiration, but the future of seven billion humans inhabiting a single planet depends upon it. Society pays scant attention to the idea of global citizenship in schools, businesses, or politics. Universities attend to this partially, but too lightly. The UN tries to further global citizenship, and some forward-thinking multinational corporations recognize the importance of the idea if there is to be a viable tomorrow for the next generation of humanity, stockholders included. Fitzhugh Mullan in a recent JAMA viewpoint describes how the traditional health professional education has expanded beyond education, research, and clinical care to also include a social mission called “beyond Flexner.” [Mullan. JAMA. 318:122, 2017]
Secularism describes nonsectarian judgment and actions, free of religious, political, ideological, orthodox, or tribal points of view. Secularism is equivalent to cosmopolitanism, that is, world views open to reasoned judgments free of commitments to prior positions, beliefs, or agendas. Secularism is at the heart of the classical liberalism explicit in the Declaration of Independence and the Constitution, with life, liberty, and the pursuit of happiness. The liberty to make judgments and express them freely is the essential basis of a free society. The general security, education, and equality that societies create through government should promote reasoned judgments, creativity, and general prosperity for their people. At least that is the hope of civilization.
Further events enhanced the summer. David Watts, gastroenterologist, poet, and performer (above) delivered this year’s masterful Chang Lecture on Art and Medicine, our 11th, called “Love, Words and Medicine.” Ford Auditorium was nearly filled and the spell-binding lecture fulfilled all of our aspirations for an inspiring articulation of the relation of art and medicine (video copy available).
Michael Ost (UM, MD 1993; Ross MBA 2017) from University of Pittsburgh gave a superb Duckett Lecture on pediatric stone disease and Jim Lingeman of Indiana University presented a panoramic view of his innovative findings on the origin of renal calculi in his Lapides Lecture. [Above – Chang Lecture, below – Lingeman & Ost]
The yearly White Coat Ceremony, where entering medical students receive short white coats and stethoscopes, is opening day for the rest of their lives (above: 2016 White Coat). The symbolism of the 2 gifts is strong. White coats signify professionalism, cleanliness, identification, secularism, and protect personal clothes. Stethoscopes are practical tools as well as metaphors for listening. They connect you to patients through physical touch and your attention. After invention in 1816 by Laennec in Paris, the stethoscope replaced the matula as the symbol of medicine. New students taking this first step into their careers share the equivalent of the altruistic gene that has accompanied Homo sapiens from the start. Below: August 1, first day of medical school. M1 groups enjoying a sunny lunch hour outside dean’s Wing.
The excitement of this moment in time for medical students, may be offset by bewilderment concerning the national healthcare scene. It is a mess, few can deny that. How can politicians, policy experts, bureaucrats, technocrats, theocrats, autocrats, plutocrats, lobbyists, capitalists, or socialists, at democracy’s table build a health system that serves the public well, educates the next generation of health care workers, and advances knowledge and technology efficiently? Clearly, the various sectarian entities are not getting the job done.
Tour de Consult. Julian Wan started something remarkable ten years ago. Back then, in those days of competing silos of the hospital-medical school- clinical departments, the hospital financial services data told us that our department averaged only 0.8 consult billings per day. That didn’t seem quite right, because even my small division of pediatric urology seemed to have 1-3 consults on a typical day. The hospital data provided lacked experiential validity, so Julian took it on himself to create a consult database. Navigating some grumbling on the administrative side and inertia of our clinical teams, Julian gained the active engagement of the residents, the key to making the database valid. Julian’s brilliant ploy consisted of making the added work fun and rewarding for the residents by turning it into a game, The Tour de Consult. Now 10 years later we find that our department averages over 8 consults daily.
[Above: Dr. Wan listing the Double Century Club contenders. Below: Yooni Yi collecting the prize at the end of July M&M Conference.]At the start of the residency training year, chief residents pick teams of colleagues for The Tour and begin a new season. The teams select their own names – this year they are Guardians of the Glomeruli, Luck and Balls, Amir’s Dynasty, and Everything’s Bigger in Texas. Periodically at Grand Rounds Dr. Wan updates everyone on team progress. Faculty are also included in the reporting, but are not on the teams. Final results and awards are presented at the end of the year. Julian himself funds the gifts and won’t take any help or contributions for the iPads and Apple computers he gives the winners. [Above: awards at Grand Rounds] In addition to the ultimate team awards, Julian has created individual awards such as the Century Club (more than 100 consults in a year), Double Century Club, and the new Triple Century Club.
The Tour has turned consults into incremental financial benefit for the department, increased the quality of care due to better attention and documentation of each consult, maximized the educational value of consults by pulling in the faculty more consistently than before, improved our ability to predict on-call coverage for our urology department, and has also turned this “experiment” into academic products, namely scientific papers from the consult data base: Prospective tracking of pediatric urology consults: knowing is half the battle by Emilie Johnson et al (J Urol 187:1844, 2012) and Pediatric urethral catheter consultations: understanding driving factors by Nina Casanova et al (J Urol 191:1396, 2014) are 2 examples.
Summertime. This classic song of this season was completed by George Gershwin in February, 1934, as an aria and lullaby for his only opera, Porgy & Bess. Gershwin didn’t get the chance for another opera, as he died of brain cancer (glioblastoma multiforme) 3 years later in July, 1937, at age 38. DuBose Heyward wrote the lyrics, as well as the 1925 novel Porgy, the basis for the opera. Over 25,000 different recordings of Summertime exist [J. Nocera. Variations on an explosive theme. NYT. Jan 21, 2012]. By interesting coincidence, Heyward was a descendant of Thomas Heyward, Jr. a signer of the Declaration of Independence.
The Ann Arbor Summer Festival is a wonderful community collaboration of city government, the University of Michigan, private businesses, nonprofit organizations, philanthropic donors, volunteers, artists, participants, and children. If you missed it this year, calendar an evening for it in 2018. The kids in blue and red above are those of Associate Professor and VA Chief Ted Skolarus and his wife, Lesli, Associate Professor of Neurology. I encountered them twirling hula hoops in front of Rackham one evening last month. I was surprised to see these hoops back in action. They were popular when I was a kid, although I wasn’t as successful with them as the Skolarus boys. Hoop dancing, an ancient method of Native American storytelling uses hoops made of wood, grasses, bamboo, and vines, but the plastic toy hoop made by Arthur Melin and Richard Knerr (Frisbee inventor) in 1958 was a major success for their Wham-O manufacturing company. Nowadays, people get stories from television, computer screens, or print media and hula hoop spinning persists as just plain summertime fun for kids of all ages. With another month to go, summertime 2017 has been good in Ann Arbor, reminding me often that we can bring art in many forms not just to medicine, but to all of life.
Thanks for reading this monthly column of mostly secular thoughts from my perspective in the Department of Urology at the University of Michigan.
David A. Bloom
University of Michigan, Department of Urology, Ann Arbor