July 6, 2018

Birthdays, graduations, and centennials
3678 words

One.

In July we welcome new residents and fellows to our urology program (more about them in the next few months) and it’s a nice time for them to be in Michigan. Si quaeris peninsulam, that is if you seek a pleasant peninsula (as the state motto goes), this is the time of year to explore this double peninsula with its 65,000 inland lakes and bordering four great lakes. Michigan is an appropriate name, coming from Ojibwe, meaning “large water.” Indigenous people inhabited this area for millennia, until 17th century Europeans moved in and called it home. [Below: Wikipedia.]

We celebrated America’s birthday on July 4 (fireworks above), but Michigan’s birthday is open to debate. Michigan Territory dates back to June 30, 1805 and statehood declaration was January 26, 1837, but an actual “birthday” doesn’t seem particularly important, federalism trumping state particularism. Michigan gained its upper peninsula in 1836 after the Toledo War. Like the ridiculous and bloodless Pig War, described on these pages last month, the Toledo Dispute grew out of conflicting geographic identities that quickly escalated, although some blood was spilled in Toledo when a young Ohio man with a penknife stabbed a deputy sheriff from Monroe, Michigan during a scuffle. Resolution of the dispute by the US Congress, during the presidency of Andrew Jackson, awarded Ohio the Toledo Strip while Michigan gained its Upper Peninsula. Annual Buckeye vs. Wolverine or Spartan contests ritualize the Toledo dispute although, for all the existential threats facing our species today, it is ridiculous that a Michigander might hate an Ohioan or a Buckeye despise a Wolverine.

Like most biologic lifeforms, we are engaged in life-long tests for survival and relevance, the relevance reflecting the necessity of belonging to some thing. Hard-wired into our genes, honed by millennia of trial and error, is the need to belong to a pack, a clan, a team, a family, a school, a community, a nation, or some belief system. Kurt Vonnegut satirized that notion of identifying with an organization or a particular geography in his book Cat’s Cradle (1969), where pride of membership in the General Electric Company, for example, or being a Hoosier seemed ludicrous. While Vonnegut challenged the meaning of such belonging, our genes compel us to those memes of identity and our national, sectarian, and religious identities are the most compelling. Identity as “an American” certainly supersedes identity as a Michigander, but endurance as a species may require a much stronger identity meme, namely that of being a global member of Homo sapiens. How we get there is anyone’s guess.

 

Two.

Beginnings. The Fourth of July was an arbitrary choice. The Resolution of Independence, legally separating 13 colonies from Great Britain, was signed by the Second Continental Congress on July 2, 1776. Congress then attempted to agree upon a document to explain the separation. The drafting of The Declaration of Independence had begun on June 11 by a Committee of Five led by Thomas Jefferson. Congress saw an early draft on June 28, but controversy over wording continued to July 2 and spilled over until agreement was reached on July 4. Signatures by state delegates didn’t begin until August and were not completed for several months [Danielle Allen, Our Declaration. 2014.].

This ambiguity gives us some license to pick a starting year for Urology at the University of Michigan. Genitourinary surgery was most certainly practiced from the earliest days of surgery in Ann Arbor but modern urology, with its educational and investigational components, is something substantially more. The actual term, urology, was invented by Ramon Guiteras, a genitourinary surgeon in New York City who founded the AUA in 1902. His book, Urology, in 1912 was one of the first 20th century texts to define the field, followed in 1916 by that of Hugh Cabot (below) an internationally famed Boston surgeon, with Modern Urology.

Disillusioned by the mercenary nature of his practice environment, Cabot accepted a “fulltime salaried” position at the University of Michigan as Chair of the Surgery Department in 1920. He brought modern urology to Ann Arbor, became the Dean of the Medical School, built a great multispecialty group practice, and presided over construction of a 1000 bed hospital that opened in 1926. His first urology trainees, Charles Huggins from Boston and Reed Nesbit from California, did well in their careers, influencing urology, worldwide medicine, and international events. Considering the various options, it seems reasonable and convenient to declare 1920, the year Cabot came to Ann Arbor, as the starting point for the Centenary of Urology at the University of Michigan.

 

Three.

Public universities. When Cabot arrived in Ann Arbor, the University of Michigan was already more than 100 years old and differed from any other institution the Bostonian had experienced. Medical education in Boston had been based on medical school relationships with separate private and public hospitals. When the University of Michigan established its own teaching hospital in 1869, however, it invented a new and different model of medical education. This has become a wholly owned and operated integrated health system containing a full range of medical practice and a research enterprise that comprises a rich milieu for professional health care education. The University of Michigan is further unusual in that it is a public university (birthdate in 1817) that pre-existed its own state (birthdate 1837).

The facet of American Exceptionalism that may matter most in the long run will likely be the magnificent patchwork of higher education consisting of public universities, private universities, liberal arts colleges, technical schools, research universities, professional schools, community colleges, and faith-based colleges functioning independently to build tomorrow’s citizenry. This patchwork is quite different from a single higher education system managed by a central state.

Public and not-for-profit colleges and universities in this country are shaped not only by their particular institutional legacies, but also by their public responsibilities. Because we are a free country, an entrepreneurial and commercial side of higher education also exists, with ultimate responsibility to owners, corporate officers, and shareholders. This sector is not the strongest point of the American patchwork.

The public status of a university and health system brings particular constraints and responsibilities. Constraint starts at the top for Michigan with ultimate authority at the board of 8 publically-elected regents, responsible to the people of the State of Michigan. Each regent also brings an individual sense of the missions of the university and its health system, aligned to the interests of their political party. Public responsibilities of public universities reflect public needs and aspirations in a larger sense, and convey to their learners, employees, and patients.

Private universities and health systems have their own boards and ultimate responsible parties, with values, needs, and aspirations are not necessarily the same as those of public institutions and therefore may align differently with learners, faculty, and employees. Even so, their not-for-profit status gives them public responsibilities.

A few months ago, these pages quoted a short campaign speech of presidential candidate John Fitzgerald Kennedy on the steps of the Michigan Union at 2 AM October 14, 1960, laying the seeds for the Peace Corps. While, JFK didn’t seem to quite understand how public universities were “maintained,” his point that they had a higher purpose was well taken: ” Let me say in conclusion, this University is not maintained by its alumni, or by the state, merely to help its graduates have an economic advantage in the life struggle. There is certainly a greater purpose, and I’m sure you recognize it.”  [Full speech below.]

 

Four.

Centennial. It is fitting that new leadership of this department of urology will be in place as we celebrate the Michigan Urology Centennial. Ceremonial interludes of this sort allow reflection, alignment, and revitalization before stepping into a new period. For purposes of planning we can start our Urology Centennial at the Nesbit Reunion in the autumn of 2019 and close it at the Nesbit Meeting in the autumn of 2020, roughly corresponding to a year in the academic calendar, but giving Nesbit alumni and friends two chances to get back to Ann Arbor for scientific and social events. A committee is already at work on this, under the leadership of Dr. Meidee Goh.

Before entering our second century, I’d like to clear up a nagging misconception. State support of public universities is dwindling nationally and this is particularly true in Michigan. Furthermore, virtually no state appropriations come to the UM health system or its medical school, aside for payment of services. It is true that other public medical schools have state-funded salary lines for faculty, but this is not so at UM. Nonetheless, many well-meaning Michiganders think their tax dollars support Michigan Medicine and that misbelief has led to hard-feelings in the competitive world of health care. One excellent referring physician from mid-state sent a rough email message to one of our faculty after hearing the UM “would not accept” his patient. In this case it wasn’t that Michigan Medicine would not accept the patient, but rather the “narrow network” of a stingy private insurer would not include Michigan Medicine in its network because Michigan’s costs have indeed been higher than average. It didn’t matter that this patient needed a complex surgical operation that is not done in most hospitals. Kudos to the referring physician for getting angry on behalf of his patient, but the anger was misdirected and to add a bit of insult to injury, the physician believed his taxes supported Michigan Medicine (wrong) noting that we would have cared for the patient under Medicaid or without any insurance (correct).

 

Five.

 

Visiting another peninsula. I was guest at another great public medical school and urology department that recently celebrated its first centennial, the University of California San Francisco. Our two institutions share many features and a number of Michigan medical students, trainees, and former faculty populate UCSF Urology. Unlike Michigan Medicine, UCSF is physically separate from its parent campus, across the Bay at Berkeley. The UCSF teaching hospital was founded in 1907, the year after the San Francisco Earthquake, and was the first university hospital in the University of California System. Schools of Medicine, Nursing, and Pharmacy co-located with the medical school on Mount Sutro along Parnassus Avenue and, like Michigan, the Parnassus Campus outgrew its geographic limits. While we at Michigan expanded to North Campus, East Ann Arbor Medical Campus, and other sites, USCF is also expanding widely, most notably to its grand new Mission Bay Campus. [Above: UCSF teaching conference with residents and an attentive canine named Peanut. Below: UCSF Assistant Professor Lindsay Hampson, UMMS 2009, next to Professor Kirsten Greene.]

[Below: top, Anne Suskind, Nesbit 2014 UCSF Assistant Professor and faculty David Tzou; bottom, Thai cooking class lunch with residents Heiko Yang UMMS 2016, Chef Sunshine, Adam Gadzinski UMMS 2013.]

Similar to Michigan, UCSF Urology celebrates graduation of its chief residents and fellows with dinner for families, faculty, and the entire resident cohort. Junior residents gently “roast” selected chiefs, just as we do in Ann Arbor. David Bayne, one of the graduating chiefs, was quoted by roaster Ian Metzler (whom I had met a few years back on the interview trail) as having once said: “Academic medicine is like a pie-eating contest, where the prize is more pie.” [Below: David & Shani Bayne.]

[Above: Peter and Laura Carroll at the St. Francis Yacht Club.]

 

Six.

Michigan’s chief dinner took place at our Art Museum the following week in June. Our graduating chief residents and fellows join a fine tradition of urology education in Ann Arbor going back to 1926, after UM opened its University Hospital (the fourth since 1869) and Hugh Cabot brought the first two urology trainees to Michigan. Since then at least 329 urology residents and fellows have come from this program. The exact number remains elusive as we don’t have a full accounting of all the fellows or the residents trained at the historic Wayne County General Hospital branch. Khaled Hafez and Gary Faerber had superb runs as program director over the past decade and the reins now pass to Kate Kraft. Our new PGY1’s were on hand for the evening.

[Above: Kate Kraft introducing new PGY1’s Kyle Johnson, Katie Marchetti, Roberto Navarrete, & Javier Santiago. Below: Amy Luckenbaugh and parents.]

Graduating chief residents are transitioning to fellowships: Amy to Vanderbilt Uro-oncology, Amir Lebastchi to the NIH Uro-oncology, James Tracey to Guys’ Hospital Andrology & Reconstruction, and Yooni Yi to UT Southwestern Dallas Reconstructive Urology. [Below: top, Amir with family and friends; middle, James and family, bottom, Yooni and parents.]

Fellows: Duncan Morhardt to Boston Children’s Pediatric Urology, Elizabeth Dray Columbia SC practice, Tudor Borza to University of Wisconsin faculty, and Courtney Streur joins our pediatric urology faculty. [Below: Duncan and wife Tina; Elizabeth with father Greg and husband David; Courtney between Professors John Park and Daniela Wittmann; Tudor between Ted Skolarus and Jeff Montgomery.]

 

Seven.

Memes. A few months back we raised the idea of the meme in relation to the blind eye metaphor. A meme is a parcel of self-replicating information that, like the biological gene, is capable not only of replicating into perpetuity, but also can modify itself through time and cultures such that the fittest versions survive. Richard Dawkins invented the neologism in his book, The Selfish Gene in 1976, noting that the concept pre-existed his description. He postulated that if one fundamental principle existed for all life it would be “that all life evolves by the differential survival of replicating entities.”

“I think that a new kind of replicator has recently emerged on this very planet. It is staring us right in the face. It is still in its infancy, still drifting clumsily about in its primeval soup, but already it is achieving evolutionary change at a rate that leaves the old gene panting far behind. … The new soup is the soup of human culture. We need a name for the new replicator, a noun that conveys the idea of a unit of cultural transmission, or a unit of imitation. ‘Mimeme’ comes from a suitable Greek root, but I want a monosyllable that sounds a bit like ‘gene.’ I hope my classicist friends will forgive me if I abbreviate mimeme to meme. If it is any consolation, it could be thought of as related to ‘memory’ or to the French word même. It should be pronounced to rhyme with ‘cream’.” [Dawkins. P. 248-249. The Selfish Gene. 40th Anniversary Edition.]

That idea of the soup of human culture corresponds to the concept of superorganisms created by eusocial species, as E.O. Wilson has elegantly described in his work. Just as the gene is the building block of information that constitutes each individual, language and memes comprise the information that constitute the superorganism. Germ theory, shoe lace tying, tweetstorms, and the meme itself, are successful memes.

 

Eight.
The soup of human culture meme recalls a sensational episode of plagiarism involving Maurice Maeterlinck (1862-1949), Belgian author and Nobel Laureate (Literature, 1911). Well-known in his time, he had a stint in the United States produce film scenarios for Samuel Goldwyn in 1919, although none became a movie. One scenario was The Life of the Bee, although Goldwyn heartily rejected the idea of a movie about a bug. Back home in 1926, Maeterlinck published a book called La Vie des Termites (The Life of White Ants), although reportedly admitted he never actually seen a living termite. His source, boldly copied, was obscure work published in 1923 in Afrikaans by Eugene Marais, called The Soul of the (White) Ant. [Wikipedia.]

Extensive field work observing termites “on the veld,” led Marais to the idea of “the organic unity of the termitary” analogous to the organ-based composite human body. Maeterlinck appropriated the Marais theory 3 years later, boldly plagiarizing the text. Marais threatened a lawsuit although didn’t pursue it due to financial barriers. A subsequent English edition of Marais’s original book contains an introduction by its translator, Winifred de Kok assigned priority and credit to Marais, while pointing out the plagiarism. [Eugene N. Marais. The Soul of the White Ant. Methuen & Co. London. 1939.]

Tracking down the meme story, I found the Dawkins neologism and then noted the Maeterlinck transgression in Wikipedia, where University of London professor of biology David Bignell described the episode “a classic example of academic plagiarism.” Not wanting to fall into the realm of plagiarism myself, I tried to track down the evidence for this claim (after all, Maeterlinck was a Nobelist!) and went to the reference cited in Wikipedia but couldn’t find the actual claim. I did find an email address for Professor Bignell, composed my question, and pressed “send.” A reply from the next morning was a wonderful surprise. Professor Bignell wrote:

“Thank you for your message. This has rather made my day. I am long since retired, but it’s always stimulating to be dragged out of retirement with a question about termites, however obtuse. … The only public reference I have ever made to the Marais/Maeterlinck issue was in my Inaugural Lecture in October 2003. In the UK, newly promoted Full Professors are obligated to give a public lecture (widely advertised and open to anyone to attend), and I might add a terrifying experience as it’s your one opportunity to make a complete fool of yourself without any subsequent means of redress. I stuck to my subject (termites) but included a reference to the plagiarism, as it had become celebrated in the world of science, and bizarrely was one of the reasons why termites sometimes command public attention.”

 

Nine.

Mimes & plagiarists. Mimicry is the biological phenomenon in which one organism evolves characteristics that resemble those of another group. This is akin to a theatrical phenomenon, the performance art of acting out a story or a persona, the term coming from the masked dancer in ancient Greek comedy called Pantomimus. Marcel Marceau, French actor and survivor of the French Resistance in WWII, became the most famous meme of modern times and brought silent mimed exercises to a high art, inspiring Michael Jackson among others.

[Publicity photo of Marcel Marceau for appearance in Seattle, Washington, 1974. Wikipedia.]

[Mime artists Jean & Brigitte Soubeyran in the play “In the Circus” 1950. Wikipedia.]

As a young surgeon I tried to mimic attributes of my key role models. At UCLA they were William Longmire, Rick Fonkalsrud, Don Skinner, Rick Ehrlich, RB Smith, and Jean deKernion. In London it was David Innes Williams and in Boston, Judah Folkman and W. Hardy Hendren. Each set high bars for thinking, clinical acumen, surgical skill, patient rapport, teaching, and wisdom. Role modeling is essential to professional education, where the so-called hidden curriculum of behaviors is as important as the conceptual knowledge and skills that are imparted.

The truism that imitation is a high form of flattery, however, stops short of plagiarism. Plagiarism is theft of an original idea or work and representation of it as one’s own. Most work of civilization is collaborative with some decree of mimicry, but deliberate plagiarism betrays civilized behavior and represents fraud, theft, and deceit. Erosion of trust in science and medicine is particularly dangerous. Even though plagiarism seems to be a rare event in academic circles of urology, it happens. Most people can easily distinguish the difference between passing along memes and outright plagiarism. Science, literature, and the other arts build upon the imagination of our predecessors, and the memes they created or passed along replicate only through re-use, evolving in that reuse through the trial and error of application (or errors in transcription). The fairness of civilization demands that credit be given when credit is due, recognized through patents, copyrights, and academic integrity.

Plagiarism happens in a number of ways. Some people, unfamiliar with traditions of intellectual honesty and personal integrity, may resort to lazy plagiarism of an idea, paragraph, illustration, or even more. Other plagiarists rationalize that their “scholarly methods” allow cutting and pasting without attribution as “honest mistakes.” I’ve heard a number of these excuses even from a few otherwise respected colleagues when caught in the peer review process. On the other hand, when journalist James Stewart wrote his factual account, Blind Eye, he used a very widespread metaphor (a meme) for the dark and true story of educational supervisors who turned a blind eye to terrible misdeeds of an aberrant human being. [Blind Eye. 1999. Simon & Shuster.] Stewart, however, didn’t need to acknowledge Admiral Nelson for the meme, we would call that fair use, and such acknowledgement would border on pedantic explanation, when no explanation is necessary. Blind eye is now part of our language.

We all replicate memes, but gross plagiarism discovered occasionally during journal review makes me angry. It wastes the time of the reviewer and discredits our “brand” as scholars in the eyes of the public. We expect our resident graduates to mimic the best of what they observe and then to build on that to become their own originals in thought and action. Furthermore, we hope they will never turn a blind eye to plagiarism or other breaches of civility.

 

Ten.

Graduating urology trainees carry with them rich identification with their training programs and join unique cadres of fellow alumni that may reach back more than a century, as for Johns Hopkins, the first formal urology program. Most physicians identify reverently with their residency training sites. Human complexity allows us to find relevance in numerous contexts and, to that end, medicine as a generality for health care, is a greater belief system than mere occupation or specialty. More than most professions, medicine is central and essential to life and its fulfillment. We each begin life as patients, are among the rare species that routinely need assistance for childbirth, and we are the only species capable of complex therapies based on shared, verifiable, and accruing knowledge and technology. Medical practice is, above all, a performance art.

The art of medicine exists in the choices of excellence, kindness, attentiveness, education, innovation, skills, investigation, and fiduciary duty brought to the daily work of clinical care, and updated in daily practice through immersion in the soup of human culture. We extend that immersion through other forms of art, as the title of a book by Robert Adams provocatively claims. [Art Can Help. Yale University Press, 2017.] Visual, musical, and other performance arts inspire thought, admiration, criticism, inquiry, and further creativity. The arts help us answer our continuous tests for relevance as trainees, new graduates, and old hands in urology.

Thanks for reading Matula Thoughts this July, 2018.

David A. Bloom
University of Michigan, Department of Urology, Ann Arbor

 

Kennedy’s speech. When you listen to a recording it differs somewhat from this official printed version.

“I want to express my thanks to you, as a graduate of the Michigan of the East, Harvard University.
I come here tonight delighted to have the opportunity to say one or two words about this campaign that is coming into the last three weeks.
I think in many ways it is the most important campaign since 1933, mostly because of the problems which press upon the United States, and the opportunities which will be presented to us in the 1960s. The opportunity must be seized, through the judgment of the President, and the vigor of the executive, and the cooperation of the Congress. Through these I think we can make the greatest possible difference.
How many of you who are going to be doctors, are willing to spend your days in Ghana? Technicians or engineers, how many of you are willing to work in the Foreign Service and spend your lives traveling around the world? On your willingness to do that, not merely to serve one year or two years in the service, but on your willingness to contribute part of your life to this country, I think will depend the answer whether a free society can compete. I think it can! And I think Americans are willing to contribute. But the effort must be far greater than we have ever made in the past.
Therefore, I am delighted to come to Michigan, to this university, because unless we have those resources in this school, unless you comprehend the nature of what is being asked of you, this country can’t possibly move through the next 10 years in a period of relative strength.
So I come here tonight to go to bed! But I also come here tonight to ask you to join in the effort…
This university…this is the longest short speech I’ve ever made…therefore, I’ll finish it! Let me say in conclusion, this University is not maintained by its alumni, or by the state, merely to help its graduates have an economic advantage in the life struggle. There is certainly a greater purpose, and I’m sure you recognize it. Therefore, I do not apologize for asking for your support in this campaign. I come here tonight asking your support for this country over the next decade.
Thank you.”
Senator John F. Kennedy
October 14, 1960