Matula Thoughts Sept 7, 2018
September skies and serendipity
Intersecting contrails caught my attention, looking out from the Mohs Surgery area (above) in our Rogel Cancer Center, and recalled the clear skies of September 11, 2001, when commercial air traffic was grounded, leaving a pristine and surreal atmosphere visually and psychologically. Transient evidence of people in aluminum tubes flying through the sky, contrails are daily proof of the enormous planetary human impact. New technology, such as the flightradar24 app that Bob Gibbons showed me in Seattle last spring, gives rough details of a particular flight if you aim an iPhone at a plane in the sky. Below, taken from the Amana Colonies in Iowa last month, is evidence of Delta 3882 Canadian Regional Jet going from Minneapolis to St Louis on July 27, containing anonymous people, particularities, and myriad stories going about their business in the midwest.
September is a transition month, as summertime vacations give way to serious business of autumn. In the Medical School, academic medicine takes center stage when fall meetings convene and new ideas get shopped around world marketplaces of research, education, and clinical care. Faculty become traveling salesmen and saleswomen not only for their ideas, but also for their presentation skills, and the University of Michigan brand in general. Trainees follow in those footsteps, adding to the thousands of Michigan people shuttling around in the skies at the vanguard of contrails, studying and rearranging PowerPoint presentations on laptops. Key meetings for our faculty this fall include the Society for Urologic Oncology, the American College of Surgeons, the North Central Section of the AUA (our Gary Faerber – now at Duke – is the President), and the Society for Pediatric Urology.
Rene Magritte, an artist who lived in and through the disruptions and transitions of 20th century World Wars, offered an intriguing view of Homo sapiens and earthly skies in two paintings he called The Human Condition. No one can know for certain what he had in mind with these, although the title hints at the rich imagination, ambiguities, illusions, and contradictions of human nature. Probably no other species looks to the skies and finds as much “content” as we do. Other life forms may, at best, derive some practical information regarding sunlight, time of day, precipitation, danger, or opportunity, but H. sapiens looks at the sky with its clouds and contrails, and builds rich imagination from excited neurons.
[Above: The Human Condition 1933. Below: The Human Condition 1935.]
Euclidean Walks, a later Magritte painting from 1955, pursues the same idea of a painting within a painting, that is, an imagination of imaginations, joining my and your imaginations to those of a Greek philosopher nearly 2.5 thousand years ago (below).
A picture is said to be worth a thousand words. The original author of this thought is unknown, although it is likely that similar thoughts spontaneously popped into many human brains over the millennia since the early times of cave art. We all appreciate the qualitative truth to this phrase, but Isaacson’s book Leonardo da Vinci, offers data to support that truth, at least within an order of magnitude. A chapter on The Nature of Man, discussing human proportion, states:
“Using at least a dozen young men as models in his Corte Vecchia studios, he measured each body part from head to toe and produced more than 40 drawings and six thousand words.” [p. 219]
That is, Leonardo used six thousand words to consider 40 pictures, giving a word to picture ratio of 1:150, surpassing conventional wisdom of 1:1000 for the average picture. Granted that he wasn’t necessarily describing all the details of each of the pictures, as merely talking about them, but data is data so you can take what you want from the numbers. Later in the book, Isaacson quotes Leonardo from a debate in 1498 on the relative merits of arts and sciences.
“If you, O poet, tell a story with your pen, the painter with his brush can tell it more easily, with simpler completeness, and less tedious to follow. Take a poet who describes the charms of a woman to her lover, and a painter who represents her, and you will see where nature leads the enamored critic.” [p. 262]
Mona Lisa (above, at the Louvre) is the obvious picture to accompany that thought.
Words are magical finite bits of information, but a single picture conveys a multitude of information, open to vast possibilities of imagination by any one individual and leaving other vast possibilities potentially detectable by someone else. While words and pictures may have had common origin in human history, visual art has extended from the representational to the abstract and Eric Kandel explains how our brains process these two different art forms in quite different ways. [Kandel. Reductionism in Art and Brain Science, Columbia University Press, 2016.]
The contrails reminded me of the acid-base balance curves I studied as a medical student, becoming nearly indelible in my brain, needing occasional refreshment for board exams and teaching sessions. Horace Davenport (1912-2005), renown physiologist and legendary historian of the University of Michigan Medical School, pioneered the modern understanding of acid base chemistry with those curves [Davenport HW. Danish M. Bull. 1955, The ABC of Acid-Base Chemistry, University of Chicago Press, 1974.] [Austin WH. Acid-Base balance. Amer. Heart J. 69:691, 1965.]
Horace was an iconic professor here at UM Medical School. He rose to the top of his field as a physiologist and was an inspiring classroom teacher. During his early career, at the Mayo Clinic, he defined the gastric mucosal barrier, working with Charles Code, and in 1947 his ABC text translated mysteries of basic physiology into working knowledge for generations of medical students and clinicians using those contrail-like curves. [Davenport HW, University of Chicago Press, 1947.] The ABCs is still in print with the original preface, admonishing students to work hard if they are to achieve understanding:
“Unfortunately, there are no effortless roads to a knowledge of acid-base chemistry, and there are no easily memorized rules-of-thumb that can be applied at all times in the clinic without risk of disaster.”
After Davenport stepped down as Michigan’s chair of physiology he became unofficial historian for the Medical School, providing a book for the sesquicentennial. [Davenport HW. Not Just Any Medical School. 1999.] I came to know Horace through the Victor Vaughan Society and its periodic dinners of medical students and faculty. Horace was unusually tall and in his later years when the occasion met at our home I would cautiously walk him out over our uneven steps and dirt road to his car, concerned for his unsteady gait. We remained in touch throughout his retirement. At one point (June 3, 1998) he wrote me from Alabama:
“I am living in my wheelchair in complete physical, social, and intellectual isolation and with rapidly increasing disability in what is essentially comfortable prison. I try to keep occupied.”
If my small collection of his neatly typed letters is any indication, he seemed to have kept reasonably well occupied for the next seven years of his life. [Obituary by Ivan Oransky. The Lancet. 366:1260, 2005.]
Two Horaces. Horace Davenport was a perfectionist and an exacting teacher. His son, Robertson Davenport and UM Professor of Pathology, kindly sent me the portrait shown above. I recall one episode of my instruction from Horace after I sent him recent work we had published on Trendelenburg, a paper that sprang from a discussion with medical students regarding the German surgeon and informed by an obscure autobiography (translated from German to English) we obtained from an Egyptian library (the beauty of inter-library loan!). Our paper detailed urological contributions of the great German surgeon that had not been widely appreciated. [Bernstein et al. Beyond the Trendelenburg Position. Surgery. 126:78, 1999.]
I thought we had done a good job of scholarship and must have been hopeful for Horace’s praise when I sent him a copy. He replied, after offering some personal news:
“I have only one comment on your Trendelenburg paper, and that is to protest the customary misuse of the word serendipity in the first paragraph. A Chicago lawyer named T.G. Remer became so annoyed that he wrote an entire book on the word: Serendipity and the Three Princes, Norman, OK. University of Oklahoma Press, 1965. I urge you to read the book which is in the Graduate Library. With best regards, Yours, Horace.” [Letter. August 24, 1999.]
Months later I went to the library, checked out the book, and read it. Horace was correct, having instructed me once again on many levels.
Remer had a compelling interest in this 14th century Persian fairy tale that had been translated into Italian and published by Michele Tramezzino in Venice in 1557. English art historian Horace Walpole (1717-1797) created the word serendipity based on a detail in the story in which the three princes discerned the nature of a lost camel through “accidents and sagacity.” Walpole no doubt had read Tramezzino’s version of the “silly fairy tale,” as he called it in a letter on January 28, 1754, when he originated the neologism. [Wikipedia, The Three Princes of Serendip.] Remer commissioned an English translation of the Italian story and included it in his book, a lovely a tour-de-force and obvious labor of love. The point Horace Davenport wanted me learn for myself was that serendipity has two necessary elements: luck and sagacity, or good fortune and wisdom, depending on how you phrase it. He was rightfully offended when I used the term as a mere synonym for dumb luck and I doubtless offended the spirit of Horace Walpole as well. [Below. Horace Walpole by Sir Joshua Reynolds. 1756. National Portrait Gallery, London.]
Our Medical School Center for the History of Medicine has a yearly Davenport Lecture that featured many superb speakers over the years including Abraham Verghese, Catherine DeAngelis, David Oshinsky, and Sherwin Nuland. The speaker next spring remains to be determined.
Art & medicine notes. Somewhere recently I came across the phrase “human confection” and wish I could recall the source. Perhaps it was in a newspaper or magazine, but it seemed an interesting conjunction. At first thought, confection indicates a sweet food item, perhaps visually decorative as well, but the meaning goes deeper and traces back to Middle English confescioun, coming from old French confeccion, and derived from Latin cōnfectiōnem meaning “to make” or “to prepare” or “to do.” Modern usage, aside from food, pertains to the process or result of preparing or making or composing things, things that may be elaborate, amusing, delicate, or possibly contrived. This is an almost uniquely human range of possibilities, so it seems that human confection fits nicely. Perhaps this is even better than the phrase human condition, that more or less merely indicates a particular state of being. H. sapiens are singularly distinguished by the range of things they do, physically, mentally, and trans-generationally.
Artists usually tell something of themselves and the world through their work. Some produce skillful representations of the real or imagined world. Others produce representations of their personal feelings. Some offer work of little immediate meaning to a viewer but, on inspection and with some effort, that work can provoke thought and interpretation, delivering valued personal meaning. Both art itself, as a generality, and medicine, as a term for health care delivery at large, are genuine human expressions of caring, opinion, belief, and observation. Both are human arts applied on a canvas of technology.
Artificial intelligence is a mildly offensive term, since intelligence is a wide-ranging biological phenomenon, and taken to entirely different dimensions of imagination by human brains. Humanism, naturally, is part of that imagination: we can imagine a better world that is kinder, safer, happier, and more sustainable than the world of yesterday and today. Self-learning algorithms can’t quite do that. We can make devices that could produce a Piet Mondrian or Jackson Pollock type of work, but those works would be devoid of the human context of the artists.
What people experience as a physician’s art is made better by the evidence physicians assemble and by their sense of humanity, evolving with their careers and growing with immersion in the soup of human culture, to use the term from Dawkins.
West Shore Urology (WSU) in Muskegon became a part of Michigan Urology only ten months ago and on my visit there last month it was nice to see the Block M logo on the sign in front and on the lab coats of the team. The photos at the front of the clinic show founder Tom Stone and the original partners, along with the current team, although the newest member, Adam Walker, needs to appear on the wall. [Below: clinic wall and Adam & Jaclyn Walker with Malissa Eversole at AUA Nesbit reception, 2018.]
We incorporated the excellent WSU faculty in our Urology Department and also acquired its clinical team and facility as a new Ambulatory Care Unit (ACU), but it is unique among the other 180 plus ACUs of Michigan Medicine in that it does not have the HOPD designation that confers payment advantages to ambulatory units unattached to hospitals. At first glance this may seem to have been an odd business decision for us, but this opportunity will force us to learn how to make clinics work in a health care world that is likely to dissolve the HOPD advantage.
[Above: WSU office staff Tracy Dinh, Jessica Phelps, Bre Rodgers, Michelle Halldorson, Gabby Perez. Below: Cris Bench, Brian Stork, Carrie Brown.]
Brian Stork, beekeeper and urologist, was in Ann Arbor just last month to give a Grand Rounds presentation linking work force burn-out to adverse childhood experiences (ACEs). It was at his instigation that I found myself stopping for lunch, the next day, in the Amana Colonies, after I happened to fly into Iowa, explaining the contrail shown earlier.
In between WSU and Ann Arbor is Metro Health Hospital in Wyoming, Michigan, south of Grand Rapids, and shown above shortly before a rainstorm last month. Metro Health became a part of Michigan Medicine in January 2017, and like our partnership in Muskegon, it is a part of an essential regional network. Peter Hahn was recently named CEO at Metro. Nearly all of our fellow health systems and academic medical centers in the state and nation have been networking vigorously in their regions and beyond for the past 2 decades, although we, at the University of Michigan, have been late to the process, but we are catching up. Our regional growth is sometimes viewed unhappily by other health care systems, but such is the nature of healthy competition. All patients need regional alternatives to find the right care at the right time and in the right place that best fits their individual particularities. Sometimes that best fit is with Michigan Medicine, sometimes it is not.
[Above: Joint Venture ceremony last month with David Miller, Rob Casalou President and CEO Mercy Health & St. Joseph Mercy System, Travis Souza, Dave Spahlinger, Alon Weizer, Denise Gray-Felder.
Below: Richard Gilfillan CEO Trinity Heath, Nancy Graebner President & CEO St. Joseph Mercy Chelsea, David Miller, Donna Lasinski Michigan State Rep 52nd District.]
Last month we (Michigan Medicine) finalized a joint venture with St. Joseph Mercy Health System Chelsea Hospital. It has been implemented with Family Medicine, Surgery, Gynecology, Ophthalmology, and Urology. Michigan Urology has a long history with Chelsea Hospital. Howard Usitalo and C. Peter Fischer are Nesbit alumni (1986 & 1979) with deep roots in the hospital and community, now joined by Andre King and Dave Lutchka PA. Mike Kozminski from our department has held a Saturday morning clinic at Chelsea for the past 4 years.
Anticipating the joint venture, Will Roberts’ Endo-urology/stone division has been active with a percutaneous renal unit aligned with Radiology and Casey Dauw has been a consistent presence in. that effort for much of the past year, along with Alon Weizer from our Uro-oncology division.
Visiting professors enrich teaching programs with new ideas, novel techniques, and different teaching skills. They challenge us with new facts and ideas, and their presence builds new connections and collaborations. When accompanied by a partner they show, by example and in conversations, how work life and personal well-being through family are negotiated – and this is especially important to our trainees and younger faculty.
Visiting professors also cost money and take time out of the working day, so we must carefully balance the academic and clinical missions against the economics of an academic medical center. A supportive departmental working culture, excellent health care system leadership, and a strong philanthropic base make this balance not only possible, but robust for us.
Mahesh Desai, a world-class urologist from Gujarat, India, was in Ann Arbor a few weeks ago to visit our department, meeting residents and younger faculty, and giving Grand Rounds before heading to Chicago for the DUST Course #4 organized by Khurshid Ghani and Will Roberts. It’s good to know people around the world like Mahesh. A number of years ago I got a call from one of our Engineering School faculty members who was on an academic trip in India and had colic from a kidney stone. An easy phone call then connected me to Mahesh and the Muljibhai Patel Urological Hospital in Nadiad, a hospital he founded with Dr. V.V. Desai. Our engineering colleague professor quickly had a solution in hand. [Above: from left, Dr. Desai & his nephew Udhav Doctor, Priyanka Gupta, Khurshid Ghani, James Tracey, Ted Skolarus, Ed Kleer, Will Roberts, Ganesh Palapattu, Mahendra Bhandari. Below: Thompson]
Our Health Services Research Symposium will reconvene this month. Chad Ellimoottil and Lindsey Herrel have organized this with 22 speakers at the Power Center September 13-14. [www.hsrsymposium2018.com]
We alternate the McGuire and Montie visiting professorships each year. Two years ago the Jim Montie lecture featured the extraordinary Ian Thompson. This October Dave Penson will come from Vanderbilt as the Montie Professor. [Below: Dave & Jennifer.]
Elusive evidence. With September, summer 2018 recedes in the rearview mirror, its pleasures having vastly outnumbered its minor annoyances, such as pesky mosquitoes, no-see-ums, houseflies, ticks, and other bugs. Even so, a recent article and letter to the editor in JAMA grabbed my attention and introduced me to the BUGG Trial. Acronyms abound in medicine, but clinical trials have taken them to a new level of silliness. Benefits of Universal Glove and Gown is the name for this trial, reported in an article by Harris et al (JAMA 310:1571, 2013), that investigated antibiotic-resistant bacteria acquisition in intensive care units.
The letter-to-editor and a current paper questioned the evidence for either employing or discontinuing contact precautions (CP) for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE). [Letter: AB Kressel. JAMA. 320:407, 2018; Article: Rubin, Samore, Harris. JAMA 319:883, 2018.] The letter makes the important point that contact precautions convey significant burdens of material costs, time of multiple implementations, and wear and tear on the workforce. While contact precautions seemed a reasonable solution for a difficult problem, its self-righteous standardization may well provide not just “no value added”, but an even worse effect of value subtracted from the health care equation. Kressel notes:
“Inaction is not the only response to the status quo in the absence of strong evidence. In the case of CPs for MRSA or VRE, it may be reasonable for each institution to make a choice based on local hand hygiene, MSRA, or VRE rates, use of chlorhexidine bathing, and use of single-occupant patient rooms.”
This last point hits close to home. First, single-occupancy patient rooms are implicit in the standard of hospitals in the industrialized world. Our local exception to this is most peculiar. [Simon et al. J Health Serv Res Pol. 21:147, 2016.] Second, the world-wide craze for hand sanitizers is, it seems to me, a nearly fraudulent alternative to simple hand washing, provided clean water and soap are available. The popular hand sanitizers have strong effects on the normal microbes of our microbiome and environment, but virtually no help with killer spores and mixed effects with viruses, some being inactivated while others are not. The visual theater of hand sanitization on entering patient spaces brings comfort to audiences, but the display tends to bug me if there is a sink nearby.
Summer nostalgia. September Song was written for the 1938 Broadway musical Knickerbocker Holiday, and resuscitated for the 1950 Hal Wallis film, September Holiday, and again in the British sitcom May to December that ran from 1989 to 1994. Ezio Pinza, Bing Crosby, Frank Sinatra, Nat King Cole, Patti Page, Eydie Gormé, Pat Boone, Dean Martin, Jimmy Durante, James Brown, Lena Horne, Ella Fitzgerald, Willie Nelson, Dee Dee Bridgewater, and many others have recorded this classic. Of course, with only 12 monthly names to inspire music and movies, it’s no surprise that September gets recycled, currently in a new September Song written and sung by JP Cooper.
Kurt Weill composed the music and Maxwell Anderson wrote the lyrics for the classic September Song, a tune produced rather hastily for the musical production Knickerbocker Holiday in 1938. The song was made specifically for the “gruff voice and limited vocal range” of the lead actor, Walter Huston, who was playing the aged dictator Peter Stuyvesant. [Wikipedia.] While the Broadway musical confection lasted only 6 months, the song has been remarkably durable and it is the Jimmie Durante version (first recorded 1955, album 1963) that I particularly favor, perhaps most resembling the original version in character. The actual content of the lyric and musical is twofold and dark: the specific story of forced marriage of a young woman to an elder tyrant while she loves another younger man, and the general metaphor of the September of our lifespans as framed by the monthly calendar.
CORRECTION: Last month’s What’s New/Matula Thoughts contained an egregious error (corrected in updated versions), where I misspelled the name of one of my favorite authors, the extraordinary John McPhee. My apologies to you and to him. It’s not so much that I blew the fact as that my brain and keyboard translation fumbled, as seemingly happens sometimes in this September of my career. Perhaps this is a new disorder one might call dystypia, a fumble less infrequent than revealed by these edited pages.
Best September wishes,
David A. Bloom
University of Michigan, Department of Urology, Ann Arbor