Academia

Autumn leaves and certitude

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Matula Thoughts 6 November 2020
4129 words



One.

Autumn leaves and Nobel Prizes normally highlight this season, although Covid, climate, and a consequential national election dominated our attention this year. The award in Medicine or Physiology last month, however, went for discoveries relating to the hepatitis C virus.

That curious terminology of medicine or physiology is a historic reminder how science was disrupting health care when the Nobel awards began in 1901. A new certainty of physiology and other scientific disciplines, explaining the basis of normal biological function and disease back then, is now widely accepted in the 21st century, although we realize that the optimal practice of medicine in addition to its scientific basis also requires art and humanism. [Above: autumn leaves, Ann Arbor westside, 2020. Below: Nobel Prize medal.]

Politics are also in the air this month, even more unpleasantly than usual, and the Nobel awards are no less political than other human enterprises. Conflicts over these prizes have involved nearly all fields including that of Medicine or Physiology. The 1923 prize to Frederick Banting and John Macleod for the discovery of insulin outrageously excluded Charles Best and James Collip. Honorably, the two named prizewinners independently split their monetary shares with Best and Collip. No award was presented in 1925; the two main contenders, Johannes Fibiger and Katsusaburo Yamagiwa, had been proposed separately as the first to induce cancer in laboratory animals, but both were branded “undeserving” with great certainty by a key member of the award committee. Fibiger had used a roundworm he called Spiroptera carcinoma (Gongylonema neoplasticum) to cause stomach cancer in rats and Yamagiwa used coal tar to create cancer on rabbit ears. After further deliberation the following year, the prize went to Fibiger, although in durable fact Yamagiwa’s work was by far the better proof of principle of chemical carcinogenesis. Nonetheless, Fibiger was the first to get this Nobel Prize for work related to cancer. The second time this happened was in 1966 when Reed Nesbit’s first urology trainee, Charles Huggins, shared the award with Peyton Rous.

The Nobel Foundation offended Adolf Hitler when it awarded the Peace Prize in 1935 to Carl von Ossietzky, the journalist who exposed the clandestine German rearmament, illegal according to the Treaty of Versailles. von Ossietzky, a Roman Catholic, had been detained and beaten in German prisons and concentration camps since February, 1933, and was hospitalized with tuberculosis when the award was announced. Hermann Göring ordered von Ossietzky to refuse the award and the Nazi regime prevented travel to Stockholm but, in an act of civil disobedience, von Ossietzky issued a note accepting the Peace Prize. The ugly politics caused two committee members to resign and Norwegian King Haakon VII dodged the ceremony, even though the recipient could not attend. von Ossietzky died in 1938 while hospitalized under Gestapo surveillance.

In February 1953 Watson and Crick assembled an accurate model of the structure of deoxyribonucleic acid (DNA). Rosalind Franklin’s x-ray diffraction images, shown to Watson by Wilkins, provided the “eureka moment” in which the double helix configuration was realized. Watson and Crick were recognized for this with a Nobel Prize in 1962, that they shared with Wilkins. Franklin, however, having died of ovarian cancer in 1958, never learned of her role in the breakthrough and, by virtue of the rules of the Nobel Prize, was ineligible because she was no longer living.


Two.

[Above: Newton, by William Blake, 1805. Tate Museum.]

Certainty 1.0. Craving certainty, we derived it for most of human history from personal observations, beliefs, and the authorities of the times. A Matula Thoughts correspondent from Georgia raised the matter of moral certainty last month, quoting H.L. Mencken on the issue:

“Moral certainty is always a matter of cultural inferiority. The more uncivilized the man, the surer he is that he knows precisely what is right and what is wrong. All human progress, even in morals, has been the work of men who have doubted the current moral values, not of men who have whooped them up and tried to enforce them. The truly civilized man is always skeptical and tolerant, in this field as in all others. His culture is based on ‘I am not too sure.’” [Minority Report: H.L. Mencken’s Notebooks (1956).]

Morality and certainty, historically, were inseparable for most of humanity, hardwired in cultures and written into laws of churches, states, and organizations. Morality, as a topic, is far beyond scholarly consideration of this set of essays, but certainty is a matter of keen concern in health care. Philosophers, religious leaders, royalty, politicians, have offered their versions of certainty over millennia, but certitude challenges easy universal agreement, as one’s certainty on an issue is based on one’s origin, belief system, willingness to reason, and livelihood. Mencken, Lewis Sinclair, C.E.M. Joad, and others have variably said: “It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

From a practical perspective as a physician, certainty means belief without rational grounds for distrust. Medical practice demands that conclusions must be drawn with certainty, for example, from urine specimens whether in matulas, under microscopes, via chemical strips, or on culture plates. Urologists, as all practitioners, depend upon certainty in diagnosis and therapy, yet we cannot be absolutely certain about everything that passes under our visage. Relative certainty is a practical and essential qualification. [Below: Constantine examines urine in matulas. 11th c. Wikipedia.]

Mencken (1880-1956), influential journalist and social critic known as the Sage of Baltimore, could turn a phrase well, but he represented a peculiar elitism and exceptionalism of the first half of the American 20th century. Self-assured in his certainty, he often was acerbic and dismissive to those he perceived as lesser intellect or “lower caste,” although he didn’t use that terminology. Mencken was contemptuous of Franklin Roosevelt, argued against the New Deal, objected to U.S. participation in WWII, and harbored admiration for the Nazi regime. Ayn Rand was one of his great admirers, but other influential voices were critical. Christopher Hitchens later offered a scathing opinion of Mencken in a book review.

“How did one of America’s seemingly great rationalists and modernists come to regard Roosevelt as more worthy of condemnation than Hitler? The answer, on the evidence of this and other studies, is that Mencken was a German nationalist, an insecure small-town petit-bourgeois, a childless hypochondriac with what seems on the evidence of these pages to have been a room temperature libido, an anti humanist as much as an atheist, a man prone to hyperbole and sensationalism he distrusted in others and not as easy with the modern world and its many temptations and diversions as he liked it to be supposed.”

Hitchens also turned his phrases well, but when he hit, he struck hard and unsparingly. [Hitchens, “A Smart Set of One,” The New York Times (17 November 2002), book review of The Skeptic: A Life of H. L. Mencken (2002) by Terry Teachout.]

Certainty, although personally comforting, closes the mind to new ideas and leads to smugness. It is irrational to expect 7 billion people to share the same certainties about all matters, short of a limited number of generally-accepted facts, such as that days follow nights, the moon has phases, eclipses occur occasionally, kindness and civility are nice, and some things such as infanticide and cannibalism are grotesque. The first rule of certainty, however, is that change is inevitable and accordingly, uncertainty rules above all.


Three.

Uncertainty. Werner Heisenberg made uncertainty respectable when his concept of indeterminacy (on a very small scale) in 1927 garnered him the 1932 Nobel Prize. Erwin Schrödinger carried the idea to the visible world in 1935 with his famous thought-experiment and paradoxical cat. [Above: Heisenberg c. 1901; Below: Schrödinger c. 1933. Wikipedia.]




[Above: Movable silhouette of Schrödinger’s fictional cat in the garden at Huttenstrasse 9, in Zurich where he once lived; visitors outside the walls cannot know the cat’s position or its direction, at any moment. Wikipedia.]

Uncertainty entered the moral dimension and popular culture, it could be argued, with Bryan Cranston’s fictional character Walter White in the Vince Gilligan television series of 2008. White, a modern-day high school chemistry teacher, is followed over five television seasons “breaking bad” into a dark world of the manufacture and distribution of 96% “pure” methamphetamine. White’s nickname Heisenberg initially conveyed his good state as a brilliant chemistry teacher, but the full irony came out when Walter turned to his dark side as a meth kingpin. [Below: Breaking Bad publicity still, Walter White.]

Mencken’s caution of self-certainty and promotion of “I’m not too sure” belied a number of other outrageous statements, defaulting to intemperate self-certainty, and forgetting his own restraint of “I’m not too sure.” Some Menckenisms reflected primal certainty that trumped morality and civility, such as “Every normal man must be tempted, at times, to spit upon his hands, hoist the black flag, and begin slitting throats.” [Mencken, The New Poetry Movement, Chapter 6.] [Below: Jolly Roger Flag.]

Momentary reversion to the primitive pirate in everyman – casting off the morality and mores of humanity, whether in thought-experiment or actuality – can’t be blamed on Mencken. He articulated the idea well, but it hardly originated or ended with him, and homicide remains widely evident in fact and fiction; even if we do not choose to be murderous outlaws, we relish them in our entertainment.

It comes as a surprise, now, 20 years into the 21st century, to find widespread craving for authoritarian rule. Possibly, this is propelled by a growing sense of nihilism where too many people prefer the certainty of “I don’t really care except for what’s good for me” over the uncertainty of “I’m not too sure.”


Four.

Independent thought. Modern society seemed to be gravitating toward the intellectual relativism of “I’m not too sure,” although maybe that was my wishful thinking.

It is reasonable to believe that throughout human history most people prayed for relief from authoritarian subjugation by clan leaders, priests, pharaohs, princes, kings, queens, and dictators. Those few leaders dictated their personal certainties to everyone else, claiming authority derived from physical strength, bullying, divine authorization, bloodline, caste, national exceptionalism, political sectarianism, or other “isms.” Physical intimidation in authoritarian societies suppresses expression of uncertainty and even more effectively, the memes of sectarian “isms” act as ideological viruses replicating the certainty of patterned thoughts in individual minds and crowds, precluding reasoning and doubt.

People, perhaps most, chafe under authoritarian rule, although they may do so silently. The contrary meme of the pirate, openly rebuking authority of the establishment, always finds sympathy in regulated societies, even those not authoritarian and repressive. An interesting example is the island of Corsica, variably contested by many authoritarian nations over the centuries and now French, proudly displays its counter-cultural pirate symbol on flag and coat of arms. [Below: Corsican symbols of independence.]


Mental acrobatics that lead to certainty are sometimes called heuristics and, aside from crude mapping by functional MRI, the neural gymnastics at play defy our best imagination and science. It is more convenient to be told what things are certain than to be figuring them out in every step of life’s way. Our historic predecessors – early humans lacking today’s sharpened tools of logic, science, and debate – must have found comfort to be given explanations for solar eclipses, earthquakes, or monsoons by tribal leaders or village priests, rather than tremble at the uncertainty of it all.

The problem with human thinking nowadays seems to be the matter of how people deal with their sense of “I’m not too sure.” Methodological thinking, analysis of information, and fair discussion can help people understand what to be sure of, what to question, and how to decide. However, these instruments of education, science and free speech are only effective when we step outside the comfort of our particular certainties and open our minds to other opinions, information, rational debate, and experiments of thought and science. Too often, we revert to the easier dogma of our sects and certainty our leaders.

The Good Doctor, a new book by our Georgian colleague, examines the importance of uncertainty in medical practice; no good physician can be a know-it-all. On the other hand, nobody wants an ambivalent doctor who offers a list of ten possible diagnoses and ten potential remedies and tells us to choose what we prefer. [K. Brigham, M.M.E. Johns, The Good Doctor, Why Medical Uncertainty Matters. Seven Stories Press, NY, 2020.]

A relevant thought comes from professor Sarah Buss here in the UM Philosophy Department who explains to her students that they can’t gain a deeper understanding of issues they consider in class without becoming less certain where they stand on those issues: “I aim to help them gain clarity, knowing that the result will often be a loss of certainty.” Professor Buss, in turn, quotes colleague Kieran Setiya:

“The patience to ask and to keep asking questions, without the assurance of agreement or the availability of methods apt to elicit it, is the philosopher’s gift. It is an expression of intellectual hope, and the repudiation of philosophy is a counsel of despair.”

[K. Setiya. Monk Justice. London Review of Books. 42 (16), 30 Aug. 2018.]

For everyday events on the human scale, in space and time, things are usually one way or another. We are used to uncertainty in life, but we prefer predictability, whether in elections, horseracing, or surgical outcomes. In fact, we depend on some degree of certainty, even if it is the probability of knowing the odds of a specific throw of dice or hand of cards, assuming fairness of the event. Statistics for a condition or certain state within a group, however, doesn’t translate well to a particular person for whom having the condition or state is a personal possibility of “yes” or “no,” that is a 50% probably in their mental calculus.

Adjectives and numbers help arbitrate uncertainty. Even simple adjectives, as in the world of genetic diseases, may offer precision. For example, “rare” conditions are said to affect less than 62/100,000 people while “ultrarare” has come to mean fewer than 2/100,000. [J.M. Friedman et al, “Exome sequencing and clinical diagnosis,” JAMA, 324:627, 2020.] By this terminology hypospadias is not so rare (2 in 500 male births), while cloacal exstrophy is ultrarare (1 in 250,000 births). A recent zoom visiting professorship to our pediatric urology division from Katherine Hubert Chan of Riley Children’s Hospital, offered a lesson on graphics in surgical decision-making, utilizing icon arrays to demonstrate frequency of a given condition. Pictographs nicely convey a sense of likelihood or unlikelihood without the abstruse jargon of high-voltage statistical tools. [Below: an icon array.]

Five.

Certainty 2.0. At some point we humans admitted a new form of certainty into our minds, basing belief on rational argument, verifiable evidence, and experiment, rather than anecdote and authority. Paradoxically, this new certainty is based on acceptance of some uncertainty that facts and models change as we interrogate them. Nonetheless this should not allow a lazy retreat to anarchy and nihilism where nothing is held true.

Certainty is desirable in surgical practice; when treating stones, congenital malformations, or malignancies, specific identification of a problem is closely linked to beneficial solution. Yet knowledge and technologies change and yesterday’s certainty becomes today’s uncertainty, thereby reintroducing the questions, how do we know what is correct and how should we act today?

Hugh Cabot, founder of urology at Michigan and man of great certainty, took wide interest in medicine, often crossing epistemological boundaries to study and collaborate outside of his field. Working with pathologists on a paper on gastric cancer in the era of the Nobel controversy, Cabot and fellow faculty member George Adie had published their thoughts on its etiology in 1925, quoting views of their colleague, Aldred Warthin. [H. Cabot and G. C. Adie, “Etiology of Cancer of the Stomach,” Annals of Surgery 82 (1925): 86–108.] William Mayo, another physician with an Ann Arbor connection (UMMS, 1883), was also interested in the topic, writing a lead article in Surgery, Gynecology and Obstetrics in 1912 that discussed treatment from his point of view: “Cancer of the stomach: its surgical cure.” [SG&O, 14 (2): 115-119.] Mayo criticized lengthy diagnostic interludes that allow the disease to progress from “week to week” until by the time a practitioner has absolute certainty of the diagnosis before referring to patient to Rochester, “This is not a case for the surgeon, but for the undertaker.” Mayo concluded: “Cancer of the stomach is the most frequent and most hopeless form of cancer in the human body. Early operation affords the victim the only chance of a cure.” Time and discovery have altered the certainty of those conclusions. Ironically, gastric cancer took Mayo’s life at age 78.

The rapidly changing conditions, information, and misinformation surrounding Covid-19 have challenged medical certainty and public certainty. Political iniquity and social media mischief accelerate the uncertainty and miscertainty. Rather than dwell on this here, we offer two essential articles from NEJM, both accessible at no charge on the internet.
One editorial says it all. “Dying in a leadership vacuum,” [NEJM, 2020; 383:1479-1480.] A perspective by J.N. Rosenquist, “The stress of Bayesian medicine – uncomfortable uncertainty in the face of Covid-19.” [https://www.nejm.org/doi/pdf/10.1056/NEJMp2018857?articleTools=true]

Postscript.

Frank Legacki, legendary Michigan Swim Team Captain of the Class of 1961, successful businessman, and friend of the University of Michigan Musical Society and Department of Urology, passed away last month on 10/16/2020, leaving his wife, Alicia Torres. [Above: Frank at Steve’s Deli, September 23, 2020.]

Born 9/28/1939, Frank grew up in a tough Philadelphia neighborhood, the oldest of eight children – six boys and two girls. His parents, of modest means, believed in education and raised the children firmly and proud of their background and opportunities. Dad, a Polish immigrant, was a carpenter. Mom, daughter of Irish immigrants, deftly managed the large family. Frank attended Father Judge High School, where by luck and hard work, joined the rudimentary swimming team his freshman year. Lacking a pool at the school, Frank and teammates trained at pools as much as 1.5 hours away. Swimming was the glue that kept him focused in high school and he became a National Catholic High School Champion and a Scholastic All-American, earning athletic scholarships at several universities. Narrowing his choices to the University of Michigan and Ohio State University, both with top Collegiate Swimming programs, Frank asked his high school coach which school to attend. The coach answered, “Probably Ohio State, Michigan is far more difficult academically and you may have problems getting through at Michigan.” Frank decided on the spot to go to Michigan. 

Education and swimming at UM shaped his life. Eligible for the team in his sophomore year, 1959, Frank became NCAA Champion in the 100-yard freestyle and anchored the winning 400-yard freestyle relay. Two weeks later at the US Open Championship (later called the National AAU Championships) he set the American record in the butterfly. Michigan’s score of 95.5 at that competition was a new record and solidified the UM 1959 Swim Team as the greatest in NCAA history. Frank and his team continued to win and set records, and he was elected captain in his senior year, receiving other honors and leadership positions outside of athletics. Frank married after graduation in 1961 and stayed in Ann Arbor for an additional year to get an M.B.A. The couple would have four daughters, divorcing after 23 years.

A business career took Frank to New York City at Ogilvy & Mather Advertising. He went on to executive positions as: Managing Director of the Strategic Consulting Group of Marketing Corporation of America; VP of Marketing for Converse Athletic Footwear; Founder and President of the Andover Consulting Group; and President of Kaepa Athletic Footwear. Frank led a buy-out of this last company and eventually sold Kaepa to Umbro Sports Apparel. During these years he returned to UM for an M.B.A., graduating in the top quarter of the class.

In the business world Frank met Alicia Torres in San Antonio in the autumn of 1993 and they became business friends and then partners. Organizing a leveraged buyout of software products, and they formed Rosebud Solutions, generating outside investments, building a skilled team, and growing the business. Their partnership became personal and they grew close, marrying in Philadelphia on August 8, 1998, and then relocating in Ann Arbor. Rosebud was acquired by McKesson, Inc. (NYSE: MCK) in 2008. Frank went on to work part-time with Fletcher Spaght, Inc., a Boston venture capital firm, eventually retiring fully.

Frank, always loyal and grateful to UM, often said: “I was born at the University of Michigan; it was here I learned how to think.” In Ann Arbor, Frank and Alicia immersed themselves deeply in university matters and the community, enlarging their network of friends and interests. Frank was recognized for his achievements by induction into the University of Michigan Hall of Honor and The Pennsylvania Sports Hall of Fame. He stayed active with the University as President of the Grey Whales (Swim Boosters); Board of M Club Letter winners; UM Alumni Association Board; UM Urology Department Board; and Chair of the Marketing Committee of the University Musical Society. Frank was also President of the Barton Hills Maintenance Corporation. Frank and Alicia regularly attended over 20 UMS performances annually as well as School of Music Theater and Dance events. They generously supported Michigan Theater and were regular presences at UM athletic events, with season tickets for Football, Basketball, Hockey, Wrestling, Softball, and Swimming meets. Active fishermen, they cast lines in Florida and exotic locations around the world. Frank loved his time with grandchildren, Sam, Sophia, and Noah, taking them fishing, to UM events, and cooking together. The kids loved “GP Frank.”

Frank shared his rich and full years generously with friends, family, neighbors, and the University of Michigan. Alicia recounts:

“Frank had an amazing life. He gave much more than was given to him, and celebrated life like very few. He loved keeping in touch with elementary, high school, and college friends and those he met during his career and travels. Frank asked strangers about their life, where they were from and then, they too became Frank’s friends. Through his travels, Frank always carried an extra U of M cap, which he would give to people who captured his heart. When Frank entered a room, he owned it, you knew he was there, in a good way.”

Paul Legacki from Sacramento, Frank’s last living brother, was a frequent visitor to Ann Arbor in Frank’s final year. Frank anticipated his final days gracefully and with good humor, requesting his epitaph be borrowed from the last lines in Edmond Rostand’s great play, Cyrano de Bergerac. In the final scene Cyrano lies in Roxanne’s arms, mortally wounded and weakening, as he looks at Roxanne and says his final words; “They have taken my life, but they have not taken my panache.” Frank lived an active and interesting life, with extraordinary panache.

In one of the sweet coincidences of life, the lovely home of Frank and Alicia is situated exactly between those of Ananias Diokno (Nesbit 1970) and Kate Kraft (Nesbit faculty 2011), and across the street from the former home of Ed McGuire who succeeded Nesbit’s direct successor as Urology Section Chief in 1983, Jack Lapides (Nesbit 1950). Ananias and Kate’s family looked over Frank in his last days. Many of us lost an extraordinary friend when Frank died. His passing, at a young and robust 81 years of age of metastatic prostate cancer, reminds us painfully that we still have a long way to go in our work in urology.


Additional Postscripts.

The Lasker Awards were held back this year due to the Covid-19 pandemic. These are awarded annually since 1945 to living persons who have made major contributions to medical science or performed public service on behalf of medicine. This year the Foundation instead highlighted the 29 awards given in the past that recognized advances in infectious diseases, the first of those going to John F. Mahoney in 1946 for treatment of syphilis with penicillin and the most recent to Douglas Lowy and John Schiller for vaccination to prevent HPV in 2017. [J.L. Goldstein, JAMA September 25, 2020.]. My bet for a 2021 Lasker Award will be on Anthony Fauci for his tireless and courageous representation of scientific truth in the public interest in turbulent times.

Apocryphal Keynes quotations: “When the facts change, I change my mind. What do you do sir?” or “When someone persuades me that I am wrong, I change my mind. What do you do?” Variants of these have been attributed to redoubtable British economist John Maynard Keynes (1883 -1946), but no direct sourcing has been found. Nobel laureate Paul Samuelson and others alluded to versions of the remark, long after Keynes died. Whatever actual the source, it is an enlightened human idea.

True fact. Face masks diminish respiratory germ transmission by respiratory droplets. This is certain and has been clear to every surgeon, nurse, and OR worker on the planet for well over a century. Argument on this point is futile and malintented.

[Above: Justin Dimick and Hari Nathan, UM Surgery Department. Below: Aditya Pandey & Paul Park UM Neurosurgery Department.]

Thanks for looking at Matula Thoughts this November, 2020.
David A. Bloom
Department of Urology, University of Michigan

Folly & truths

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WN/WN/MT Aug 2020

Folly & Truths

2472 words

One.

The Cure of Folly. Overwhelmed by insanity, the world might be a better place if we had a surgical cure for madness, but alas, surgeons can’t fix everything or everyone. Hieronymus Bosch (c. 1450 – 1516) imagined this scene around the time Christopher Columbus made his second voyage to Caribbean Islands and just before John Cabot was the first known European on the North American mainland – journeys that to “Flat Earther believers” seemed examples of pure folly. [Above: detail from The Cure of Folly, Museo del Prado, Madrid.]

Belief that removal of a “stone” in the head could cure “madness” was one of many unscientific ideas of humanity that spawned strong believers and industries. Such “stones” might have been actual subcutaneous nodules or more deeply-situated objects imagined in the brain. Factoids lurked behind fantasy, as so happens with many other follies. Bladder stones, for example, surely were real and caused grief. These unmitigated miseries could be relieved only by lithotomy, for patients lucky enough to survive the horrible experience of surgery without anesthesia, extensive blood loss, and likelihood of postoperative sepsis. No such evidence of relief exists for relief of mental illness by removal of scalp nodules or drilling into the skull by trepanation, beyond a placebo effect. Surgical cure for insanity, was an insanity itself, as Bosch’s painting attests, where he not only visually spoofed the bizarre idea of surgical cure of madness, but also implied a cure to the folly, in the operating theater of public opinion by means of the satirical title.

How does an individual gain confidence or belief in an idea, a skill, or a technology? The discernment of the utility of some thing or the truth of an idea is a critical function learned in childhood and honed throughout life. An open mind that is willing to learn and unconstrained by ideology helps this arbitration. A mind further trained by education and critical analysis improves the odds of giving fair measure to an idea, skill, or device. Humans have had countless ideas and inventions, but for any of these to persist in society they must be tested in commercial and intellectual marketplaces and reconciled to public belief and utility. An idea or technology sticks around when enough of the public – a quorum – becomes confident of its value and truth.

During a recent virtual pediatric urology meeting, in discussions over ideas of validity and truth, Julian Wan reminded us: “there are three types of arguments – the nature of relevant knowledge at hand; pragmatism; and sectarian belief.” As the tagline for The X-Files once promised: “The truth is out there,” although it’s not the same for everyone.

The large contest in play for H. sapiens today, is the ability of people to coalesce around some shared sense of basic truths that enable them to discern and choose between authoritarian societies versus representative democracies. This matter is especially intense now in this interconnected and fragile world where our technologies can distort truth and physically destroy the planet.

 

Two. 

Truth. Isabella Baumfree is a timely person to consider. Born into slavery in a small Dutch-speaking community in the Catskills around 1787, she grew up known as “Belle.” Although New York state began to abolish slavery in 1799, emancipation was not complete until July 4, 1827.  Belle “escaped” just before this, in 1826 with her infant daughter, but she preferred to say that she “walked off,” anticipating the emancipation. She had to leave three other children behind and two years later she went to court to recover her son, then five years-old and enslaved in Alabama. Remarkably, she won. In 1843 she renamed herself Sojourner Truth and became an abolitionist and women’s right’s activist. Her speech in 1851 at the Ohio Women’s Rights Convention in Akron “Ain’t I a woman?” established her celebrity and was reiterated widely throughout the years of the Civil War. Sojourner Truth moved to Battle Creek, Michigan, in 1857 and died at home in 1883.  [Picture above, National Portrait Gallery, c. 1870.]

Sojourn, of course, describes a temporary stay or condition and the extraordinary name Sojourner Truth, writ large, implies a traveler who experiences various postulations of truth in pursuit an ultimate best version of it, through their days and times. The conditionality of facts and truths is not just a matter for philosophers – it is the daily work of historians and scientists who seek to disprove established beliefs (and follies) with better facts and reasoning. Sojourner Truth’s name is a fitting metaphor for the conditionality of truth, whether ascertained by ideology and sectarian fiat or by observation and reasoning, and even once ascertained it is always amenable to further examination.

 

Three.

History and science are good antidotes to folly, provided that their logic trumps the  ideologies and beliefs that so often constrain people. Folly is the antithesis of good history and science. It is, by definition, foolish – lacking defining characteristics of our species: good sense, reason, prudence, and foresight. The rigor of history and science brings verifiable data and rational argument to old beliefs, in pursuit of the idea of truth. This pursuit depends upon free inquiry, free speech, peer review, criticism, and public education – all characteristics of open societies and the institutions sustain those societies. Ultimately, however, the cure of folly requires that people change their minds, based on data, analysis, and argument.

Governments, universities, industries, and all businesses, as they serve themselves, also serve the public interest and their integrity is tied to the public trust. Naturally, our expectation is that self-interest for industry and business is usually greater than their public service, but for governments and universities the public interest should dominate. Good science and good history (in the sense that “good” captures the idea of truth and reflects fundamental values of humanity) do not necessarily find nourishing soil in authoritarian societies, universities, corporations, or “top-down” organizations. In fact, authoritarian government has never worked well for people, history, or science. [Above: The Alchemist, Mattheus van Helmont.]

Society’s instruments, namely its governments, universities, and businesses, too often maintain stubborn illiteracy of history and science. These organizations ignore some truths that are becoming very clear with massively-accruing evidence of basic facts: infectious diseases recur in catastrophic waves, people need basic securities, and human environmental impact is deleterious to a human future. One wonders, then, what are the actual purposes, the main value, of those institutions (governments, universities, businesses, the press, etc.) to “we, the people?” Limiting the question just to government (recognizing that a huge body of scholarly work, beyond capacity of this writer and essay, continues to study this question). The Declaration of Independence, states it simply:

“… in order to form a more perfect union” so as to protect the basic human aspirations for “life, liberty, and the pursuit of happiness.”

Government facilitates these aspirations most fundamentally through basic securities of public safety, public education, assurance of jobs and justice, as well as public and personal health. Security of food and shelter are no less important, as this Covid epidemic is showing. These are the needs of “We, the people.”

 

Four.

New medical students just joined us in Ann Arbor, although the absence of our usual White Coat Ceremony at Hill Auditorium deprived us of the chance to see them on stage, hear their introductions, and give them short white coats, stethoscopes, and MCAS pins. Cliff Craig recently sent Matula Thoughts a note recalling his precise moment of entry in 1969, before the White Coat Ceremony was introduced to our medical school. Cliff and his fellow students assembled to hear the dean, without any family members, children, or friends on hand to offer support and cheers, as would come with the White Coat event years later. [Below: Cliff c. 2019.]

“It was 1965, the first day for the University of Michigan Medical School class of 1969. We saw no white coats, nor short ones either. Dean Hubbard said (paraphrased): ‘You are all worried about failing out, I am not worried about that. I am worried that some of you will be bad doctors, and I wish I knew who you were, I’d kick you out right now.’ That was immediately followed by our first class; – so much for class ‘bonding.’

One year later, in 1966, on the first day of our second year, we were all advised to show up with a short white coat which could be purchased at Ulrich’s (along with the books we needed for the second year). It was a year punctuated by many demonstrations and sit-ins on campus against the Viet Nam war (Tom Hayden etc.). Dean Hubbard then addressed us again (paraphrased): ‘I want you to remember when you wear your white coat, you represent not only yourself but this medical school, the medical profession, but most importantly you represent me! If you want to participate in any of the activities on central campus, take off the white coat.’

I met Dean Hubbard at commencement in the early 2000s, and reiterated what he told us on those occasions. His response: ‘Did I really say that?'”

Time passed and now Cliff is professor at UMMS, specializing in the pediatric orthopedics. He keeps in touch regularly with several classmates including otolaryngologist Mike Johns, who served UM brilliantly as interim EVPMA after being Dean of the Medical School at Johns Hopkins and then Chancellor of Emory University. Rick Rapport, another classmate, is a retired neurosurgeon in Seattle.

 

Five.

William Hubbard was the first “full time” dean at UMMS, in the sense of having no conflicting duties such as departmental chair (like Cabot) or clinical practice (like Furstenberg). Hubbard served from 1959 through 1970, resigning to become a senior vice president at the Upjohn Pharmaceutical Company in Kalamazoo. Just the year before, the regents had given him responsibility as dean to also manage the hospitals of the growing medical center.

One evening in March, 2006, after usual work hours, voices were heard in the otherwise quiet hall outside the office of the Associate Dean for Faculty Affairs, who was curious to see who was wandering about in the administrative area of Dean Allen Lichter. This led to the good fortune of meeting former Dean William Hubbard who had come by to view his portrait. Fortunately, a camera was nearby to capture Dr. Hubbard and his painting from more than 30 years earlier. Fashions change and our deans’ portraits are now in storage. It was fortunate to have been hanging when history was still on display when Dr. Hubbard strolled by and he seemed pleased to reflect back on his time at Michigan. It is too late to ask Hubbard to recall his memories of Nesbit and Lapides, or to get his recollections on the issues of his years as dean, but we can hear Dr. Hubbard through his former students, Drs. Craig, Johns, Rapport, and other classmates who have turned out pretty well. Their origin stories certainly place strong emphasis on the roles of the University of Michigan Medical School, deans like Hubbard, and many of the Medical School teachers who helped form generations of leaders and best.

 

Postscript.

Clair Cox was one of the leaders and best to have come from the University of Michigan Medical School. As a resident in the 1970s at UCLA, reading the urology literature, I became familiar with the name Clair Edward Cox, II, who published interesting and good papers from Bowman Gray School of Medicine (now Wake Forest Medical School) and later the University of Tennessee in Memphis. Little did I know we would become friends during my time in Ann Arbor, where the University of Michigan connected us. I’m sad to report that Clair passed away a few weeks ago.

Clair was born on September 3, 1933 in St. Francisville, IL, and grew up in Mt. Pleasant, MI, excelling in studies and sports. With a Regents Alumni Scholarship, he completed three years of undergraduate studies at the University of Michigan and then entered the Medical School. In his sophomore year, he met junior nursing student Clarice Adele Wicks and they married in 1958 when Clair graduated with an M.D. His Medical School Class of 1958 was a remarkable group in a remarkable time, entering postgraduate medical education in the new era of specialty practice, massive research funding, and a high point of academic medicine. At Michigan, this was at the end of Furstenberg’s long tenure as dean, from 1935 to 1959, when the dean practiced medicine at nearly a fulltime clip whilst tending to the medical school administration. Frederick Coller retired as chief of surgery in Clair’s graduating year and Reed Nesbit, head of urology, was nearing the peak of his career having brought Transurethral Resection of the Prostate (TURP) to the mainstream of international urologic practice. Both men inspired Clair as a medical student and Nesbit, particularly, became a resource as Clair ascended the hierarchy of academic urology.

Clair and Clarice moved to Denver for surgical training at the University of Colorado, anticipating a path to thoracic surgery, but urology gained the upper hand in his interest and the couple continued west to San Francisco for urology training that he completed in 1963 at the University of California. The couple returned east across the country to Winston-Salem, NC for an academic urology position at Bowman Gray where Clair advanced through the ranks to professor. In 1972 Clair was recruited to lead urology in Memphis at the University of Tennessee and held the chair position for 27 years until he stepped down, having trained 90 residents. He continued to work for another 10 years until retiring in 2009.

Dr. and Mrs. Cox raised four boys who would give them 12 grandchildren. In retirement Clair enjoyed his family, their home, and the family ranch in Hernando, Mississippi. His last academic paper, a historical investigation, entwined the stories of a fellow Memphis urologist (Thomas Moore), Graceland, Elvis Presley, and the American Urological Association. Michigan Football frequently brought Clair, Clarice, and occasionally a son and grandson back to Ann Arbor. Of Clair’s multiple university affiliations, the Michigan connection was the strongest, as evident to visitors to the lovely Cox home on Sweetbriar Cove in Memphis where maize and blue colors and UM symbols flourished. The Nesbit Alumni Society includes UM Medical School graduates along with the UM trainees who became urologists and Clair was pleased to be a member, after all Nesbit was his first teacher of urology. Clair once said that while he enjoyed working in five excellent medical centers, it was the University of Michigan that was always closest to his heart and running through his veins. Just as he felt the University of Michigan distinguished him as a citizen and a urologist, he distinguished the University of Michigan as an exceptional alumnus, educator, clinician, and scholar.

Clair Edward Cox, II, died peacefully at home on July 9, 2020. [Above, Dr. Cox on his ranch in Hernando, 2017.]

 

Thanks for reading Matula Thoughts, this first Friday of August 2020.

David A. Bloom

University of Michigan Department of Urology

 

Matula Thoughts February 7, 2020

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Matula Thoughts 7 February 2020 Leaps, literacy, & opinions 2142 words One. Leap Year. A celestial accounting anomaly this month on Saturday February 29 will have only minor impact on people’s lives and world economies. The extra business day, when … Continue reading →

2020 – a new blank slate

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Matula Thoughts 3 January 2020

A new blank slate

2376 words

One.

 

Tabula Rasa 2020.

Optimists begin New Years with clean slates. Most people negotiate internal tension between optimism and pessimism, but the sense of opportunity that comes with a new year generally tilts the balance toward optimism and the chance to start anew with mistakes and sins of the past perhaps forgotten, if not forgiven. The blank slate, though, is only a metaphor; each year ahead will build on stories of the past – history – and the contingencies of immediate moments. [Above: Blank wax tablet.Wikipedia.]

The new year, next decade, and century ahead for Michigan Urology, may be shaped by the century that unfurled after Hugh Cabot came to Ann Arbor late in 1919, but the critical determinants of the future will be the ingenuity, industry, and success of our educational programs, research, and clinical delivery. The idea that the essential deliverable of academic medicine is patient care, while not historically prominent, is absolutely clear today. That essential deliverable, as we have said in our department of urology for some years, is kind and excellent clinical care, thoroughly integrated with education and innovation. With that, as the “North Star,” navigation becomes simple.

The Latin phrase tabula rasa originates from blank slates or waxed tablets that, after erasure of chalk or melting the wax, are available for fresh notation. Aristotle was one of the early thinkers who likened the mind to a clean writing slate and Avicenna, Thomas Aquinas, and John Locke, among many others, expanded the idea until modern neurobiology brought science to the matter. Metaphors are merely tools for thinking and communication, not absolute “true facts” that Don Coffey sought to recognize amidst the litter of contemporary information. Steven Pinker’s book of 2002,Blank Slate: The Modern Denial of Human Nature, calls out the metaphor and explains that human behavior is not constructed on a blank slate, or tabula rasa, but is heavily programed. [See Pinker’s TED Talks 2008 and 2019.]

Blank Slate is also the clever name for an Ann Arbor Ice cream shop, the actual ice cream serving as a medium for an ingenious palate of flavors. Ice cream, one of the great inventions of humankind, is a delight in any season, although winter demand slackens enough for the Creamery to close up for the coldest months (above at Liberty and S. First Streets). Having borrowed the metaphor for this monthly message, I was duty bound to ask (and receive) permission from Michigan grad Janice Sigler who opened Blank Slate in July, 2014, with her husband.

 

Two.

January 1920 was an optimistic time for Hugh Cabot in Ann Arbor at a high point of his career. Modern Urology, his noteworthy 1918 textbook, capped his 15 year rise to central authority in the field. An early volunteer for the European conflict, well before American entry made it a world war, Cabot commanded a 2,500-bed general hospital on the Western Front by war’s end. His return to Boston at the end of January 1919 was front-page news in the Boston Herald, although not without glitches. Cabot’s team of doctors and nurses was blocked from leaving the train at the Boston station where a reception was waiting for them. A military authority ordered the ensemble to remain on the train and continue on the train to Camp Devon, Massachusetts and then New York City for official discharge of duties. After discussion Cabot declined the order and the entire medical team disembarked from the train to join the waiting reception and then dispersed into the crowd to resume civilian life. [Below: Boston Herald. Front page. “Harvard Surgical Unit held prisoners by error on arrival in Boston.” January 31, 1919.]

As Cabot resumed civilian life the world seemed enroute to a better future in terms of public health, geopolitics, economics, technology, and art. The devastating Great Influenza Epidemic was over, but other pandemics followed. Geopolitical solutions to WWI would pave the way to WWII and later conflicts. The economic world collapsed in less than a decade. Rapid advances of technology that seemed so wonderful in the early 20thcentury proved two-sided by century-end with antibiotic resistant bacteria threatening food safety, robots displacing jobs, computer malware holding businesses and cities hostage, identity theft via internet, and social media manipulation of public elections. The public eagerly embraces Orwellian Big Brother – reassuringly renamed Alexa, Hey Google, and Siri – with ubiquitous cameras on streets and in homes paving the way to authoritarian control of society through artificial intelligence.

 

Three.

The “blank slate” of the new year, brings to mind resolutions and the human itch for personal mastery of something – work, play, family, or hobby. Just as they were once inspired, Bach and Casals are posthumously inspiring future composers and musicians today. The cello suites have had a remarkable 300-year journey since Bach started writing them as exercises for his young wife in 1717. Casals discovered the largely-forgotten music in a shop in 1890 and mastered its performance by 1896 when he became principal cellist in Barcelona at the Gran Teatre del Liceu. [Below: Title page of Anna Magdalena Bach‘s manuscript: Suites á Violoncello Solo Senza Basso. Wikipedia.]

Casals had ups and downs, like everyone, but the worst immobilized him for two weeks in 1939 when he didn’t leave his room in Paris, exhausted from recording the six Bach suites (Casals hated the recording process) and despairing over Franco’s take-over of Spain. Casals was thoroughly burned out, although the favored terminology of the time described him as emotionally exhausted and depressed. Thankfully, he rebounded and his career reached new heights. Nearly 20 years later, at age 80, he married 20-year-old Marta Montañez y Martinez, dismissing concerns over their age discrepancy: “I look at it this way: if she dies, she dies!” [Cesare Civetta. Mar 14, 2018. “Pablo Casals sacrificed his career to protest Franco.” https://CesareCivetta.com/blog] [Below: From Encyclopaedia Britannica, Pablo Casals, 1965. Erich Auerbach, photograph, Hulton Archive/Getty Images.]

The inspiration of the suites lives on: Yo-Yo Ma was inspired by Bach’s cello suites at age 4 and today, at 64, travels six continents to perform all six suites in single sittings at 36 locations.

Combustion control has been a defining feature of our species beginning around campfires for comfort, cooking, and conversation. Heat may erase tabula rasas, but metaphoric self-combustion in modern society seems a new thing. It is not clear when burnout is a “legitimate” dysfunction or an extension of quotidian fatigue? That state of reduced personal efficacy, emotional exhaustion, and depersonalization describes the condition today called burnout, that suddenly, it seems, has become epidemic in many professions, including health care. Conferences, surveys, and editorials proliferate and  medicalize the matter. The Lancet offered a useful perspective in an editorial, Physician burnout: the need to rehumanise health systems. The wording is counterintuitive – the “rehumanization” of human health care. [The Lancet. 394: 1591, 2019.]

 

Four.

So how is it that health care became “dehumanized”– that very suggestion seems to be an oxymoron, a contradiction in terms, as René Magritte cleverly depicted in his surreal paintings such as the 1953 Wonders of Nature (©René Magritte). The dehumanization phenomenon in medicine seems linked to the systematization, corporatization, and commoditization of healthcare. Systems are necessary in modern healthcare, of course, but the displacement of what historically was called the doctor-patient relationship with checklists, guidelines, and clinical pathways distracts from the human element. The EHR-directed patient “encounters” have largely replaced the narratives of the human conditions wrapped-up in taking “the history.”. Corporate medicine is quickly replacing small practices and bringing with it tainted ideas of business management, specifically the failed ideas of Taylorism, managerial accounting, and the North Star of shareholder value.

The idea of the limited liability corporation has largely built the modern world, as human society has given corporations many special rights such as limited liability, free speech, and some special benefits that ordinary people cannot have. (Back around 2003 Julian Wan gave me a book that explains this – The Company – A Short History of a Revolutionary Idea, by John Micklethwait and Adrian Wooldridge.) Undeclared but implicit in that Victorian innovation is a social contract that businesses exist not merely for shareholder value, but more broadly for stakeholder value – jobs, employees, benefits, suppliers, community – and for value to society-at-large, the most important stakeholder of all.

It is natural that some parts of health care are legitimate commodities, functioning optimally in a market-based economy without the necessity of an intermediary professional agent. Examples are many – flu shots, over-the counter medications, food supplements, and countless others. Other healthcare functions are complex, multilayered, and highly professional, such as renal transplantation, mental health treatment, and management of malignancy. In between these extremes are the essential transactions of visits to physicians, dental care, emergency department visits, orthopaedic care, periodic eye care, and treatment of urologic conditions – these are a mix of commodity and profession. The arbitrage of those two elements of society is an endless conversation.

The extension of personal mastery in one’s subject of choice, whether by New Year Resolution or not, is self-vaccination against burnout. The enhanced personal well-being can re-humanize your medical workplace in more ways than this essay can explain. Recently, up in Flint at the Hamilton Community Health Center, Mike Giacalone, Jr., the Chief Medical Officer, was explaining Hamilton to interviewing journalists and said that for the Flint patients, “every visit is not just a medical visit, but equally so a social, economic, and behavioral visit as well.” While particularly relevant in Flint, this should be a universal aspiration in health care. The medical gaze should try to “take it all in” and triage the needs of a patient and family as best possible, in spite of the rigidity of the EHR- constrained medical encounter programmed around a chief complaint.

 

Five.

Media and messages. Whether the medium is ice cream, canvas, blank paper, musical instrument, computer screen, stage, construction site, clinic room, operating room, or learner – artistry can be performed.

Everyone is a lifelong learner, but the health care field demands special attention. Undergraduates and beginning medical students are the most impressionable blank slates and for that reason the responsibility of role models, teachers, and mentors is perhaps the greatest for them among the learners we teach. For many of the younger set their first experiences seeing a physician, nurse, or physician’s assistant at work (sometimes in instances of personal care of a UTI, stone, or surgical correction) imprints and fosters a lifelong pursuit. Whenever possible, these opportunities for shadowing or introductory teaching should be embraced. Residency training, however, is the most critical blank slate of all in medicine, fashioning the knowledge, skills, artistry, and professionalism for a career. [Images above & below from “the internet.”]

Blank slates are opportunities, but risk erasure of the past although that is necessary with wax tablets and chalkboards. Parchment and paper were a big improvement allowing durable manuscripts and books, still at risk from fire (accidental or intentional) or other forms of destruction or deterioration. The new world of digital information carried the conceit that humans could become “paperless”, but that is ultimately not only impractical but also a genuinely bad idea for free societies.

When governments, sectarian authorities, or corporatocracies control printing presses, airwaves, or other social media – society is captive to a few reigning opinions because inconvenient stories, opinions, ideas, or truths are conveniently avoided or erased. Clever memes and tweets easily subvert social groups and human ideals. One great feature of the human condition is the testing and synergism of opinions, ideas, and technologies that can build civilization for the greater good of mankind and sustainability of the planet. The central idea of free speech at the heart of civilization, is being sorely tested by the unexpected opportunities of modern technological social media.

From our parochial perspective in the art and business of health care, erasure of history is an especially unfortunate reality, but we see it with each change of technology in health records. The operative procedure notes and pathology reports from the earlier part of my career seem to have vanished with the paper records we utilized when I started here in Ann Arbor, as I have learned when trying to answer requests from people regarding, say, an exstrophy closure operative report in the 1940’s, a hospital course in the 1960’s, or thyroidectomy pathology findings from the 1970s. Those floppy discs we had in the 1980s and zip-drives of the 1990s are increasingly difficult to access as obsolete technologies disappear. No one today can ensure that the massive data in electronic records will be converted to the media of the future – it seems unlikely that the “data cloud” of 2020 will be maintained in a future data cloud or its equivalent of 2050.

When Ed McGuire brought me to Ann Arbor in 1984 my blank slates were 3×5 index cards and the newly launched Macintosh Computer. Our hospital then had separate inpatient and outpatient paper charts. The Surgery Department administrators cautioned me to not get used to my Apple Computer as UM was preparing to launch the Wang Computer System. I didn’t listen – but still have the cards (one for with every patient I saw at Michigan) and that original Macintosh (now a book end).

 

Postscript

Matula Thoughts analytics, 2019. We have no sense of the total readership of the monthly What’s New delivered by email, but the web version matulathoughts.org has levelled off at 3357 views and 2199 visitors from 78 countries as of 31 December 2019, down from 3458 views, 2226 visitors from 89 countries in 2018, probably due to personal retreat from the chair position of the Urology Department at the University of Michigan. This past year we shortened the essay from 10 to 5 numbered items and dropped the word count to 2000 or so, although still far less convenient than a 140-character microblog tweet.

This leveling-off of Matula Thoughts recalls the Hippocratic Aphorism: Art is long, life is short, opportunity fleeting, experience hazardous, and judgment difficult. Other interpretations of the Ancient Greek vary the nuance and words, but clearly this personal essay, the first Friday of each month, is anachronistic and risky in offering personal judgments and observations. Those facts are more than balanced by the personal delight in hearing back from a handful of readers each month, thus extending these essays to dialogue and conversation, challenging facts, pointing out errors, and teaching me. Comments last month were especially appreciated. For all these, thank you.

 

David A. Bloom

Department of Urology

University of Michigan, Ann Arbor

November one

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DAB Matula Thoughts November 1, 2019

One hundred years of urology
2615 words

One.

The origin of urology at the University of Michigan centers around its first three urologists Hugh Cabot, Charles Huggins, and Reed Nesbit, each having enormous impact in their individual ways. Cabot’s impact was academic, clinical, and organizational. Huggins came to Michigan for what was then called “postgraduate training” under Cabot and was inspired to a career in urology that took him to the University of Chicago as chief of urology and eventually to a Nobel Prize. Nesbit, roommate of Huggins as trainees, became Cabot’s successor and a noteworthy urologist, whose clinical innovation, organization leadership, and education of future leaders of his century, had few equals.

The story of genitourinary surgery, of course, actually began much earlier, with pre-Hippocratic roots and slow evolution until the second half of the 19th century when health sciences, modern technology, and medical subspecialties emerged and revolutionized medical care. The University of Michigan story is entwined with those changes, as one of the earliest public universities and in 1869 it was the first university to own and operate a teaching hospital. By the early 20th century the University of Michigan Medical School was noteworthy among its peers in teaching and research, but lagged behind in the clinical arena, a fact that some viewed as due to its small-town location. After the 1902 neologism by Ramon Guiteras the term ii replaced that of genitourinary surgery, although not until many years later in Ann Arbor.

Exactly one hundred years ago, on November 1, 1919, the University of Michigan Medical School, although still stuck in educational and clinical paradigms of the previous century, was on the precipice of major change that would launch it into the major leagues of 20th century academic medicine. Dean Victor Vaughan, an immeasurable influence since his arrival in 1874 as one of Michigan’s first two Ph.D. candidates, had been distracted by duties in Washington during WWI and was reeling from the death of one of his sons who had been about to return home from his service in Europe on the Western Front. Vaughan had other national leadership responsibilities on his plate in addition to the war effort and his inattention to Michigan had left the Medical School without chairs for its two main departments – internal medicine and surgery. In Boston Hugh Cabot had recently returned home from 2.5 years of service overseas to find his private surgical and urologic practice “evaporated.” He discovered the Ann Arbor opportunity for a fulltime salaried job as chair of surgery and jumped at it. Beginning work on October 12, 1919, he initially stayed at the Michigan Union, but soon convinced the regents to allow him with his wife and four children to live in the unoccupied University’s President House until a new president was in place.

Cabot was a necessary change agent for the Medical School. He was a top-of-the-line international urologic celebrity even before his 1918 textbook Modern Urology. It is telling that his predecessors in genitourinary teaching and practice at Michigan, interim surgery chair Cyrenus Darling and clinical professor Ira Dean Loree, had been holding on to the older name for the field. Cabot was a self-declared urologist. A prolific speaker and writer, he was assiduous in connecting with new ideas, other specialties, and novel technologies. During the war he became a skillful administrator, ultimately rising to Commanding Officer (CO) of a British Expeditionary Force (BEF) hospital with over 2,000 beds near the front. While he would bring leadership and modernity to Ann Arbor, his brusque style had already created detractors on the national scene, as evident in files at the Bentley Library where a letter to Victor Vaughan from Bostonian Dr. Frederick Shattuck on September 30, 1919 commented:

“Dear Vaughan:
I am greatly interested in your capture of Hugh Cabot for whom I have high regard and much affection, not so much because he is a first cousin of my wife, though very much younger, as for himself and what he is. His departure will be a loss to me, personally, and I think a loss to this community; but the more I reflect on the matter the more I feel that he can render greater service, and thus derive greater satisfaction from life by accepting your offer. Like other strong, positive men, he has made enemies, but I think his capacity to deal with men developed markedly during his service as C.O. of Base Hospital No. 22, B.E.F. There were difficulties connected with that practice which do not appear upon the surface, and it is my belief that, taking all things into consideration, he handled the job extremely well…”

Shattuck concluded the note offering condolence to Vaughan on the recent loss of a son in Europe, referring to the actual moment Vaughan got the terrible news just about as he was to preside over a session of the AMA at its Atlantic City meeting that summer. Cabot also must have been at that meeting, according to the correspondence, and it is likely that it was when and where he first learned of the Ann Arbor job, perhaps directly from Vaughan (letter below).

 

Two.

The first century of urology in Ann Arbor: October 1919 to October 2020. Michigan Urology now entertains a year-long celebration of its centennial. Cabot introduced modern urology to the University of Michigan when he arrived on October 12, 1919, and began to build a formidable clinical engine. He recognized that clinical practice is the essential piece of the tripartite mission of academic medicine, providing the milieu for medical education, factory for new knowledge, and regional reference point for clinical expertise. The clinical milieu generates inquiry and provides a testing ground for the ideas and technology to improve healthcare, and it is the spiritual center of the organization. Clinical programs provide the essential deliverable of academic medical centers. The clinical enterprise is also the financial engine.

Since 1972, Michigan Urology has called its alumni group the Nesbit Society, not from ingratitude to Cabot, but out of respect to his trainee Reed M. Nesbit who became the first Section Head of Urology, after Cabot’s abrupt departure in February, 1930. Over the next 37 years Nesbit made Ann Arbor an epicenter for medical education and clinical innovation. Nesbit trained nearly 80 residents and fellows (we are still trying to determine the exact number), and an extraordinary number of them became leaders in academia and their communities. As a principal innovator and master of transurethral prostatectomy, Nesbit made Ann Arbor a destination for doctors wanting to learn the operation as well as for “patients in-the-know” to get treatment. A number of Cabot’s other clinical faculty also became internationally dominant figures in their newly evolving clinical arenas, of thoracic surgery, neurosurgery, and orthopaedics as well as general surgery, thus bringing the University of Michigan to the center stage of clinical medicine for the first time in its evolution. Nevertheless, Cabot’s vision of a synchronous multispecialty academic health system eluded the University because the hospital functions and professional units (the clinical faculty) were competitive rather than synchronized.

 

Three.

The Nesbit 2019 Scientific Day last month was packed: Peggy Pearle from UT Southwestern in Dallas (above, with Stu Wolf from Dell Medical School in Austin, and Rod Dunn from our Dow Health Services Division) was featured as our Nesbit Visiting Professor with one talk on controversies in medical management of stones as well as another on ureteroscopy; UM President Emeritus Jim Duderstadt discussed the unique impact of the University looking back and looking forward; Jim Cogswell of the School of Art and Design gave a multimedia presentation on the mysteries of dark matter; Dan Dierdorf UM offensive lineman from the famed 1969 team and famed sportscaster presented his Michigan Memories; Stuart Wolf our own star faculty alumnus described the Michigan lessons he is deploying at the new Dell Medical School in Austin, and our departmental leaders gave updates on their divisions including Program Director Kate Kraft and CopMich Co-chair Jens Sønksen. This writer presented Centennial Thoughts and Ganesh Palapattu gave the State of the Department address. We had many wonderful returning alumni and I wish I could have shown them all on these pages, but more pictures can be found on the Nesbit100.com website. I also wish we could have had our traditional alumni talks, but we deferred those for this special Centennial Program, save for Peter Fisher’s unique talk of his personal experience that was both terrifying and uplifting: Everyone should experience sudden cardiac death —- and live. [Below from the top: Dan Dierdorf, Pete Fisher between Will Roberts and Phil Sweetser, Ganesh & Manfred Stöhrer.]

Manfred Stöhrer from Germany, Jens Sønsken from Denmark, and Kash Siddiqi from the UAE travelled far for this meeting. Some of us had been with Jens just a few weeks earlier in Copenhagen, and our ties to him and his team in Copenhagen go back nearly 30 years. The association with Manfred is just as long, with strong ties through Ed McGuire (below) and myself. Our actual but geographically distant faculty included Sherman Silber, now adjunct professor from St. Louis (below with postdoc Yuting Fan – Fanny), and Brian Stork and Jessica Phelps of our Muskegon West Shore Urology practice.

We consider UMMS graduates, residency trainees and alumni, faculty, regional colleagues, and other friends of the Department of Urology as Nesbit Society members, and many joined us to enrich the meeting. Bruce Bracken, John Hall, Phil Sweetser, Betty Newsom, the Chang duo of Cheng-Yang and Ted, Mike Rashid, Dave Morris, the Taub duo of Marc and David, the Kozminski duo of Mike and Michael, C. Peter Fischer, Howard Usitalo, Stan Swierzewski, Charles Gershon, Charles Reynolds, Jay Hollander, Amy Li, Parth Shah, Hugh Solomon, Joanne Dale, George Schade, Noah Canvasser, Katy Konkle, Bert Chen, Tim Schuster, Craig Kozler with son Oliver, Pete Fisher with son Jake who was interviewing for medical school, Brian Lane, Herk Khaira, Atreya Dash, Ray Tan, Ron Suh, and Scott Gilbert. Rebekah Beach, Frank Begun, Tim Bradford, David Burks, Ward Gillett, David Harold, Will Johnston, Earl Koenig, Surendra Kumar, Amy Luckenbaugh, David Perlow, Paul Sonda, and Nick Styn. Ed Kleer and Elena Gimenez from St. Joseph’s Hospital. Samir Basata, Bob Isacksen, Andre King, David Lutchka, Konda Mouli, Eric Stockall, and David Wenzler. UMMS alumnus Richard Tsou came from Hawaii Pacific Health. Jim Peabody and Nesbit alum Hans Stricker from Henry Ford Health System. From East Lansing we were honored to have Shirley Harding from Michigan State and Nesbit alum Len Zuckerman and Sparrow Residents Margeaux Dennis, Eric McKeever, Andrew Schwinn, Alex Shannon, and Ross Voelker. David Miller won the Konnak Faculty Service Award.

The evening reception at Zingerman’s Greyline event space at the Marriott was terrific with Thad Polk and Red Berenson who offered stories of hockey and Putin. Next year’s meeting will conclude this year-long Centennial Celebration of Michigan Urology and will center around the Wisconsin football contest. The dates will be September 24-26, 2020.

 

Four.

The game. The tailgate at Nub Turner’s GTH Investments provided a more relaxed social gathering point than the scientific program of the previous day. With the concurrent Homecoming Weekend and Parent’s Weekend, Ann Arbor was hopping. The victory over Iowa was a modest win, and it was largely won by our defense. The B-52 flyover was a crowd-pleaser, and the Veteran of the Game was a UM graduate named Thomas Houdek (below).

Michigan Urology has many notable veterans, although none more distinguished than Edward J. McGuire, the man who succeeded Jack Lapides in 1983 and hired me in 1984. Courtesy of Julian Wan we sat in the Club seats with Khaled and Mary Ellen Hafez (below).

 

Five.

Seasonal note. Autumn is fishing season in academic medicine when senior medical students prowl the nation’s training programs for residency education to select where they hope to learn their lives’ work. This process of residency training, postgraduate medical education, was quite informal in Cabot’s time, a century ago – a sort of “arrange-it-yourself” process for periods of time from weeks to years in length. Now the process has been standardized and is regulated by professional organizations including the AUA, ABU, ABMS, and ACGME.

Training programs simultaneously audition medical students in clinical clerkships in summer and fall of the senior years and interview them formally in fall and winter. Each party then submits their “rank lists” to a national site and matches are made for urology residency training positions. The process of interviews, selection, and then the actual residency training of 5-8 years is delegated to the Program Director, a position that has grown increasingly complex over the years since the terms of Gary Faerber, Khaled Hafez, and now Kate Kraft. Selection, education, and supervision of residents requires a small village of helpers and Kate is assisted by Sapan Ambani and a team of committees. This year Michigan Urology had over 375 applicants, offered around 66 interviews, and will end up matching with four trainees who will begin their residency training next July 1. Michigan Urology matched five last year, one of whom will have an 8-year period that will include a substantial research component, and this is Joel Berends. Ganesh, Khaled, Kate, and Sapan plan to alternate 4 and 5 year classes.

 

Postscript.

Vaughan’s reply to Shattuck. Only two days after Shattuck’s revealing response to the dean’s reference inquiry, Vaughan replied:

“My dear Friend:-
I am fully aware of the fact that Dr. Hugh Cabot being as strong a man as he is has made enemies and their criticisms have not failed to reach my ear, at least some of them. However I believe in Dr. Hugh Cabot and am greatly pleased that the prospect lies before me of having him as my colleague in work which I believe to be of the greatest importance to the future of American medicine. I congratulate myself and my school upon being able to obtain his services.

I wish to thank you for your words of sympathy. I had five sons in the Army and it seemed that the good fortune of having all of them returned to us was about to be accomplished. My eldest son was Chief of the Medical Service in the Roosevelt Hospital at Chaumont during the entire period of the war. After the armistice he was detailed to work up typhoid fever in the American Expeditionary Force. He had collected all of his data and was on his way home when he was accidentally drowned in a small river in France. It is the first time that death has visited our family. Time alone will assuage the sorrow but words of sympathy from such a dear friend as you will do much to mitigate our sorrow. Yours sincerely, V.C. Vaughan” [letter below]

 

PPS

In little over a decade Cabot brought the University of Michigan Medical School into the top tier of academic health centers. He recognized that a superb, attractive, and financially robust clinical engine was at the center of medical academia and he delivered on that necessity. Yet he spent down political capital rather than building it and he had a tin ear for the faculty and staff he led; it was not quite like his successful, albeit shorter-lived, experience as commanding officer at the Western Front of WWI. His successors in urology at Michigan continued to build one of the finest urology programs in the world, and Cabot surely would have been astonished to see what it looked like 100 years after he first set foot in Ann Arbor as its one and only urologist. [Below: Faculty, residents, alumni, guests at Nesbit Society meeting 2019.]

We thank those who joined us for this kick off for our Urology Centennial Celebration and invite you and those who couldn’t make it this year to the conclusion in 2020, September 24-26.

Best wishes as we begin November, 2019.
David A. Bloom
University of Michigan, Department of Urology, Ann Arbor

A century and a millennium

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DAB Matula Thoughts October 4, 2019

A century and a millennium

Michigan urology begins its centennial celebration
2087 words

One.

But first, consider what happened in 1623. Horace Davenport, the great American physiologist, University of Michigan educator, and de facto historian of the Medical School asked that question when he introduced physiology to a class of medical students. This story has been told here before, but it deserves repetition for each new generation of trainees as well as for the rest of us, who tend to forget Davenport’s lesson. The prize for the correct answer, Davenport said, would be an “A” for the class with no further expectations – no attendance, no labs, no homework, or exams.

The medical students scrambled with answers, all erroneous and some ridiculous, but no one came close to the correct one – the publication of Shakespeare’s First Folio in 1623. After the playwright died in 1616, friends collected his works, many printed in smaller books called quartos, and they published the First Folio, actually titled Mr. William Shakespeare’s Comedies, Histories, & Tragedies. This consisted of 38 plays and over 150 poems, in addition to Shakespeare’s portrait by Martin Droeshout, one of two authentic images of the author. Of the 750 copies printed, 223 survive and 82 are in the Folger Collection in Washington, DC.
Davenport’s point was that the practice of medicine doesn’t play out in isolation, it is part of the context of life, the unique circumstances of humanity with its individual stories, dramas, aspirations, co-morbidities, and accomplishments. William Shakespeare’s work encompassed the range and depth of the human condition more completely than any artist before or since.

Before learning physiology, much less practicing medicine, Davenport claimed, the human condition must be studied to the extent best possible by each of us although the “self-awareness” of humanity as a species can never be complete. Self-awareness requires some sense of time and place, and these senses are enhanced by knowledge of history. The history we each know may be reality or mythical, a distinction that good historians just as good scientists work to discern. The arts help navigate the ambiguities of that distinction.

 

Two.

And what happened in 1919? One hundred years ago, Hugh Cabot, Michigan’s first urologist and new chair of the surgery department arrived in Ann Arbor and performed his first operative procedures at the University of Michigan. Cabot’s first specific urologic cases in Ann Arbor have not yet been identified, but a letter in the papers of UM President HB Hutchins of 1919 explains the successful appendectomy on a patient known to and likely referred by Hutchins “in the Surgical Clinic October 13.” This was Cabot’s second day at work and he helpfully told Hutchins:

“Since the operation patient has progressed very satisfactorily and we see no reason why he should not make an uneventful recovery. Twenty-four hours later this case would have been a complicated one, and the prognosis would not have been as hopeful.”

The letter was typed on stationary that read: University of Michigan, Department of Surgery, University Hospital (nearly identical to what this senior author found on arrival to the Medical School and Hospital 65 years later, although the names were different). The faculty listed in 1919 were C.G. DARLING. M.D. GENERAL SURGERY; I.D. LOREE. M.D. GENITO-URINARY SURGERY, C.L. WASHBURN. M.D. ORTHOPEDIC SURGERY; AND C.J. LYONS. D.D.Sc. CONSULTING DENTIST.

Ira Dean Loree was Michigan’s principal genitourinary surgeon up until that time in the small Surgical Department, although his senior, CG Darling, also did work in that emerging subspecialty as well. If stationary is to reflect mindset, neither Darling nor Loree embraced the new terminology of urology, the neologism of Ramon Guiteras in play since the formation of the American Urological Association in 1902 (of which Cabot had been president in 1911) and embraced by Cabot in his influential textbook Modern Urology in 1918.

 

Three.

A thought experiment. Given that Hugh Cabot came to Ann Arbor and introduced modern urologic practice to the University of Michigan a century ago, we might reflect upon what happened a century before then, in 1819, when the fledgling University of Michigan was only two years old. Not much was actually going on educationally in its initial Detroit site then and no medical school existed in the territory of Michigan, which was not yet a state.

The year 1819 brought the first major peacetime financial crisis in the United States and the Tallmadge Amendment that was passed in the House of Representatives, but got lost the next year in the Missouri Compromise. The amendment would have prohibited slavery in the impending statehood of Missouri, but got traded away for the admission of Maine as a free state.
What about 1719, 300 years ago? The world was being mapped with increasing realism and imagination. Herman Moll’s “codfish map,” A New and Correct Map of the Whole World in London was a step along the way to visualization of the political and geographical reality of the planet. Also that year Robinson Crusoe, was published, arguably the first English novel, a fictional account of an actual event.

Slavery began in the American colonies a century earlier, it was in August 1619 according to the illuminating 1619 Project, a partnership of the Pulitzer Center and the New York Times. The Idea of America, an essay by Nikole Hannah-Jones, is informed and provocative. [NYT Magazine. August 18, 2019. The 1619 Project.]

Five hundred years back in time, on 20 September 1519, Portuguese explorer Ferdinand Magellan began his trip that would circumnavigate the planet, thereby quieting down the Flat Earth enthusiasts of the time, although that stubborn phenotype reappears in alternative forms, notably, the climate change deniers of today. Magellan had five ships, two more than Columbus, and carried supplies for 270 men and two years. In spite of mutiny, desertion, catastrophic storms, starvation, and raids from local natives, Magellan made it to the Philippines by March, 1521, where he was killed in battle by natives who resisted his offer of religious conversion. Other officers took charge and a single ship made it back to Spain on 6 September 1522. Leadership lessons still abound.

In 1419, during the Hundred Years War, France surrendered to Henry V and Normandy was re-annexed to England providing the nidus for Shakespeare’s great imaginative play 180 years later. Joan of Arc would have a fiery end in this town in 1431 and Charles VII, King of France, recaptured the city in 1449. A strong earthquake devastated the city of Ani in Armenia in 1319. A century earlier, in 1219, Genghis Khan sought advice on the Philosopher’s Stone from Qui Chuji (Taoist Master Changchun) and St. Francis of Assisi introduced Catholicism to Egypt during the Fifth Crusade. Navigation was improved in 1119 by Chinese author Zhu Yu who described the innovative use of magnetic compass and separate hull compartments in ships. Japanese statesman Fujiwara no Michinaga (966-1028) retired from public life in 1019 after installing his son as regent, but remained behind the scenes as Japan’s de facto ruler until his death nine years later. In spite of the coincidence of pronunciation, however, there is no way to connect Michinaga to our State of Michigan today in October, 2019, more specifically than as bookends to a millennium of human stories and progress.

The point to this thought experiment is that matters of immediate moments pale in the grand scheme of human centuries and glacial millennia. Nevertheless, those momentary and seasonal concerns constrain most human attention. Our lives are framed by the past and moments of grand inspiration transcend the mundane times. King Henry V’s exhortation to his troops at Agincourt, as imagined by the Bard of Stratford, is as inspiring as George Gipp’s softer “Win one for the Gipper” speech before Army played Notre Dame in 1928, and portrayed by Ronald Reagan in the classic film Knute Rockne, All American, in 1940.

 

Four.

Autumn in Ann Arbor brings the excitement of new students, football, and the academic season of meetings and visiting professors. Marty Koyle came from Toronto (with provenance from the Brigham, Dallas, UCLA, Denver, and Seattle) last month as our visiting professor in pediatric urology. Marty is a great clinician, surgeon, and educator, and he is one of the few urologists today with an active practice in pediatric renal transplantation (in addition to the astonishing John Barry). Over three days Marty interacted with faculty and residents, leaving an indelible imprint. Courtesy of Julian Wan, we repaid Marty and his wife Ellen in part with the Michigan Football experience, witnessing a close struggle to defeat Army. [Above: Army on the defensive; Below: Marty at the Pediatric Urology Conference.]

The tradition of visiting professors was indoctrinated at Michigan in the time of Cabot, who himself shuttled among peer institutions and brought the best experts to Ann Arbor faculty and students, notably with strong relationships between the Mayo Clinic and St. Bartholomew’s in London. Cabot’s successors, Frederick Coller, Reed Nesbit, Jack Lapides, Ed McGuire, and those who followed, maintained the important tradition to expose our learners to the best surgical educators and ideas. [Below: Puneet Sindhwani, Department of Urology and Transplantation Chair, University of Toledo with Marty Koyle after Grand Rounds.]

[Above: Tailgate at Zingermans.]
Athletic traditions have been closely entwined in the academic mission, offering counterbalance from book-learning and clinical medicine. Performances, great or aspiring to greatness, entertain and serve as rallying points for institutional spirit. Even back in Cabot’s time, important conversations and political alignments took place on the sidelines as the following letter shows – when Cabot followed up to Governor Green (1927-1930, Republican):

“You may remember at the time of the Wisconsin Football Game you were kind enough to suggest that I write you after election concerning certain matters of medical interest which we discussed that day. Now that this turmoil of election is over I am taking the liberty of complying with your suggestion. …”

This was hardly a rare follow-up to social encounters at Michigan games.

 

Five.

A century of urology followed at the University of Michigan after Cabot’s arrival, directly impacting hundreds of thousands of patients, more than ten thousand medical students, and hundreds of residents – who in turn impacted their share of patients and learners. In that century, two world wars and other conflicts were fought, two major economic collapses occurred, and climatic and geologic catastrophes pummeled the planet. In the grand scheme of things, the particular story of urology at Michigan may be small, but it is our history to know and tell. Furthermore, some of the myriad stories within the larger story are instructive, many are inspiring, others are sobering, and all should be examined in context.

Today, October 4, 2019, our current departmental faculty, residents, nurses, clinical teams, research teams, staff, and alumni are gathered for the Nesbit Society events, culminating with the Michigan-Iowa gridiron contest, where, no matter the outcome, important conversations and good fun will be had at the tailgates and on the sidelines.

 

Postscript.

October factoids. On 16 October 1901, shortly after moving into the White House, President Theodore Roosevelt invited his adviser and friend Booker T. Washington (below), to dine with him and his family, provoking an outpouring of condemnation from southern politicians and press. No other African American was invited to dinner at the White House for almost thirty years.

Sinclair Lewis, author of Arrowsmith, a book modeled on the University of Michigan Medical School in the early 1900s, suffered a terrible personal loss this month in 1944, when his first son was killed during efforts to rescue the Lost Battalion.

The 1st Battalion, 141st Infantry (36th Infantry Division, originally Texas National Guard) had been surrounded by German forces in the French Vosges Mountains on October 24, 1944, and attempts by other troops failed to extricate the men. The 442nd Regimental Combat Team, a segregated unit of Nisei (second-generation Japanese Americans), ultimately was successful after 5 days of battle and rescued 211 men by October 30, but suffered more than 800 casualties. For size and length of service the 442nd is the most decorated unit in U.S. military history. Above is Wells Lewis with father and stepmother Dorothy Parker in 1935 on way to accept Nobel Prize. The death of Wells in France took place only nine years later.

131st Field Artillery, 36th Infantry Division (Texas National Guard of the U.S. Army) who were survivors of the sunken USS Houston. They were captured by Japanese forces and taken to Java in March 1942 and then sent to Singapore and Burma where they worked on railway construction crews, as later depicted in the 1957 film The Bridge on the River Kwai. It was not until September of 1944 that it became known they were prisoners of war.

Thus went some highlights from the last century and the last millennium.

Thanks for reading Matula Thoughts.

 

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

Matula Thoughts September 6, 2019

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Matula Thoughts September 6, 2019

Urology at Michigan is a century old
2411 words

 

One.

The origin of Michigan Urology. The state of Michigan and its sole university had no medical school when Moses Gunn (above) came to Ann Arbor in 1845. Gunn had heard rumors that a medical school might be formed in this small town and moved here after graduating from Geneva Medical College in New York. He came by train in mid-winter with a cadaver in a trunk and began practicing medicine, accruing surgical expertise, and teaching anatomy to aspiring students in the back room of his office.

Gregarious, talented, and confident, Gunn networked with Zina Pitcher and others interested in creating a medical school for the University of Michigan and within three years the school became a reality. Dr. Pitcher, leading the university board of regents, included Gunn among the five founding faculty of the medical school in 1848 and classes began in the fall term of 1850, after a building was constructed. Gunn taught anatomy and practiced a wide range of general surgery, perhaps best reflected in the textbook of his contemporary, Samuel David Gross, A System of Surgery, although that didn’t appear until 1859. Genitourinary surgery was then an important facet of general surgical practice and the first textbook Gross wrote earlier in 1851 was specifically on the topic of genitourinary surgery – A Practical Treatise on the Diseases and Injuries of the Urinary Bladder, the Prostate Gland, and the Urethra. Gunn undoubtedly was familiar with these books of his fellow academic surgeon, at some point in his career.

Genitourinary surgical disorders were necessarily taught and practiced at the University of Michigan since those early days of the medical school in Ann Arbor and Moses Gunn was the starting point, although the actual first moment is unknown. His operation on a man with “phymosis” in a surgical demonstration for medical students is the earliest example we have found of Gunn performing an ancient procedure necessary for men with symptomatic restriction of the preputial aperture. Nothing innovative was offered at that occasion, but it must have been a useful lesson for the medical students in 1866. Gunn by then had moved to Detroit to live and practice, believing Ann Arbor’s medical school should have been relocated there because of its hospitals and larger population. He returned to Ann Arbor, twice weekly by train, to teach by lecture and surgical demonstration, until gong to Chicago in 1867 as professor of surgery at Rush Medical School.

Procedures such as Gunn’s dorsal preputial slit or circumcision for phimosis, paraphimosis, or recurrent balanoposthitis, have been necessary since the earliest days of mankind. More complex interventions, such as lithotomy for bladder stones, had also been performed since well before the days of Hippocrates, who cautioned healers to leave “cutting for stone” to specialists of the time – namely itinerant lithotomists. They were itinerant for good reasons, they didn’t readily want to share their single skill and their clinical outcomes probably mandated short stays in any location. Little information about them exists, aside from Frere Jacques and the nursery rhyme that commemorates him two millennia after Hippocrates.

Genitourinary surgical practices muddled along with little change over the millennia until science and technology permitted innovations, safety, and better outcomes in the later 19th century. Moses Gunn, by then in Chicago, witnessed these changes amidst the emergence of a group of surgeons who incorporated new skills, instruments, and the novel tool of cystoscopy into their larger practices. Cyrenus Darling as Lecturer on Genito-urinary and Minor Surgery in 1902, and Ira Dean Loree as Lecturer in Genito-urinary Surgery in 1905 and Clinical Professor of Genitourinary Surgery in 1907 (both pictured below) were the first specifically-designated genitourinary practitioners and teachers at the University of Michigan.

[Above: Darling; below: Loree. Bentley Library]

 

Two.

Urology and the 20th century. Small clusters of genitourinary specialists accumulated in several locations in North America, notably Boston and New York. Ramon Guiteras in New York was one of these young men and in 1902 he came up with a new word to define the newly re-tooled specialty, partly to differentiate it from the empiric practice of venereology that had been part of the genitourinary domain. Urology, the new word, was not quite perfect semantically, but worked well enough and replaced the older terminology, more quickly in some places than here in Ann Arbor, where the Medical School and University Hospital job titles held on to genitourinary surgery. Both the school and the hospital needed to enter modernity and the new century, which had moved on since the fin de siècle of the 19th century.

Hugh Cabot, a young surgeon in Boston, was among the first to embrace the Guiteras neologism of urology, and his textbook in 1918, Modern Urology, was among the earliest to use the name in a title after the Guiteras text of 1908. A progressive in many ways, although startlingly biased in other dimensions. After more than two years on the Western Front during WWI, Cabot found private practice in Boston unfulfilling and was eager for a career change when he arrived in Ann Arbor around this time of year in 1919.

Cabot hit the University of Michigan like a hurricane and within a decade brought the modernity of urology to the medical school and the hospital. The amateur historian in each of us sometimes defaults to a “before and after” construct, and urology at the University of Michigan truly began when Cabot first arrived in Ann Arbor, in September, 1919. Michigan’s genitourinary surgeons, Darling and Loree, quickly recognized their incompatibility with the new boss and resigned from the medical school leaving Cabot, the urologist, their practices and teaching responsibilities.

 

Three.

Imagine that world of 1919: World War I was winding down and the Spanish flu was still ravaging North America and Europe. The Great War killed 17 million people, while the influenza epidemic killed 20 million, proving once again that humans don’t really need to kill each other off as other species can do so far more effectively. Prohibition and women’s suffrage were occupying much of the national political conversation. At the University of Michigan President Hutchins was ready to step down but the regents hadn’t found a replacement and the Medical School was at loose ends.

Victor Vaughan had been a transformational figure at Michigan since his starting days in 1874 and assumption of the medical school deanship in 1891. He became a national figure academically though his initial investigations and teaching in biochemistry, physiology, and bacteriology, followed by his medical service during the Spanish American War. The medical school, that Vaughan had effectively stewarded, shined in the 1910 Flexner Report but began to run down, especially during World War I as he spent time in Washington helping manage military medical affairs and was increasingly distracted from duties as dean. By 1919 the chairs of internal medicine and surgery remained vacant, in spite of modest efforts to fill them, and plans for a much-needed replacement university hospital were dormant. [Below: Vaughan portrait by Gari Melchers, also shown here last month.]

The year 1919 was one of deep loss for the Vaughan family, when one of their five sons perished by drowning just before returning from duty in France. Dean Vaughan was notified while in Atlantic City at a meeting of the American Medical Association in June and, after what must have been a horrible pause, collected himself enough to deliver concluding remarks for the session he was chairing at the moment.

[Class picture 1919]

In Ann Arbor, prior to Cabot, the teaching and practice of genitourinary surgery had been mostly in the hands of Ira Dean Loree, a respected member of the community and one of the 20 local citizens behind the creation of Barton Hills Country Club, that opened in 1919 with its Donald Ross golf course. Loree, Vaughan, and Darling are seen in the UMMS class picture (above) at the end of the 1919 spring term, unaware that Hugh Cabot was about to disrupt their lives. As summer came to an end, Vaughan was resuming life back in Ann Arbor still faced with the two open chairmanships and the deteriorating clinical and educational physical infrastructure of the Medical School. Meanwhile, in Boston, Cabot had returned from duty in France but was frustrated on resumption of his clinical practice. At some time around then, Cabot learned of a unique opportunity in Ann Arbor, and he jumped at it. He had not been on anybody’s radar screen of candidates at that time. Vaughan, in fact, quietly favored his internal faculty candidates Carl Huber and Frederick Novy, according to a personal letter to one of the Vaughan sons in the autumn of 1918.

 

 

Four.

Cabot’s decade in Ann Arbor began with a first visit in September, 1919. He came by train and stayed at the new Michigan Union, where Vaughan and President Hutchins housed their major recruits. The first visit impressed the Michigan leadership and impressed Cabot as well, who saw the Medical School as a perfect canvas for his bold ideas that fused the provision of just and medical care to a democratic society, emerging subspecialties, brisk incorporation of new technologies, multi-specialty group practice, and clinical education from full-time salaried academic clinicians. Cabot was an excellent educator, a powerful administrator, a world-renown urologist, and an effective politician who usually got his way. He came to Michigan as professor and chair of surgery, following Gunn and de Nancrede, but unlike them built a powerful surgical faculty known not only for teaching, but also for academic productivity and clinical excellence. He was also predominantly a urologist. Cabot recruited and developed a robust cadre of young faculty, especially distinguished in the surgical fields with Max Peet, John Alexander, Frederick Coller, Charles Huggins, Reed Nesbit, and others who enriched and dominated their emerging subspecialties, winning accolades up to and including the Nobel Prize.

Within a year and a half from his start, Cabot became dean of the Medical School where his accomplishments were extraordinary. While managing day-to-day functions of the medical school and continuing to grow his voice in urology, he presided over the dissolution of the Homeopathic College, the construction of a new University Hospital (the fourth iteration of our hospital since 1869), and the deployment of the first world class cadre of clinical faculty at the University of Michigan.

We intend to elaborate on this story in two parts to mark our centennial. The first part, The Origin of Michigan Urology, will be in print later this autumn and will tell the story of our field and our university up to (and through) the Cabot era. The next part, The First Century of Michigan Urology, will cover the ensuing 100 years up through 2020 and we project its completion in two years as the story evolves. It was a remarkable century.

 

Five.

Fast forward over an astonishing 100 years from Cabot’s arrival in 1919 to last month in Copenhagen and the CopMich Urologic Symposium. Dana Ohl and Jens Sønksen began a collaboration two decades ago that culminated in this biennial event alternating between Ann Arbor and Copenhagen, where Jens is chair of the surgery department. This Third CopMich Urology Symposium was held west of Copenhagen at the lovely Hotel Hesselet in Nyborg on the seaside of the “Great Belt” a wide strait between Copenhagen and Jutland, connected by the magnificent Øresund Bridge. The three-day symposium (above) covered reproductive urology, urologic oncology, pediatric urology, stone disease, pelvic floor and pain, patient information, psychosexual health, telemedicine, and an amazing new generation of research projects mentored by Dana Ohl and Jens Sønksen. From this collaboration, nearly 100 peer-reviewed publications have resulted. [Below: a.) Jens, Diana Christensen, Christian Jensen; b.) Anne Cameron, John Wei, Mikkel Fode; c.) Helle Harnish, Nis Nørgaard, Yazan Rawashdeh.]

Danish and Michigan faculty produced a superb collection of talks over the 2.5 days and planning is already underway to return this symposium to Ann Arbor in 2021 was given the chance to give one talk about anything I wanted, in addition to assignments of more usual urologic topics. Reverberating from the dozen years of Chang Lectures on Art and Medicine we concluded in Ann Arbor last year, I returned to that theme to talk about the role of art in dealing with the “TMI” (too much information) of our medical world. Our arts compress, abstract, or replicate things artists find beautiful, meaningful, or otherwise worthy and those windows onto the world help the rest of us expand our own windows. Matula Thoughts, What’s New, and CopMich last month provide opportunities to delve into these matters, not from any learned perspective as an art historian, but only from the simpler framework of a citizen and physician deluged by the constant typhoon of TMI. [Below: a.) Mette Schmidt, Cea Munter, Klara Ternov, Marie Erickson; b.) Jens, Hans Jørgen Kirkeby, & Dana; c.) Ganesh Palapattu.]

[Below top: Maiken Bjerggard “Queen of Jutland”, Erik Hansen, Pernille Kingo, Anna Keller. Bottom: CopMich ensemble 2019]a

 

 

Postscript.

This is hurricane or typhoon season for much of the world. Cabot may have hit Michigan metaphorically like a hurricane in 1919, but real mega-storms regularly challenge eastern and south central states at this time of year and today Hurricane Dorian is running itself down after a week of devastation and terror. The Waffle House Index comes to mind. This informal metric was conceived of in 2011 after the Joplin tornado when FEMA noticed that two Waffle House restaurants in Joplin stayed open during the storm, eliciting the idea of a measure of community robustness – that is, its ability to function in the face of overwhelming forces. This “index” abstracts from all the noise (all the overwhelming “information” of the hurricane and its effects) some measure of community functionality. The Waffle House, unlike most other restaurants and businesses that close when environmental conditions deteriorate, is reputed to do its best to remain functional for its communities, following the lead of the first responders, police departments, fire stations, and hospitals. The Waffle Health Index, unlike abstruse statistical measures, is simple, understandable, and meaningful to most people. An abstraction of regional disaster to a useful metaphor, or a meme, that brings some clarity to mass confusion and facilitates useful response.

One could hope for similar indicators of biodiversity, local or global environmental integrity, generalized human well-being, or academic health center viability, to give clear appraisals of complex conditions as a basis for appropriate responses. The individual biologic response to threat may be prompt, as we recoil from fire, but the systemic response of the human species to impending disaster is woefully inadequate.

 

September & centennial greetings,

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

Matula Thoughts August 2, 2019. Impressions

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Matula Thoughts

August 2, 2019

Impressions & metaphors:

Thoughts from a UMMS faculty member
2224 words/20 minutes

 

One.

As a medical student, my first impressions of children’s surgery imprinted on my brain much like a duckling gets imprinted when it initially sees its mother, or whatever creature first walks by. I went to UCLA for surgery residency in 1971 and then to London for a year in 1976 to learn from David Innes Williams, a founder of pediatric urology (above, Shaftesbury Hospital, 1976). The experience was rich. At first I was as an observer and later served as a registrar, the UK version of my status in the U.S. Mr. Williams was the consummate professional and his attitude was reciprocated by patients, trainees, and staff. My first impression of “DI,” as we called him, was one of the perfect English gentlemen, with unparalleled expertise and skill in one’s field. I noticed that even the poorest families coming to see him dressed for the occasion, the men often wearing a coat and tie, and the children well-scrubbed up and disciplined. Formality was echoed by kind and polite staff (Sister Fay and Sister Val) and by Mr. Williams himself who invariably offered a proper English greeting.

Mr. Williams was always addressed as “MR. WILLIAMS”– the appropriate title for a surgeon in the British world of medicine since the days of King Henry VIII who chartered the Barber Surgeons Guild in 1544. The physicians (internists) had been chartered in 1522 and were addressed as “Doctor” and the surgeons, a very distinct class of practitioners were “Mr” back then and remain Mr. to this day. Additional medical customs and traditions persisted in the National Health System and when I was a clueless young American, a colleague then ahead of me in training, Mr. Robert Morgan, took me under his wing and kept me out of trouble. Just as British ways sometimes confused foreigners like me and American ways tended to befuddle the British who, for example, couldn’t understand why Henry Kissinger came to be addressed as Doctor.

I returned to London in 1986, as a young UM faculty member on leave under Ed McGuire, to serve as a locum tenens for several months. Sir David Innes Williams (above, recently knighted) had retired from a large administrative post in the National Health System (NHS) and his successor Phillip Ransley was the sole pediatric urologist in London. American colleagues were taking sequential turns filling the spot that soon became formalized with a second NHS pediatric urologist, who turned out to be Patrick Duffy, the registrar working with me those months in 1986. I was self-conscious to be sitting in the same chair and at the same desk Mr. Williams had used to see patients, but I seemed to be tolerated by staff and patients.

In the decade between my times working for the NHS, the dress code and sense of formality of the clinic visits had relaxed. Families were more causal in dress, perhaps reflecting acceleration in the pace of life, only occasionally putting on their Sunday best for clinic visits, more likely quickly assembled from work and school to rush to Great Ormond Street Hospital by tube, bus, or cab (rarely by car, because where could they park?). Nevertheless, greetings were not rushed, but rather were moments of catching one’s breath on both sides of the table, with casual inspection, mutual taking measure, and kind acknowledgements. Those first impressions the parents and children have of the physician/health care provider are lasting.

 

Two.

Life is a social business and medical practice and education are especially social. That’s why we have frequent visiting professorships, like the Duckett Lecture last month, with Chester Koh from Baylor. Chester spoke on medical devices and discussed cases with residents, who also observed his professionalism and communication skills.

[Above: Pediatric uroradiology conference with Chester; Below: Kate Kraft, Chester, John Park.]

The first words patient hear often set the stage for their entire relationship with a health care provider. It is no surprise that one of the more offensive introductory phrases patients report is: “Why are you here?” Clinicians never intend any offense, and I myself may have cluelessly used those words in past days, trying to figure out the needs of a patient. Health care providers have many pressures for excellence, self-education, relevance, academic productivity, and equanimity. Furthermore, they are belabored by systemic pressures that are, perhaps, the greatest drivers of professional burnout: organizational metrics, throughput demands, rigid schedules, mandatory web-learning programs (fire safety, compliance, “high reliability training,” new chaperone rules, opioid regulations, and other modules every year). Electronic health record systems set the stage – demanding entry of a chief complaint at the outset of each “encounter.”

To many patients, however, that first question, Why are you here, is a slap in the face, interpreted by some as an accusation (“why are you wasting my time?”) or is evidence of an unread letter of referral or poor preparation. Patients may be anxious, looking for reassurance, expertise, and kindness. Parents with sick children will be especially distressed and for them, “Why are you here?” is a poor choice of the starting position for the physician or provider. If you put yourself in the place of the mother in Gari Melchers’ painting after the hassle and expense of getting to the clinic with your baby, you might not respond favorably to that question. If the provider was, perhaps, “burned-out” from a busy clinic schedule, the electronic health record, systemic mandatory demands, and short ancillary staffing, it is very likely that the mother with the sick baby was equally stressed, if not more so.

[Mother and Child. Gari Melchers. C, 1906. Institute of Art. Chicago.]

 

Three.

White Coat Ceremony. The stethoscope, invented in 1816 by René Laënnec in Paris, is not just an effective tool for auscultation, it is an equally effective metaphor for listening, which is itself a metaphor for seeing, hearing, or otherwise sensing the needs of a patient and family. [Below: Laënnec, National Library of Medicine. Below: Laennec’s 1819 monograph.]

Laënnec died of cavitating tuberculosis at age 45 on August 13, 1826 in Kerlouanec, leaving a wife but no children. [Ariel Roguin. René Theophile Hyacinthe Laënnec (1781-1826): the man behind the stethoscope. Clin Med Res. 4(3):230-235, 2006.]

The meme of the physician as a listener and observer is worth preserving, especially in this day of corporate medicine and formulaic encounters based on electronic medical record work flow. To institutionalize this idea of listening, our medical school began giving all entering medical students top-of-the-line stethoscopes on their first day of school at the White Coat Ceremony on 2004. The instruments were gifts from the clinical departments and some friends of the medical school interested in the actual and metaphoric listening skills of our “next generation” of physicians. Some of the best listeners in health care are themselves hearing-impaired and have trained themselves to go beyond casual vocal encounter with patients to discriminating perception of their patients with all senses.

[Above & below: UM White Coat Ceremony July 27, 2019.]

White Coat Ceremonies date back only to 1989 when, at the University of Chicago, a professor complained that first-year students “were showing up in shorts and baseball caps … where the patients are pouring their hearts out.” Dean of Students Norma Wagoner responded by starting a ceremony where students were supplied with white coats and instructed: “for any session where we have patients present, we expect you to look like professionals, wear the white coat, and behave appropriately.” [Peter M. Warren. “For new medical students, white coats are a warmup. Los Angeles Times. October 18, 1999.]

In 1993 Dean Linda Lewis at Columbia University College of Physicians and Surgeons, joined with the Arnold P. Gold Foundation to sponsor a white coat ceremony that is mirrored in medical, dental, and osteopathic schools today, among many other health professional schools. (Today, many of these medical schools bear the new names of their modern benefactors.) The white coat as a uniform of a health care provider is importantly a symbol of personal hygiene and responsibility. [Below: White Coat Syndrome, 2008, by Pat Curry, RN.]

The matula was the most prominent symbol of the medical profession for 650 years, as evidenced in art of the times, until Laënnec’s stethoscope in 1816 and the white coat even more recently. What the prominent symbols of the healing professions will be a century from now remains to be seen, but with luck regarding human destiny they won’t revert to the Aesculapian staff and matula.

 

Four.

The moral universe. The compelling imagery of a moral universe is a comforting metaphor. In 1958 Dr. Martin Luther King wrote “Let us realize the arc of the moral universe is long, but it bends toward justice,” in The Gospel Messenger, noting it to be a known aphorism. He used it again in 1964 for commencement exercises at Wesleyan University. The phrase has a deep history, traceable to 1853 and “A Collection of Ten Sermons of Religion” by Theodore Parker, Unitarian minister, American transcendalist, and abolitionist. A book in 1918, “Readings from Great Authors,” quoted Parker. A columnist in the Cleveland Plain Dealer reiterated the phrase, but omitted the word “moral” in 1932. The phrase has been since repeated on many occasions such as in a 1940 New Year version by Rabbi Jacob Kohn in Los Angeles: “Our faith is kept alive by the knowledge, founded on long experience, that the arc of history is long and bends toward justice.” President Obama used the phrase and credited Dr. King in 2009. [Above: Chagall Windows. Art Institute of Chicago.] Whereas some things in life are described as “soul-crushing,” this phrase is soul-compelling.

The physical universe and the universe created by the collective brains of Homo sapiens overlap and the human one increasingly changes the other, at least for the present in the Anthropocene moment. The change is simultaneously creative and destruction – think Mona Lisa or the miracles of contemporary health care versus genocide and environmental deterioration. But if we accept the fact that the human universe is ours to create, then we must recognize that it is (it should be or it can be) a moral universe, thus validating the aspiration of King and those who came before and after him with this belief.

The idea of a universe is a human construction and belief in a moral universe is a particularly human invention. Not eager to invite liturgical criticism, few can deny that Homo sapiens has built extensively around concepts of spiritual faith. But such is the nature of our species to imagine, discover, plan, and pass the information we find and create along to successive generations. In that sense, it is up to us to build that moral universe within the gargantuan amoral physical universe around us.

 

Five.

Ann Arbor August. In much of the northern hemisphere, August is a time for vacation, although the modern workplace of 52 weeks and 365 days per year, and 24 hours per day, requires some people at work every minute such that August is no longer a month of universal leisure time. I recall that when the yearly calendar was unveiled to my surgical internship group at UCLA in July, 1971, the first vacation assignment (namely July), went to the most hyperactive of our class, who was expecting to dive immediately into the world of operating rooms, intensive care units, conferences, and clinics.

That intern was very displeased at being told to “stand down” for his first month. The rest of us, I suspect, would have been more accommodating. In the end, he accommodated just fine, and over the course of a distinguished career, Ron Busuttil ended up as chair of the surgical department at UCLA himself. Summer or winter today, the life of a resident provides more downtime and one expects that our new PGY1s will have time for the pleasures of Michigan this month and next.

The Ann Arbor Farmers’ Market (above), operating since 1919, is a lovely feature of our community – a perfect example of Adam Smith’s second-best quotation (a favorite of John Wei):

“It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own self-interest. We address ourselves not to their humanity but to their self-love, and never talk to them of our own necessities, but of their advantages.”

[Below: top, local farm sales; local idiosyncrasy – Wolf Man; bottom, Sweet Dirt – Melissa Richard’s Ann Arbor ice cream]

 

Michigan Urology has its own centennial this year. We begin this celebration next month, 100 years after Hugh Cabot came to Ann Arbor, recruited by Dean Victor Vaughan, and will conclude it in the autumn of 2020, to coincide with Cabot’s first academic year at the University of Michigan. Cabot brought modern urology to Michigan in the multiple dimensions of clinical care, education, research, and the international stage.

 

Postscript

Gari Melchers (1860-1932), whose Mother and Child was shown earlier, originally from Detroit, was awarded an LL.D. from UM in 1913. His impression of Victor Vaughan was presented to the university in 1916.

Melchers’s Theodore Roosevelt, originally in the Detroit Freer Collection, is now at the Smithsonian Freer-Sackler Galleries. [Donaldson BM. An Appreciation of Gari Melchers (1860-1932). Michigan Alumnus, Quarterly Review. 1934. P. 506-511.]

As you enjoy August we prepare for the Michigan Urology Centennial, marking the start of modern urology in Ann Arbor under Hugh Cabot.

 

• Centennial Celebration launch, Nesbit Society Annual meeting October 3-5, 2019, Ann Arbor.
• AUA Nesbit Society reception May 17, 2020, Washington, DC.
• Centennial Gala Celebration. Nesbit Society Annual Meeting, September 24-26, 2020, Ann Arbor.

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

Independence

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Matula Thoughts July 5, 2019

Independence Day

2055 words

Above: American flag. Copyright: Sticks Object Art & Furniture, Des Moines, Iowa.
Private collection, with permission.

“Paul Revere? Ain’t he the Yankee who had to go for help?” – old Texas joke. [DH Fischer. Paul Revere’s Ride. Oxford University Press, 1994.]

 

One.

July 4, 1776, meant different things to different people of the time. The British Parliament, indigenous peoples, enslaved workers in colonial states, southern planters, northern industrialists, loyalists of King George III, colonial rabble rousers, federalists, antifederalists, abolitionists, France, Spain, Irish Protestants, or Irish Catholics – to consider just some of the stakeholders – each had their own view of the matter.

Paul Revere’s midnight ride on April 18, 1775, was an iconic event leading up to Independence Day the following year, although its role as an actual tipping point between colonial discomfort with Britain’s royal authority over it and explosion into full-blown revolutionary action is beyond this essay. Causality aside, Revere’s ride inspired popular imagination, legend, and poetry. Henry Wadsworth Longfellow’s poem, published nearly 85 years later in January, 1861, in The Atlantic Magazine, reverberates in my brain, having learned it in my grade school yet another century later: “Listen my children and you shall hear of the midnight ride of Paul Revere …” That meme had legs and the idea of 13 United States of America became a reality and eventually transformed into the idea of a nation.

American regionalist painter Grant Wood (1892-1942) imagined the midnight ride from a bird’s-eye perspective in 1931 (above). You can view the original in Washington DC at the SAAM. The tiny detail in front of the church repeats the once-common misperception that horses gallop with all four legs in the air, extended front and back (below, top). Grant Wood either didn’t know better or else was deliberately naïve in using the archaic style. He was not really a student of the art of motion, his work only occasionally depicting moving objects such as the impending calamity in Death on the Ridge Road, painted in 1935 (below, bottom).

 

Two.

We celebrated independence for our chief residents and fellows  last month at the Art Museum of the University of Michigan. [Above: chiefs, courtesy Ankita Shah] The Museum had its origin in 1910 as Alumni Hall and I have fond attachments to it, not just because of the appearance, the contents, and its generous uses to the university and the public, but personally as well because our youngest daughter was married there, the Shirley Chang Gallery is housed there, and my late friend Helmut Stern left much of his great collection there as well.

Most graduations are moments of personal liberation and independence. Residents and fellows usually jump from an intense paradigm of responsibilities, schedules, and education to the freedom of their practices of urology, although that world has become more constrained than a generation ago. The idea of the “private practitioner” in health care, especially for surgical specialists is ancient history, although even back in those old days when most urologists entered small groups, they carried the discipline and professionalism of their training mentors and programs with them, out into the world.

Our graduation at the Art Museum was much more about character and culture than personal liberation. Junior residents presented the life stories of the graduating chiefs with grace and humor. Ella Doerge (story told by Rita Jen) will go to London for fellowship with Tim O’Brien at Guy’s Hospital. Ted Lee (story told by Matt Lee) will undertake a three-year Boston Children’s Hospital Fellowship. Zach Koloff (story told by Chris Russell) will also go to Boston to a first-rate Lahey Clinic – affiliated practice. Parth Shah (story told by Michael Fenstermaker) will join the excellent USMD Urology group in Dallas-Fort Worth. Over the five years these chiefs spent with us they became physicians, surgeons, and urologists that I’d trust in a heartbeat with the care of friends, family, or myself.

Our fellows were profiled two weeks ago in What’s New. Deborah Kaye (Society of Urologic Oncology/Health Services Research Fellow) will join the Duke faculty. Nnenaya Agochukwu (Global Health Services Research/RWJ Fellow) will undertake a second fellowship, this being at the University of California in San Francisco in reconstructive urology. Irene Crescenze (Female Pelvic Medicine Reconstructive Surgery Fellow) will join the Ohio State University faculty, under chair Cheryl Lee (Nesbit 1977).

Faculty awards went to Professors Matt Davenport and Jim Shields of the Department of Radiology and Chris Sonnenday of the Department of Surgery who have been essential collaborators with urology. Professor Alon Weizer was recognized as the Team Player of the Year. Among his many gifts, Alon is both a great virtuoso surgeon and a selfless team player, a very rare combination of talents. Vesna Ivancic, the embodiment of professionalism, was recognized for that crucial characteristic of a physician-teacher. The residents presented two awards to faculty: Sapan Ambani was given the Silver Cystoscope Award and Khaled Hafez was given the Julian Wan Award for Excellence in Resident Mentorship.

Chair Palapattu supervised a great evening and the new awards were wonderful additions. Kudos to Program Directors Kate Kraft and Sapan Ambani, Nesbit Society President Mike Kozminski, and Lora Allen. The evening was especially enjoyable for me, freed of responsibility for being sure all went well and the bill was paid.

 

Three.

New folks. Here in Ann Arbor we didn’t need a Paul Revere to announce the good news that our new residents and fellows joined us a few days ago and thankfully no calamities were encountered enroute. Joel Berends from San Antonio is the first-ever recipient of the American Urological Association and Urology Care Foundation Physician Scientist Training Award that will take him from now through June 20, 2027. Anna Faris from Cleveland Clinic, Mahir Maruf from Ross University in Florida, Catherine Nam from Emory, and Alexander Zhu from Des Moines University have also joined Michigan Urology and their program will go through 2024. The annual residency refreshment of July is always eagerly anticipated, although why it happens this particular month of the year and not at the beginning of the fall semester, as is usual in academics, is an interesting question, possibly due to coincidence with start of the common fiscal year of hospitals.  [Below: AA Farmers’ Market]

 

Four.

Chang Lecture. From 2007 to 2018 the Urology Department held a series of yearly lectures on art and medicine, to celebrate Dr. Cheng-Yang Chang for his educational and clinical roles at Michigan Urology and his work in pediatric urology. Dr. Chang’s father, Chang Ku-Nien, was a master painter of 20th century Chinese art and much of his work resides at the UM Art Museum. The Shirley Chang Gallery, named for Dr. Chang’s late wife, is a peaceful and beautiful refuge. [below: Shirley Chang Gallery]

Dr. Chang began training under Reed Nesbit and completed the program here under Reed Nesbit and Jack Lapides in 1967. His two Chang sons remain closely tied to Michigan Urology. Ted completed training in urology under Ed McGuire in 1996 and is now in practice in Albany, working near another great Michigan urology alumnus Barry Kogan. Ted’s older son, Kevin, recently graduated from UM, but is headed for the business/informational technology world. Hamilton, UM 1989, is an investment banker in Chicago and one of Michigan urology’s greatest advocates. [Below: Ku-Nien Chang. Taiwan Cross Island Highway, 1967. UMMA.] While it seemed appropriate to sunset the yearly Chang Lecture series when the urology chair turned over to Ganesh Palapattu, the idea of intertwined art and medicine lives on in our department and periodic Chang art and medicine events are likely to appear.

The Chang Lectures had three objectives. The first two were: celebration of an important and worthy Michigan Urology family and the responsibilities of universities to offer “public goods” – open lectures on general topics (even from a specialized department such as urology). The third goal relates to a belief that discussions of the conjunctions of art and medicine belong in medical schools and health care training programs. Art and medicine converge at the human interior. For artists, that interior is a matter of intellect, soul, hope, aspiration, fear, grief, love, and beauty. For those of us who tend to the contingencies of physical bodies, the interior is a matter of brains, bones, organs, fluids, cells, systems, and naturally includes our visible integument. When we began the lectures, visual art took center stage, although no art form was out of bounds and Joel Howell’s inspiring talk in 2009 focused on music.

 

Five.

The Smithsonian American Art Museum (acronym, SAAM) is a favorite stop in Washington, DC. Once known as the National Portrait Gallery, SAAM is a wonderful place for a quick visit, something less feasible at most other Smithsonian museums, but you certainly can spend a day at the SAAM where Paul Revere’s Ride by Grant Wood resides. When you happen by there, the Daguerre monument on the museum’s Seventh Street side is worth a look. Daguerre’s work grew into modern photography that would show how horses actually gallop.

Leland Stanford, a horseman among other things, commissioned photographer Eadweard Muybridge (1830-1904) to study galloping horses photographically. The gallop is too fast for human eyes to analyze and for centuries visual artists depicted all four legs were simultaneously in the air, extended forwards in the front and backwards in the rear, during a gallop. On June 15, 1878 Muybridge depicted Sallie Gardner at a Gallop, a series of 24 pictures in rapid succession and its 24 frames constitute the first moving picture. The gait analysis showed that when all four feet were simultaneously in the air the legs were gathered below the belly of the horse rather than extended front and back. Sallie Gardner was Stanford’s Kentucky-bred mare and the jockey was named Gilbert Domm.

 

[May 4, 2019; Louisville, KY, USA; Luis Saez aboard Maximum Security (7) crosses the finish line during the 145th running of the Kentucky Derby at Churchill Downs. Mandatory Credit: Jerry Lai-USA TODAY Sports – 12643976]

Luis Saez riding Maximum Security crossed the finish line at the 145th Kentucky Derby at Churchill Downs, May 4, 2019, ahead of the thundering herd, but was disqualified for interference with other horses. [Above: Reuters photograph] One hopes the interference was accidental, but rules are rules, the photographic evidence of the interference was self-evident, and it’s reassuring to find occasional evidence that the end doesn’t always justify the means. The arc of the moral universe may be long, but sometimes we live long enough to see it bend toward truth.

 

Postscript

Independence Day celebrates the first days of the American nation, as proclaimed in the astonishing Declaration of Independence, a beautiful piece of prose hammered out by committee with compromises made. The Constitution, produced also by a team, is a clunkier set of rules and regulations that was amended more than a year later with some ideas many of its signers took for granted and assumed the original Constitution offered no constraints on essential freedoms in a democracy. James Madison, principal author, finally was convinced that certain amendments were necessary including explicit enumerations of specific freedoms that people needed from government. The original Bill of Rights listed explicit protection for freedom of speech, religion, the press, assembly, and the right to lobby the government for redress of grievances. These were listed in the Third Article of the Bill of Rights that became incorporated in the First Amendment of the first ten amendments to the Constitution. The original First Article of the Bill of Rights dealt with the formula for representation in the House of Representatives and the Second Article specified details of laws related to compensation of the representatives.

Historian Gordon Wood, who once taught at Michigan and was popularized in a scene of a Harvard Square tavern argument in the 1997 film Good Will Hunting, once wrote: “… it was Madison’s personal prestige and his dogged persistence that saw the amendments through the Congress. There might have been a federal Constitution without Madison but certainly no Bill of Rights.” [Representation in the American Revolution, University of Virginia Press (Charlottesville, VA), 1969. (ISBN 978-0813927220)]

Human potential – with its science, technology, knowledge, and truth – is severely deformed and stunted when government restricts freedom of speech. Freedom of religion, the press, assembly, and the right to petition actions of government necessarily follow freedom of speech. Truth, equality, and the rights of The First Amendment come close to being the most basic secular principles of humanity and are always at risk and threatened in every civilization.

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

Ga-ga now and then

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DAB Matula Thoughts June 7, 2019

Ga-ga then and now

2172 words

[Above: Nesbit reception at 2019 AUA Annual Meeting in Chicago. Ice sculpture.]

 

One.             

Senior medical students are getting ready this month for the next big stage in their lives and careers, just as I did in June of 1971 heading west from Buffalo to Los Angeles, to start nine years of training at UCLA. I don’t recall much of the drive along the evolving interstate highway system, a vision of President Eisenhower only 20 years earlier, but the exhilaration of beginning something totally new with surgical residency under William P. Longmire certainly dominated my thoughts on the road. The intellectual and conjoined physical capabilities of surgery as a profession excited me. The first day of internship, in line to check in, I met fellow intern Doug McConnell and quickly befriended John Cook, Erick Albert, Ed Pritchett, Ron Busuttil, Arnie Brody, John Kaswick, Dave Confer and the rest of our 18 at the bottom of the UCLA training pyramid. Over the five-year process, we learned the knowledge base, skills, and professionalism of surgery through experience, teaching, study, and role models. In the blink of an eye 1971 has become 2019 and, suddenly I’m near the end of my career.

Reading Arrowsmith and the recent story of the Theranos debacle in John Carreyrou’s Bad Blood, I saw those protagonists wanting to change the world. My hopes in 1971 were not so grand, I just wanted to find my own relevance and hoped to become good in my career. Most people similarly want to make their mark in one way or another, through job, family, art, or community. Some, however, actually intend to change the larger world, although their idea of “change” may be someone else’s deformation.

Last month a large cohort of our University of Michigan urology residents, faculty, nurses, PAs, and staff met in Chicago at the annual AUA national meeting to learn, teach, exchange ideas, network, enjoy reunion, and circulate word of our new chair Ganesh Palapattu. The Michigan brand was strong with hundreds of presentations from our faculty, residents, and alumni. The MUSIC and Nesbit Alumni sessions were great gathering points. [Below: UM podium events with alumni Cheryl Lee, Jens Sønksen, Barry Kogan, and Julian Wan.]

Cheryl has been back in Ann Arbor this week as visiting professor.

A group of our residents and one incipient PGY1 were ga-ga at the AUA Museum booth. [Below in front: Juan Andino, Catherine Nam; back row: Adam Cole, Scott Hawken, Rita Jen, Ella Doerge, senior faculty member, Colton Walker, Matt Lee, Kyle Johnson, Udit Singhal.]

 

Two.

Surgery, the word, derives from Greek, kheirourgos, for working by hand and the term moved through Latin, Old French, and Anglo-French to become surgien in the 13th century. The epicenter of that world was the doctor/patient duality, based on an essential transaction as old as humanity with exchange of information, discovery of needs, and provision of remedies and skills. The knowledge base and tools are far better since Hippocratic times, but the professional ideals are much the same. It seemed pretty awesome to my 21-year-old self that I might one day be able to fix things with my hands like Drs. Longmire and Rick Fonkalsrud. History mattered to our UCLA professors who insisted that trainees know the back stories of each disorder and treatment.

New interns arriving next month, called PGY1s for their postgraduate year status, may have parallel thoughts to those of mine 48 years ago as they start their journeys. Pyramidal training models no longer exist – PGY1s can reasonably expect to complete their programs. Their experiences will be replete with contemporary expectations, notably patient safety, value propositions, clinical outcome assessments, co-morbidities, social determinants of disease, personal well-being, attention to patient experience, and teamwork with diversity, equity, and inclusion. Acronyms have proliferated, tools are more powerful, and regulation grows more burdensome. Nevertheless, essential transactions remain at the center of health care with needs of patients addressed by the knowledge, skills, and kindness of healthcare providers, one patient and one provider at a time.

While taking pride in the labels doctor, physician, surgeon, nurse, and physician’s assistant we realize now that teams of providers with many types of expertise congregate around each single patient, either immediately physically as “bedside teams” (in clinics as well), sequentially, or virtually (with office staff, coders, laboratories, or electronically). Teams offer exquisitely specialized expertise and “wisdom of crowds,” although patients often find no single person in charge of their care.

 

Three.

Patient safety was a given when I was a resident. It was wrapped up in regular Morbidity and Mortality conferences without explicit use of that phrase, patient safety. Around that time a young graduate student in sociology, Charles Bosk, embedded himself in an academic surgical team for 18 months to discover how surgery was learned, practiced, and lived at an unnamed “Pacific Hospital.” The result was his book in 1979, Forgive and Remember: Managing Medical Failure. Bob Bartlett, my friend and colleague in the Surgery Department, introduced me to it a few years later. A second edition in 2003 was reviewed by Williamson. [Williamson R. J Royal Soc Med. 97(3):147-148, 2004.]

Patient safety has grown since my internship from an obvious but unarticulated expectation to a distinct field of study modeled after other industries, notably aviation. Health care has learned much from other professions such as the concepts of safety culture, standardization of procedures, checklists, and so forth, although healthcare is more multidimensional and nuanced than those other worlds. Bosk recently reflected on the health care exceptionality in a Lancet article, “Blind spots in the science of safety,” written with Kirstine Pedersen, concluding:

“There is a science of safety to reduce preventable adverse outcomes. But health care also has an irreducibly relational, experiential, and normative element that remains opaque to safety science. The contribution of a kind and reassuring word; a well delivered and appropriately timed disclosure of a bad diagnosis; or an experience-based evaluation of a small but important change in a patient’s condition – all are difficult, if not impossible to capture in a performance metric. Accomplishing safety and avoiding harm depend on discretion, effective teamwork, and local knowledge of how things work in specific clinical settings. Finally, the successful practice of a science of safety presupposes in theory what is most difficult to achieve in practice: a stable functioning team capable of wisely adapting general guidelines to specific cases.” [Bosk CL, Pedersen KZ, “Blind spots in the science of safety.” The Lancet 393:978-979, 2019.]

 

Four.

The Michigan Urology Centennial is nearly here and the process of writing our departmental history has elicited many names and stories. Bookends demarcating any era may be discretionary choices and our starting point could easily be debated. Perhaps the first “urologic” procedure of Moses Gunn initiated this specialty at Michigan in the 1850s, or the first faculty appointments with the term lecturer on genitourinary surgery, held by Cyrenus Darling (1902) or clinical professor of genitourinary surgery by Ira Dean Loree (1907) might qualify. Unquestionably, though, the arrival of Hugh Cabot in the autumn of 1919 brought modern urology with its academic components to the University of Michigan. Cabot was the first to use the 20thcentury terminology, urology, at UM and he was Michigan’s celebrity in the field. He literally brought Modern Urology to Ann Arbor, as that was the name of his two-volume state-of-the art textbook of 1918, repeated in a second edition in 1924. Cabot probably didn’t anticipate becoming Medical School dean when he left Boston two years earlier, but his advancement was hardly accidental. A number of other prominent faculty members were well-positioned to replace Dean Victor Vaughan, but Cabot played his political cards well and won the job.

Frederick George Novy (1864-1957) was the strongest competitor. Born and raised in Chicago, Novy obtained a B.S. in chemistry from the University of Michigan in 1886. His master’s thesis was “Cocaine and its derivatives” in 1887. Teaching bacteriology as an instructor, his Ph.D. thesis in 1890 was “The toxic products of the bacillus of hog cholera.” After an M.D. in 1891 he followed the footsteps of his teacher Victor Vaughan as assistant professor of hygiene and physiological chemistry. Visiting key European centers in 1894 and 1897, Novy brought state-of-the-art bacteriology to Ann Arbor, rising to full professor in 1904 and first chair of the Department of Bacteriology. His studies of trypanosomes and spirochetes, laboratory culture techniques, anaerobic organisms, and the tubercle bacillus were widely respected. Our colleague Powel Kazanjian wrote a first-rate book on Novy.

 

Five.

Paul de Kruif (1890-1971), one of Novy’s students, bears particular mention. [Above: de Kruif, courtesy Bentley Library.]  de Kruif came from Zeeland, Michigan, to Ann Arbor for a bachelor’s degree in 1912 and then a Ph.D. in 1916. He joined the U.S. Mexican Expedition (“the Pancho Villa Expedition”) against Mexican revolutionary paramilitary forces in 1916 and 1917, then saw service in France with the Sanitary Corps, investigating the gas gangrene prevalent in the trenches of WWI. de Kruif returned to Michigan as assistant professor in 1919 working in Novy’s laboratory, publishing a paper on streptococci and complement activation.

Novy helped de Kruif secure a prestigious position at the Rockefeller Institute in 1920, to study mechanisms of respiratory infection. While there de Kruif wrote an anonymous chapter on modern medicine for Harold Sterns’s Civilization in 1922. The 34 chapters were mainly written by prominent authors, including H.L. Mencken, Ring Larder, and Lewis Mumford, so how de Kruif, a young bacteriologist (and non-physician), came to be included in this compilation is a mystery. de Kruif’s 14-page chapter, however, caused the biggest stir, skewering contemporary medical practice and doctors for “a mélange of religious ritual, more or less accurate folk-lore, and commercial cunning.” de Kruif viewed medical practice as unscientific “medical Ga-Ga-ism,” but his article was sophomoric at best.

Once de Kruif was revealed as author the Rockefeller Institute fired him in September, 1922. The newly unemployed bacteriologist came in contact with a newly prominent author, Sinclair Lewis (1885-1951), praised for Main Street (1920) and Babbitt (1922). Lewis was ready for his next novel and two friends, Morris Fishbein and H.L. Mencken, persuaded him to focus on medical research. Lewis, son and grandson of physicians, knew little of medical research, so Fishbein, editor of JAMA, connected Lewis to de Kruif. A bond and collaboration ensued for Arrowsmith (1925) in which a central character, Max Gottlieb, was modelled around Novy. Lewis gave de Kruif 25% of the royalties for the collaboration, but held back on sharing authorship, claiming that it might hurt sales. At the time de Kruif thought his share generous, but later became somewhat embittered as book sales soared with Lewis as sole author. [Henig RM. The life and legacy of Paul de Kruif. Alicia Patterson Foundation.]

Arrowsmith was selected for the 1926 Pulitzer Prize, but Lewis refused the $1,000 award, explaining his refusal in a letter to the Pulitzer Committee:

“… I invite other writers to consider the fact that by accepting the prizes and approval of these vague institutions we are admitting their authority, publicly confirming them as the final judges of literary excellence, and I inquire whether any prize is worth that subservience.”

Four years later, however, Lewis accepted the $46,350 Nobel Prize. His Nobel lecture was “The American Fear of Literature.”

Leaving lab behind, de Kruif became a full-time science writer, one of the first in that new genre of journalism. His Microbe Hunters, published in 1926, became a classic and inspired me when I read it as an early teenager, unaware of the controversies around it. [Chernin E. “Paul de Kruif’s Microbe Hunters and an outraged Ronald Ross.” Rev Infec Dis. 10(3):661-667, 1988.] Arrowsmith was re-published in 2001 by Classics of Medicine Library and Michigan’s Howard Markel provided the introduction. [Markel H. “Prescribing Arrowsmith.”]

 

Ga-ga notes

de Kruif’s adjective ga ga for American medicine in the 1920s intended to mean foolish, infatuated, or wildly enthusiastic. It can also denote someone no longer in possession of full mental faculties or a dotard. (Dotard recently came into play in the peculiar rhetoric of the North Korean and American leaders.) The ga ga origin may be from early 20thcentury French for a senile person based on gâteux, variant of gâteur and hospital slang for “bed-wetter.” Gateau, of course, is also French for “cake” and gateux is the plural. de Kruif himself was negatively ga-ga with his criticism of medical specialism. Lady Gaga brings the term to a new level of consciousness and a new generation.

The past week was big on three continents for those who go ga-ga over historic anniversaries. Two hundred years ago, on 31 May 1819, Walt Whitman was born on Long Island. His Leaves of Grass, among much else, had the intriguing phrase “I am large, I contain multitudes,” a prescient reminder of our cellular basis, microbiome, or the plethora of information that leads to TMI (“too much information”) or burnout. Seventy-five years ago, on 4 June 1944, Operation Overlord at Normandy, France, initiated the Allied invasion of Nazi-occupied Europe. Thirty years ago, on 4 June 1989, protests in a large city square between the Forbidden City and the Mausoleum of Mao Zedong turned violent and are now referred to as the June Fourth Incident in the People’s Republic of China.

 

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor