Sunrises, sunsets, & summer imaginations

Matula Thoughts Aug 3, 2018

Sunrises, sunsets, summer imaginations & facts

3951 words

One.

Michigan sunrises and sunsets are hard to beat this time of the year. [Above: Michigan sunrise: Campbell Cottage, Platte Lake, 6 AM July 9, 2018.] Regional newcomers find our summer nights come late, due to the fact that Michigan is about as far west and north as you can go in the U.S. eastern time zone. The western claim seems to be a true fact, at a tiny corner of Ontonagon County in the Porcupine Mountains, west of Silver City, Michigan (89.887453 west and 46.766675 north). The nearest named place on the map is Lafayette Landing, northeast along the Lake Superior shoreline (longitude 89.8407 west, latitude 46.7991 north) where August sunsets will be late and no doubt amazing.

Michigan still stretches further west to Gogebic County, but all four Michigan counties bordering Wisconsin are in the Central Time Zone (Gogebic, Iron, Dickinson, Menominee). If you extended the entire Eastern Time zone to a line drawn south from Lafayette Landing, the zone would incorporate Madison, Chicago, Memphis, Jackson, and Bogalusa, Louisiana (89.83881 west, 30.780556). Michigan comes close regarding the northern claim, but the most northern U.S. mainland place in the eastern time zone is actually Estcourt Station in Aroostook County, Maine, at a latitude of 47.4582 north with a population of 4, barely displacing Eagle Harbor in Keweenaw County, Michigan, at 47.45 north, 88.156 west (population 76).

However, if you are willing to navigate to Isle Royale National Park, you can expand the northerly  claim. Even better, Isle Royale has 450 minor islands and Gull Island may be the most north (48.2622 north, 88.26472 west). Rock of Ages Lighthouse is further west in Lake Superior, (89.3133 west, 47.86667 north), but not as west as Lafayette Landing. Possibly some real navigators could improve on these claims of fact, all derived from maps and Internet.

New house officers are a big academic feature of summer at the University of Michigan. We select them carefully and anticipate their arrival eagerly. This is sunrise for their most critical phase of medical training, graduate medical education (GME), where they learn the art, science, and skills of their careers as doctors, a phase more intense than medical school and may take more than twice as long. New trainees and new faculty (see item eight) regenerate our department and our field. Joining us as residents (postgraduate level 1 or PGY 1) last month: Kyle Johnson from University of South Carolina, Katie Marchetti from UM, Roberto Navarrete from Wake Forest, and Javier Santiago from Baylor. Joining us as fellows are: Giulia Lane from the University of Minnesota and Jeff Tosoian from Johns Hopkins. Their starting month was intense, after undergoing extensive onboarding processes, but their time off in Ann Arbor and environs should be pleasant with long sunny days to enjoy the Summer Festival, Art Fair, Farmers Market, Purple Rose Theater, Metro Parks, Detroit Tigers, restaurants, Manchester United vs. Liverpool at Michigan Stadium, and regional explorations, among countless other opportunities. All too soon daylight will shorten, work will intensify, as the full academic season unfolds next month and 2019 lines up in the batter’s box.

[Above: Lake Michigan sunset, Esch Road Beach near Empire, August 18, 8:43 PM 2011. Below: Sunset & rainbow, Grand Haven, July 22, 9:15 PM, photo credit, Carol Spahlinger.]

 

Two.

The term Michiganders surprised me the first few times I heard it after arriving in Ann Arbor in 1984 but now, accustomed to it, I occasionally use it myself. Michigander is a demonym, although a favorite author, John McPhee, didn’t include it among citations of other examples, such as Mancunians, Minneapolitans, Providentians, Haligonians, and Liverpudlians [McPhee. Draft No. 4. Farrar, Straus and Giroux, 2017. p. 173.] Sense of place matters deeply to most people, defining personal identity in large part. As much as Vonnegut deflated the notion of self-identification with organizations or geography, as for example being a Hoosier, pride of place memes are important. [Cat’s Cradle, 1963.]

In addition to its soccer team, Liverpool brings up memories of the Beatles, however pediatric urologists and pediatric surgeons of my vintage also think of Mr. Herbert Johnston (above, c. 1986), who practiced at the famed Alder Hey Children’s Hospital where innovations of safe prolonged general anesthesia advanced the range of pediatric surgery and urology. From its first public demonstration in 1846 until the mid 20th century, general anesthesia carried significant morbidity and mortality risks that increased with the duration of anesthetic time, so procedures had to be brief. With safe induction, tracheal intubation, controlled gas flow, and vital sign monitoring, surgical procedures grew in length and complexity. Blood gas, end-tidal CO2, and peripheral oxygen saturation measurement further enhanced safety and permitted extraordinary interventions including cardiac operations, organ transplantation, extensive cancer extirpations, and major bodily reconstructions. With operating rooms less tense and frantic, background music became commonplace and, given the popularity and sheer quantity of Beatles tunes, it is likely to hear them during surgery in operating rooms around the world today.

Soccer, or European football dominated many conversations in our department last month and in spite of the loss of his beloved British team the day before, Khurshid Ghani sportingly hosted a backyard viewing of the World Cup final between France and Croatia (below). Last weekend at Michigan Stadium, Liverpool defeated Manchester United 4:1 during their U.S. tour, jumping the Liverpudlian factor in operating rooms around the world from two-pronged to three-pronged when conversations turn to soccer, before or after, but never during “time-outs” of course.

 

Three.

The Chang Lecture last month connected me to Joel Babb, an artist living in Maine. Having spent many childhood summers in Maine I jump at the chance to reconnect there, obvious demonym notwithstanding. Joel’s depiction of the first successful renal transplantation, on display at the Peter Bent Brigham Hospital in Boston, was featured in our Chang Lecture, and Joel was very generous with permissions and digital files. He created the painting with the help of its principle innovator, the late Joe Murray, a close friend of my former professor at UCLA, Will Goodwin [Above: Joel Babb, self-portrait with dog, Ruskin. Below: Joe Murray visiting UM and a younger DABc. 1990.]

The First Renal Transplantation shows a large team of two operating teams and consultants necessary for that landmark event in 1954. [Below: study for First Renal Transplantation, Joel Babb.]

Joel sent us other examples of his work including the first face transplant in the Western Hemisphere, and a book by Carl Little, Nature & Culture, The Art of Joel Babb. [University Press of New England, 2012]

Medical care, initially a simple one-to-one expression of human empathy, has expanded to team-based efforts that blend science and the art of humanism. The balance is asymmetric according to teams, individuals, and locations. Organizational culture largely determines the blend, varying from day to day and hour to hour, as is true for most human efforts. Intrinsic to the humanism of medical care are principles of equity and kindness, although these are susceptible to submersion by political and economic milieus, whether based on consumerism, capitalism, socialism, or any other “ism” other than humanism. Some new meme of universal humanism is an existential necessity for our species, but it is expressed far too weakly and drowned out by larger themes of place and personal identity. That new meme must somehow embrace deep respect for all places and identities, but it seems sadly faint just now.

 

Four.

Place, whether urban space or landscape, has been a dominant part of Babb’s work and his surgical paintings seemed, at first glance, a departure. Sense of physical place gives familiarity and security, whether pastoral landscape, city, neighborhood, occupational, or particular health care location – operating room, ICU, emergency room. The human need for relevance makes us seek that sense of place in teams, although exaggerated sense of place, is destructive, leading to smugness, self-importance, or xenophobia. In the sense of teams, then, as place, Babb’s surgical paintings are really no departure from theme.

When sense of place is disrupted, particularly for reasons beyond an individual’s control, the disturbance must be unimaginable for those of us naïve to such grim experience. An astonishing statistic appeared in a recent book review in The Lancet by Jennifer Leaning: “One out of every 113 people in the world is either an asylum seeker, a refugee, or internally displaced, according to the United Nations High Commissioner for Refugees (UNHCR).” [The Lancet. 390:2136, 2017.] The book at issue, Refugee by Alexander Betts and Paul Collier, brings a new category of refugee into play in increasing numbers, the climate refugee. It seems that we owe it to ourselves, as a species, to secure safety of place – the idea of home – through our governments, and to mitigate it as best we can when we encounter its disruption. This should be a cardinal responsibility of the civilization we maintain for ourselves and build for our successors.

Disturbance of personal homeostasis threatens the most immediate sense of place, namely bodily place. Loss of limb, organ, or essential function carves away a person’s ultimate and closest geographic identity, the individual physical and mental place of self. The immediate human corporal reality, physical integrity, is our most fundamental place and we locate ourselves, we see ourselves most literally, in the image of our own faces. The face is the most essential part of identity, evidenced by facial recognition by self-learning algorithms. Loss of face, once an exaggerated figure of speech, is the penultimate reduction of “being.”

Joel Babb’s painting of the full face transplantation (above) demonstrates an extraordinary realization of human imagination and civilization, the capability to replace a human face. That painting carries his work across the spectrum of the human experience of place, from landscapes, to cityscapes, and then to the core visible essence of ourselves and its new mutability with full facial transplantation. For the story behind the face transplant, Joel referred me to an article by Raffi Khatchadourian. The patient, Dallas Wiens, was electrocuted in a boom lift when he contacted a high voltage line while painting a church roof in Fort Worth. [Transfiguration. The New Yorker. February, 2012.]

 

Five.

Imagination and reality go back and forth, and it is sometimes difficult to know the priority of chicken or egg. Human imagination has been wildly in play since our earliest days, as with the Lowenmensch chimera (above), a figurine from the Upper Paleolithic period (40,000 years ago) of a lion head on a man’s body, found in a German cave in 1939. One wonders what that artist was thinking while fashioning the figure, what god or superhero was imagined in the work. The Sphinx at Gaza, a more recent reverse example, with a woman’s head on a lion’s body.

The imagined miracle of transplantation is a related theme, wherein body parts could be exchanged. Saints Cosmas and Damian, twin Arabic physicians and Christian martyrs, practiced in the third century Roman province of Syria, now the town of Yumurtalik in Turkey. The story of their transplantation of an Ethiopian’s leg to a white man was their big miracle (Above: 16th century, Entstanden in Württembergisches Landesmuseum, Stuttgart, Wikipedia.). Details are sketchy, histocompatibility uncertain, but positive outcome must be inferred, otherwise how else could the miracle be explained?

The enduring meme of chimerism, returned with the zitiron, a mythical “merman” illustrated in Meydenbach’s natural history encyclopedia of 1491 (above: Wikipedia). The figure of a man-fish is suited up with armaments for battle. A more appealing chimera is The Little Mermaid story of Hans Christian Anderson in 1837 that reverberates in The Little Mermaid Statue, on Langelinie Promenade in Copenhagen, having survived vandalism, decapitations, and a 6-month sojourn in Shanghai. The story echoes again in Ron Howard’s 1984 film, Splash, with Daryl Hannah. [Below: Edvard Eriksen statue in Copenhagen, 1913]

As imagination informs reality, laboratory chimeras and body-part transplantations are now commonplace facts of life. I recently ran into colleague John McGee in a hospital corridor and noticed his chimeric lapel pin, the logo of his transplantation society. [Below: Dr. John Magee with pin.]

 

Six.

Challenged by modern medical practice, in technology-intensive specialties such as urology, residents and fellows may wish they could splice several contradictory heads on themselves to balance empathy and science, kindness and detachment, to better serve their patients. Our trainees can become adept at transplantation and making laboratory chimeras, but fundamental traits of humanity are more difficult to acquire and perfect.

Just after sending the May edition of this column, I came across a Piece of my Mind in JAMA by the well-known medical oncologist Marc Garnick, an oncologist who became a patient, reeling from bladder cancer and then confronting non-Hodgkin lymphoma the following year. His concluding paragraph captured my aspiration for our profession.

“The patient-physician relationship is unique among any other human experience, something to be understood and appreciated. By filling in the gaps and tending to the patient’s broader needs – not just those pertaining to diagnosis and therapy, but the fuller context in which treatment occurs, all of us – patients, physicians, nurses, hospital administrators, staff, and humanity – stand to benefit.” [Garnick. JAMA. 319:2079, 2018.]

This relationship is embodied in conversation that may merely begin and end with an initial “History and physical exam” moment, but might further develop over days, weeks, or years of a relationship. Whether limited to a single encounter or developed over time, that conversation has the potential to yield practical therapeutic value and even spiritual meaning to both patient and physician. I don’t mean to overstate or understate the idea of the conversation. It can be a mundane exchange of facts and desires from a patient, eliciting understanding and perhaps therapy from the provider. Yet, even at the simplest level, it is built on integrity and trust. If more ensues, so much the better.

 

Seven.

Chang Lecture notes. We began this series of talks in 2008 to honor Dr. Cheng-Yang Chang, who initiated a pediatric urology focus here in Ann Arbor. His father, Ku-nien Chang was a famous artist of the landscape literati style in China and Taiwan, and over 80 of his works are rotated through exhibits at our UM Art Museum, in the Shirley Chang Gallery. The lecture series was a particular enthusiasm of my term as chair and, expecting a successor, it seems suitable to conclude this series of talks, with great appreciation to all those who supported it with their interest and presence. In its way, the Chang Lecture series has fulfilled some part of our obligation as a university in offering things to public audiences – public goods.

Some shout outs are in order. Emily Soto has catered this event from the start. In the audience with many friends, colleagues, and members of our department were 2 former Medical School Deans, Allen Lichter and Jim Woolliscroft. Bob and Janet Bahnson came from Columbus with George and Tina Skestos. [Above: Emily, David, and daughter-in-law Aimee Soto with DAB. Below: Bob, George, Janet, Tina.]

George, three-time UM degree recipient, has the only Maize and Blue box at The Ohio State Horseshoe Stadium. Bob is former chair of urology at Ohio State, and Cheryl Lee, Nesbit alum 1997 is current urology chair. Hamilton and Lilly Chang joined us from Chicago, and Ted Chang and Mary Gallant drove from Albany. Our most distant attendee was Otto Lin from Hong Kong, industrial and systems engineer, although I suspect his main purpose in Ann Arbor was to visit his daughter, Associate Professor Ann Lin of the Gerald Ford School of Public Policy (below).

 

Eight.

Art Fair. With a new season of GME beginning in July we initiate our first major academic events during the Art Fair, starting with the Chang lecture on Art and Medicine late Thursday afternoon and then Duckett and Lapides lectures and teaching sessions on Friday morning, while the administrative staff simultaneously holds professional development training. Then, for most people, the afternoon is free as a sort of yearly “birthday present.” In this way, we drastically close down all but the most urgent clinical operations in the interest of education and recreation.

 

The John W. Duckett Visiting Professor began in 1997 in honor of a foundational figure in pediatric urology and friend and mentor to me as well of Michigan Urology. John had passed away unexpectedly and we began this series in his honor. Doug Canning of CHOP was our first Duckett lecturer and this year Rosalia Misseri, of Riley Children’s Hospital in Indianapolis, spoke about “Closing the loop: lessons learning by the pediatric urologist caring for the adult spina bifida patient.” The Lapides Lecture began in 2006 and this year it was given by Hadley Wood of the Cleveland Clinic, who has defined the field of urologic congenitalism. Her talk was “Applications and pitfalls in the use of video urodynamics in adult congenital neuropathic bladder.” Robust discussion with residents and faculty in attendance was robust and enhanced by the fact that Drs. Misseri and Wood had met the residents and fellows over the dinner the previous evening, while the Chang Lecture group had a simultaneous event at another site. [Above: Friday afternoon at the Art Fair. [Below: Hadley Wood with Rosalia Misseri and husband MortGreen, pediatric anesthesiologist at Riley.] Appended to this posting is a list of Chang speakers.

Peggy Duckett and George Drach, of Philadelphia have been with us from the start of this academic/Art Fair convergence. George and Peggy announced their engagement here in Ann Arbor to us on Jim Montie’s deck during the third Duckett Lecture season. George gives socioeconomic, philosophical, or practical talks during our Friday sessions, and this year spoke about the Urological Knife. If any readers want to know what that’s all about, he is available to give the lecture again.

[Above: Martha Bloom, George and Peggy.]

 

Nine.

Bomalaski Scholars. In 2014 Dave Bomalaski (Nesbit pediatric urology fellow 1996) and his wife Sue (above) generously endowed a recurring scholarship for a resident to explore a career in pediatric urology.

Julian Wan presented the award this year to Lauren Corona, PGY 3 (above & below). Previous Bomalaski scholars were Duncan Morhardt (Nesbit 2017), who is starting fellowship at Boston Children’s Hospital, Courtney Streur (Nesbit 2018), and Ted Lee (Nesbit 2019), who will follow Duncan to Boston in 2 years.

Two new faculty join us this year, both in the pediatric division – Courtney Streur and Bryan Sack (below). After training in Birmingham, Alabama, Courtney joined us for a 3-year fellowship with a masters degree in health services research. Bryan trained at Medical College of Wisconsin and then fellowship at Boston Children’s Hospital. [Devin & Courtney, Bryan & Melissa.]

Michigan Urology now has 7 pediatric urology faculty, 6 in endo-stone, 6 in neuropelvic reconstructive urology, 3 in sexual reproductive, 4 in general urology, 5 in community urology in Muskegon at West Shore Urology, and 13 in uro-oncology, and 4 faculty in our fulltime research cadre. Six faculty cover VA positions and we have multiple joint faculty with other departments, as well as a number of adjunct faculty.

 

Ten.

Diversity enriches nightscapes of Michigan, Maine, and all other places in innumerable ways. Tree frogs and lightening bugs are distinctive sounds and sights of Ann Arbor summer nights, starting up in June and disappearing around September. In the dark winter months, I’ll be longing see and hear them again. Diversity makes the natural world work, a fundamental fact obvious to any scientist or any other rational thinker. The most prominent living spokesperson for biodiversity, E.O. Wilson, visited Michigan as convocation speaker for our Life Sciences Institute (2004) and to receive an honorary degree (2009) as noted in our previous essays . I recently spotted this new portrait of him at the Smithsonian American Art Museum. [Above: by Jennie Summerall, 2006]

I hear frogs most summer nights when walking my dog, Molly. The chorus frogs, genus Pseudacris, comprise a genus in the Hylidae family named according to their sounds (“false locusts”) and the Northern spring peeper (Pseudacris crucifer) may be the noisy males I hear, advertising their social interests by means of their ancient social media. The Linnaean system of classification divides life into kingdoms, phyla, classes, orders, families, geni, and species. Scientific nomenclature dictates that  names of taxa above the genus level (families, orders, etc.) should be in roman type, but those at genus level or below are italicized. Wikipedia explains that the order of frogs and toads, the Anura, is divided into three suborders: the Archaeobatrachia, Mesobatrachia, and Neobatrachia. That last suborder (neo=new, batrachian = frogs) accounts for most anurans and consists of over 5,000 species, some of which live in trees, the so called arboreal frogs. Many frogs around here belong to the Hylidae family. Twelve frog species are listed among the amphibians of Michigan, including the Cope’s gray tree frog (Hyla chrysoscelis) and the Gray tree frog (Hyla versicolor). The American green tree frog (Hyla cinerea), extensive throughout the southeast, may be emigrating north as climate changes. These are popular pets, although they don’t do well with frequent handling.

Fireflies, the winged beetles I see most nights, are scientifically classified in the Lampyridae family of insects among the beetle order, Coleoptera. Over 2000 species of fireflies exist worldwide and the light they produce is a cold light, nearly 100% efficient in that it produces no heat. The light flashes are its social medium for courtship, warning, or predation. The predominant firefly in the eastern U.S. is the Photinus genus and its flashes bring males and females together for mating at night. The female lays eggs on or in the ground a few days after mating, and hatching occurs 3-4 weeks later. The larvae feed in the summer and hibernate over the winter, underground or in bark or other sites of refuge. Another use of the visual language of fireflies is to warn predators that they taste badly and may be poisonous, due to the lucibufagins, defensive steroids similar to the cardiotonic bufadienolides in some poisonous toads. Some fireflies, notably females of the Photuris genus, mimic mating flashes of other species in order to attract and then devour the unlucky males that fly to them in expectation of a different outcome.

Beetles and fireflies may be prominent contributors to Michigan nights, but they are only a tiny part of the rich web of life seen, heard, or unnoticed as we pass through these summer months. Tunes from open windows of cars and houses, patios, or block parties, drown out the tree frogs, just as outdoor lights or July fireworks obscure the fireflies. Seeing the cold light flashes from my porch and hearing music in the air from a neighbor begged the question whether that beloved musical group had a spelling problem. In 1957 John Lennon’s first group, the Blackjacks, became the Quarrymen, so named after their high school, Quarry Bank. Paul McCartney, age 15, joined Lennon in July and in the following March brought along George Harrison. By January of 1959 the other original Quarrymen had left the group and the three remaining guitarists, then attending Liverpool College of Art, briefly took up the name Johnny and the Moondogs for gigs. Art school friend Stuart Sutcliff joined as a fourth guitarist in January, 1960, bringing a new name for the band, the Beatals, after Buddy Holly and the Crickets. They became the Silver Beatles in May and by August, they were simply the Beatles. Sutcliff left the band in 1961 after its second Hamburg period and Ringo Starr joined in 1962.

While the name of the Liverpudlian musical group may have had a link to insect nomenclature, the spelling variations remain unexplained, perhaps the educational fault of Liverpool’s Quarry Bank High School (now Calderstones School), pharmaceutical influence, or simply poetic license in Liverpool’s hot summer nights.

 

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

Appendix
Chang Lecturers
2008 James Steward, DPhil, UM.
2008 Mysoon Rizk, PhD, University of Toledo.
2009 Joel Howell, MD, PhD, UM.
2010 Shinming Shyu, MS, EMU.
2011 Thomas Cole, MD, MPH, UNC, Contributing Editor, JAMA.
2012 Charles Yeo, MD, Thomas Jefferson University.
2013 Richard Prager, MD, UM.
2014 James Ravin, MD, University of Toledo.
2015 Pierre Mouriquand, MD., Claude Bernard University, Lyon.
2016 Don Nakayama, MD, MBA, Florida International University.
2017 David Watts, MD. University of California, San Francisco.
2018 David Bloom, MD, UM.

Birthdays, graduations, and centennials

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

Rules, boundaries, and stories

DAB What’s New June 1, 2018

Rules, boundaries, & stories

3722 words

 

One.

Colors explode as summer opens up in June around Ann Arbor. The visuals are unsurpassed in the UM Nichols Arboretum Peony Garden, adjacent to Mott Children’s Hospital. The garden is a few years short of a century old and derives from Dr. WE Upjohn’s flower collection (pictures above and below, May 29, 2018).

Schools let out in June and summer vacation begins for most students north of the equator, echoing our agrarian history when children needed to be free to work on family farms. Today, farms don’t depend on child labor and most schoolchildren come from urban/suburban homes, the rural: urban ratio having flipped in the last 150 years. In 1870, 25.7% of the US population (38.5 million) was urban and 74.3% was rural, while by 1990 the ratio was 75.2% urban and 24.8% rural (population 248.7 million) and the trend continues, although summer vacation still rules in most schools and workplaces. [Table 4 US Census Data 1993.]

Doctors in training don’t get summers off, they have full 12 month cycles of education, with one random month for vacation, and our new cohort begins its turn next month here in Ann Arbor. [Above: Grand Rounds.] Time has framed graduate medical education in urology since the formalization of the American Board of Urology in 1935. Urology trainees at Michigan spend five years of postgraduate training after medical school, shorter than my time of residency at UCLA, although residents today are increasingly likely to put in additional years for fellowship training. The idea of “duty hour” limitation was a reaction to a few bad training programs that exploited residents, and the 80-hour work week is the national standard for residents in training. Another quantitative constraint is the concept of minimum numbers of specific operative procedures.

A qualitative dimension of regulation, educational milestones, was implemented within the last decade. Milestones reflected the enticing idea that GME should not routinely progress only according to clock, calendar, and case numbers, but according to acquisition of skills. The increased burden of administrative time and paperwork to document milestones, however, has been unmatched by any demonstrable value for trainees or programs and, if common sense prevails, milestones will likely get swapped out for another idea or experiment. Nonetheless, it is clear that time and numbers alone should not be the only measures of residency education.

Our new GME cohort. Residents Kathryn Marchetti from UM, Kyle Johnson from University of South Carolina, Javier Santiago from Baylor Medical School, and Roberto Navarrete from Wake Forest School of Medicine. Fellows Giulia Lane from University of Minnesota (FPMRS) and Jeffrey Tosoian from Johns Hopkins Hospital (SUO).  New Faculty: Bryan Sack from Boston Children’s Hospital and Courtney Streur who completes her pediatric urology fellowship both join our Pediatric Urology Division. Kristin Chrouser has joined our faculty this year from the University of Minnesota in NPR and will be mainly at the VA.

 

Two.

Time, curiously, has no role in baseball, the game of summertime. The sport has no relation to a clock – rather milestones of innings, runs, and outs mark the game’s progress. In this, baseball lends itself to being the ideal summer sport, unfettered by time and limited only by accumulation of three failures or “outs” and innings unless bad weather intervenes or until it gets too dark to play.

Baseball at Night, a painting by Morris Kantor on display at the Smithsonian American Art Museum in Washington, DC, shows a minor-league game in West Nyack, NY, around 1934. Stadium lighting was a rarity then, given the long days of summer when play could continue until dark, although twilight made the game tenuous. Stadium lights shifted quickly from novelty to necessity and major league teams have played deliberate night games since 1935.

It’s hard to imagine baseball or any other sport without limits and rules, even if arbitrary or parochial, such as the designated hitter rule that now applies to one major league but not another. Rules matter and when different leagues play each other, they find it necessary to have rules that supervene their particular league rules. Rules create fair playing fields, allowing games to go forward and conclude peacefully.

Rules are equally essential for other social activities, organizations, and governments. The USA has the Constitution and Bill of Rights. The State of Michigan has its own constitution and laws, including term limits that guarantee frequent refreshment of the state legislature, but at the expense of deep institutional knowledge of the state and its components. The University of Michigan has its Regent’s Bylaws and Standard Practice Guide, as well as Michigan Medicine’s own sets of Bylaws. In all of these we rely on consensus for decisions, achieved casually in daily operations, more formally in committees (using Robert’s Rules of Order), and more broadly by public voting.

 

Three.

Communication skills are a pre-requisite for medical practice in both the essential transactions of direct patient care and in the complex team play of modern specialty medicine. [Above in foreground, Brent Williams, Professor of Internal Medicine, communicating with Michael Giacalone, Jr., Chief Medical Officer of the Hamilton Community Health Network in Flint.] Listening, speaking, reading, and writing skills are taught with variable degrees of success in elementary schools up through college, but medical practice demands more vocabulary and capabilities. Medical students, it is said, double the size of their vocabularies.

The traditional algorithm of healthcare starts with listening to the concerns of patients and then probing for additional information to construct a medical history, including relevant comorbidities and circumstances. Patients are physically examined and data is assembled into coherent narratives. Diagnosis, prognosis, and therapy derive from those stories in which authenticity and accuracy are assumed.

Modern electronic systems impose new communication challenges. Email and texting are immediate and convenient, but lack the human factors of facial cues, thoughtfulness, and social grace. Electronic medical records (EMRs) constrain work flows to templates and replace human narratives with check lists, pop-up choices, keyboard entries, and cut-and-paste phrases. The actions of data entry detract from listening, looking, and communicating with patients. Healthcare processes today do not prioritize stories, and it seems to me that appreciation of the art of the story lies at the heart of excellent clinical care. It’s no great leap of faith to claim that the art of authentic storytelling and story construction is the basis of most human relations, from compelling stories around campfires to A3 storytelling in lean process engineering. Truth and authenticity matter. Listening to them and weaving them are art forms.

 

Four.

Physician-author William Carlos Williams appeared on these pages earlier this spring and since then I’ve been thinking of the different contexts in which physicians write, and first and foremost, physicians write the stories of their patients.

Williams, you may recall, was the author of Spring and All of which a recent edition included an introduction by C. D. Wright comparing Williams to an earlier poet from New Jersey, Walt Whitman: “Like Whitman, he [Williams] would gradually come to a great human understanding, an apprehension that eluded most of his peers.” [Spring and All. WC Williams. New Directions Book, 2011.]

We pursue that greater human understanding on a daily basis, working in medicine, through stories learned and experiences gained, patient-by-patient. The dilemmas of patients are understood in terms of their stories, that must be heard, elucidated, and constructed from evidence and reasoning on the part of those who undertake the responsibility for helping. Stories are important to people, and we dignify them with our attention.

Electronic medical records are poor platforms for authentic narratives. The construction of narratives in the minds of physicians and the translation to visible words in some medium is a core element of the profession of medicine, framing the response of the care-giver in terms of advice, reassurance, therapy, and prognosis. This is the central organizing feature of the doctor-patient relationship, comprising the daily shop-talk of medical practice. A story must be accurate, with true facts, but also authentic, in reflecting circumstances and co-morbidities (an economist might call these externalities) framing the “present illness” and creating a context for further conversation and therapy. In my experience, an authentic and empathetic story only fully emerges after the history, physical exam, and further discussion with patient and family.

My own clinic notes were once written or dictated well-after the clinical visit when the story was relatively complete and coherent. The reduction of clinical notes to formulaic elements such as the SOAP format (subjective, objective, assessment, and plan) or the E&M format (Evaluation & Management: chief complaint, history of present illness, review of systems, etc.) fits computer entry systems nicely, but has disrupted the traditional medical work-flow that create stories.

It is challenging to find the words to describe this fundamental type of medical writing whether in narratives or EHR. Quotidian medical communication seems to fit, even though not everyone is familiar with the use of quotidian for daily or routine. Quotidian communication must be accurate, truthful, and authentic to each patient. Most healthcare workers are writers and their products are stories of patients. A brief piece in The Lancet by Roger Kneebone called “The art of conversation” expresses the idea of the clinical conversation that we have clumsily called “taking a history.” Kneebone expressed his thoughts more elegantly than I have, so I’ll just quote two sentences and refer you to the rest. [The Lancet. 391:731, 2018.]
“A conversation is a one-off live performance that can never be repeated. Its essence is its evanescence, and attempts to capture in writing are as thin as reading the script of a play or film.”

 

Five.

Stories suffuse all types of medical writing. Scientific writing for journals, grants, or textbooks is the bedrock of healthcare research and progress. Just as with stories of patients, this writing is predicated on accuracy, and clarity is enhanced when a meaningful story is constructed from the science. Medical journalism, another form of medical writing, communicates to the public about medical science and practice. Medical memoir is another important genre, also written for the public but usually as personal storytelling or essays.

William Carlos Williams and others divert into creative reflections through prose and poetry. These writers mainly tell stories they create, often based on authentic experiences, but with “literary license.” Many of these physician-writers venture into fiction at the other end of the spectrum of medical writing, although this too requires authenticity in that stories revolve around individual experiences, conflicts, tensions, issues, and environments that are genuine to the reader’s senses. The fictions may involve other species or galaxies, as with the work of Michael Crichton, but if the stories are well-crafted they contribute to that greater authentic human understanding. To summarize medical writing variants: a.) the daily writing of clinical practice, b.) scientific writing, c.) medical journalism, d.) medical memoir, e.) creative reflections, and f.) fiction.

We are a species of stories and understand ourselves through stories far better than through data. That greater human understanding is accessed through narrative better than through numbers. The novelist Kazuo Ishiguro, in his 2017 Nobel Prize Lecture, praised the “… quiet private sparks of revelation …” to be found in stories. “Stories can entertain, sometimes teach or argue a point. But for me the essential thing is that they communicate feelings. That they appeal to what we share as human beings across our borders and divides.” [Ishiguro. My Twentieth Century Evening and Other Small Breakthroughs. AE Knopf. NY 2017.]

 

Six.

A pig story. It doesn’t take much to disturb a comfortable status quo or otherwise disrupt peaceful human relations. An obscure story exemplifying this began on June 15, 1859 on San Juan Island, a place east of Vancouver Island where both the United States and Great Britain claimed sovereignty, after the Oregon Treaty of June 15, 1846, exactly 13 years earlier. [Below: blue Haro Strait boundary favored by US, red Rosario Strait favored by Britain, green compromise proposal. Copyright Derek Hayes, Historical Atlas of the Pacific Northwest. Sasquatch Books, Seattle, 1999.]

Peaceful co-existence remained in play until a British pig, owned by Hudson’s Bay Company employee Charles Griffin, wandered onto an American farm to eat some potatoes. This wasn’t the first transgression and Lyman Cutlar, the American farmer, shot and killed the trespassing pig. Cutler’s offer of $10 compensation was refused and the British threatened to arrest him. Sixty-six American soldiers under the command of Captain George Pickett were dispatched to the island to prevent British forces from landing. The British countered, bringing three warships offshore, soon escalating to five ships, 70 guns, and 2140 men. American forces then swelled to 461 men with 14 cannons, as diplomacy failed and the dispute escalated into The Pig War. The British governor of Vancouver Island ordered Rear Admiral Robert Baynes to land his marines on San Juan Island, but Baynes wisely refused to further escalate the “squabble over a pig” and the war remained bloodless, aside from the porcine tragedy.

In October, President Buchanan sent General Winfield Scott to resolve the crisis and negotiations resulted in an agreement that the British could occupy the north half and the Americans the south with each side allowed up to 100 troops pending further formal agreement. No wall was built, and in 1872, a full 13 years after the ill-fated pig, an international commission led by Kaiser Wilhelm I, decided that the entire island should fall under American control and so it remains.

 

Seven.

Henry Martyn Robert was one of the 66 American soldiers stationed on San Juan Island under Pickett’s leadership. It’s hard to know how he felt about his mortal jeopardy over the cause of a pig, but it’s a good thing the conflict remained bloodless and Robert went on to bigger things. Born in Robertville, South Carolina, he grew up in Ohio where his family moved due to their opposition to slavery. Robert’s father, Reverend Joseph Thomas Robert, would later become the first president of Morehouse College (1871-1884). Henry went to West Point and graduated fourth in his class in 1857, becoming a military engineer and building the fortifications on San Juan Island in 1859. He remained with the North during the Civil War, attending to defenses around Washington, Philadelphia, and New England Harbors. After the war, he served the Army Division of the Pacific from 1867-1871, then developed ports in Wisconsin and Michigan, later improved harbors in New York and Philadelphia, constructed locks and dams in Tennessee, and performed more civil engineering pertaining to the Mississippi River and Hurricane Isaac in Galveston. He died in 1923 and is buried at Arlington. [Below: Brigadier General Henry Martyn Robert, Wikipedia.]

Although Robert’s military service was significant, we remember him today for his civil engineering of practical rules for human interaction. These came about in 1876 after losing control of a church meeting he was leading in New Bedford, Massachusetts when it erupted over abolitionist views. Robert blamed his ineptitude for the fiasco and decided to teach himself how to run a meeting. His study of the procedures of the House of Representatives led to his Pocket Manual of Rules of Order for Deliberative Assemblies. He wrote:
“One can scarcely have had much experience in deliberative meetings of Christians without realizing that the best of men, having wills of their own, are liable to attempt to carry out their own views without paying sufficient respect to the rights of their opponents.”

Robert’s world was framed by his gender and faith, but his rules have endured because they are independent of his particularities. Robert’s Rules of Order apply to almost any human gathering and, like the rules of baseball, Robert’s Rules level the playing field and allow the game to go forward. [“Historical Vignette 038 – An Army Engineer Brought Order to Church Meetings.” U.S. Army Corps of Engineers – Office of History. November 2001. Retrieved 2015-12-02.] His rules offer protocols for civilized and democratic behavior.

 

Eight.

Michigan hosted its first Teeter Symposium last month, focusing on bladder cancer in honor of our Ann Arbor friend Bob Teeter, who died a decade ago from bladder cancer in spite of radical cystectomy. [Above, Bob and Betsy Teeter; below, Teeter Laboratory Plaque.]

Since then, knowledge and therapy of bladder cancer have increased by a quantum leap, although more leaps are necessary to obliterate the pain, suffering, and mortality of that disease. The day-long event, organized by Alon Weizer, featured 2 guest speakers and held an attentive audience that topped 50, with excellent talks and superb discussions. The event fulfills one of the items on my bucket list as department chair and honored not just Bob and his surgeon Jim Montie, but also some generous gifts for laboratory investigation that we gained after Bob passed away.

The first guest lecturer, Thomas Bender, MD, PhD (above) from Dow Chemical, spoke about the Health Hazard Evaluation Program for former employees of a chemical plant that had been closed in 2002, but Dow later acquired its parent company, Morton, in 2009. As I sat in the audience, wondering how to link this month’s Matula Thoughts to the Teeter Symposium, Dr. Bender said a magic word: Paterson. That’s where the chemical plant had been since 1929. Paterson, New Jersey, was the home of William Carlos Williams.

The next invited speaker, Elizabeth Plimack MD, MS, Chief of Genitourinary Medical Oncology at Fox Chase Cancer Center, grew up in Ann Arbor. Her parents and mentor Richard Swartz were on hand to hear her excellent talk Immunotherapy and Beyond. In attendance was Monica Liebert (Nesbit 1984 below), now retired, but still working in our laboratories. Monica developed many bladder cancer cell lines in her heyday and these are still utilized in our research efforts.

Our own Khaled Hafez (below, Nesbit 2004) closed the event with a superb talk on Clinical Management of Patients with Locally Advanced Bladder Cancer, a topic close to his heart and emblematic of his skill set, as he is surely one of the best in the world at this craft.

 

Nine.

The AUA annual meeting last month in San Francisco featured the usual strong Michigan presence. San Francisco was also the site in 2010 where the picture of our inaugural chair, Jim Montie (Faculty Nesbit 1995), was taken. In addition to turning over a very strong group of faculty and department, in 2007 when the current departmental administration began, Jim turned over a positive team culture, rather than a “me-me-me” culture. Jim not only remained relevant to the department, but remains a keen participant and a role model of leadership.

 

Looking through those 2010 Nesbit reception pictures, I found a picture of the late and truly great Cornell Urology Chair, Darracott Vaughan, flanked by Jennifer Anger of UCLA and Hunter Wessells, chair at the University of Washington in Seattle (below).

But now back to 2018.

Above: Emilie Johnson, Nesbit 2011, with her iconic mentor from Boston, Alan Retik. Below: Julian Wan, Nesbit 1990, at one of his podium appearances, knocking it out of the park.

[Below: Music reception with Khurshid Ghani, Faculty Nesbit 2013, & David Miller, Nesbit 2005.]

The Nesbit reception this year at the Hotel Vitale on Mission Street hosted around 100 alumni, friends, and current team of the Urology Department. Below, a partial view of the crowd.

 

[Above: Damon Davis, Nesbit 2007. Brian Sack will start with us in pediatric urology this summer. Kristin Chrouser joined us this winter from Minneapolis and is centered at the VA. Below: Irene Crescenze current fellow FPMRS, Cheryl Lee, Nesbit 1997, now chair at Ohio State, Bert Chen, Nesbit 2006.]

[Above: Stu Wolf, Faculty Nesbit 1996, now in Austin, Udit Singhal PGY 2, Alon Weizer Faculty Nesbit 2005, Bunmi Olapade-Olaopa Nesbit, 2000. Below; Betty Newsom, Nesbit 1990, Bart and Amy Grossman, Nesbit 1977.

[Above: Lynda Ng, Nesbit 2005 and Jerilyn Latini, Faculty Nesbit 2003. Below: Steve & Faith Brown, friends of Michigan.]

[Above: Tom Stringer, Dept Urology Florida, Barry Kogan, Nesbit 1981 and Chair Albany. Below: Hugh Flood, Nesbit 1991, of Clonlara, County Clare, Ireland. Below: Simpa Salami, Nesbit 2017 & guest Mohamed Jalloh of Dakar, Senegal.]

 

Ten.

Boundary matters. A few months past the JAMA column, A Piece of My Mind, came from Jeffrey Milstein at Penn Medicine [Milstein. The envelope. JAMA. 319:23, 2018] and detailed his office visit with a 70-year-old patient who carried a large white envelope, assumed to be “outside records.” Most of us get these, not infrequently, indicating that a second or third opinion is expected. On the occasion of this particular visit, the details were those of a 32-year old son who had recently passed away due to cancer. The envelope contained a stack of records with an obituary on top. The patient first wanted to talk about his son and then the course of his disease, tests, hospitalizations, treatments, and emotional toll. Then, after “a long moment of silence” the patient explained that he himself had not been to a physician in years, but needed to tell his son’s story before committing to his own care. The clock had run down by then and “the time for the visit” was over leaving nothing that could be documented in the EHR about the patient himself. The author noted “so another visit must be scheduled.”

So, it seems medical care today has tight boundaries of time and information. Boundaries for nations, sports, politics, education, business, are important, but some are more important than others. The Pig War, a foolish dispute, easily could have escalated to bloodshed, leaving us no Robert’s Rules. Rules and boundaries in sports allow games to proceed fairly and end peacefully. Some boundaries in health care are tight and timeless, as evidenced in the Hippocratic Oath or as shamefully dishonored by occasional bad actors. The constraints of the EHR are self-inflicted wounds of the business of medicine, and should be viewed with minor contempt and never honored at the expense of a patient.

Baseball, timeless as it is, nonetheless must be somewhat mindful of the clock. Some fans may have babysitters, while transportation drivers and other workers are paid by the hour. The number of pitches thrown is a clock of a sort. Still, the essence of the game is indifferent to time. The same is true for conversations with patients. Life and schedules are much easier when each patient’s visit goes according to clockwork precision, but the essential transaction of the crucial conversations not infrequently runs afoul of anticipated timed encounters. These conversations are unique in the human repertoire and can have the most profound implications. Skilled clinicians know when and how to diplomatically crowd the later patients, run through lunch, or regroup with an expansive patient later in the day or soon thereafter. Such is the art of medicine.

 

Thanks for reading Matula Thoughts this June, 2018.
David A. Bloom
University of Michigan, Department of Urology, Ann Arbor

Mays and blues

DAB Matula Thoughts May 4, 2018

Mays, blues, & other thoughts
3855 words

 

One.

Each May brings a sweet spot to Ann Arbor’s calendar with mild temperatures, bright colors, chirping birds, and happy graduations. Foliage on the UM Medical Center ‘Hill” is a welcome sign of May and a favorite sight, seen above from last year, is a weeping ornamental cherry with spectacular magenta flowers. It sits outside the dean’s wing so enjoy it while you can, as that area is scheduled for demolition due to anticipated new construction. Magenta, a tertiary color and the complementary color of green, comes from mixing equal parts of blue and red on computer screens, midway between the two primary colors on a color wheel or with paint or crayons.

Maize & blue colors are prominent in graduations of the 19 schools and colleges of the University of Michigan this month. Michigan’s official azure blue is not quite the bolder darker “Go-Blue” color so well-known through our athletic programs. Azure blue is halfway between blue and cyan. Wikipedia describes azure blue as the color of the sky on a clear day, although looking out the window on a recent flight to Seattle it seemed that the sky can have many shades of blue.[Below: sky & mountains south of Great Falls, MT, with 737 engine.]

Medical School graduation is a grand occasion at Michigan and rightfully so being a milestone of medical education, the moment of awarding the M.D. The ceremony, at Hill Auditorium next week, reconnects attendees to the roots of our profession. Even if you don’t have a family member in the graduating class or are not a departmental chair sitting on the stage, the event is a lovely way to spend an hour or two on a springtime Friday, see the Michigan colors in the academic gowns and join a recitation of the Hippocratic Oath.

 

Two.
Resident and fellow graduation. Less widely recognized and less ceremonious. but equally important, is the career-defining milestone of a medical career, when residents and fellows celebrate completion of their training programs. Residency graduates are the capstone product of medical education, coming from the phase of graduate medical education (GME) that may exceed twice the time of medical school itself. Michigan has nearly two times as many residents and fellows in training as medical students at any moment and the education of all of them requires a large base of patients for clinical experience, especially at the higher levels of complexity. This is the key reason for the current expansion of Michigan Medicine; a referral base in the range of 4 million patients is necessary to support 2000 medical learners at Michigan Medicine, 28 of whom are in the Urology Department. Add to these nursing students, pharmacists, dentists, and others training and its clear how much depends upon a broad patient base.

[Urology graduation/Chief’s Dinner, 2015 – UM Art Museum.]

Numerous trainee graduations of clinical departments are scattered throughout Ann Arbor this month and next. The graduates then quickly immerse in their fields of choice to become independent practitioners. In time, they will be the experts of their generation and in this lengthy and complex educational process, “The Maize and Blue,” as the University of Michigan is informally called, is unsurpassed.

Urologists with Michigan roots comprise the Reed Nesbit Society, named after Michigan’s first urology section chief. Later this May the American Urological Association (AUA) holds its annual meeting where we will host our Nesbit reception that Sunday night in San Francisco. If you are reading this newsletter, whether Nesbit alumnus or friend, you are welcome to join us, so please contact our office for details. Our Department of Urology will have a vigorous presence at the AUA, with well over 100 presentations of various sorts and our faculty are active in most leadership forums and arenas.

 

Three.
The AUA origin story begins with Ramon Guiteras, a prominent New York surgeon who had interest and skills in genitourinary surgery. After work one day in 1900 he took his team to an East Side tavern, The Frei Robber, that featured homemade wine and limburger cheese. The pungent cheese kept other patrons strategically away from the clinical shoptalk. Amidst the fruitful conversation, the group named itself the New York Genitourinary Society and decided to meet periodically.

Genitourinary surgery was then a facet of general surgical practice and some surgeons like Guiteras were consolidating the special skills, knowledge, and new technology of its practice. Guiteras proposed a new word for the field, combining the Greek terms for urine (uro) and study (logy) and it seemed to catch on, even if semantically it doesn’t quite hit the mark of accuracy. Guiteras, no doubt, intended the word to capture the idea of the practice and study of the urinary (and genital tracts) as evidenced in his subsequent textbook of 1912.

The NY Genitourinary Society continued to meet at various locations. Two years later, assembling at the home of Guiteras, in February, the group renamed itself the American Urological Association, an intentional stretch, even though they all were New Yorkers. They held a “convention” in June, 1902 at Saratoga Springs. Membership expanded and the following year a second “annual convention” was held in New Orleans and a third in 1904 in Atlantic City, with 34 members in the convention photograph. In 1905 the group met in Portland, Oregon, reflecting the national growth.

By 1910, 320 active and 16 honorary members were listed and Hugh Cabot became president. His presidential address the following year, at the Chicago convention was: “Is Urology entitled to be regarded as a specialty?” Clearly, the Guiteras neologism had been accepted. Cabot’s Modern Urology in 1916 was the second authoritative urology text in the 20th century, and Young’s in 1926 would be the third.

Cabot’s rhetorical question reflected daily tension in the workplace between general surgeons and genitourinary specialists, still widely considered “clap doctors.” General surgeons resisted the loss of turf to a new cadre of highly skilled genitourinary surgeons like Cabot who were claiming the new clinical territory. Anesthesia, antisepsis, analgesia, and modern technology with electrical illumination, x-rays, cystoscopes, and precision instruments allowed the new breed of lithotomists to differentiate themselves. When Cabot came to Ann Arbor in 1920 he opened up the era of academic and modern clinical urology at Michigan.

 

Four.

Blues. Medical School and residency training graduations are highpoint in our circle of educational life. Above from the 2013 Medical School graduation you see current academic vice-dean Carol Bradford, former EVPMA Mike Johns in maize and blue, along with former dean Jim Woolliscroft.

While Michigan’s maize and blue is far flung around the world, another shade of blue, that of Levi Strauss, is truly ubiquitous, visible every day, nearly anywhere you find people on Planet Earth. I felt a little creepy when I captured the street scene below, but I wanted a picture of an anonymous person wearing these universal trousers. Such is the nature of human beings, that if a centralized government mandated everyone to wear a blue jeans uniform, people would find any excuse and no doubt risk punishment to avoid the uniformity. Ironically, despite their pervasive presence, blue jeans are an expression of individuality and freedom to be casual, comfortable, and at liberty to choose from a variety of jeans that seems nearly infinite in terms of hues, logos, fit, manufactured wear and tear (often with holes and rips), as well as actual states of well-earned damage. Blue jeans seem to be a mark of a free society.

Cotton’s utility is enormously important, but its production and manufacture tied to particular geographies came historically (and perhaps currently) at the cost of great human misery. Fustian, a heavy cloth woven from cotton, an odd word for most modern ears, is also used for pompous or overblown speech, deriving from cotton padding in clothing. The ancient city of Fustat, Egypt’s first capital under Moslem rule, was a center for cotton manufacturing, although it’s subsumed now by Cairo. Jeans, a trouser fabric, emerged from Genoa, Italy and Nimes, France. The term, jeans, may derive from Genoa. Denim, another cotton fabric, came from serge de Nimes. Dungaree was a thick cotton cloth allegedly named for a dockside village near Bombay called Dongri. Exported to England, dungri made good workman’s clothing that were often colored blue, as were jeans. The coloring dye, indigo, mostly came from Pakistan, although American plantations became another large source until indigo synthesis was developed in Germany in the 19th century.

Levi Strauss, an 18-year old German immigrant, with his mother and 2 sisters in 1847 joined 2 older brothers who had begun a dry goods business in New York City. Strauss’s name at birth (February 26, 1829) was Loeb Strauss, but he changed it to Levi in New York for ease of pronunciation. The family came from the Franconia region of the Kingdom of Bavaria, where Levi’s birthplace is now a museum.

[Strauss home, Buttenheim, Bavaria. Source: Wikipedia.]
After a stop in Louisville, KY to sell dry goods, Levi became an American citizen early in 1853 and moved to San Francisco in March of that year to head the family’s new shop in the epi-center of the Gold Rush. He lived with his sister Fanny and her family. The business, Levi Strauss Company, flourished, selling imported dry goods brought by ship to San Francisco and Fanny’s husband, David Stern, helped run the firm. Jacob Davis, a Reno tailor who regularly purchased bolts of cloth to make clothes, wrote Strauss in 1872 to ask for help patenting a heavy-duty trouser with copper rivets at stress points at pocket corners and base of the fly. After trials of different materials, including cotton duck (a linen canvas), they settled on denim (Genoa style “genes”) dyed blue. Davis and Strauss shared costs to develop the patent application and on May 20, 1873 US patent No. 139,121 was issued to Davis for “Improvement in Fastening Pocket-Openings.” These were originally called “riveted waist overalls.” Miners liked the durable trousers and “Levi’s” soon became popular with cowboys as well. The company grew robustly. Strauss never married and after he died in 1902, he left his estate and company, worth around $6 million dollars, to his 4 nephews.

 

Five.
The same year Strauss got off the boat in NYC, a Philadelphia physician, Samuel David Gross, published a book in 1851 that marked the start of a new era for the practice and study of genitourinary diseases. Gross, at Jefferson Medical College, was the most prominent of a new era of general surgeons, empowered by the new tool of anesthesia and skilled with broad capabilities across the human anatomic terrain, including areas that would devolve to surgical sub-specialists over the next century. As it happened, Gross was particularly interested in the genitourinary system, and proved his mastery of the emerging field with his textbook, A Practical Treatise on the Diseases, Injuries and Malformation of the Urinary Bladder, the Prostate Gland and the Urethra.

Having exemplified one paradigm shift, Gross missed the boat in failing to take note of antiseptic surgical technique, in spite of Lister’s convincing evidence published in 1867. The famous Gross Clinic painting by Eakins in 1875 celebrates Gross as a powerful surgeon, at first glance, but in fact calls him out as an “antisepsis denier” in contrast to the more rational Agnew Clinic, painted by Eakins 14 years later, coincidentally also in Philadelphia. Gross had no excuse, the conclusive antisepsis work by Lister in 1867 in The Lancet was well-recognized across the world. Gross obstinately led the American reaction against antisepsis saying in 1876:

“Little if any faith is placed by an enlightened or experienced surgeon
on this side of the Atlantic in the so-called carbolic acid therapy of Professor Lister.”

This story was nicely told here at our Chang Lecture on Art and Medicine in 2014 by Charlie Yeo of Jefferson Medical College. Both Gross and Agnew embraced the belief that general surgeons, true to their adjective, should cover the entire anatomic terrain when surgery was necessary. Evolving technology and specialized knowledge would make it impossible for that paradigm to persist. Ophthalmology was one of the earliest modern specialties to find its own turf. Genitourinary surgery remained encompassed within general surgery for a longer time, even though a number of leading authorities in general surgery embraced genitourinary skills by the turn of the 20th century. New technical skills and specialty knowledge was exceeding the ability of most general surgeons to keep up across the entire anatomical terrain and the growing number of subspecialty experts craved conversations and identification with each other.

 

Six.
Festschrifts are academic celebrations to honor people and careers, and two of these coincided, in Seattle, for great genitourinary surgeons. By chance, after my arrival for these, I ran into Nesbit alums Atreya Dash and George Schade who had just emerged from a conference at the Fred Hutchinson Institute (below, Nesbit 2004, 2013).

The next day, Virginia Mason Clinic (VMC) celebrated Dr. Robert Gibbons who, among many other things, pioneered the indwelling ureteral stent. After service in Korea, Bob was recruited to the clinic early in his career by Nesbit trainees Tate Mason, Jr. and Roy Correa (Nesbit 1949, 1965). The Michigan/VMC relationship grew deeper with Bob Gibbons’ mentorship of Jim Montie (below: Jim & Bob).

The day began with Grand Rounds at VMC, continuing through dinner on Mercer Island at the home of Kathy Kobashi (Section Head, Urology & Renal Transplantation) and Chris Porter (Uro-oncologist and Co-director of Clinical Research at VMC). Other VMC, UM, and personal connections emerged during the celebration. We saw Gary Kaplan, UMMS alumnus and the legendary VMC Chairman & CEO, who has returned many times to advise us in Ann Arbor (below: Gary, Chris, Kathy.)

John Ryan, VMC vascular surgeon, gave a wonderful talk on the use of the gracilis muscle in urology. We noticed him wearing a Nesbit Society tie from his dad, Dr. John Ryan (Nesbit, 1948). Steve Skoog, my friend since our days at Walter Reed and former chief of pediatric urology in Portland, OR (below) and John and Mary deKernion, friends and role models since my days at UCLA, were also on hand to honor Bob.

[Below: Jean and Mary DeKernion.]

Wally Gibbons, nephew of Bob and urologist in Wenatchee, Washington, came for the event. Wally’s group recently hired Ian McLaren (Nesbit 2017) who we hear is doing very well, as Nesbit alumni do. [Below: Wally Gibbons, Bob Gibbons, Bob’s daughter Jennifer Hayes, Jack McAninch, Kathleen Kobashi, Becky Schwaegler, Fred Govier, Jim Gasparich.]

The following day we celebrated Dr. Richard Grady, former UMMS student who became a pioneering pediatric urologist at Children’s Hospital under the mentorship of Mike Mitchell, innovator of the transformational single stage exstrophy repair. Rich carried this technique, along with general pediatric urology, fearlessly around the world, to underserved and sometimes dangerous locations. Rich’s event, held in the lovely University of Washington Research Buildings in downtown Seattle, featured friends of Rich from all over North America. It was a moving and richly educational day, highlighting Rich’s skill as a surgeon, educator, and connector of people. His kindness, optimism, and social responsibility were extraordinary, seemingly coalesced into his sunny smile, right to the end last year when brain cancer cruelly interrupted Rich’s life in spite of courageous therapeutic efforts.

Rich’s last appearance at the AUA national meeting was in New Orleans (below, 2015) where he had a podium appearance wearing a head device that he cheerfully explained was “birth control for brain cancer” utilizing tumor-treating fields (TTF) for an antimitotic effect that interferes with glioblastoma cell division and organelle assembly by delivering low intensity alternating electric fields (below). A randomized clinical trial for glioblastoma with TTF and maintenance temozolomide involving 695 patients in 83 centers found a median progression-free survival of 6.7 months in the TTF group vs. 4.0 months in those without the electricity, with corresponding improvement in median overall survival, a small but meaningful step. [Stupp et al. JAMA. 318:2306, 2017.]

 

Rich and his wife Laura moved to Southern California for another clinical trial (Chimeric Antigen Receptor T cell therapy) at City of Hope where he was the first patient to complete the treatment that, in fact, melted away his tumors, although the effect was not durable. Nonetheless, the astonishing result was an important increment of progress. Honoring Rich were Dave and Sue Bomalaski (Nesbit 1996) from Anchorage, where, Dave after retirement from the Air Force, practices with the Indian Health Service. Mike Mitchell from Milwaukee and Joe Borer from Boston are seen below on either side of Dave (below).

[Above: Grady Festschrift group photograph.]

 

Seven.
Hospice is an important part of healthcare. Most of us in the business of healthcare go to great lengths to avoid speaking of death. We want to be optimistic saviors of life and are uncomfortable speaking directly of its end. Having had little or no training in terminal life, we offer no more to our current trainees. Fortunately, our geriatric colleagues, palliative care experts, and hospice teams are uncommon exceptions to the rest of us. Rich’s last days were eased by hospice care as were those of a good friend, John Reed, former UM Law School Dean and neighbor of Dr. Chang, who passed away recently, having nearly reached 100 years of age with full capacities until the end of 2017.

Australian writer, Cory Taylor, published a noteworthy memoir two years ago, detailing her struggles with melanoma since 2005, noting among other issues that a metastasis obstructing her urinary tract “necessitated the insertion in 2011 of a plastic stent to keep my right kidney functioning.” She didn’t report further urinary tract issues, so presumably the stent was changed periodically and kept that area of her anatomy out of harm’s way.

Her book, Dying: a Memoir, confronts a phase of life that most people will experience, unless their death is violent or otherwise totally unexpected. Taylor’s writing is lucid, frank, and lacking in self-pity. I found the memoir unexpectedly comforting. As Taylor looked back on her life, toward the end, she objectively examined its many positive memories, and voiced particular regrets but didn’t let them drift into immobilizing grief. She explored the lure of personal euthanasia, finding comfort in obtaining the means for it, yet was held back by downsides she imagined: the horror of the person who would come upon her corpse and the idea that the taking of her own life would define her.

“It worries me, for instance, that my death certificate would read ‘suicide’ as a cause of death, with everything that the term implies these days: mental angst, hopelessness, weakness, the lingering whiff of criminality – a far cry from, say, the Japanese tradition of seppuku, or suicide for honour’s sake. The fact that cancer was actually my killer would be lost to posterity, as would the fact that I am not, by any fair measure, mad.”

 

Eight.

Indigo Carmine, a dye used by urologists, became unavailable sometime last year until we got it back on our shelves recently, as Bruce Angel (Urology Nursing Service Lead) informed me. A note he forwarded me from the OR pharmacies explained that the price has gone up from $3.00 per ampule to $123.45. Indigo Carmine (indigotindisulfonate sodium) solution was once used to in testing renal function, but now is mainly used to find ureteral orifices during cystoscopy. An intravenous injection of 5 ml (40 mg) appears in urine within 10 minutes.

Indigo is a natural dye extracted from certain plant leaves, most commonly the tropic genus Indigofera, that also has analgesic and anti-inflammatory properties. It is one of the less common natural colors and has an ancient record. Junius Bird (1907-1982), an American archeologist born in Rye, New York, and a possible inspiration for the fictional Indiana Jones, excavated a prehistoric settlement in Peru in the 1940’s that yielded the earliest evidence for human use of indigo dye.

 

Nine.

 

 

Sunshine on a cloudy day. When Smokey Robinson, in 1964, penned the lyric “I’ve got sunshine on a cloudy day and when it’s cold outside I’ve got the month of May,” he identified sunshine and May with the sweetest things in life. His inspiration, “my girl” of the song, was his wife Claudette and fellow Miracles band member. [Above: 1965 album; below Claudette Rogers Robinson, March 12, 2013 at star for the Miracles in Hollywood. Wikipedia.] I saw Smokey on a plane a few years back and he was still a magnetic presence, 50 years after that enduring song. May is a busy time for most people, but it’s an optimal time to restock and recharge the sweet memory bank with sights, sounds, and experiences of Spring.

Whether tomorrow brings sun or clouds, the greatest 2 minutes in sports, The Kentucky Derby, will bring its own form of sunshine for the crowd, the champion, and those who pick the trifecta. This will be the 144th race, although the trifecta only goes back to the 1970’s when the betting opportunity of picking first and second place finishers in order expanded to the first three. Smokey’s trifecta seems to have been Claudette, sunshine, and May.

 

 

Ten.
More shades of blue. Azure, as a color name traces back to the days of heraldry, deriving from the deep blue stone, lapis lazuli. A lighter blue, bleu celeste, more closely mimics the sky. Royal blue, darker than azure, dates back to a dress made for Queen Charlotte, consort of King George III. Driving down Washtenaw Avenue in May, east of the campus, you will see many blues splashed on “The Rock.” These colors come from real buckets of paint, rather than tidy computer color wheels and display the exhilaration of school kids anticipating the end of school and the freedom of summer or the intoxication of graduation. Some people driving by this object to the messiness, but most of us take pleasure in the exuberant freedom its colors reflect, with the schoolkids as stand-ins for the rest of us.

[Above: The Rock.]

[Above: refracted May sunlight on carpet. Below: color wheel from Wikipedia.]

Jill Macoska, Nesbit faculty alumna and currently the Alton J. Brann Endowed Distinguished Professor in Science and Mathematics and Cancer Biology at University of Massachusetts in Boston, was just back in Ann Arbor for the graduation of her daughter Nicole. Jill wrote last month to identify those tiny blue flowers mentioned here last month. “Good morning, David – Those tiny blue flowers are called ‘squill’; they and snowdrops are usually the first bulbs to poke their heads up out of the snow in spring!  Boston has been a good fit for the Macoska family. Nicole came back to UM for a double major in Political Science and Communications (Below: Class of 2018, high distinction, Phi Beta Kappa.).

Jill wondered how many new UM alumni children and grandchildren came from the Urology Family.

Department chairs no longer sign Medical School diplomas individually by hand. I miss the scheduled sessions when we took our turns signing upwards of 200 certificates (extras, because a few inevitably get messed up). It might be viewed as a waste of time, but for me it was a reflective ceremonial interlude. A sweet “hard-stop” in the busy cycle of academic medicine, the signing reminded me that we are here in our roles at Michigan for very consequential reasons. Below you see Dr. Valerie Opipari, Chair of Pediatrics, a few years back with the azure seal of the maize and blue up close.

 

Thanks for reading Matula Thoughts.

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

November matters

DAB What’s New Nov 3, 2017

3742 words

One.
The matula, an historic symbol of the medical arts and title of this electronic periodical, was the transparent beaker used to examine urine in the pre-scientific days of health care, as people sought explanations for and expectations from their illnesses. Fear and uncertainty exacerbate human illnesses and our earliest prehistoric ancestors found comfort from their fellows in clans and caves to care for and sometimes heal them. The matula is a useful metaphor for the acts of looking, listening, and examining evidence to discover what really matters in clinical situations.

In ancient days what really mattered to people with illness or injury were the issues of treatment and prognosis: what can be done to help, what comes next, will I live, or will I die? The specific matter of diagnosis was most likely subsumed by the idea of what caused the problem. Gods, fates, cosmic forces, evil-doers, bad luck, or obvious injury were likely culprits before germ theory, organ-based dysfunctions, or other explanations based on a verifiable conceptual basis of health and illness. A sense of prognosis, however, was of practical value.

Uroscopists inspected urine for color, consistency, clarity, sediments, smell, and sometimes taste of urine, to find clues for treatment and prognosis. This was not illogical. Pink urine from infection or trauma might be followed by recovery. Gross blood and particulate sediments would suggest recurrent bladder stones. Scanty concentrated urine from dehydration might signal severe gastroenteritis and a grim prognosis. Uroscopy grew into a complex pseudoscience with fanciful claims of prognostic significance based on intricate characteristics of urine samples. Newer tools, such as the stethoscope and microscope superseded matulas and the future will bring better tools.

Thoughts about the future occasionally slide into dystopian visions and invite the question: what really matters to each of us? Putting aside occupational questions of healthcare professionals (making a diagnosis, ascertaining a treatment), political ideology (conservative or liberal, R or D, libertarian or socialist), or pragmatic issues (where do I live, what car do I drive, what’s for lunch?), we each have our own beliefs, although ultimately most people share similar fundamental desires for safety, comfort, and peace of mind. Family and friends matter.

We cherish personal liberty, physically and intellectually. Beauty, curiosity, and clarity matter. Social matters are important to most people; kindness, truth, integrity, respect, belonging, and sustainability are essential in a civilized world. The last item may seem a bit out of place, but as we sustain health, welfare, independence, and safety, for ourselves, our families, our communities, and our descendants, by simple logic we need to sustain our environment.

 

Two.


With Michigan’s gorgeous autumn colors fading in the rear-view mirror, November’s matula brings Thanksgiving into sight and notably the iconic holiday images of Norman Rockwell. His Four Freedoms paintings, based on Franklin Roosevelt’s State of the Union Address in 1941, illustrated the freedoms that FDR thought mattered greatly: freedom of speech, freedom of worship, freedom from want, and freedom from fear. These freedoms extended the sense of the liberty entrenched in the second paragraph of the Declaration of Independence.

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty, and the Pursuit of Happiness, – that to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, …”

Roosevelt’s four freedoms are more specific than the liberty mentioned in The Declaration at the dawn of the Revolutionary War, although political liberty was not far from Roosevelt’s mind when he gave the speech 11 months before the U.S. entry into World War II. The speech also slyly broke with America’s non-interventionism, by advocating support for our allies already in armed conflict. The words of Roosevelt and paintings of Rockwell mattered greatly to Americans in the 1940’s and they seem to matter now in this new century. Rockwell’s Four Freedoms paintings appeared in the Saturday Evening Post in 1943 and were used in war bond posters and postage stamps.

Rockwell also painted enduring images of healthcare professionals, some modelled on his neighbor Dr. Donald E. Campbell. After this topic was discussed in previous pages of WN/MT (March 4 & May 6, 2016) the doctor’s great granddaughter, Moira Dwyer, kindly sent us information and photographs that the family kept. Dr. Campbell, born in 1906, graduated in 1939 from Middlesex Medical School and practiced in Stockbridge, Massachusetts providing nearly the full spectrum of medical care to his community. He retired at 83 and died in 2001 at 95. Like the English physician, John Sassall, detailed in John Berger’s book, A Fortunate Man, Campbell was an indelible part of his community, providing far more than clinical services for patients by going beyond the specificity of medical conditions of his patients to understand their co-morbidities, inner needs, and social constraints. [Matula Thoughts Oct, Nov, Dec. 2016 & Feb. 2017]

As a footnote to Dr. Campbell, Middlesex College of Medicine and Surgery was founded in 1914 in East Cambridge, Massachusetts and was affiliated with a hospital of the same name. The campus moved to Waltham in 1928 and by 1937, it also included schools of liberal arts, pharmacy, podiatry, and veterinary medicine in addition to its school of medicine. Accreditation by the AMA became problematic, ostensibly due to issues of funding, faculty, and facilities although many claimed the merit-based admission policy and unusually diverse student body of Middlesex grated on the far more homogeneous American medical establishment at mid-20th century. Medical schools then maintained ethnic and religious admission quotas and Middlesex was an unabashed outlier with its diverse student body. In 1946, the Middlesex trustees transferred the charter and campus, with the hope that the medical and veterinary schools would be continued, to a foundation that created Brandeis University two years later. Middlesex Medical School did not survive the transition to the new university.

 

Three.
It is a profound community asset to have a Campbell or Sassall and it is impossible to fully measure their impact as a citizen, leader, mentor, and role model. These essential anchors of society bring not just their professional skills, but also their values, leadership, and expectation of fairness to a community. They look out for the common man and particularly for the most vulnerable members of the community. It is no coincidence that a universal ploy of anarchists, revolutionaries, and authoritarian pretenders as seen widely across the planet, is assassination of these “honest brokers.” The moral example and leadership of doctors such as Campbell and Sassall is our ultimate expectation for the medical professionals we teach. These mentors and role models act as epigenetic factors for the larger “superorganism” of humanity. They are operational factors between human genetics and civilization.

Education and training of physicians changed since 1939 when Campbell graduated medical school. The 4-year curriculum deepened with the growing scientific basis of biology and disease while graduate medical education (GME) also expanded with enlarging technology and new specialties of health care. The period of residency practice and study is now the career-defining facet of a doctor’s learning. Nearly 80 years since Dr. Campbell’s graduation, medical students enter fields of GME in as many as 150 areas of focused medical practice with learning experiences that may exceed twice the years the trainees spent in medical school.

Healthcare education differs from that of lawyers, engineers, and most other career paths. Physicians, pharmacists, nurses, and dentists require an immediate educational context of patient-care. The University of Michigan recognized this fact in 1869 when it converted a faculty house into a hospital, thereby becoming the first university to own and operate a medical center. We recognized this anew when we began to create a wider health care network, in the past few years, capable of supporting our large educational mission, now educating 900 MDs and health care PhDs, 1100 residents and fellows in medicine, as well as dentists, nurses, and pharmacists. One could easily argue that universities should offer a wider coherent educational milieu. A grander educational vision to include all parts of the health care workforce (physician assistants, surgical scrub technicians, medical assistants, etc.) would have a great effect on state economy and on our workforce pipeline. It could be done with robust partnerships not only with the UM Flint and Dearborn campuses, but also with our adjacent and regional community colleges.

 

Four.
In its more rudimentary days, the UM academic health center was distinguished by its implementation of  fulltime clinical faculty, terminology indicating that physicians who practiced or taught exclusively within a teaching hospital had a fulltime salary independent of their patient care revenue at that site. In the early days of UMMS this model attracted national luminaries such as Charles de Nancrede in 1889 and Hugh Cabot in 1920. de Nancrede was an attending surgeon and clinical lecturer at Jefferson Medical College, among other Philadelphia medical institutions, and was a major name in American surgery as a clinician, teacher, and pioneer in antiseptic and aseptic technique. At Michigan he presided over the construction of the new West Hospital in 1892, established a world-class surgery department where he practiced exclusively, and wrote an influential textbook of surgery. [World J. Surg. 22:1175, 1998.] Cabot was an even more stellar addition, coming from Boston as an internationally known urologist, where he had become disillusioned by the monetary nature of medical practice.

The world of healthcare practice, education, and investigation is different in the 21st century. The few academic medical centers that will survive well in the future will be those with the best and brightest geographic fulltime faculty, the majority of whom will be busy clinicians. Their milieu may well depend upon robust clinical productivity that brings the most challenging clinical problems to them and their facilities, but this will also require a very substantial volume of more routine clinical work as the context for education of all learner groups and clinical trials, in addition to inspiring basic science investigation. This clinical milieu will require a robust array of endowed professorships to give faculty a modest disconnect from clinical practice to allow teaching and academic work.

 

Five.

Fellow professionals. Modern specialty-based health care has shifted emphasis from individual all-knowing utility-player doctors like Campbell and Sassall to large teams that deliver their parts of today’s healthcare. The knowledge base, growing list of specialties, and technology of medicine today is so great that the centrality of a single physician is a model that no longer works well for health care delivery. Furthermore, linguistic confusion arises as other terms are awkwardly deployed to indicate all healthcare providers (not just physicians) more inclusively. This matter became acute as we have been creating bylaws for our new University of Michigan Medical Group (UMMG). A good nomenclature solution arose from Gerald Hickson, a Vanderbilt pediatrician (above), speaking to the UMMG this summer about programs that build professionalism and create a culture of safety. His phrase, fellow professionals, nicely includes MDs, DOs, nurses, PAs, physical therapists, podiatrists, occupational therapists, optometrists, respiratory therapists, pharmacists, medical assistants, etc. [Hickson et al. A complementary approach. Acad. Med. 82:1040, 2007]

 

Six.
Medical professionals are under stress today from many sources, but the idea of a career in medicine still drives some of the best and brightest young people into our work, as judged by the medical school and urology residency applicants we see each year. I’ve just read applications, personal statements, and letters of recommendations from nearly 70 candidates for our 4 positions to start next July, and again I am blown away by the breadth and depth of these fourth-year medical students who will, all too soon, become our successors as urologists. They will have to resist the pressures to commoditize, corporatize, and industrialize their work as the 21st century rolls along. The electronic record is one of the pressures. A paper in Health Affairs last April surveyed primary care physicians and found they spent 3.17 hours on computers (desktop medicine) for every 3.08 hours spent with patients. [Tai-Seale et al. Electronic health record logs. Health Affairs. 36:655, 2017.]

It is impossible to predict the world that will envelop our successors. The conceptual basis they will learn and the skills they acquire are merely momentary assets. Ideas and techniques will change as long as human progress continues. The values, mores, social skills, curiosity, imagination, and ultimate kindness of our successors will be the principle assets to distinguish their careers, their effects on their communities, and their value to society in general. The influence of their ambient role models is as important as the book-learning and clinical skills imparted in graduate medical education. The epigenetic nature of values, mores, social skills, and role models show us, our colleagues, and our successors how and when to deploy the vast stores of information and skills we have accumulated. Just as importantly, some among them will be inspired to discover new knowledge and develop new skills.

 

Seven.

With Thanksgiving coming up, I’m appreciative for precarious and relative world peace, food security, respite from climactic disasters, and the happy, healthy, lives we may have. [Above: Jennie Augusta Brownscombe, The First Thanksgiving at Plymouth, 1914, Pilgrim Hall Museum, Plymouth, Massachusetts.] The great minds who have made this world so interesting are another blessing, people who looked at the world with clarity to make observations or find patterns that escaped everyone else at their moments.

The name, Conrad H. Waddington, probably doesn’t spring to mind, but is worth consideration. Born on a tea estate in Kerala, India, around this time of year in 1905 this British developmental biologist introduced the concept and word epigenetics. At age four he was sent off to England to live with family members while the parents remained at work in India for the next 23 years. In England, a local druggist and distant relation, Dr. Doeg, took the boy under his wing and inspired his interest in sciences. At Cambridge, “Wad” took a Natural Sciences Trips (a flexible curriculum across sciences) and earned a First in geology in 1926. With a scholarship he studied moral philosophy and metaphysics at university, assumed a lectureship in zoology, and became a Fellow of Christ’s College until 1942. During WWII he was involved in operational research for the Royal Air Force, and in 1947 became Professor of Animal Genetics at the University of Edinburgh where he worked for the rest of his life except for one year at Wesleyan University in Connecticut. Waddington’s landmark paper in 1942 begins with four lovely sentences.

“Of all the branches of biology it is genetics, the science of heredity, which has been most successful in finding a way of analyzing an animal into representative units so that its nature can be indicated by a formula, as we represent a chemical compound by its appropriate symbols. Genetics has been able to do this because it studies animals in their simplest form, namely as fertilized eggs, in which all the complexity of the fully developed animal is implicit but not yet present. But knowledge about the nature of the fertilized egg is not derived directly from an examination of eggs; it is deduced from a consideration of the numbers and kinds of adults into which they develop. Thus genetics has to observe the phenotypes, the adult characteristics of animals, in order to reach conclusions about the genotypes, the hereditary constitutions which are its basic subject-matter.” [Waddington. Endeavor. 1: 18-21, 1942]

Later on the first page he suggests the term epigenetics to encompass the “whole process of developmental processes” that carries genotypes into phenotypes. The influence of Dr. Doeg, whom Waddington called Grandpa, was no doubt significant. The specifics of Dr. Doeg eluded me as I read about Waddington. Too bad, because it would have been illuminating to understand the nature of the fruitful mentorship that shaped Waddington’s curiosity, lucidity, communicative skills, and sociability that left him a context to discover what he did.

 

Eight.

Black Bart, legendary stagecoach robber, committed his last robbery on this date in 1883. He specialized in Wells Fargo robbery, and it’s a bit ironic that the bank’s more recent history indicates it has internalized that larcenous bent to its own customers. Black Bart was actually Charles Earl Boles, variously known as Charley Bolton, a gentleman bandit in Northern California and Oregon. Born in Norfolk, England, he and his brothers joined the California Gold Rush in 1849. The brothers died and by 1854 Charles was married and living in Decatur, Illinois with a wife and four children. After serving in the Civil War he returned to California and gold prospecting in 1867, leaving his family behind. In 1871 Bolton wrote his wife and described an unpleasant encounter of some sort with Wells Fargo & Company agents and vowed revenge. He fulfilled the vow, adopting the name Black Bart, and robbed at least 28 coaches in California and Oregon, although never fired a weapon or harmed anybody. The last known robbery was in Calaveras County, between Copperopolis and Milton, when he was wounded in the hand while escaping. Detectives found personal items at the scene and through laundry marks traced a handkerchief to a San Francisco laundry on Bush Street. They quickly located Boles, living in nearby boarding house, and convicted him of the November 3 robbery.

Black Bart served four years at San Quentin and after release he was constantly shadowed by Wells Fargo detectives. In a letter to his wife he said he was tired of the attention, and disappeared after being last seen near Visalia on February 28, 1888. A distinctive feature of Black Bart was that he was consistently a gentleman, always polite and never using profanity. It might be said that he was a rare and exemplary professional in his business, living according to his values. His sense of mission will never be exactly known to us today, but Black Bart was somehow compelled to right some perceived wrong and, like most of us, he needed an income so Wells Fargo was a fitting opportunity.

Even in his risky occupation Black Bart remained kind and harmless, other than theft from a corporate entity of questionable kindness itself, it turns out. If he could act kindly in spite of living on the edge as he did, health care professionals such as us might consider him as a role model, although somewhat of a peculiar one. Somewhere along the line he must have had the parenting, mentorship, or experience that built his character of kindness, larcenous though it might have been. [Above book cover. Black Bart: Boulevardier Bandit. George Hoeper. Word Dancer Press, 1995]

 

Nine.

Jack Lapides. As we unearth stories of Michigan Urology, colorful anecdotes come to light and many involve Jack Lapides. The personal story of a patient who underwent a life-changing Lapides vesicostomy was told on these pages in July and that gentleman was ultimately laid to rest in a ceremony at Arlington in August. Another story from a former medical student was that of Jack teaching the students the art of cystoscopy when he would ask the students to peer over his shoulder and look through the scope to describe what they saw.

It is said that Lapides sometimes mischievously disconnected the light source cord as someone leaned in to look and occasionally an uncertain student provided a fanciful description of the dark or black field. This may have been one origin of his Black Jack moniker, although just as likely it might have been related to the fear he struck among rookies in his expectation for high standards and excellence. Dr. Lapides’s conferences were legendary. He was exacting and tough, requiring that all presentations be stripped of jargon and abbreviations. The IVP, for example, was intravenous pyelogram. Conferences today are more causal. The tradition of teaching conferences persists, but on a larger canvas since Lapides’s days with 4-5 faculty, our scale having increased by a factor of 10. Just below is Thursday morning Grand Rounds. Further below is the Friday AM Mott imaging conference that follows a formal review of operations scheduled the following week. In both instances we have outgrown our rooms.

Yet another Lapides anecdote turned up last week when I was at the American College of Surgeons (ACS) meeting and spent an evening with Lou and Ginger Argenta (below: with Tony Atala of Wake Forest, in San Diego October, 2017).

Lou had been our plastic surgery head in my early years at Michigan and innovated, with Michael Morykwas at Wake Forest, the Vacuum-Assisted Closure (VAC) device, a paradigm-changing system to manage burns and wounds. For this he won the Jacobson Innovation Award from the ACS in 2016. Lou recalled how Jack Lapides, in his retirement years, took up welding and small engine repair, learning and teaching them at Washtenaw Community College. Jack kindly performed a welding repair on the broken bicycle of young Joey Argenta, and the work held up for years of further bicycle abuse.

Lapides stories will undoubtedly continue to emerge. The man and his work had a long reach.

 

Ten.
What really matters to us, to our patients, to our colleagues, to our community, and our 7 billion global brethren is a deep question usually lost in the daily hustle of life. Most people have roughly similar ideas about what matters, although each has a particular take on things. Donald Campbell, Charles de Nancrede, Charley Bolton, Jack Lapides, Dr. Doeg, CW Waddington, FDR, and Rockwell had their particular world views that shaped their legacies. All, no doubt, shared many of the things that mattered to them, although each likely ordered and interpreted those characteristics idiosyncratically, perhaps Black Bart most peculiarly.

It is no accident that the four essential freedoms that Roosevelt identified have a strong basis in health care. Freedom from want is most obviously tied into food security, but it could just as easily be interpreted as freedom from needs that rationally include shelter and health care. Freedom from fear was illustrated by Rockwell as a fear of illness, but safety and personal security could just as easily have been the visual that Rockwell used. Liberty in the political sense is not so far from liberty in its mobility sense. An authoritarian regime may enforce curfews or travel restrictions, just as health conditions restrict people from being out and about to participate fully in society. If governments are to promote life, liberty, and the pursuit of happiness, the four freedoms are essential.

Human values and role models are the factors that translate human beings into the superorganism of human civilization. Those factors can go the way of apoptosis or can epigenetically build a prosperous, just, beautiful, robust, and sustainable version of itself for the next generation.

[Autumn foliage, my neighborhood 2017]

 

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

February, Sunday feelings, and Monday facts

DAB What’s New February 3, 2017

February lows and highs; Sunday feelings, Monday facts
3916 words

 

icicle

One.
February is the nadir of winter as well as the shortest and most variable month, with average snowfalls of 13 inches, highs of 35℉, and lows of 20℉ in Ann Arbor (U.S. Climate Data. Wikipedia). Even though not quite the coldest month February seems the wintriest, lacking the enticements of December holidays and the exhilaration of January’s new year. This February, a regular one without the extra day, allows only 20 business days to pay the challenging bills of academic urology. Educational and research expenses always exceed their funding streams and require clinical and philanthropic dollars to maintain them.

korlebu

[Michigan team and the Korle-Bu and Military Hospital staff, Accra.]

Last month 3 faculty and 2 residents escaped Michigan winter for a week of operating and teaching in Ghana. Sue and the late Carl Van Appledorn initiated this yearly trip and other generous donors help offset its draw on clinical revenue. John Park, Casey Dauw, and our former faculty member Humphrey Atiemo (now Program Director at Henry Ford Hospital) accompanied by residents Yooni Yi (UM) and Dan Pucheril (HFH) spent a productive week in Accra. Casey led the team in performing the first successful percutaneous nephrolithotomy in that part of the world. The Korle-Bu Hospital, affiliated with the University of Ghana, is one of the largest teaching hospitals in Africa. John Park will give further details in an upcoming What’s New/Matula Thoughts.

casey-perc

[Casey at bat.]

Back here in the USA the economic side of health care is ambiguous. Governmental funding, public policy, regulation, corporatization of the clinical domain, market segmentation, and escalating costs in pharmacologic/technology industries are some factors in the turmoil. Most healthcare industries maintain the public trust and behave admirably in seeking profits and market share – we certainly see this in the companies with whom we deal such as Johnson & Johnson, Medtronic, Boston Scientific, Storz, etc.

A few egregious actors stand out. The Mylan company’s repackaging of a natural chemical (epinephrine, for which nature holds the patent) with a syringe and needle was a mildly clever gimmick, but creating a monopoly for this lifesaving device and raising the prices for a two-pack from $100 in 2007 to $608 in 2016 is greed beyond the bounds of public acceptance. Mylan’s half price “generic,” offered recently, is a pathetic peace-offering to the public – a generic of a generic is elementary Orwellian Newspeak. [Epinephrine auto-injectors for anaphylaxis. JAMA; 317:313, 2017.] Teva Pharmaceutical was another one of the six drug makers recently sued by 20 state lawmakers on price fixing. These two companies are the largest generic drug makers by market cap. (It must have been awkward for Mylan’s CEO Heather Bresch to justify EpiPen prices because of research and development expenses in testimony to the House Oversight and Government Reform Committee last October.) [M. Krey. Investor’s Business Daily. Mylan launches cheaper EpiPen generic amid drug pricing saga. 12/16/16.] Below: Table A from 10/5/16 letter from CMS Administrator Andrew Slavitt to Senator Ron Wyden regarding Medicaid and Medicare Part D Expenditures on EpiPen products.

table-epipen

 

search
Two.

Regulation for the public good is essential in a world economy of 7 billion people and GDP of $78 trillion. All businesses exist because of the public trust, going back to the early days of the limited-liability joint-stock company, a story explained in a book called The Company that Julian Wan gave me years ago [John Micklethwait & Adrian Woolridge. Modern Library, NY 2003.] Most US businesses understand their public responsibilities, but uncommon greedy actors erode public trust and diminish the standards for the rest.

Regulation is under attack. It is inevitable that government regulations dampen corporate bottom-lines and short-term economic growth, that is the nature of regulation, but few rational people can deny that serious regulation of highway traffic, airways, nuclear energy, banks, health care, etc. is in the public interest. Offensive governmental regulatory overreach is bound to happen in any complex bureaucracy and should be called out when discovered, but these instances hardly disprove the necessity for regulation by impartial public agencies and civil servants in a healthy democratic society.

By now, in February’s wintry days of cold and snow, the EpiPen story is old news, but we hope that the protective regulatory functions of governmental regulation do not get snowed over or subsumed by corporate world grudges. Like most things in life, balance is essential.

 

Three.

iran-blizzard

The world’s deadliest known snowstorm began this February day in 1972, lasting a full week and killing around 4,000 people. The blizzard centered on the city of Ardakan in southern Iran, the region of Shiraz, cultural capital of Iran and known for the eponymous grape. Storyteller Isak Dineson (Baroness Karen Blixen-Finecke, 1885-1962) linked that grape to urology in her short story, The Dreamers: “What is man when you come to think about him, but a minutely set, ingenious machine for turning, with infinite artfulness, the red wine of Shiraz into urine.” Blixen created coherent and compelling stories at a moment’s notice, and told her own life story in the 1934 book Out of Africa, that became a film in 1985 with Meryl Streep and Robert Redford. The complete passage in The Dreamers is particularly intriguing and relevant to urologists.

“ ‘Oh, Lincoln Forstner,’ said the noseless story-teller, ‘what is man, when you come to think upon him, but a minutely set, ingenious machine for turning, with infinite artfulness, the red wine of Shiraz into urine? You may even ask which is the more intense craving and pleasure: to drink or to make water. But in the meantime, what has been done? A song has been composed, a kiss taken, a slanderer slain, a prophet begotten, a righteous judgement given, a joke made…’ ”  [Isak Dinesen. Seven Gothic Tales. The Dreamers. 1934, Random House. P. 275.]

Blixen’s choice of Lincoln for the first name of one of the three central characters in her imaginative story is curious, for although it is a well-known surname it is an uncommon given name.

karen_blixen_and_thomas_dinesen_1920s

[Karen Blixen and brother Thomas Dineson on her farm in Kenya, c. 1920s. Royal Danish Library.]

 

Four.
Imagination is the ability to form ideas, images, and sensations without direct sensory input. The practice of medicine, its instruction, and its innovation demand imagination. The imagination to think through the plausibility of things, is inseparable from critical thinking. Observation and reasoning, experience and experiment, are feats of imagination that challenge dogma with new ideas in search of the best truth possible. Such creative thinking is a necessary, but often forgotten piece of the essential skeptical analysis that good physicians and scientists practice and instill in students, residents, fellows, and colleagues.

A recent Lancet article referred to the early American physician Benjamin Rush (1746-1813), who called imagination “… the pioneer of all other faculties.”

“When Rush spoke of imagination, he wasn’t talking about dragons or unicorns, he called that mental faculty fancy, and fancy had no place in medicine. Rather, Rush was talking about how the doctor’s mind gathered observations and experiences, shifting and shaping them until new truths became clear. Memory was a component of this imagination, and understanding resulted from it.” [S. Altschuler. The medical imagination. The Lancet. 388:2230, 2016.]

I’d challenge the claim that no hard line exists between those dragons or unicorns and the new ideas, hypotheses, and truths we hope to discover. Fanciful fiction, visual art, and music enrich mental milieus and provide metaphors, symmetries, dissonances, harmonies, and analogies that make clinical work and science sharper, more multidimensional, and of greater relevance than they would be without the “fancy.” E.O. Wilson infers this in his conclusion to Consilience, a book named for and about the unity of knowledge.

“The search for consilience might seem at first to imprison creativity. The opposite is true. A united system of knowledge is the surest means of identifying the still unexplored domains of reality. It provides a clear map of what is known, and frames the most productive questions for further inquiry. Historians of science often observe that asking the right question is more important than producing the right answer. The right answer to a trivial question is also trivial, but the right question, even when insoluble in exact form, is a guide to major discovery. And so it will ever be in the future excursions of science and imaginative flights of the arts.” [EO Wilson. Consilience. Alfred A. Knopf. New York.]

Creativity can also spring from irrational thought as a song in the new film La La Land suggests. Audition (The fools who dream) sung by Emma Stone: “A bit of madness is key, to give us new colors to see. Who knows where it will lead us and that’s why they need us.” Human exploration of reality requires consilience of all the tools we can muster, including scientific knowledge, historical facts, stories, and imaginative fancy.

 

Five.

puppet
When you read a story or experience visual art you may discover something new to which your brain can connect and that will illuminate other stuff in your brain at that moment or later on in reflections, dreams, or sudden denouements. Those connections provoke imagination, test reality, and elicit wisdom that affects your world view and your work. Insight and inspiration from art provide limitless opportunities in the practice, teaching, or investigation of medical care. The story of British pediatrician Harry Angelman (1915-1966) offers a minute and excellent example of illuminating connection.

“It was purely by chance that nearly thirty years ago (e.g., circa 1964) three handicapped children were admitted at various times to my children’s ward in England. They had a variety of disabilities and although at first sight they seemed to be suffering from different conditions I felt that there was a common cause for their illness. The diagnosis was purely a clinical one because in spite of technical investigations which today are more refined I was unable to establish scientific proof that the three children all had the same handicap. In view of this I hesitated to write about them in the medical journals. However, when on holiday in Italy I happened to see an oil painting in the Castelvecchio Museum in Verona called . . . a Boy with a Puppet. The boy’s laughing face and the fact that my patients exhibited jerky movements gave me the idea of writing an article about the three children with a title of Puppet Children. It was not a name that pleased all parents but it served as a means of combining the three little patients into a single group. Later the name was changed to Angelman syndrome. This article was published in 1965 and after some initial interest lay almost forgotten until the early eighties.” [Quotation from Charles Williams. Harry Angelman and the History of AS. Stay informed. USA: Angelman Syndrome Foundation. 2011.]

Giovanni Francesco Caroto (1480-1555), the Renaissance painter in Verona, created the Portrait of a Child with a Drawing and the circumstances of the subject will probably never come to light. It may well be a coincidence that the picture resembled the patients that provoked Angelman’s curiosity.

chromosomes

[Chromosome 15]

chr-15
Deletion or inactivation of genes on maternal chromosome 15 with silencing of the corresponding normal paternal chromosome is responsible for AS. Similar genomic imprinting, but with deletion or inactivation of paternal genes and silencing on the maternal side happens in Prader-Willi syndrome, that shows up more often in our pediatric urology clinics. These two conditions along with Beckwith-Wiedemann and Silver-Russell syndromes were early reported instances of human imprinting disorders. An excellent update on these conditions appeared last month in Science. [J. Cousin-Frankel. Fateful Imprints. Science. 355:122-125, 2017]

 

Six.
New residents. We just matched our new cohort of PGY1s, a stage of medical education once called internship, that starts each July to initiate the transition of medical students into specialists. The medical student is the last universal common ancestor in the evolution of a medical specialist. About 150 areas of focused practice (per American Board of Medical Specialties) are available to freshly minted MDs and those last universal common ancestors in medicine evolve into the new species of their chosen specialties during their residencies.

This educational experience is a primary reason we exist as a Department of Urology. The UMMS was formed to produce the next generation of physicians for the State of Michigan in 1850 when this mission required 2 years of medical school lectures to achieve the MD necessary to practice medicine. The medical school then needed only 5 faculty and 2 departments (Medicine as well as Surgery and Anatomy) to provide that education. Today’s world of specialty medicine requires 4 years of medical school (with lectures, laboratory work, and clinical experience) as well as graduate medical education in one of 100 areas of specialty training offered here in Ann Arbor. Our medical school faculty numbers 2500 in 30 departments. We educate, at any moment, about twice as many residents in specialties as medical students – and the period of residency training may be more than twice as long as medical school itself.

New members of the UM Urology family are: Juan Andino with BS, MBA, and MD degrees from UM; Chris Tam with BS from UC San Diego and MD from the University of Iowa; Robert Wang with BA and MD degrees from Washington University in St. Louis; and Colton Walker with BS from Stanford and MD from Louisiana State University in New Orleans. Who knows where they will lead us?

 

Seven.
Darwin & Lincoln’s birth, on the same day in the same year, was the wonderful coincidence of February 12, 1809. Two more different circumstances for those neonates would be difficult to imagine although both families had roots in England. Both men had big imaginations that changed the world in positive ways that endure today. Darwin arrived in the center of the civilized world, Shrewsbury England, to a prosperous family. His grandfather, Dr. Erasmus Darwin, was one of the great thinkers of his time and his father Dr. Robert Darwin was a successful physician. The house where Charles Darwin was born was distinguished enough to have a name, The Mount. Abraham Lincoln was born in a small primitive cabin, now long gone, on the Sinking Spring farm on the western periphery of a nation barely 33 years in existence. The nearest town, Hodgenville, didn’t even get its name until 1826, long after the Lincoln family, short on money and education, had moved on.

400px-charles_darwin_photograph_by_herbert_rose_barraud_1881

[Above: Photo by Herbert Barraud, last known picture of Darwin. 1882. Huntington Library. Below: Last known high-quality Lincoln photo, March 6, 1865. Library of Congress.]

lincoln-warren-1865-03-06-jpeg

Darwin’s idea, The Origin of Species, contained the belief that species couldn’t breed with different species. The classic example of reproductive isolation that many of us recall from childhood was the mule, the result of a donkey and horse breaking the species barrier recreationally, but the resulting progeny was sterile and incapable of creating a further bloodline. That belief in a barrier to interbreeding, or hybridization as biologists term the process, has fallen away in the new era of genomic information. The Neanderthal and Denisovan genes in the Homo sapiens genome is a rather intimate example of species interbreeding. It turns out that hybridization has played an important role in evolution throughout most kingdoms of life.  The mule is joined by the liger (lion/tiger), Hawaiian duck (Mallard/Laysan duck), red wolf (coyote/gray wolf), and pizzly (polar/brown bear). Domestic dog and wolf interbreeding has given wolves a variant immune protein gene, β-defensin, that conveys a distinctive black pelt and improved canine distemper resistance to wolf/dog hybrids and their descendants. [Elizabeth Pennisi. Shaking up the tree of life. Science: 354:817-821, 2016.] In a practical sense for our work in healthcare, bacterial swapping of DNA presents great challenges. Darwin recognized a mighty force – nearly as mysterious and pervasive as gravity – that crops up way beyond biology. Even in social ebbs and flows of life, Darwinian forces are at play, for surely they have made markets, politics, and academia increasingly creative.

 

Eight.
LUCA. Central to the multiple facets of our interests and knowledge as clinicians, surgeons, and urologists, we are ultimately biologists. In that spirit, the mystery of how life began on Earth is an irresistible intellectual puzzle and if you align to the Darwinian line of the speculation the concept of a very simple common ancestor holds traction.

Such a single cell, bacterial-like organism would have begat the three great domains of life: archaea, bacteria, and later the eukaryotes. Of the 6 million protein-coding genes in DNA data banks, William Martin et al at Heinrich Heine University in Dusseldorf speculated that 355 were present in that most primitive of ancestors, called the Last Universal Common Ancestor (LUCA). These probably originated around volcanic sea vents that supplied just the right conditions. Whether or not LUCA came from sea vents, warm ponds, or other environments should become clearer as biologists dig deeper into our roots. LUCA might have looked like any of the archaea and bacteria we recognize today with stiff walled rods or cocci. More complex shapes required the flexible cell walls that came later with eukaryotes. LUCA probably existed as an anaerobe in a vent-like hydrothermal geochemical setting and was based upon 355 genes according to a paper from the Institute of Molecular Evolution at Heinrich Heine University in Düsseldorf.

luca

[Figure from MC Weiss, FL Sousa, N Mrnjavac et al. The physiology and habitat of the last universal common ancestor. Nature Microbiology. 1, Article number 16116, 2016.]

Much has happened since LUCA. Given the Darwinian trials of variation by error in the face of minor and gross environmental challenges over millions of millennia, new species developed in fits and starts. The Cambrian explosion of new creatures was one of many responses of speciation to planetary change. We humans seem to be at the far opposite end of the phylogenic spectrum from LUCA. Our complexity is not just a matter of our biology and our cerebral skills, but no less a matter of the social nuances that elaborate the human condition.

 

Nine.
A Fortunate Man. The classic study of an English general practitioner in the 1960s, alluded to on these pages last year sharpened my perspective as a physician. [John Berger, A Fortunate Man, Random House, NY 1967.] The ancient perspective of healthcare, documented since medical recipes in ancient early Egyptian papyri and Hippocratic writings, was a matter of dualities: one patient-one physician, one problem-one solution, and one teacher-one student. This changed in the past century due to medical specialties and technology that have introduced unmeasurable complexity. Patient care and medical education are no longer two-body problems, but are now part of a multidimensional healthcare matrix.

Even that multidimensional professional matrix is dwarfed by the complexity of patients with their own multidimensional physical, mental, familial, social, economic, political, and environmental comorbidities. You might lump all these comorbidities together and simply call them “the human condition” that Berger probed in A Fortunate Man, hinting that we really have little sense of what our patients are all about. However, as we practice our art, we become better at understanding the holograms of the patients as they present themselves in our clinics even in the short time frames at hand and the insistence of electronic health records and economics that force us to default to two-body problems (augmented with a few clever comorbidities that can permit a more realistic billing code).

Berger died last month (January 2) at 90 in the Parisian suburb where he lived. I didn’t know much about him since I read his book just last year (and I wish I could remember who told me to read it). Berger (pronounced BER-jer,) was known as a “provocative art critic” in the obituary by Randy Kennedy that included this example:

“He was a champion of realism during the rise of Abstract Expressionism, and he took on giants like Jackson Pollock, whom he criticized as a talented failure for being unable to ‘see or think beyond the decadence of the culture to which he belongs.’” [Kennedy. New York Times Tuesday January 3, 2017.]

The obituary ran for three columns and mentioned a number of Berger’s books, but not A Fortunate Man.

 

Ten.
That other birthday celebrant of February 12, 1819, would also have been 198 years old this month. Human biology at its best wouldn’t have given Lincoln that chance, but it was political extremism that cut him down short of his potential fourscore and ten years. While Darwin’s ancestors provided more than a hint of greatness for their descendent, Lincoln’s ancestry offered no such clue, but his insatiable drive for education and personal distinction contrasted remarkably with the rest of his family. His improbable success in law and politics leveraged his even more unlikely ascent to the presidency of the United States. No one could have predicted that his ultimate comorbidity would have been an actor with a Philadelphia Derringer at Ford’s Theater on April 14, 1865.

currier-ives

wilkes_booths_deringer

rimfire-cartridge

[Top: Currier & Ives print of assassination April 14, 1865. Middle: The actual Derringer. Bottom: 0.41-caliber Rimfire cartridge.]

Lincoln’s assassin jumped to the stage and escaped on a horse waiting near the backstage door. The following day he stopped near Beantown, Maryland (now Waldorf) seeking treatment at the home of Dr. Samuel Mudd, an acquaintance, for a broken left fibula. Mudd cut off Booth’s boot, splinted the leg, provided a shoe, and arranged for a local carpenter to make a pair of crutches. After catching some sleep at the doctor’s house Booth travelled on to Virginia where he was caught and killed on April 26. Mudd was arrested, charged with conspiracy, and imprisoned at Fort Jefferson in the Dry Tortugas. He tried to escape once, but became a good prisoner and was released after pardon by President Andrew Johnson on March 8, 1869. Mudd returned home to Maryland where he lived until January 10, 1883 dying of pneumonia at 49 years of age. Mudd’s grandson, Dr. Richard Mudd, unsuccessfully petitioned a number of presidents (Carter and Reagan) and also failed in other avenues to clear the family name of the stigma of aiding Booth. The family name remains Mudd.

600px-booth_escape_route-svg

[Booth escape route. Wikimedia Commons. Courtesy, National Park Service.]

Our world has changed enormously since Lincoln’s time. The American democracy is better, healthcare  is more effective, and the Earth even when viewed from far out in our solar system looks amazingly different (below); Edison’s electrical illumination, invented in 1880, has impacted both the visible planet and environment due to the fossil fuel consumption for those lights.

earth-earth-at-night-night-lights-41949

A short book on Darwin and Lincoln, Angels and Ages by Adam Gopnik [Alfred A. Knopf, NY 2009] noted:

“What all the first modern artists, from Whitman to van Gogh, have believed is that, for whatever reason, and however it came to be, we are capable of witnessing and experiencing the world as more than the sum of our instincts and appetites. Our altruism is not simply our appetites compounded; our appetites are not simply our altruism exposed. ‘Reason … must furnish all the materials for our future support and defense,’ Lincoln said, and reason alone can point us to its limits. We can argue about anything, even about the nature and meaning of our mysticisms. [Kenneth] Clark called our liberal faith ‘heroic materialism’ and said it wouldn’t be enough. Human materialism or mystical materialism, is closer to it, and it remains the best we have. Intimations of the numinous may begin and end in us, but they are as real as descriptions of the natural; Sunday feelings are as real as Monday facts. On this point, Darwin and Lincoln, along with all the other poets of modern life, would have agreed. There is more to a man than the breath in his body, if only on the hat on his head and the hope in his heart.”

 

[Footnotes: Numinous = inspiriting spiritual or awe-inspiring emotions. Mystical = having spiritual meaning neither apparent to sense or obvious to intelligence.]

 

 

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

Matula Thoughts. September 2, 2016.

DAB What’s New Sept 2, 2016

Matula Thoughts. September 2, 2016. News & views.

3821 words

 

Sept 2016

One.   Summertime news.  Yesterday was the beginning of meteorological autumn and tomorrow is Michigan’s first football game of the season, here at home with Hawaii. Ann Arbor days were hot this summer, but are getting shorter, although not so short yet since we can travel between home and work in daylight at least in one of the directions. [Above: the drive on Huron Drive] September was the seventh month in the old Roman calendar when March served as the first month of ten in the year (see April 1st Matula Thoughts). Calendar reform added January and February to create a 12-month year and September got demoted to the ninth month, but retained its historic name.

       We had a good summer, overall, in spite of local, national, and worldwide tragedies admixt with the ongoing environmental degradation of which we are no longer innocent. Our particular geographic microcosm, however, has been mostly pleasant and constructive with the entry of new house officers, promotion of their seniors, incorporation of new fellows, and initiation of first year medical students. We enjoyed the Ann Arbor Summer Festival, Art Fairs, Chang-Duckett-Lapides lectureships, White Coat Ceremony, and lovely three-day weekends that come to an end with Labor Day on Monday. A few weeks back Mani Menon from Henry Ford Hospital gave a brilliant Grand Rounds talk on his remarkable achievement of translating radical prostatectomy to the robotic platform, and thus introducing a new paradigm of therapy worldwide (below: Mani Menon, Khurshid Ghani, Andy Brachulis). Stu Wolf had his last day a week ago and will now be doing his part to build a new medical school in Austin, Texas.

Menon

In mid-August we lost a wonderful colleague and pediatric surgeon, Dan Teitelbaum (pictured below), after a difficult struggle with brain cancer. Dan partnered with us in the Disorders of Sex Development program and was a world authority on pediatric gastrointestinal problems both clinically and in the research world. Dan was more than just a colleague, he was a kind, skilled, and reliable partner-in-care and his excellence made us better. We could always count on Dan. Brain cancer, all cancer, is an evil destroyer of the good things in life. We are making progress against cancers on many fronts, but not in time for Dan.

Dan

A road trip this summer to Toronto featured Sick Kids Hospital’s Gordon McLorie symposium for the latest news in pediatric urology. [Below: McLorie Symposium] The Olympics captured much attention during my visit north of the border and, flipping back and forth on television, it seemed that Canadian coverage favored more actual sports and news than broadcaster celebrities and opinions on American networks.

McLorie Symposium

Bruce Hornsby & The Noisemakers appeared back in Ann Arbor at the Summer Festival one evening. Many of us (of a certain age) recall the classic song, The End of the Innocence, Hornsby wrote with Don Henley in 1989. At the Power Center Hornsby and the Noisemakers expanded the piece into an amazing long version with riffs, explorations, and pleasing dissonances. I wondered if the composers intended some reference to Songs of Innocence and Experience by William Blake in 1789 and 1794, but in any case the piece struck me more meaningfully this summer than when I first heard it years ago. Jeff Daniels joined the Hornsby ensemble for an encore and performed his new composition on the iconic environmentalist Henry David Thoreau.

EO & JD

Back in 2009 Daniels and E.O. Wilson received honorary degrees from The University of Michigan (pictured above). Wilson, above on left, is our planet’s most credible spokesman for biodiversity. Recognizing this at a dinner in their honor, Daniels commented self-effacingly something like: “I really don’t know why I am here, for after all, my claim to fame is a film called Dumb and Dumber.” In fact, both honorees are substantial contributors to society and they have comfortably crossed intellectual boundaries. Daniels’ work, for example in The Newsroom, not only entertains, but also speaks to the better nature of mankind, offering an example of a trustworthy television journalist navigating the challenges of corporate broadcasting. Wilson, on the other hand, successfully ventured out from his academic world with the novel, Anthill.

Blake - innocence

[Title page: Songs of Innocence and Experience Showing the Two Contrary States of the Human Soul. 1826 edition. At Fitzwilliam Museum, Cambridge, UK]

 

 

Two.   Experience. A new season of academic medicine begins each September and renews the process of turning innocent medical school graduates into experienced urologists. Medical students cram our urology services to test out the idea of careers in urology and audition for 4 available PGY1 (intern) slots, while our residents quickly ascend their ladders of experience and our faculty hone their practices.

Consult DB

Above you see Julian Wan at Grand Rounds presenting awards to residents Duncan Morhardt, Amir Lebastchi, and Parth Shah for their achievements with consults in Julian’s innovative Tour de Consult. The next picture shows faculty and residents that same Thursday morning at 7 AM listening to talks from medical students. The newly redecorated conference room is a big improvement over its previous 1986 version, although we still run out of space.

Grand Round

Our residents, however, are enjoying ample private space in their new residents’ room we gained recently and which was significantly upgraded thanks to contributions by Jens Sönksen (Nesbit 1996) and a number of other alumni. [See picture on our matching departmental Instagram https://www.instagram.com/umichurology/, courtesy Pat Soter]

This autumn we expect 21 clinical clerks (six 4th year medical students from UM and 15 from other medical schools) to rotate with us. The individual Grand Rounds presentations they make during their stints over the course of my career at Michigan get better and better in sophistication of presentation skills and subject mastery, indicating that the next generation of urologists should surpass us. Later this autumn a subset of our faculty will personally interview about 40 other students from a pool of 350 applicants. In December we will rank all applicants just as they will rank us, a computer will do the matching and by February we will know the names of our next 4 entering residents.

Autumn will also be busy with sectional and subspecialty conferences, national meetings of the American College of Surgeons and other organizations. Abstracts will be due for next year’s big clinical congress of The American Urological Association in Boston. Family life restructures for many of our faculty when children head back to school. Also this fall a presidential election will take place, so make arrangements now so you can vote on Tuesday, November 8.  I’ve learned from sad experience that busy clinicians and staff cannot count on finding a voting window during election day unless they have made deliberate plans, like absentee ballots, far in advance. Unprepared, you may get lucky – or not.

 

 

Three.

Radio tuner 1920s

Far from the town crier and printed circular, radio was a big step in the dissemination of news. Radio itself began in 19th century, arguably with the wireless telegraphy patent of Guglielmo Marconi in 1896, but the first tuning system, patented a century ago, brought choice and accessibility to the public. Ernst Alexanderson, an engineer for General Electric in Schenectady, New York, developed the selective tuning system. Station choices grew on AM radio [Above: vintage radio tuner c. 1920s, Wikipedia] and later with FM, thanks to generous regulation and commercial competition. When I spent a year training in Great Britain as a resident in 1976-77 only 4 radio choices were available on my radio, in addition to an off-shore “pirate” station, because government tightly controlled airwaves.

1939_RCA_Television_Advertisement-1

[Radio & Television Magazine X (2): June, 1939. NY: Popular Book Corporation]

Television portended the end of radio after the first public television broadcast in 1927 and color TV in the 1960s made the medium even more irresistible. The prophecy was wrong, however, as radio rebounded with multiple new consumer channels and TV became just the newer communication layer. Radio stations provided “narrow networks” of sports talk shows, partisan political commentary channels, business news stations, religious channels, local news, weather, and some splices to television channels. Reemergence of radio’s early variety shows appeared with Garrison Keillor and the ubiquity of NPR gave radio large new audiences; the final broadcast of A Prairie Home Companion this past July 2 completed its extraordinary 42-season run. Commercial satellite radio produced an explosion of new radio species for an astonishing range of human interests from Elvis to POTUS Politics. Cable TV ended the domination of broadcasting networks, although the proliferation of new television channels added only precious few of quality.

Radio and television “news”, however maintained a sense of integrity with trusted journalist/broadcasters such as Edward R. Murrow who told it clean and straight, in contrast to advertising or propaganda. At some point, however, the term “content” subsumed “news” and clarity began to vanish. Entertainment mingled with news broadcasts and trusted news broadcasters appeared in fictional stories further blurring the border between truth and fiction.

Podcasts, cable and satellite media, and other innovations offered content to seriously compete with network television and the movie industry. Home Box Office (HBO) produced its first original movie for cable TV in 1983 (The Terry Fox Story) and other memorable films and series followed including Breaking Bad (2008-2013) and The Newsroom (2012-2014) with Jeff Daniels who should inspire a future generation of good journalists. (What Game of Thrones inspires is not so clear). Personal phones, computers, and video streaming bring yet newer layers and innovations to communication, information, and entertainment. Mini-series binge-watching eroded prime time network television while Netflix’s video streaming expanded into a new model of content production. Abandoning the pilot and sequential release of episodes, House of Cards (2013) offered an entire series for immediate consumption. The bottom line: new communication technologies add new layers rather than replacing the older media.

 

 

Four.

Alex Zazlovsky

Quorum sensing.  A few months ago at Grand Rounds Alex Zaslovsky, representing the lab of Ganesh Palapattu, gave an excellent presentation showing how platelets communicate with tumor cells to help them metastasize.

A process much like bacterial quorum sensing seems to be occurring, and perhaps this type of communication is prevalent throughout all life forms, whether gaining a consensus in a microbial biome to release endotoxin or a majority in a society for an election or an action on an issue. Strictly speaking, quorum sensing is a matter of individual gene regulation in response to news of cell population density. In other words, gene expression is coordinated according to the size and needs of the population. In the larger sense, quorum sensing allows individuals, that by themselves may be insignificant, to become superorganisms. Bacteria thus act in congress like multicellular organisms and this process works in bigger species such as social insects, fish, mammals, and likely all biologic creatures in ways we have yet to understand. This phenomenon brings us back to the seminal work of E.O. Wilson who linked ant pheromones to sociobiology and then to human consilience.

Quorum sensing is basically a matter of getting news, that is acquiring information about the environment so as to change or maintain behaviors. Weather (temperature, humidity, and pressure) is a form of news, but news about other creatures (one’s own species and different ones) also has great relevance for the immediate and intermediate future. Just as people learn individualistically, they collect news idiosyncratically. A hurricane or a full solar eclipse in mid-day gets everyone’s attention, but most news we need or crave is more discrete, while the media we employ to collect it are many and increasing in variety. Newspapers, radio, television, personal computers, and smart phones expand human quorum sensing and newsgathering far beyond the wildest expectations of Gutenberg with his printing press. New forms of social media layer upon each other and get tested in the market. Michigan Urology has its regular What’s New email, web site, Facebook page, Twitter Account, Matula Thoughts blog, and will now test out a weekly Instagram photograph that we hope will attract not only viewing interest, but also contributions from the readership.

We started putting Matula Thoughts on a web site three years ago mainly as an archive and an alternate access because our What’s New email list was getting cumbersome. While we don’t know much of our ultimate email audience, due to multiple forwarding, the matulathoughts.org web site provides visibility of readership as seen in the snapshot below of the first 6 months of 2016.

MT readership 2016

 

Five.   Thoreau away thoughts.  Coming into work one day this summer I was listening to an audio book by Chris Anderson, the head of TED Talks, and had just come to his optimistic conclusion about mankind when I stepped out of my car on the Taubman lot and was offended by a bunch of pistachio nutshells someone had dumped on the deck. My first thought was “What jerk did this?” but after reconsidering I thought Why should I care?

Pistachio

After all I was wearing shoes and those shells weren’t going to hurt my feet. They don’t harm the environment, aside from minor aesthetic degradation, and even so some modern artist might consider the pattern a compelling expression of random human graffiti. Possibly I myself had been such a jerk making similar transgressions in the past, before my sensibilities (presumably) matured. No sharp demarcation exists between the clueless citizen and the clinically certified narcissist, although most of us can tell the difference at any moment. Another label for the parking lot perpetrator springing to mind was the less complimentary anatomical term for the gastrointestinal tract terminus, a word that has an important place in organizational theory (RI Sutton, The No Asshole Rule, The Hachette Book Group, 2007). Thanks to the ubiquitous cell phone camera I was able to record this minor breech of civility for a teaching opportunity. The lesson being that the environment is our nest, but general appreciation of its limits is poor, in spite of great thinkers from Lucretius to Henry David Thoreau to E.O. Wilson who have tried to raise our sensibility.

Thoreau

Thoreau was a curious fellow, best known for his Walden Pond seclusion, possibly because he didn’t consider himself very sociable. The above daguerreotype was taken in response to a request by Calvin R. Greene, a Thoreau disciple living in Rochester, Michigan. Greene began corresponding with Thoreau in January, 1856 and asked for a photographic image, that Thoreau initially denied, saying: “You may rely on it that you have the best of me in my books, and that I am not worth seeing personally – the stuttering, blundering, clodhopper that I am.” Greene’s persistence paid off and in June of that year Thoreau sat for three daguerreotypes at 50 cents each in Worchester, MA at the Daguerrean Palace of Benjamin Maxham. Henry David must have at least liked the third image, sending it to Greene, noting: “… which my friends think is pretty good – though better looking than I.” [Image and description, National Portrait Gallery, Washington, DC]

 

 

Six.   News. It’s a nice coincidence that NEWS could be an acronym for north, east, west, and south. The reality, though, is that the English term arrived in the 14th century as a plural form of “new” information. For 14th century English village folk, relevant news included weather, gossip, crop issues, births & deaths, accidents, plague, and war. In turn over time town criers, newspapers, radio, and television carried news among villages, through cities, and across continents. A new profession arose as journalists pieced events together and investigated them to derive factual stories. Photographs and today’s video clips offer powerful encapsulations of news in images and voices. Aggregation of news and targeting it to audiences with narrow interests is not new, we saw it in People magazine, the Racing Form, and Popular Mechanics, but daily news aggregation on the internet compiles information on a global scale and devastated the business model of investigative journalism. The Newsroom attended to the tensions between regurgitated information, narrative truth, and corporate self-interest. Human quorum sensing is immeasurably more complex than that of E.coli, although the basic principles must be quite similar. The variety of ways to collect and disseminate news from quorum sensing to Instagram will continue to expand, and each of our growing number will adapt our own methods and devices to capture what we will.

Newsboys Pose c 1890 copy

[Ann Arbor newsboys c. 1890]

 

 

Seven.    Urology news & Ig Nobel Thoughts. Later this month the 2016 Annual Ig Nobel Prize Ceremony takes place at Harvard’s Sanders Theater (September 22) to introduce 10 prizewinners for accomplishments “that make people laugh then think.” We expect no winners from the ranks of UM Urology, although it is worth mentioning that one winner last year was a study of mammalian urination times that found “golden rule” wherein urination times ranged around 21 seconds regardless of the species or bladder volume. This work, published in PNAS (a curious acronymic homonym), begs further investigation to explore gender differences, age effects, and the relations to various pathologies such as BPH [Yang et al Proc Nat Acad Sci 111:11932, 2014]. Notably, the first reference in the paper was Frank Hinman, Jr.’s book On Micturition (1971). The Ig Nobelists, however, missed Hinman’s smaller limited edition book called The Art and Science of Piddling [Vespasian Press, San Francisco, 1999] Hinman (shown below) playfully censored the retromingent stream of the rhinoceros on the book cover. To what end this unusual direction of micturition has evolved remain unclear, but extinction may void the species before an explanation is discovered.

Piddling

Hinman-office copy

 

 

Eight.   Photography. If you happen by the National Archives, as we did on a brief visit to Washington this summer, you might spot the Daguerre Memorial on Ninth Street by the Department of Justice. American sculptor Jonathan Scott Hartley (born in Albany, NY 1844, deceased 1912) produced the relief bust of Louis Daguerre honored by a female figure representing fame while a garland encircles the globe in homage to the universality of photography. Harley also made busts of Nathaniel Hawthorne, Washington Irving, and Ralph Waldo Emerson, Thoreau’s friend and colleague.

Daguerr Statue

Daguerreotypes transitioned to portable film cameras and now digital images on universal camera phones that allow great visibility of the particulars of the world. Visual images are fundamental to modern communication and newsgathering. Walking near the Daguerreotype monument we noticed a discarded snuff can in a planter box similar the pistachio shell arrangement shown earlier, further evidence that the great pageant of humanity marches forward and continues to leave its mark, although now subject to universal documentation.

Skoal

A yearly photographic competition of The Lancet, called Highlights,  further opens the door to the world’s cellphones and cameras. Last year’s contest yielded 12 winners detailing: a ruined hospital in western Syria, moments of patient care, community action, a poster showing health advantages of raised beds with mosquito nets, smoking prevention, Ebola hot zone management, road traffic accidents, cleft lip repair, and the politics of social justice. [Lancet. Palmer & Mullan. Highlights 2015: pictures of health. 386:2463, 2015]

 

 

Nine.   A somber note. Last month this column concluded with reference to the Hiroshima bomb, an existential threat that has increased since 1945 by many orders of magnitude. There is little question what Henry David Thoreau, among many wise thinkers of the past and present would say on this matter of nuclear weapons: they must be contained and their spread prevented. Failing that, a doomsday scenario is not unlikely and only luck has prevented this from happening so far. A new book, My Journey to the Nuclear Brink by William Perry (US Secretary of Defense 1994 – 1997), explains our precarious situation better than anything else I’ve read. You can understand his point in a “Cliff’s Notes” fashion by going directly to Perry’s website, but his book is quite compelling and readable. Perry, currently emeritus professor at Stanford University and senior fellow at its Hoover Institution, founded the William J Perry Project in 2013(http://www.wjperryproject.org/), a non-profit organization intended to educate the public on the current dangers of nuclear weapons. Addressing close calls of the past, Perry reveals that the Cuban Missile Crisis came far closer to the brink that most people suspected, but for two unreported “mistakes” on both sides of the conflict (USA and Soviet Union) that prevented nuclear deployment. Today the risk is greater and more complex as the weapons are far more massive and numerous than 71 years ago over Hiroshima. Opportunities for accidents, terrorism, rogue nations, territorial disputes, or mistaken perceptions of “responsible” nations are too many to count.

AtomicEffects-p7a

[Above, Hiroshima before blast, above ground zero, with 1000 foot circles marked; below, after the explosion with not much left standing.]

AtomicEffects-p7b

 

 

Ten.

Cassandra

Cassandra. In Greek mythology, Cassandra was a curious prophet, who turned out to be an ineffective communicator. Attempting to seduce her, Apollo gave her the power of prophecy, but when she refused his advances he spat into her mouth with the curse that no one would believe her prophecies. Prophecy skepticism has endured since her time. Right or wrong, but forecasts require consideration, especially when backed by information, whether in the form of news or other information. [Cassandra, in front of burning Troy, by Evelyn De Morgan, 1898]

The current likelihood of a nuclear incident is great and in recognition of this an exercise called Mighty Saber was held last year by the Defense Threat Reduction Agency at Fort Belvoir, Virginia to simulate a detonation in a US city and trace the origin of the device. An article by Richard Stone in Science concluded: “… to have any chance of unraveling the details of a nuclear attack, investigators have to lay the scientific groundwork – while hoping it will never be needed.” [Stone. Science. 351:1138, 2016]

The world is full of danger and nuclear devices are but one of a number of catastrophic threats. This fact needs to be acknowledged as people go to the polls to vote for their legitimate self-interests that may involve party loyalties, economic matters, civil rights, first and second amendments, immigration, border security, health care equity, public education, government size, gender issues, free speech, law enforcement, etc. Our ultimate self-interest, however, is immediate survival of our species and the security of our children’s future. With this in mind we individually must make the best choices we can for the elections at hand. Just as importantly we, as a society, must do a far better job of leadership succession to prepare educated and wise future civil leaders rather than leaving succession up to random populists, celebrities, or narcissists who crave power and the ultimate corner offices. Geopolitical and world market stability are severely challenged and we are terribly short of good leaders and great ideas. The grim political landscape at hand, however, doesn’t give anyone of us the right to be aloof from the politics and processes of representational government.

You may ask what does all this have to do with our profession, our patients, our trainees, and our science? The answer is – everything. Our successors won’t consider us innocent if we hand over to them a diminished future in a dysfunctional society on a damaged planet. Join the important political conversations, the next generation is counting on it.

 

Thanks for reading Matula Thoughts for this first Friday of September, and on future first Fridays if you are so disposed.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

Matula Thoughts June 3, 2016

DAB What’s New/Matula Thoughts June 3, 2016

 Matula_Logo1

 3659 words

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.

 

Screen Shot 2016-05-29 at 8.22.24 AM

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]

JM Award

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.

Montie, Straffon

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 16

[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).

McLarens

[Above: Bob & Ian McLaren, below: Len & Jack Zuckerman]

Zuckermans


Jens, Dana

[Above: Tim Miller (London, UK), Jens Sönksen (Nesbit 1996), Jim Dupree (faculty), Dana Ohl (Nesbit 1987).

Screen Shot 2016-05-29 at 8.33.55 AM

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.

Barry & Parry

[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.

 

 

Four.

Pythagoras

[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.

 

 

Seven.

Poppy field

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.

WizardofOz_poppies

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.

Poppies 2010

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 .

Screen Shot 2016-04-10 at 5.05.23 PM

[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.

cerny

[Above: Joe Cerny, Carl, Cheng-Yang Chang. Below Gordon, Tom & Sharon Shumaker, Bill Steers, Adrian Wheat]

Gordon

Tom & Sharon 2013 copy

Steers

Adrian

 

 

Nine.         Good transitions. This year 4 anchors of the Urology Department are moving on to great new phases of their careers.

Gary F

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.

Lee, Cheryl

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.

Oldendorf

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.

Wolfs

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.

JOW

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.

Screen Shot 2016-05-29 at 8.52.34 AM

[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

ADMIT MISTAKES

SAY IT SIMPLE

BE CALM

SMILE

Shortliffe poppies

[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

Matula Thoughts May 6, 2016

DAB What’s New May 6, 2016

Matula Thoughts Logo2

(3948 words)

 

Carl

Carl Van Appledorn, friend, Nesbit alumnus, and colleague, passed away last week. Carl trained under Jack Lapides and fulfilled an illustrious career as a superb urologist and beloved physician at St. Joseph Mercy Hospital. He spent a mini sabbatical in pediatric urology in Cambridge, England working with Bob Whitaker and when I came to Ann Arbor, Carl welcomed me most generously although I was “the competition.” We talked periodically about patients and I admired his work and gracious manner. As a University of Michigan and Nesbit alumnus, he supported his alma mater to the hilt. Later in his career Carl and his wife Sue developed an interest in international health for the underserved and they focused their attention in Ghana. Among other efforts, they facilitated care for a youngster with bladder exstrophy whom they brought to Ann Arbor and Mott Children’s Hospital with his mom for reconstructive surgery by John Park. The Van Appledorns generously created an endowment between the departments of Urology and OB/GYN for clinical and educational links to Ghana and the program is ongoing and growing. Carl’s passing is sad news indeed, but his name will carry on with his global program.

 

 

One.           May, at last.

May 2015

Ann Arbor and the University of Michigan Campus are especially lovely just now (shown above from the west side of the Cardiovascular Center last year). Cold days and wintry mixes are over and we are primed for spring. May brings, among other things, academic commencements, watershed moments when change is in the air. Last month in this column we referred to a commencement address by President John F. Kennedy at American University in 1963, for its relevance to environmental stewardship.
With Cuba “back” in the news recently, Kennedy’s speech is also relevant at a geopolitical level. In the aftermath of the Cuban Missile Crisis of October, 1962, when a showdown with the Soviet Union took us very close to the brink of nuclear war, Kennedy knew that world security was precariously dependent on constructive dialogue with our adversaries and his commencement address, called Strategy for Peace, helped turn the tide of the escalating confrontation and ushered in an improved era of diplomacy. A cautionary phrase from the speech is worth repeating again this month: “For in the final analysis, our most basic common link is that we all inhabit this small planet. We all breathe the same air. We all cherish our children’s futures. And we are all mortal.”                             Thanks to the Internet, you can scour the world for notable commencement speeches, that while typically forgotten in the momentary excitement of most graduates and families, are retained the collective human memory of newspapers, libraries, and YouTube clips. An NPR web site (npr.org) lists 354 of The Best Commencement Speeches, Ever.

 

 

Two.           Significant speeches.
Even when unconnected to graduations, speeches may open opportunity for commencement of a new idea, if an audience picks up on it.
Around this time of year in 1850, May 15 to be exact, a young physician Ignaz Semmelweis gave a talk to the Imperial Viennese Society of Physicians urging physicians at Vienna General Hospital to clean their hands when they went to the delivery room. Animal experiments and clinical observation, coupled with a mentor’s death after an autopsy wound in 1847, convinced him that childbed fever was due to contaminating agents. His clinical experiment showed that the simple act of hand rinsing in chlorine markedly decreased the high incidence and fatality of childbirth sepsis in his hospital. While not a commencement speech, his talk might have commenced a new era in health care, but few in Semmelweis’s audience accepted the idea. (Our colleague at Michigan and current editor of Milbank Quarterly, Howard Markel, presented a discussion of this on PBS News Hour last year and John Park recently referred to it in his Mott Children’s Hospital blog.)
The same opportunity had been missed seven years before the Semmelweis speech when Oliver Wendell Holmes advanced the contagiousness concept at an evening scientific meeting of the Boston Society for Medical Improvement, yet the idea gained no traction. In 1867 Joseph Lister working in Glasgow wrote 2 papers in The Lancet that conclusively showed how antiseptic techniques converted the universal fatality of open fractures into probable survival, yet colleagues again failed to accept the idea. Listerian antiseptic methods were first only appreciated by German physicians and the idea diffused slowly back to England and the rest of the world over the next 20-30 years. Even today, we could do a better job of regular handwashing (actual washing, rather than “Purell” propaganda, in vogue today).
Failure of commencement of the ideas of Holmes, Semmelweis, and Lister is another cautionary tale for us today. A quote on a cover of The Lancet several years ago sums it up well: “The most entrenched conflict of interest in medicine today is a disinclination to reverse a previous opinion.” [Yudkin, Richter, Gale. Lancet 377:1220-1221, 2011.] While academic health centers have self-righteously implemented stern conflict of interest policies, we seem oblivious to the proven fact that it is not the ballpoint pen with drug company logos or the pizza from surgical suppliers at grand rounds that we have to fear, rather it is our own prejudices that close our minds to new ideas.

 

 

Three.           UMMS graduation.

Cropsey copy

[Above: University of Michigan Medical School. c. 1850. Cropsey painting.]

This month the UMMS will graduate its 166th class of medical students. Back in 1850, when Semmelweis spoke to an unreceptive audience in Vienna and cattle grazed in front of the Medical School in Ann Arbor, Michigan’s first M.D.s were about to go out to independent general practices in a world quite different than today. What inspired those students to study medicine then is a matter of conjecture for us now, but it is likely that role models, the ability to help people, the respectability of the occupation, and perhaps some attraction to body of knowledge of human disease, were motivational factors.
Those same motivational factors are at play for our class of 2016 about to graduate, but newer attractions such as the magic of health care science and technology, cures for cancer, and surgical wizardry including robotics, lure many of young people to medicine now. Some students are also inspired by deep personal and family health care experiences.
What is also different now from the 19th century is that after graduation nearly the entire class of 2016 will continue further formal education in residency training for 3-10 additional years before they are ready for independent work in one of nearly 150 areas of focused practice.
While the curriculum and conceptual basis of medical practice have changed enormously, the spirit of professionalism and necessity of continuous learning through experience, reason, and study have remained constant. Medical school and residency training are now just a start. Even back in 1850 medical societies and professional journals played key parts in what we now call professional development. Students and physicians, even more readily today, travel to distant sites of expertise to improve knowledge and skills. In today’s world, conferences, visiting professorships, and web-based educational programs intensify learning experiences as knowledge and technology accrue with dizzying speed.

UMHS

[UM Health System 2016]

 

 

Four.           Role models.

JOW & MJ

This picture shows former Dean, Jim Woolliscroft and former Interim EVPMA, Michael Johns, at Medical School Commencement several years ago. As of January 1 this year those two jobs have been rolled into one, namely Marschall Runge (seen below), an equally great role model for students, residents, and faculty.

MR

[Marschall at the Urology Retreat March, 2016 Michigan Union]
Jim will be our Medical School commencement speaker later this month and I’m sure he is focusing intensely on his remarks right around now. Our rich history at Michigan and the changing world of medical practice, education, and research may enter his speech, and I bet he will also have something to say about professionalism and the lifelong learning required of physicians today.
Role models often conflate into ideas and images of idealized doctors. Last month we contrasted Norman Rockwell’s idealization (shown below) to the crayon artistry of a 7-year old girl illustrating a clinic visit: the family is looking at the viewer while the physician is turned away facing the computer while dutifully documenting the encounter. In our brave new world of technology, computerized documentation is a poor surrogate for the essential transaction of the doctor-patient relationship. The classic role model of the attentive, kind, and expert physician will become only more highly prized and that should be the Michigan Difference in our medical graduates, trainees, and faculty.

Family Doc

It turns out that Rockwell’s idealized physician was an actual doctor named Donald Campbell and I learned this through Maria Muller of our development office, who wrote me after she read Matula Thoughts in March, that Dr. Campbell was the grandfather of a friend of hers.

1989 -- Stockbridge, MA: Dr. Donald E. Campbell, model for artist Norman Rockwell's illustrations, smiling, walking arm in arm with his daughters (L) Jeanie Campbell Jones and (R) Bonny Campbell Flower, who holds her daughter Hana. (Photo by Steve Liss/The LIFE Images Collection/Getty Images)

[1989 — Stockbridge, MA: Dr. Donald E. Campbell, model for artist Norman Rockwell’s illustrations, smiling, walking arm in arm with his daughters (L) Jeanie Campbell Jones and (R) Bonny Campbell Flower, who holds her daughter Hana. (Photo by Steve Liss/The LIFE Images Collection/Getty Images)]

         Campbell was Rockwell’s neighbor in Stockbridge, Massachusetts and for many years the sole regional physician, charging $2 for an office visit and $3 for a house call. Born in 1906, Campbell was educated as a physician and married, in time fathering 4 daughters. He retired at 83 just after making his last house call in 1989 and died in Stockbridge at 95 on May 14, 2001. [New York Times article May 16, 2001. Photo via Getty Images for a payment of $150]

 

 

Five.           Three stories.
After residency training at UCLA I went on to obligated military service at Walter Reed Army Medical Center under Ray Stutzman and David McLeod, enjoying my time so much that I stayed for an additional 2 years, leaving when Ray retired from the Army to join Patrick Walsh at Johns Hopkins. Dave is still in uniform in Washington.

Stutzman, DAB, McLeod

[McLeod, Bloom, Stutzman at USUHS]
At Walter Reed I re-encountered an older friend of my family who was working at its Institute of Research (WRAIR). This distinguished physician became my patient, in fact his was the last radical prostatectomy that I performed in an adult. Long gone now, he told me at the time that it had been his idea to create the weekly section in JAMA called A Piece of My Mind. How accurate this claim is I have no way to know, but without reason to doubt him I’ve been regularly attached to this column and frequently refer to its essays. Three recent ones are of particular interest.
  What Now? What Next? was written by a pulmonologist and medical intensivist at the University of Pennsylvania who became a patient in his own ICU and discovered, in the experience, that the current idea of shared decision making with acutely ill patients, especially on an a-la-carte basis (formal consents for central lines, transfusion, hyperalimentation, etc.) may be ill-advised: “I think we should bundle consent for the acute phase of intensive rescue. … Whether on a ski slope or battlefield, or in an emergency department, operating room, or intensive care unit, the foundation of respect for patient autonomy lies not in multiple permissions and consents, but rather in mutual understanding and trust. In the context of acute critical care – once the goals of care are clearly defined – we clinicians (thankfully, I am one of ‘us’ again) should not substitute asking permission at every step for the hard and time-consuming effort of earning trust.” [J. Hansen-Flaschen. JAMA 315:755-756, 2016]
The second essay, The Unreasonable Patient, came from a palliative care physician at the University of Pittsburgh and discusses a man in his early 50s with metastatic prostate cancer. At a terminal point in his life the patient, Walt, was viewed by the health care team as “unreasonable.” The author writes: It turned out that Walt wasn’t ‘unreasonable’ – he just wasn’t completely understood. After getting to know him better – after sitting and taking the time to explore his emotions and concerns – it was clear that Walt knew what he wanted, but he needed information in a certain way. He needed a recommendation without ambiguity, and he needed someone to speak to him as Walt the Husband and the Mechanic, not Walt the Man with Prostate Cancer. [A. Thurston. JAMA. 315:657-658, 2016]
I had initially missed the third essay, until it was sent to me by an extraordinary applicant to our OB/GYN residency. Caiyun Liao is an MD/ MPH doing research at Johns Hopkins and I got to know her through our Nesbit alumnus Sherman Silber. The article is called A Place to Stay and was written by Yale physician Bennett Clark. [JAMA 315:871, 2016] Clark shows how a patient taught him that what makes the hospital a hospitable place to live and die is “having people,” meaning having genuine human connections around him. This thought, expressed so much better by Clark than by me, circles back to Paul Kalanithi’s observation (last month’s Matula Thoughts) that, for many people, life’s meaning is found in their relationships and connections. These externalities bring meaning to our individuality.

 

 

Six.           Electronic journal club.
When I began this periodic essay for our Department of Urology, alumni, and friends in 2007 I thought it might serve as a sort of electronic journal club and I still harbor hopes that some readers will guest-edit a paragraph or entire issue to join me in this process. (What have you read that you want to tell the rest of us about?) These three articles from A Piece of My Mind are linked and offer much to consider.
Hansen-Flaschen’s observation as a patient in the ICU reflects a very particulate level of concern: My visual world reduced to the confines of a small room. The space was both familiar and foreign to me as I looked outward for the first time from the head of a hospital bed. There was both little and much to see. The clock showed the wrong date and time. The sink faucet dripped. Two ceiling tiles were stained by previous water leaks. The harsh overhead lighting cast yawning shadows that provoked my imagination. By comparison to Ebola wards in West Africa last year, the annoyances of inaccurate clocks, ceiling tiles, and dripping faucet are less compelling than the very matter of survival. Yet, in the industrialized world and most expensive health care system on the planet, I wonder why we can’t address these simple matters of hospitality. Our basic “hotel management” is too often inhospitable to patients. Even our newest hospitals can’t coordinate the clocks – why bother to have them if they’re correct only twice a day? Little things are important to patients and visitors, such as working elevator lights, paper towels in clean bathrooms, and general orderliness.
Another point to make comes from Thurston’s paper, when he said … after sitting and taking the time to explore his emotions and concerns… We use this phrase a lot – sitting down to talk and listen. Posture in space is not the point, this expression of speech conveys the idea that we are taking time (more time than might be usual or expected) by sitting down to listen and respond.

 

 

Seven.          Big questions.
Last month I asked you to consider what might be the big questions in health care and offered a short list with thoughts regarding the first question.
a.) What is health care?
b.) How should it be provided?
c.) How is it improved and how does innovation occur?
d.) How is it taught?
e.) How is it funded and how are escalating costs managed?
The second question follows naturally; if you consider all the things that comprise health care and then imagine the various avenues society can use to provide those things, you need to decide what health care goods every human in a society should have by right. Few could argue that clean air and water, food safety, prevention of communicable disease, along with maternal and pediatric care, are mandatory for everyone in a modern just society. So, too, is care for trauma or other general hazards of life.
At the other extreme, some services are purely discretionary – such as Botox for wrinkles or plastic surgery for facelifts. However, things get complicated because Botox for neurogenic bladder is sometimes very necessary, as is plastic surgery for craniofacial reconstruction. No insurance system or single payer system can reasonably satisfy the overall demand for health care – from the fetus to the end of life, the demand curve for health care and the therapeutic possibilities in our toolkit are growing relentlessly. A variety of systems and avenues are necessary, but wise choices need to be made and agreed upon as to what services are mandatory public goods, what services are discretionary, and what robust systems can provide these facets of health care.

 

 

Eight.           Harvey & hearts.

Screen Shot 2016-04-26 at 4.28.40 PM

Four hundred years ago William Harvey, the English physician we referred to last month, began a series of anatomy talks as Lumleian Lecturer at the Royal College of Physicians in London. By coincidence William Shakespeare died just the following week at Stratford-on-Avon. [JAMA 315:1524, 2016] Harvey continued to study and learn while he taught and practiced medicine and 12 years later, in 1628, published some extraordinary findings, cleverly introduced at the annual book fair in Frankfurt, Germany, to ensure wide publicity and dispersion. He offered a novel explanation for the systemic circulation based on the pumping of blood from the heart to the body and brain. The short title of the book was De Motu Cordis, but you will find it on Amazon as On the Motion of the Heart and Blood.
Harvey was on my mind last month since his birthday was on that entertaining first day of April, back in 1578. Those were dark times in Europe with civil wars, witchcraft persecution, and sectarian violence, but the spirit of inquiry and discovery was not quiescent. Francis Drake was circumnavigating the globe and European universities were holding their own, for the most part, nurturing ideas and preparing for the next generation that would include Harvey and other bright lights.
Harvey came to mind again when I read a review of a new novel called The Heart, by Maylis de Kerangal, a French writer. Being on the road at the time (visiting professor in Houston at Baylor) and intrigued by the review, I succumbed to the temptations of Amazon and ordered the book (apologies to local booksellers Literati and Nicola’s Books). The story takes place in a single 24-hour period, much like the Homeric Odyssey, but it happens in France when a 19-year old dies after a motor vehicle accident. The book runs from the instant the young man wakes up to join friends for morning surfing to the moment the team that transplanted his heart to an older woman leaves a Parisian operating room. The accident and subsequent transplantation of the heart involved many individuals, including the boy, parents, girlfriend, doctors and nurses in the rural hospital, transplant coordinators, transplant teams, and recipient in Paris. The victim and all these people have their own metaphorical “hearts” in terms of their feelings, motivations, and hopes. The personal tragedy, families, health care teams, and hope are all knitted together around a single human heart that transcends the story. The story is compelling, although the translation and a few technical details fall short. Urologists have a place in the story as the anchor positions in the operating room sequence of the multi-organ harvest.

Screen Shot 2016-04-26 at 4.32.15 PM

A final Piece of My Mind reference: Louise Wen’s article 2 weeks ago in JAMA, called Meeting the Organ Donor [JAMA. 315:1111, 2016]

 

 

Nine.
One of the pleasures of academic medicine is the chance to visit great centers of excellence and learn from them while teaching residents. I’ve done my share of these tours, and as my career winds down. I don’t expect to be doing many more, but recently enjoyed such a chance to visit Baylor Medical School and friends at Methodist Hospital. Fannin Boulevard in Houston is one of the world’s greatest constellations of health care assets, a tribute to the life and vision of the great cardiac surgeon, Michael DeBakey (1908-2008), role model to thousands of students, trainees, and colleagues. His surgical and educational contributions are unsurpassed in world-wide medicine. DeBakey’s knitting ranged from Dacron grafts to clinical, educational, and research institutions that resulted in the combination of Baylor Medical College, Methodist Hospital, St. Luke’s Hospital, MD Anderson Cancer Hospital, superb urology training programs at Baylor and the University of Texas Houston, Ben Taub Hospital, Hermann Hospital, Texas A&M programs, etc.
The balance was sadly disrupted by governance and leadership blunders, severing the cherished Baylor-Methodist bond. As a result Methodist Hospital of Houston, oddly now, has its academic affiliation with Cornell in Manhattan. The unfortunate story, well recounted in a weblink the residents sent me, could well have been our misfortune at Michigan as one of the perpetrators had been selected by a former UM president and Board of Regents to be our EVPMA, but withdrew in favor of a better deal from Baylor. [Weblink: courtesy Michael Brooks PGY 5 at Baylor- Article in Texas Monthly, March 2005, by M. Schwartz. https://shar.es/1CUXX5 The marriage of Baylor College of Medicine and Methodist Hospital should have been made in heaven—and until recently, it was. Their nasty breakup is a bell tolling for American medicine.]
In spite of the institutional breakup, urologists and their educational programs in Houston get along very well and gave me a great 3-day visit. Edmond T. Gonzales, Jr., the founder of pediatric urology in Houston, had been the first partner of Alan Perlmutter in Detroit. Edmund is a wonderful role model as a pediatric urologist, teacher, and leader. By a rare coincidence he, Ed McGuire, and Jean DeKernion had been on the same dormitory floor as young men in college together in New Orleans.

Baylor fac & DAB

[Above Baylor faculty; Below Baylor case conference. Edmond – top right]

Res Conf


Boone & Bloom

[Above: with Tim Boone. Below: two old friends now in Houston – David Roth chief of pediatric urology and former intern with me at UCLA, Brian Miles former resident with me at Walter Reed and later colleague at Henry Ford Hospital]

Roth & Miles


Chester

[Above: Chester Koh at robot performing pyeloplasty on pancake kidney in the Edmond Gonzales operating room. Below: Residents at dinner.]

Residents dinner

[Below: Michael DeBakey, museum photo]

220px-Michael_DeBakey

Harvey, DeBakey, and thousands of physiologists and physicians who followed have extracted increasingly detailed knowledge of the heart as a living physical entity, but it takes imaginative exploration of the heart’s metaphysicality, such as Maylis de Kerangal’s penetration of this realm, for complete understanding. Fiction thus builds a better understanding of reality.

 

 

Ten.           UMMS & Department of Urology Notes.
Since Jim Montie’s era as chair transitioned to mine in 2007, our department has grown with only modest attrition consisting of Humphrey Atiemo to the Henry Ford System, Jerilyn Latini to Alaska’s Indian Health Service, Dave Wood as CMO of the Beaumont Hospital System, and Jill Macoska as endowed professor at the University of Massachusetts. In terms of joint faculty we lost Ken Pienta to Johns Hopkins. This year, however, we lose four more of our best. Nevertheless, our fulltime faculty will nonetheless grow to around 40 after the loss of Gary Faerber and his wife Kathy Cooney to Salt Lake City (Kathy, our joint faculty member, became chair of Internal Medicine and Gary joined the urology team there), Cheryl Lee to become chair of urology at Ohio State, Stu Wolf to help form a new medical school of the University of Texas at Austin, and the irreplaceable Ann Oldendorf is retiring. On the plus side, Sapan Ambani, Casey Dauw, Priyanka Gupta, Chad Ellimoottil, Arvin George, and Sam Kaffenberger will join our faculty this summer and more candidates are in play for FY 17.
Why the growth? Several reasons: A.) Our 7 clinical divisions, although already robust, need more bench depth to accommodate our growing clinical needs and future faculty turn-over; B.) Increasing sub-specialization demands more people in areas of tightly focused practice; and C.) Our newly reorganized UM Health System needs a larger clinical footprint to sustain our educational programs and to remain relevant in the new paradigm of American health care.
Residency training programs learn from each other through the recurring interchanges of visiting professorships, national meetings, research collaborations, migrating students and trainees, etc. It is nonetheless healthy for programs to undergo more formal evaluations through internal reviews and external reviewers as we have done recently with Bradley Leibovich of the Mayo Clinic, Mark Litwin of UCLA, and Ed Sabanegh of the Cleveland Clinic. They were superbly analytical and very helpful.

Bradford, Carol

Most recent news: Carol Bradford, our chair of Otolaryngology, was named by Marschall Runge and the Regents as inaugural Executive Vice Dean for Academic Affairs, as the UMMS puts a new structural paradigm in place.

Thanks for looking at our monthly commentary for May 2016.
David A. Bloom, University of Michigan, Department of Urology

Matula Thoughts December 4, 2015

DAB What’s New/Matula Thoughts

December 4, 2015

Paris, Band-Aids, & the coarse emotions of mankind

3140 words

 

 

1.    Hosp corridor Dec December is at hand, although in the busy everyday world of clinical medicine days and seasons seem to blur. Nevertheless, clues abound that make it  hard to mistake this holiday month. Above you see the second floor corridor of UM Main Hospital with decorated windows on a previous early weekend December morning. The holiday season has grown from theological roots to a cosmopolitan sensibility of advancing human welfare. This is a time of year we try to think beyond ourselves and the hunger of others is especially compelling whether in front of you on downtown streets of Ann Arbor or in the news reports from the Middle East, Africa, Asia, or South America. Food security is as much, if not more, an essential part of human welfare and health as the specific morbidities that capture our attention as specialists.

Astrologic, seasonal, and meteorological explanations of illness are residues of the more superstitious days of medicine, but with nuggets of truth these links remain in play today. The seasonal and climactic influences on human welfare and health are unquestionably substantial, and as the dinosaurs discovered large extraterrestrial bodies can impact life on Earth.  Our bodies down to the cellular level pay attention to calendar, clock, and climate. Illnesses like holidays have seasonality; we know that the incidence and mortality of coronary artery disease peaks in winter and reaches a low in summer while many other conditions also have their own seasons. [Pell JP, Cobb SM. Quarterly J. Med 92:689, 1999] Then, of course, there is the “July effect,” the enduring speculation that it’s risky to be ill in the hospital when new house officers start on the job. Happily today it’s December and all our house officers are well seasoned.

A 1984 music video from the movement called Band Aid “Do they know it’s Christmas?” is a 4-minute classic that is as fresh today as it was 31 years ago – you can find it on YouTube. The supergroup, formed by Bob Geldof of the Irish band Boomtown Rats, raised over $24 million for famine relief in Ethiopia with the video. The most recent incarnation, Band Aid 30, raised funds for 2014 Ebola victims and prevention.

 Feed the world 

 

 

2.     We humans, uniquely among all species, are intensely emotional and inquisitive about our health. Healthcare in any season is a matter of attending to small and large problems, from Band Aids to urosepsis 24 hours a day, seven days a week, and each of us needs help from time to time attending to these problems. Victorian novelist George Eliot wrote: “What do we live for, if not to make life less difficult for each other?” This may not be a universal human sentiment, but it surely is a key part of a good physician’s credo and any society must have good physicians. Healthcare workers naturally prefer fixing medical problems and otherwise helping their patients rather than completing electronic medical records or collecting RVUs. Healthcare is also a matter of teaching patients (and learning ourselves) how to live healthier and manage the morbidities and comorbidities of life. We do this work individually, in teams, and across the larger geopolitical world. Tempting as it is, even as specialists in the comfort of our specialized fields, we can’t ignore that larger geopolitical realm. Our urologic cocoon is a fulfilling workspace, yet we have no choice but to also attend to the geopolitical space through curiosity about events around us, by speaking out, and leading when we can. The world is predictably disruptive and explosive, as witnessed just last month in many places from Mali to Paris, the latter more properly an epicenter for peace, as with the Treaty of Paris of 1763 (ending our French and Indian War), the Treaty of 1898 (ending the Spanish American War), and more recent attempts to restore international order.

The 2015 United Nations Climate Change Conference is now meeting in Paris (Nov 30-Dec 11), nearly coincidental in timing to the recent terrorism events. This is the 21st annual meeting of a team that aims to achieve a legally binding and universal international agreement to reduce greenhouse gases and to contain global temperature within 2 degrees Celsius of pre-industrial levels. Forward-looking businesses are starting to recognize the simultaneous necessity and business opportunities of global stewardship. 

 

 

3.     On this day, 4 December, in 1918 President Woodrow Wilson crossed the Atlantic for WWI peace talks in Versailles, a suburb of Paris. That made him the first US president to travel to Europe while in office. After a trip back home for 3 weeks in February he returned to Versailles for the duration of the talks until June. Wilson’s personal physician Cary Grayson accompanied him on both trips and remained with him the whole time in France. The outcome of the talks was the Versailles Treaty of Peace with its inclusion of the League of Nations. Wilson believed in the League of Nations as a hedge against future conflict and on his final return home (shown below) undertook a nationwide tour to campaign for the treaty, but suffered a stroke in October of 1919. Grayson and Mrs. Wilson masked the severity of the stroke from the government and the public, while Senate Republicans opposed the treaty. Henry Cabot Lodge proposed a compromise that Wilson refused. Ultimately the Senate rejected the treaty and the U.S. never joined the League of Nations. Wilson’s internationalism didn’t take hold in the USA, but his efforts were admired internationally with the Nobel Peace Prize in 1919.

WoodrowWilson

Wilson wasn’t at his best in those days with urologic issues in addition to the stroke. Severe benign prostatic hypertrophy (BPH) with urinary retention further hampered his effectiveness as a politician in that critical time. In the days when our Journal of Urology attended to matters of urologic history, an excellent paper by Fogg, Kutikov, Uzzo, and Canter addressed this interlude of Wilson’s health. [J Urol 2011, 186:1153] Historical scrutiny has also revealed Wilson’s paradoxical gaps as a humanist. His racial views and employment decisions, whether as President of Princeton or of the United States, although considered “centrist” for early 20th century America, were strongly bigoted against non-whites and non-Christians.  [Berg AS. Wilson. 2013. The case against Woodrow Wilson. New York Times. Editorial November 25, 2015]

 

 

4.     Dec Limbourg North of Paris by 24 miles sits the Musée Condé and library at the Château de Chantilly in Oise, housing the manuscript Très Riches Heures du Duc de Berry with its beautifully illustrated monthly panels. The December panel is remarkable. While traditional iconography for the Christmas season would feature a more nostalgic visual, this panel shows the more visceral details of dogs dismembering a boar after a hunt with the Château de Vincennes of Charles V on the horizon and the trees curiously still in leaf (a warm winter?). The castle still stands in that Parisian suburb. The scene, as in all the Duc de Berry illuminations, depicts everyday agrarian life with people going about their daily business. Illness, disability, and intimate details of healthcare, urologic issues most particularly, were too indelicate for such public display, although such aspects of everyday life were real concerns for everyone then as they are today.           

Urology has progressed with technology and new knowledge, yet it remains focused on its genitourinary geography, staked out in ancient Egyptian times with urethral catheterization, in Hippocratic days with lithotomy, and in the nineteenth century with cystoscopy. Gone are the days of Frère Jacques Beaulieu, the itinerant lithotomist, who travelled throughout France in the early 18th century with his “certificates of cure” and removed agonizing bladder stones with his secretive technique. [JP Ganem, CC Carson. J Urol 1999;161:1067]

Nowadays, urologists work in teams and seek innovation for their own practices while freely disseminating their ideas and techniques to others. Urology, at least as much as the other core facets of medical practice, is a social business. President Wilson’s urologic issues would be treated better and more expeditiously today,  and even better tomorrow with, perhaps, the histotripsy technology pioneered here in Ann Arbor by Will Roberts and his team of biomedical engineers and radiologists. 

 

 

5.     Like many of our faculty, I’ve been on the road this autumn in that pursuit of new ideas and knowledge, in addition to dealing with the clinical and administrative work flows at home. In Irvine, California at Ralph Clayman’s festschrift I heard state of the art talks on stone disease. Ralph seems glad to be back to the real world of urology after his five years of good service as medical school dean. In Nijmegen, Netherlands I participated in the 50th anniversary of the excellent Radboud University Medical Center urology unit. Their discovery, education, and clinical work is world-class, and the visit gave me some thoughts related to our impending 100 year anniversary of Michigan Urology. The American College of Surgeons, with its annual meeting in Chicago this fall, is an important avenue of engagement for urologists from the educational, discovery, and public policy perspectives. A visiting professorship in Portland, Oregon game me a chance to see another superb department of urology, formerly headed by John Barry and currently by Chris Amling. My colleague Steve Skoog leads the pediatric urology team, our former medical student Sarah Hecht is performing well there as a resident, and some of our finest Michigan Urology graduates are leading in the regional practice of urology. Steven Steinberg was Michigan’s contribution from the McGuire days here in Ann Arbor and Rou and Jeff are more recent Nesbitonians.

Wheat & Wang

[Nesbit alumni Jeff Wheat and Rou Wang, now of Portland, during my visit]

In Baltimore the 100th anniversary of the Brady Institute coincided with the Clinical Society meeting hosted by Alan Partin and Pat Walsh. We heard superb presentations from Hopkins faculty, including Ken Pienta (formerly with us in Ann Arbor) and Nobelist Carol Greider who discussed her work on telomeres. She extolled the virtue of “curiosity-driven research” and told how her work was inspired by investigations of Tertrahymena thermophila. (In this odd single celled animal, with only 40,000 chromosomes, the telomere was recognized as tandemly repeated hexanucleotide sequences.) [EH Blackburn, JG Gall. J Molec Biol 1978;120:33] A number of Michigan names showed up in slides of other talks presented in Baltimore: Chinnaiyan, Feng, Tomlins, and Roberts, for example. Hopkins’ new clinical facilities are lovely and functional, yet they have artfully left strong structural remnants of their rich history as a storied urology department.

 Carol Greider

[Picture: Carol Greider advocating curiosity-driven research and showing slide noting that “New discoveries come from unlikely places”]

 

 

6.     Screen Shot 2015-11-30 at 8.02.19 AM  Ann Arbor’s first snowfall took place this year, somewhat early, on November 21. With winter many plants go dormant and others  self-destruct, while most of us animals simply endure the cold and prepare for the next warmer seasons. What’s New, our monthly newsletter, is getting ready for a new calendar year. This communication began in the dean’s office of Allen Lichter around 2001 and morphed into a Urology Department weekly profile of individuals and teams in 2007. On the first Friday of each month we have carved out an issue for my gratuitous thoughts. Nearly 3 years ago we mounted a simultaneous version of the first Friday piece on a blog site and called it Matula Thoughts, with the idea that older pieces could be archived and that the communication could be accessed more easily than email that has become too crowded and too painful a place for most of us to linger. The blog site (wordpress) also allows us to visual the reach of this monthly habit of our Department of Urology.

World Nov 24

[Above, 2015 blog visitors, geographic distribution. Below, histogram of last 3 years.]

Histo Nov 24

For me this communication is a periodic Band-Aid for the excessive emails, endless Twitter feeds, and other electronic distractors. Matula Thoughts also provokes curiosity, for example, with the word Band-Aid, that you might consider a brand name. Invented as recently as 1920, the story goes that Earle Dickson (1892-1961), a cotton buyer at Johnson & Johnson, had a wife named Josephine who often cut or burned herself while doing housework and cooking. His handmade prototype (squares of gauze kept in place by crinoline on a roll of tape) allowed Josephine to manage her own wounds. Dickson continued to refine his product and by 1924 the company had a machine that could mass-produce sterile adhesive bandages. With trademark genericization Band-Aid lost its protective status and became a generic term for all adhesive bandages.

Band-Aid

[Thank you Wikipedia. Our annual $100 contribution is in your bank for 2015, and no doubt you’ll need another one in 2016. “The Story Behind Band-Aid Brand” Changing Times; The Kiplinger Magazine December 1964: p. 32]

 

7.     In 2016 we will begin a new iteration of administrative structure at the University of Michigan Medical School and Health System. Except for a several year interlude after February 1930 when the regents fired Hugh Cabot as dean (he was Michigan’s founding urologist-educator), the University of Michigan Medical School has always had a dean. On January 1,2016 the duties of the dean will be added directly to the job description of Executive Vice President for Medical Affairs, Marschall Runge. We must thank our outgoing dean, Jim Woolliscroft, for his 8 years in associate dean positions and 9 years of service as dean. Jim has been a superb internist, educator, and statesman of medicine. We hope he will remain with us for in these tricky times and turbulent socioeconomic waters we need his good counsel and intellect. The clinical chairs established an annual lectureship on medical education in Jim’s name and a perpetual full tuition medical student scholarship. [Picture below Jim Woolliscroft and his early mentor and previous chair of Internal Medicine at Michigan, Bill Kelly at the UM vs. MSU game this autumn]

JOW Bill Kelly

Clin chairs JOW

[Picture above: Clinical chairs & Dean Woolliscroft after presentation of Woolliscroft Lectureship and Scholarship]

 

 

8.     Preview of 2016. I can’t predict much of anything for the upcoming year, other than to say we should expect the unexpected – we should anticipate surprises that may be planetary and in our ecosphere, geopolitical and terroristic, economic, healthcare related, regional, and intramural here at the University of Michigan. We can’t change the occurrence of most of these events, but we can reinforce our values and rehearse our responses. A recent article in Pediatrics by Plant, Barone, Serwint, and Butani called “Taking humanism back to the bedside” concludes with a quotation from George Eliot in Middlemarch that might help reset our humanism thermostats [Pediatrics, 2015; 136:828].

“We do not expect people to be deeply moved by what is not unusual. That element of tragedy which lies in the very fact of frequency has not yet wrought itself into the coarse emotion of mankind and perhaps our frames could hardly bear much of it. If we had a keen vision and feeling of all of human life, it would be like hearing the grass grow and the squirrels’ heartbeat, and we should die of that roar which lies on the other side of silence. As it is the quickest of us walk about well wadded with stupidity.”

220px-George_Eliot_BNF_Gallica

George Eliot was the pen name of Mary Ann Evans (1819-1880) about whom much more could be said than space now permits. Her only known photograph is an albumen print from around 1865 and held in Paris at the Bibliothèque Nationale.

 

 

9.     Screen Shot 2015-11-30 at 7.50.01 AM Beaches. On that recent trip to Portland, Oregon  as visiting professor, my friend Steve Skoog (former resident of mine at Walter Reed and subsequently our Duckett lecturer here in Ann Arbor) took us to Cannon Beach, where we saw Haystack Rock, shown above. Beaches like this are places to find relaxation, recreation, and inspiration among the waves, seaweed, seagulls, crabs, fish, and bivalves that are doing their daily jobs. We all need moments to unwind and walk around, although perhaps not so obtusely as Eliot believed “well wadded in our stupidity.” For us humans, the beach is expected to be a place of peace, so we are shocked when we encounter perversity there in the form of fatal riptides, tsunamis, the terrifying fiction of Jaws, or real sporadic shark attacks. The predicted rise of the oceans should give us pause as well. Perversity is a word that fits nicely here, meaning something so wrong that it is strange or offensive. Such things are wrongheaded, that is turned away from that which is right or good. Perversity is something that is obstinate in opposing what is reasonable or good. Perversity persistently intrudes on humanity, as we have seen most recently in Paris.

 

 

10.  By now most people have forgotten Aylan Kurdi the 2-year old boy who drowned with his mother and 4-year old brother in the Mediterranean off the coast of Turkey while fleeing the civil war in their native Syria. Their intended destination was the island of Kos. This was the site of the Hippocratic School of health, education, and the enduring oath 2.5 millennia earlier. Perversely, the bitter irony of the image of Aylan Kurdi lying on a beach to the east 20 miles away is less enduring in our minds than shark attacks in the recent news. Shark attacks on humans occur on an infinitesimally small scale and the Kurdi family tragedy is just one of millions this year alone. How can it be that our brains lead us to fear sharks more than ourselves?

Syrian toddler

The innocent suffer the most from mankind’s follies such as self-righteous tyrants, political and religious zealots, bigotry, corporate greed, failed national policies, and diplomatic breakdown. The staggering numbers of international refugees (60 million by last count and half of these are children) will exhaust all nations. Any solution to this crisis, if there is to be a solution, is not a matter of expanded quotas in kindly nations. Solution is beyond the ability of any sovereign nation. The solution requires strong international agency that demands national responsibility and accountability, enforces national borders, stewards human future by means of planetary sustainability, and protects the common man above all ideologies, religions, economic theories, biases, and disputes. Wilson’s League of Nations was a valiant, but failed attempt. The United Nations of today is a weak work in progress, although clearly better than nothing as we hope for a favorable outcome of the human experiment. We need some sort of vaccination against the ideological and sectarian viruses for which human brains seem so susceptible. The current crisis of 60 million refugees fleeing civil wars hasn’t been enough to galvanize international response. Greater crises are likely to come from instability of climate, geology, cosmos, and terrorism. With 2016 at hand, we have to hope our species can get its act together soon. While science will provide some tools to that end the essential political solutions will come from educated and humanistic world citizens. Art, in particular, can pull us out of the cocoons of daily life and serve as an antidote to our “well wadded stupidity” for in the words of George Eliot: “That element of tragedy which lies in the very fact of frequency has not yet wrought itself into the coarse emotion of mankind.”

 

Thanks for reading What’s New and Matula Thoughts and best wishes for 2016. 

David A. Bloom