Matula Thoughts March 1, 2019

 

DAB What’s New Mar 1, 2019

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Stories

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[Above: childbirth fever pamphlet 1855 – a fatal complication. Below: M&M complications conference at UM Urology.]

One.             

M&Ms.  Once a month our department gathers at 7 AM on a Thursday morning for Morbidity and Mortality (M&M) conference, as is typical of most surgical training programs. This recurring touchpoint integrates the triple mission of medical academia so we can learn from the serious complications inherent to our work, improve the quality of that work, and discover new avenues of investigation. Typically, residents or fellows tell a story of a complication or a death, faculty members involved consider “what might have been done differently,” others share their experiences and thoughts, and sometimes a literature-based short presentation is offered. Complications are classified by the Clavien system. [Above: January 2019 M&M with Priyanka Gupta discussing the new complications entry system.] These conferences fine-tune our mutual relevance, allowing regular inspection of our complications, discussion from the perspective of quality improvement, and calibration of individual work with that of colleagues.

When I was a resident, grand rounds centered around the chair, whose every opinion mattered. Performances as residents could make or break progression through residency and chances for fellowships or good jobs. The chair critiqued everyone else and molded the department in his image (always a “his” during my training), much like an Autocrat at the Breakfast-Table, the title of essays by Oliver Wendell Holmes in 1858. Those of us who made it through the process naturally carried a deep respect and even fondness for the chair, while others were not quite so enamored. Things have changed, especially in big departments, with decentralization to divisions and teams much more the order of the day, and while structure is still necessarily hierarchical (the buck must stop somewhere), a more democratic flavor rules the day at M&M conferences and grand rounds.

Although chairs are no longer the center of departmental universes, they set much of the tone and represent the team administratively to the rest of the institution. Departments improve when leadership rotates carefully, as it has in our case, and today it’s official: we welcome Ganesh Palapattu to our chair position, and Brent Hollenbeck as vice chair of the University of Michigan Department of Urology.

 

Two.

The Clavien-Dindo system, described in 2004 by Zurich surgeons Pierre Clavien and Daniel Dindo, assigns grades to surgical complications: Grade I events are small deviations from normal expected operative or postoperative courses; Grade II events are atypical medication needs, including blood transfusion and total parenteral nutrition; Grade III are complications requiring surgical, endoscopic, or radiologic intervention – with or without anesthesia; Grade IV are life-threatening complications; and Grade V is death. [PA Clavien et al. Ann Surg. 250:187-196, 2009.] Our M & M conferences focus on Clavien III or greater complications, mainly to identify learning opportunities: what could we do better, personally, or in our teams and systems? Human activities are inevitably susceptible to periodic errors and negative outcomes, but medical complications are serious disappointments and sometimes tragedies for patients and their families. Each complication is a story, often a complex one. Faculty and residents must learn from them, grieve over them, and learn to deal with the adversity. Just as importantly, surgeons must move on to take care of the next patient. The seminal book Forgive and Remember by Bosk, discussed on these pages in the past, is worth renewed attention. [Bosk CL. Forgive and Remember. Managing Medical Failure. University of Chicago Press. 1979.]

Getting “the story” right is a universal necessity, whether from personal points of view, social perspectives, or occupational demands. Journalists, teachers, politicians, engineers, lawyers, and physicians need to understand stories and ascertain truth. Surgeons need to know a patient’s story from the diagnostic perspective in order to come to operative solutions, and if complications occur, then it is imperative to understand those stories, for only then can the practice of medicine improve.

 

Three.

The idea of what is “right” – that is what can be proven true or is generally accepted as correct – is surprisingly complex, requiring a socially shared sense of “truth” and factual reliability.  A person’s ability to adhere to truth is a matter of integrity, and we expect higher levels of integrity from physicians, scientists, and engineers than many other occupations. Yet, shouldn’t we expect integrity in all responsible occupations, from chefs to politicians? When is it forgivable to tamper with the public trust for personal gain or malicious reason and what are the boundaries of the First Amendment? These tough questions are beyond solution in Matula Thoughts, but should be considered and discussed by all members of society.

It is a fact, as this line is written, that it is not raining outside my window, but that fact will change with time and environment. Some facts are difficult to ascertain and people sometimes have legitimate misconceptions of reality, uncertainty being intrinsic to humanity. Deliberate misrepresentation of reality, however, is corrosive to any social group and to society at large. Deliberate misrepresentation is expected in the products of fiction and the entertainment industry, but not in their business dealings. Misrepresentation in business, politics, religion, etc., erodes trust, essential for a healthy society. When stories become propaganda, or opinions masquerade as journalism, free speech is abused. Misrepresentation in medicine and science, worse matters, are social crimes.

These last charges are tricky, running contrary to the First Amendment and the cherished idea of free speech. Yet, “yelling fire” in a theater or its equivalent on social media is too  dangerous for society to tolerate. Democratic societies have yet to figure out where and how to draw the line between deliberate misrepresentation and free speech, and the hyper-pace of contemporary social media exacerbates the dilemma. Given that the ideas of the First Amendment are self-ordained “rights” of humanity, it is unlikely that they can be preserved if they cannot be better stewarded to serve the public, rather than serve individuals, factions, or ideologies.

Then, too, there is the matter of the “backstory,” the history, conditions, and other narratives leading up to a particular story and the circumstances that frame it. In health care the backstory includes co-morbidities, while in the field of economics such circumstances are dismissed as externalities. Although stories are simpler and easy to “understand” when stripped of complicating and confounding matters, stripped-down stories rarely convey the whole truth of a matter for accurate understanding.

 

Four.

It is hard to escape the name Oliver Wendell Holmes in American history. There were two of them, the first an iconic American physician (1809-1894) and the second, his son, an iconic supreme court justice (1841-1935). Both lives and careers centered on stories and truth.

Medical practice is a highly social profession and business. Socialization of practitioners with specialized knowledge and experience, sharing their stories, is a route to progress and today’s M&M conferences are programmed opportunities for this teamwork. Medical education, standards of practice, quality improvement, and research have been built around socialization since ancient times of Mediterranean and Asian medical practice, medieval professional guilds, and doctors in the early days of the United States.

One sparkling example was The Boston Society for Medical Improvement, doctors who wanted to share ideas and ascertain truths. Established in 1828 by John Spooner with 11 members, the Society quickly grew to 35 by 1838. Meetings were held the second and fourth Monday each month, originally in Spooner’s rented room on Washington Street.  A cabinet keeper managed a collection of specimens contributed by the members. Only “elite” practicing physicians of Boston were eligible and a younger set of physicians in 1835 formed their separate Boston Society for Medical Observation, echoing the terminology of Professor Louis in Paris, under whom Holmes studied. The two competing Boston groups ultimately merged in 1894.

The picture above, from the Countway Library Center for the History of Medicine, shows the Boston Society for Medical Improvement in 1853: sitting – George Bethune, Oliver Wendell Holmes, Samuel Cabot, Jonathan Mason Warren, William Coale, James Gregerson; standing – Charles Ware, Robert Hooper, Le Baron Russell, Samuel Parkman. Samuel Cabot was the grandfather of Arthur Tracy Cabot and Hugh Cabot, two of the most influential urologists in the transitional fin de siècle between the end of the late 19th century and early 20th. Hugh Cabot’s arrival in Ann Arbor in autumn 1919 defines the Michigan Urology centennial.

 

Five.

Puerperal fever & a murder. At a summer meeting in 1842 of the Boston Society for Medical Improvement, JBS Jackson queried fellow members their opinions regarding the possible contagiousness of puerperal fever. Jackson was concerned by the death of a colleague after treating an infected woman, and he knew of other infections incurred by subsequent patients the decreased physician had treated before he died. Holmes, a member of the original French Society of Medical Observation during his study in Paris a decade earlier, took up Jackson’s question and presented his own independent research, “The contagiousness of puerperal fever,” back to the Society on February 13, 1843. The presentation was commemorated in a 1940 painting by Dean Cornwell, That Mothers Might Live (below).

OWH 1843

The New England Quarterly Journal of Medicine and Surgery published Holmes’s talk in April and it was reprinted as a pamphlet (top, lead picture). Holmes was certain that “obstetricians, nurses, and midwives were active agents of the infection, carrying the dreaded disease from the bedside of one mother to the next.” This was among the earliest good evidence for germ theory of disease.

Holmes was dean of Harvard Medical School when he factored in the sensational murder case of wealthy Bostonian George Parkman in 1849. Parkman had studied medicine, but never practiced, so it is likely that the Parkman identified in the Boston Society for Medical Improvement was his relative. The murdered George Parkman was a wealthy Bostonian who had studied abroad, received an MD in Aberdeen, Scotland, and studied further in France, taking particular interest in mental illness. After returning home, however, he never practiced medicine, instead managed family property, so was ineligible for the Medical Improvement Society, although an admired friend of Holmes.

John Webster was also from an affluent family and had studied abroad. Later in Boston Webster became professor of chemistry and geology at the medical school, but ran into debt often and borrowed extensively, including from George Parkman. In an argument over a debt, Webster killed Parkman in his medical school office on November 23, 1849, dismembered the body, and hid it in a locked cellar basement restroom. An astute custodian, Ephraim Littlefield, concerned about the popular missing Bostonian, broke into the room and discovered the body remnants on November 30, 1849.  Holmes testified persuasively at the 12-day trial and Webster was executed by hanging on August 30, 1850. Holmes dedicated his 1850 introductory lecture to the medical school class in Parkman’s memory. [Below: OW Holmes c. 1879.]

Holmes enjoyed stories, although happier ones than that of his murdered friend. He wrote poetry and books of fiction and nonfiction. A founder of the Atlantic Magazine, he contributed to it regularly and mingled with the literary set in Boston, including J. Elliot Cabot, James Russell Lowell, Ralph Waldo Emerson, and Henry Wadsworth Longfellow. Holmes popularized the term Boston Brahmin and was certainly one of them. The Autocrat of the Breakfast-Table is a collection of 1857-1858 essays Holmes wrote for The Atlantic, published in book form in 1858. The stories are one-sided dialogues between a genial and “anonymous author” and other residents of a New England boarding house. It is, perhaps, more than a coincidence that the fictional detective imagined 40 years later by Dr. Arthur Conan Doyle, would share the Holmes surname.

 

Short story. Frédéric François Chopin born this day in 1810, six months after Holmes, lived a short life of only 39 years. Although numerous photographs exist of Holmes, only two exist of the great Polish composer and virtuoso pianist. [Below: top, Chopin c. 1847, http://commons.wikimedia.org/wiki/File:Chopin1847_R_SW.jpg]

Photography as a technology was new and rare during the early lives of these two men, but Holmes’ luck of longevity gave him greater opportunity as a subject. [Above: Chopin c. 1849. Daguerreotype by Louis-Auguste Bisson.]

 

Thanks for reading Matula Thoughts.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

 

 

February 1, 2019

DAB What’s New Feb 1, 2019

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Sands of time, transition, & short thoughts on rules
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One.

time

February, the shortest month, begins today, this Friday, and its periodic extra day comes next year on a Saturday. Although 2019 is only a month old, the sands of time slipped away for one iteration of Michigan Urology, and the metaphorical hourglass reloads today for our Michigan Urology version 8 that will refresh our department. Regental privilege requires that the next urology chair requires formal action, although most of us know the party in question, who begins today as acting chair. Ganesh Palapattu will do an excellent job leading the faculty, residents, and staff – the parties who will actually do the refreshing. Our new chair will face challenges and, if history is any guide, our team will support him fully for the next chapter of the Michigan Urology journey. In that context, this is a good time to examine the past and re-articulate our history, as Richard Feynman (1918-1988), American theoretical physicist, once wrote:

“Why repeat all this? Because there are new generations born every day. Because there are great ideas developed in the history of man, and these ideas do not last unless they are passed purposefully and clearly from generation to generation.” [Feynman RP. The Meaning of it All. Thoughts of a Citizen Scientist. 1998.]

It may be a long stretch from the “great ideas in the history of man,” to a modest history of Michigan Urology but I hope you allow Matula Thoughts some slack and accept this belief in regularly rearticulating the past for each cohort of our successors.

screenshot 2019-01-29 14.12.14

I first met Ganesh when I was visiting professor at UCLA, my urology alma mater, and he was a resident under Jean deKernion, a wonderful urologist, leader, and friend. As a visiting professor at a number of places, I often tossed out ideas for papers, but Ganesh was perhaps the only one over the years who took the bait and completed a paper with me. His career took him to Johns Hopkins, The University of Rochester, and then Baylor in Houston at Tim Boone’s program. At great loss to Tim, but with his consent and blessing, Ganesh and his lab, with Alex Zaslavsky, came to Michigan at the start of my term as chair. Ganesh is well prepared. He is a terrific teacher, effective leader, excellent surgeon, and has led our largest urology section, uro-oncology, very well. When a need is identified he steps up – he was among the first to volunteer in Flint at the Hamilton Community Health Network clinic, when that opportunity materialized. His lab has done well with a recent 2% score on its latest grant submission. Ganesh will be thoughtful, consensus-building, and creative as he leads Michigan Urology in its mission (education, research, and clinical care), and our essential deliverable – kind and excellent patient-centered care. [Above: Ganesh with Anu. Below: with Kirtan and Elina.]

 

Two.

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Anticipating the centennial of Michigan Urology, we’ve been working on a new volume of our story, previously written by the late John Konnak and urological scholar Dev Pardanani nearly 20 years ago. It is impossible to understand the urology story in Ann Arbor, without a larger sense of the story of our state, our specialty, and our university. It might be said that melodies of the past haunt the reveries of our stories, to tweak Hoagy Carmichael’s phrase. So, our story properly began around 11,000 years ago, well before Hippocrates and the known roots of medical practice, with the inhabitants of the Mound Builder and Woodland cultures who populated our geographical area after the last glacial period receded. The Holcombe beach site near Lake Saint Clair has evidence of Paleo-Indian settlement in that era and by the 17th century, Huron, Odawa, Potawatomi, and Iroquois people inhabited the region. Dates are difficult to ascertain, but legend, archeology, and solar eclipse history suggest that an Iroquois Confederacy of Five Nations around the Great Lakes formed by then. Those people surely suffered from urological problems and undoubtedly tried many remedies to ease their pains, although the ailments either dissipated or claimed the poor sufferers’ lives. [Above: Painting by Roy Lichtenstein, 1965. Below, Map of Five Nations, De Lisle, 1718. Darlington Collection, University of Pittsburgh.]

map_of_the_country_of_the_five_nations_belonging_to_the_province_of_new_york_and_of_the_lakes_near_which_the_nations_of_far_indians_live_with_part_of_canada_taken_from_the_map_of_the_lou

French explorers, beginning with Étienne Brûlé, around 1610, Samuel de Champlain, and later René-Robert Cavelier de La Salle, attempted to colonize the regional home of the Cayuga, Mohawk, Oneida, Onondaga, and Seneca who comprised the Iroquois Five Nations. The Tuscarora joined the confederacy in 1722 to become the Six Nations that eventually were overwhelmed by Europeans.

 

Three.

Prelude to UM. Detroit, a settlement town in the western territory of a young United States, was initially referred to as the straights. Michigan became a distinct territory, carved from the Northwest Territory by congressional act, 30 June 1805. First governor William Hull and presiding judge Augustus B. Woodward described its history, in their first report, with the French penetration of Lake Michigan, the “Ouisconsin” River and the Mississippi down to its “mouth,” defaulting to the French feudal system of property ownership by aristocratic right (seigniorial), but offering no sensitivity to the Native American perspective:

“Prior to this era the settlements of the strait had commenced, and Detroit claims an antiquity of fifteen years superior to the city of Philadelphia. The few titles granted by the government of France were of three French acres in front, on the bank of the river, by forty feet in depth, subject to the feudal and seignoral conditions, which usually accompanied titles in France.” [Michigan Historical Collections. 36:107, 1908.]

The claim in the report refers obliquely to La Salle who buried an engraved plate and cross near what is now Venice, Louisiana, on April 9, 1682 to assert ownership of the territory by France. Hull and Woodward didn’t have all their facts in order regarding Philadelphia, also founded in 1682 but a month earlier on March 4 when William Penn made it the capital of Pennsylvania Colony. Great Britain assumed the French possessions after the 1763 Treaty of Paris ended the Seven Year’s War. Another Treaty of Paris, in 1783, ended the Revolutionary War, and the territory that would become Michigan was acquired from Canada by the United States. The Hull and Woodward Report tells of the sad circumstances of Detroit in June of 1805 just after it had burned to the ground:

“It was the unfortunate fate of the new government to commence its operations in a scene of the deepest public and private calamity. By the conflagration of Detroit, which took place on the morning of the 11th of June, all the buildings of that place, both public and private, were entirely consumed; and the most valuable part of the personal property of the inhabitants was lost. On the arrival of the new government [Woodward arrived Saturday June 29 and Hull on Monday July 1]. A part of the people were found encamped on the public grounds, in the vicinity of the town, and the remainder were dispersed through the neighboring settlements of the country; both on the British and the American side of the boundary… The place which bore the appellation of the town of Detroit was a spot of about 2 acres of ground, completely covered with buildings, and combustible material…” [Central Michigan University. Clarke Historical Library. 1805. Hull.]

Detroit rebounded from the fire and was on the upswing when The War of 1812 broke out and the town, indefensible, surrendered to the British on 6 August. An attempt to regain Detroit by General William Henry Harrison failed in January 1813, but on 10 September Commodore Perry’s fleet of nine small ships defeated six heavily armed Royal Navy ships on Lake Erie and returned the city to the United States. One quarter of the recruited American soldiers were African American. The British retreated up the Thames River in Canada, where the decisive Thames Battle on 5 October turned the tide against Great Britain and Tecumseh’s Confederacy (recounted here in Matula Thoughts last year). This story is a prelude to the University of Michigania, organized in Detroit in 1817.

 

Four.

New Year resolutions have faded into memory by now for all but the most resolute of us, although it’s worth reflecting that resolutions and intentions reflect the best versions of our imperfect selves. Franklin Delano Roosevelt, an architect of some of the best of modern American society, was particularly good with his public words, few more noteworthy than in his First Inaugural Address on March 4, 1933 during the depth of the Great Depression: “So, first of all, let me assert my firm belief that the only thing we have to fear is fear itself – nameless, unreasoning, unjustified terror which paralyzes needed efforts to convert retreat into advance.” Yet, no more or less imperfect than most of us today, FDR sometimes crumbled from fear himself, as early in WWII with Executive Order 9066 February 19, 1942, authorizing the Secretary of War to prescribe “Military Areas”:

“Whenever he or any designated Commander deems such action necessary or desirable, to prescribe military areas in such places and of such extent as he or the appropriate Military Commander may determine, from which any or all persons may be excluded, and with respect to which, the right of any person to enter, remain in, or leave shall be subject to whatever restrictions the Secretary of War or the appropriate Military Commander may impose in his discretion. The Secretary of War is hereby authorized to provide for residents of any such area who are excluded there from, such transportation, food, shelter, and other accommodations as may be necessary, in the judgment of the Secretary of War or the said Military Commander, and until other arrangements are made, to accomplish the purpose of this order. The designation of military areas in any region or locality shall supersede designations of prohibited and restricted areas by the Attorney General under the Proclamations of December 7 and 8, 1941, and shall supersede the responsibility and authority of the Attorney General under the said Proclamations in respect of such prohibited and restricted areas.” [Below: FDR at Yalta. DG Chandor portrait at SAAM, Washington.]

chandor. fdr yalta

The Executive Order quickly became actual law on March 21, 1942 when Roosevelt signed Public Law 503, put forth by Congress after 30-minute discussion in the House and an hour in the Senate, thus evicting 122,000 men, women, and children of Japanese ancestry (two thirds were American citizens) from their West Coast homes to incarceration camps. Americans of German and Italian ancestry were similarly targeted, but with much smaller numbers. Another Executive Order, number 9102 signed 18 March 1942, created the War Relocation Authority (WRA) to manage the forced relocation and internment. Milton Eisenhower was its first director, but only for a few months. His successor, Dillon Myer asked Eisenhower if he should take the job and was told:

“Dillon, if you can sleep and still carry on the job my answer would be yes. I can’t sleep and do this job. I had to get out of it.” [NYT 3 May 1965.] [Oral history interview with Dillon S. Myer. Harry S. Truman Presidential Library.]

Ultimately, 18 Civilian Assembly Centers, 10 Relocation Centers of the WRA, 9 Justice Department Centers (with German-American and Italian-American detainees), 3 Citizen Isolation centers (for “problem inmates”), 3 Federal Bureau of Prisons sites (mainly for draft resisters), 18 U.S. Army facilities, and 7 Immigration and Naturalization Services’ facilities were involved in detentions. The Japanese American Memorial to Patriotism During WWII revisits this sad story with the Golden Crane sculpture of Nina Akamu showing two Japanese cranes caught in barbed wire. Semicircular granite walls name the ten main WRA internment camps and The Archipelago on the open perimeter along Louisiana Avenue near D Street in Washington, DC, symbolizes the Japanese Islands and the five generations of Japanese Americans affected by the war. [Below: Two Cranes. DAB January, 2018.]

japanese monument

 

Five.

Hourglasses turn the ephemeral notion of time into physical reality. The grains of sand are elementary chemicals assembling by physical rules into worthy objects, stardust like ourselves. Laws of chemistry and physics that created stardust are durable and universal. Human rules are fungible and we hope that representational government and good leaders bend them to fairness, allowing redress when rules are improper, archaic, wrong-headed, or harmful to the public good. All sorts of rules, federal, state, local, professional, organizational, sectarian, familial, and personal ones constrain us, and sometimes they seem to come out of the blue as with presidential directives. Lincoln’s Emancipation Proclamation, considered here last month, and FDR’s Executive Order 9066 raise the issue of these curious sidebars of American law. A report of the Library of Congress, Congressional Research Service, by legislative attorney John Contrubis (updated March 9, 1999) explains the origin and usage of these two “Presidential instruments” (below).

pres proclam

The Constitution provides no explicit authority for executive orders and proclamations, although Article II states: “the executive power shall be vested in a President of the United States,” “the President shall be Commander in Chief of the Army and Navy of the United States,” and “he shall take care that the laws be faithfully executed.” Dogmatic originalism, might then argue to exclude the Air Force from presidential authority, or stipulate that a president execute all laws faithfully to their letter (rather than broad interpretation of Constitutional intent), or that a president must be a “he.” Such pedantic exercises unnaturally infuse human rules with an immutability similar to natural laws of chemistry and physics.

emanc proc

As humans, we elevate some of our laws to higher truths, such as belief in human liberty, the sanctity of life, equality of opportunity, and the right to pursue happiness, recognizing that these “self-evident truths” are perhaps on a higher plane than laws of prohibition, zoning, speed limits, or executive orders. Executive orders are legally binding directives given by the president to federal agencies in the executive branch, while executive proclamations may be ceremonial, policy announcements celebrations (Mother’s Day), or statements of a condition (e.g. of national mourning for the death of George HW Bush). Clearly there is overlap between orders and proclamations; the Emancipation Proclamation was as much an order as a proclamation. [Above: Emancipation Proclamation, Clements Library, University of Michigan. Below: 1914 Proclamation of Woodrow Wilson designating Mother’s Day.]

mother's day proclamation copy

 

Six.

Lysekno. Civic laws can cast long shadows that undermine education and science, setting human laws and policies at odds with the natural world. The Trofim Lysekno (1898-1976) story is a cautionary tale. That Russian biologist rejected Mendelian genetics and proposed his own theory of environmentally-acquired inheritance, offering experimental results with improved crop yields by his methods (unverified by others) and convincing Joseph Stalin to embrace Lysenkoism nationally. Soviet scientists who opposed the idea were dismissed from their posts, if not killed as “enemies of the state.” [Fitzpatrick S. Stalin’s Peasants: Resistance and Survival in the Russian Village after Collectivization. Oxford University Press. 1994. p. 4-5.] Forced collectivization and famine followed in the 1930’s, but Lysenko’s political power consolidated and in 1940 he became director of the Institute of Genetics of the USSR Academy of Sciences. In 1948, scientific dissent from Lysenko’s theory was outlawed.

After Stalin died in 1953, Nikita Khrushchev retained Lysenko in his post, but scientific opposition resurfaced and his agricultural influence declined. In 1964, Andrei Sakharov (1921-1989) physicist, architect for the Soviet thermonuclear bomb, but later Soviet dissident and Nobel Peace Prize Recipient (1975), denounced Lysenko to the Russian Academy of Sciences in 1964 saying:

“He is responsible for the shameful backwardness of Soviet biology and of genetics in particular, for the dissemination of pseudo-scientific views, for adventurism, for the degrading of learning, and for the defamation, firing, arrest, even death, of many genuine scientists.” [Norman L, Qing NL, Yuan JL. Biography of Andrei Sakharov, dissent period. The Seevak Website Competition.] [Cohen BM. The descent of Lysenko. The Journal of Heredity. 56:229-233, 1965.] [Cohen BM. The demise of Lysenko. The Journal of Heredity. 68:57, 1977.]

Lysenko died in Moscow in 1976 with only brief mention in the daily national newspaper. His politically enforced scientific pseudo-science had tragic consequences for millions of people in Soviet Russia. Lysenko wasn’t the first to consider the effects of environment on inheritance, Lamarck (1744-1829) had that thought much earlier. Open scientific give and take has since shown that Mendelian and other genetic processes are indeed influenced if not largely regulated by epigenetic factors. Science works well, but not when corrupted by ideology.

 

Seven.

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Too bad Gerrymanders aren’t mythical creatures. These Homo sapiens look-a-likes actually exist, grabbing and abusing transient authority to distort reality and fairness to gain political advantage. Democracy as expressed in our origin-document, The Declaration of Independence is built upon shared belief in fairness, but when fairness is seriously undermined, authoritarianism creeps back into public life – authority of a political party, authority of a leader, authority of a particular ideology, authority of a religion, or authority of a class of people. History shows this human propensity again and again with tribalism, kingdoms, monarchies, dictators, cults, single-party nations, etc. Gerrymander came from Elkanah Tisdale’s cartoon in the Boston Centinel, 1812, showing the district created by the Massachusetts Legislature to favor incumbent Democratic-Republican candidates over the Federalists. [Above: Tisdale’s creature in the Centinel, 1812. Below: Michigan districts.]

 

mich congressional

Eradication of the gerrymander is one of democracy’s existential necessities. This problem is exacerbated by the algorithmically-targeted misinformation made possible by personal data mining. This perversion of free speech is dramatized in the Netflix film, Brexit.

 

Eight.

history hall

History Hall. Along the passages connecting University Hospital, Frankel Cardiovascular Center, Rogel Cancer Center, and Medical Sciences I buildings are pictures of most of the Medical School graduating classes. Even as faculty and staff walk briskly through them, discussing their work, the decorative walls and the light from the glass tunnel are pleasant and even refreshing. If you have a chance to linger briefly and look, the pictures take your walk through a history of paradigm changes, economic booms and busts, great discoveries, inspiring leaders, wars, bad actors, duds, and all the other stuff of 170 years. Each student and faculty member in the class pictures is an individual summation of countless personal dramas and stories. [Above: David Fox and Joe McCune.]

Maybe stepping aside as chair (I don’t think of it so much as “stepping down” or a loss, but I am truly pleased to have Ganesh Palapattu pick up the challenges, present and ahead) gives me too much time for lingering walks and gratuitous thoughts. Framed by all the larger problems of the world (geopolitical conflict, terrorism, poverty, widening inequality, economic unpredictability, environmental degradation, infectious diseases, and other existential threats) one must wonder: can we humans successfully control our own destiny? If so, some structure and rules are obviously necessary for 7 billion people on a small planet, but will the structures and rules revert to ancient painful models of authoritarian rule and pyramidal hierarchy, or could they tilt toward libertarian, laissez-faire, or anarchistic models although those have never proven successful at large scale?

The question is not merely rhetorical, it is existential and an answer needs to be found between those extremes, within some central range. How we find, set, and reset that optimal place in our laws is the ultimate political question. Representational democracy, even as terribly imperfect as it is, seems to offer the best framework to balance individual freedom and happiness with optimization of societal function, human destiny, and planetary sustainability. This same dilemma of governance, structure, and rule-setting is recapitulated in localities and large organizations, even that of Michigan Medicine. These may seem strange Matula Thoughts for the moment and solutions are beyond the wisdom of this writer, but with 7 billion points of wisdom, good answers should abound. Lingering walks through history halls can help.

 

Nine.

Academic urology at Michigan effectively began in the autumn of 1919 when Hugh Cabot came to Ann Arbor, and for that reason we begin a year of centennial celebration with our Nesbit Alumni Reunion October 3-5, 2019. Cabot’s 11 years at Michigan were transformative, but disruptive and (yes) often authoritarian, leading the regents to dismiss him in February, 1930, “…in the interests of greater harmony.” His next phase of work was at the Mayo Clinic where he focused on large issues of health care, such as testifying to Congress in favor of multispecialty group practice against the position of the AMA. Cabot’s final book, The Patient’s Dilemma, written in 1940, concludes with reflections on the problems that democratic systems have in planning the future. “It may well be – if we preserve our sense of humor – that we may suspect that the phrases ‘long distance planning’ and the ‘democratic process’ are in fact contradictions of terms.” While allowing for individual freedoms of opinions and rights to change them and exercise them through voting, Cabot explains that a democratic society that cannot make long term plans and carry them out is reduced to an “absurdity.” Cabot ends the book thus:

“…we have an immense body of opinion, part of which is in this country, a handsome part of it elsewhere, which continues in spite of discouragements, to believe that there is in all human beings an inherent and irresistible desire for certain freedoms which can be obtained only under democracy. Such a view seems to me based upon irrefutable evidence going back to the beginnings of the world. Its validity I cannot doubt. Once we admit this premise, once we admit that we believe that there are in democracy certain inherent benefits essential to progressive civilization, then we are driven to the conclusion that though long distance planning under democracy is beset with many vicissitudes, nevertheless such plans must be made and, by dint of good temper and the laws of the cosmos, they may come to fruition.”  [Cabot H. The Patient’s Dilemma: The Quest for Medical Security in America. 1940.]

 

Ten.

Stardust, Hoagy Carmichael’s popular song, came to his mind in 1927 when visiting his alma mater, Indiana University, where he had earned a bachelor’s degree in 1925 and law degree in 1926. Mitchell Parish added lyrics in 1929 and the song has been recorded by Bing Crosby (1931), Nat King Cole (1956), and Willie Nelson (1978) among many others. The music and the lyrics are equally compelling, with Parish linking “the purple dust of twilight time,” the stars, and memories of a lover: “And now my consolation is in the stardust of a song.”

The original title was two words, Star Dust. Astronomers have learned much about the topic since Hoagy’s day: the elements of stardust larger than hydrogen and helium up to the size of iron required solar furnaces for their creation, but larger elements required the greater manufacturing complexity of supernovae. The fact that life is literally made of stardust is not just a figure of speech, the stardust of a song is a lyrical metaphor of a higher order of magnitude. Lying somewhere between cosmic stardust and its human incarnation is the daily work and politics of humanity, and these have been the focus of matulathoughts.org.

I came to Ann Arbor in 1984 from Walter Reed and the U.S. Army at the invitation of Section Head Ed McGuire, who very positively impacted the world of urology and myself. I inherited the stewardship of Michigan Urology from another great urologist and our inaugural chair, Jim Montie. Previous leaders of urology at Michigan educated superb urologists from Nobel Prize winner Charles Huggins and Reed Nesbit, the first section head, through Jack Lapides who trained another splendid cohort, including Hugh Solomon whom we often see at Grand Rounds. [Below, Hugh and Jim.] Following Jack, we had Ed, Joe Oesterling, Bart Grossman, and then Jim. They all brought things to the table, so to speak.

screen shot 2019-01-16 at 7.47.03 am

My appreciation is profound to our faculty, staff, Nesbit alumni, and friends of the department. You have made my time as chair a joy. Sandy Heskett has been with me from the start of my administrative duties in Allen Lichter’s dean’s office and she has somehow dissolved the problems of each day and kept our department as well as your old chair on track. Jack Cichon and Malissa Eversole have been incomparable in their work and loyalty to our team. Thanks, too, to my colleagues and friends on the faculty, in the Dean’s office, and on central campus. It has been a great run for me, but it isn’t over yet.

We appreciate your interest and will be back here on the first Friday of March at this website: matulathoughts.org. and meanwhile encourage any comments from you.

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

 

Sun rise 2019

Matula Thoughts Jan 4, 2019

Sun rise 2019
3734 words

 

Periodic re-explanation. This column, Matula Thoughts, recalls ancient uroscopy flasks called matulas, used for centuries to examine urine for clues to illness. People want to know “what comes next,” a question, explicit or unspoken, dominating most conversations in medical practice: “can it be fixed and what will happen to me?” Remedy and prognosis mattered more than diagnosis in ancient days, when technology and verifiable medical knowledge were sparse, and understanding pathophysiology (using today’s terms) was not as useful to a patient as remedy and prognosis. Direct examination of urine, particularly for color change, was one of the few early tools of practitioners and the matula was the dominant symbol of the medical profession for over 600 years in western art, until Laennec invented the stethoscope in 1816.

As a monthly collection of thoughts, relevant and random, from a senior genitourinary surgeon, the title seems appropriate. This electronic column began nearly 20 years ago in Allen Lichter’s dean’s office as a weekly email called What’s New. After returning full time to Jim Montie’s Urology Department in 2007, we continued What’s New as a weekly communication, published every Friday by varying members of our department, except for the first Friday of each month when I claimed the electronic podium. A parallel version began 5 years ago on the website MatulaThoughts.org. Happily, the Department of Urology will soon have a new chair with forms of communication to better match the times and people of the next decade. Nevertheless, this monthly habit will continue at MatulaThoughts.org reflecting personal observations, relevant and irrelevant, and events related to Michigan Medicine and the Department of Urology. [Above: Sun face on ceiling fresco, church of Saint Jean-Baptiste de Larbey, Southwestern France. 1610. Wikipedia. Below: variant of Nesbit log by Julian Wan.]

 

One.

Imagine just 100 years ago how different things were for our predecessors at the University of Michigan Medical School: Americans were recovering from WWI and the first two deadly waves of the 1918 influenza epidemic; Woodrow Wilson was US president, having been Princeton president when he was offered the Michigan job ten years earlier; women couldn’t vote and any adult could drink alcohol on this day in 1919, but by the end of the year women’s suffrage was secured in the 19th Amendment and prohibition came with the 20th Amendment; socialist and communist parties were on the rise; anarchists were preparing for spring bombings; and racial tensions festered nationally. Meanwhile, the University of Michigan carried on with its work at the Medical School and University Hospital, as life went on in Ann Arbor. [Above: Approaching New Year’s Eve, December, 2018, Liberty & Ashley, Ann Arbor.]

The University in 1919, already more than a century old as an organization and in Ann Arbor for around 80 years, was amidst a building binge under President Hutchins with the new Union, Art Museum, Hill Auditorium, and other defining structures. The 60-year old Medical School, which had looked quite good to Flexner on his visit in 1909, had since fallen behind its peers in terms of facilities. The hospital was badly out of date well before the war and replacement was further delayed by the national emergency. The practice of urology at UM was a little more than a single faculty effort in a surgery department consisting of a handful of other individuals.

Late in 1919, Medical School dean Victor Vaughan recruited Boston urologist Hugh Cabot, who would engineer 11 years of change bringing the Medical School back to the top of medical education internationally and at the pinnacle of state-of-the-art clinical practice for the first time. Academic urology in Ann Arbor surely began with Cabot.

 

 

Two.

Pundits and ordinary folk made predictions and resolutions when the sun rose on 1919 and we repeated these customs three days ago. Events will happen and paradigms will surely change over the next 12 months, but the only solid predictions this posting will offer for 2019 are: a new chair will begin stewardship of this fine Department of Urology sometime soon and we will celebrate the Michigan Urology Centennial later in the year. Other than those predictions, the rest is noise (to borrow the title of the book on 20th century music by Alex Ross). Sunrise each new day or year brings uncertainty and new possibilities. Predict and resolve whatever you wish, paradigm changes are usually outside your control, although the ability to recognize their inflection points is a useful gift. [Below: Encyclopaedia Biblica, 1903. Public domain.]

The centrality of the Sun to life is a fundamental feature of biology and logically a universal symbol in human civilizations. The 14th century BC image of pharaoh Akhenaten (Amenhotep IV) worshipping sun god Ra, in form of Aten, shows a partial solar disc with rays ending in little hands. Curiously, Akhnaten (1983) was one of three biographical operas written by American composer Philip Glass, the other two being Einstein on the Beach (1976) and Satyagragha (in 1979, about Mahatma Gandhi).
Inevitably, an Anthropocene imprint was added to the sun, seen in the introductory figure from Larbey and much earlier in a 4th century BC marble relief of sun god Helios driving his chariot at the Temple of Athena in Troy. [Below: Pergamon Museum, Berlin.]

The man-in-the-moon, a whimsical anthropomorphic imagination, when combined with a solar face suggests the ancient Asian complementary opposites yin and yang. [Below top: Amiens, Bibliothèques d’Amiens Métropole, manuscrit Lescalopier (Fourth Day of Creation) c. 1200. Wikipedia. Bottom: yin and yang.]

 

Janus, Roman god of beginnings, looked to both the future and the past, presiding over transitions such as war and peace,  and might be viewed as a symbol of paradigm shifts in modern times . [Below: Janus, Vatican Museum.]

Solar symbols, seen on some national flags, are ubiquitous in the Happy Face, the mother and father of all emoji, designed by commercial artist Harvey Ball in 1963. Charles Kuralt’s Sunday Morning show, launched by CBS News on January 28, 1979, continues to employ a solar disk theme throughout 40 years of reiteration by Charles Osgood and Jane Pauley, remaining a pinnacle of news and civilized commentary as each episode rolls through a set of beautifully curated solar symbols. [Below: Sunday Morning (top) & Authentic Worcester Smiley (bottom).]

 

Three.

Isaac Newton’s big paradigm shifts began inauspiciously when he was born this day in 1643. His birth date in the old-style calendar was 25 December 1642, but Gregorian conversion brings his birthday to today in the modern calendar and solar year. Bad luck shaped him from the start; father died three months before he was born and mother commented that Isaac, ar birth, could fit inside a quart mug (Wikipedia). Mother remarried, but young Isaac, unhappy at home and bullied at school, reacted by focusing on his studies, becoming a top student at Trinity College in Cambridge. Apples, gravity, planetary motion, and mathematics come to mind at first with Newton’s name, which is also celebrated in the term for a unit of force.

Newton’s color theory was another product of his astonishing ability to think about the world and find clarity about how things work. Countless people before him had seen white light refract through glass prisms into the colors of the visible spectrum and everyone sees rainbows. Yet only Newton carried those observations into a theory of color, described in a book he wrote at 71 years of age in 1704: Opticks: or, a Treatise of the Reflections, Refractions, Inflexions, and Colours of Light. [Above: double Alaska rainbow. Eric Rolph. Below: Color wheel of Goethe. Wikipedia.]

Color theory continued to attract great minds, including German polymath Johann Wolfgang von Goethe (1749-1832) and Scottish scientist James Maxwell (1831-1879) whose differential equations in 1865 explained the electromagnetic spectrum. [Below, User:penubag, Wikipedia.]

An early Apple Computer symbol (above) was perhaps an intentional play on Newton himself and Adobe’s color disk (below) fragments color into infinitesimal gradients of hue.

 

Four.

Urine may not be a window to the soul, but it’s a useful indicator of disease through color, sediment, or odor. Red is an obvious hallmark of trouble, whether renal trauma, urinary stone, kidney cancer, bladder cancer, infection, BPH, structural anomaly, metabolic dysfunction, rhabdomyolysis, or genetic mutations. Ancient uroscopists expanded color change into fanciful imaginations and medieval uroscopy charts offered wild speculations of what color, sediment, consistency, smell, and taste of urine might portend in terms of prognosis. [Below: uroscopy clinic. Hortus Sanitatis. 1491, Mainz. Courtesy Dick Wolfe, Countway Library.]

The paradigm shift from uroscopy to urology occurred over two centuries replacing sensory examination of urine by eye, nose, and occasionally tongue, with microscopy and chemical analysis. Nevertheless, persistent uroscopic fortune-tellers claimed legitimacy even in the face of emerging scientific reason. Thomas Brian’s book in 1637, The Pisse Prophet, is a classic example of rational attempts to debunk dogma and fraud.[Below: Wellcome Library, 1655 copy.]

The metabolic dysfunction porphyria (named for purple urine) affected Scottish physician, Archie Cochrane, born 110 years ago in 1909 on January 12, and the prime advocate in modern times for evidence-based health care. Later this month Guilia Lane, our FPMRS fellow, will educate us on Cochrane in What’s New. [Below: normal urine sample on left and porphyria sample on right.]

This sample below from my clinic a few years ago was oddly green, but I failed to make note of the cause. Color still matters in modern urinalysis although, since matulas gave way to microscopy and chemical analysis, physicians rarely demand to view urine themselves before it heads to a machine or laboratory.

Macroscopic uroscopy gave way nearly completely to modern urine investigation with specific gravity measurement, chemical analysis, microscopic exam of spun sediment, bacteriologic culture, antibiotic sensitivity testing, and who knows what will come next. Twentieth century urinalysis was a cornerstone of urologic practice when it was unimaginable for a patient to leave the office of a good urologist without submitting a urine for examination. Hinman’s Eight Steps to Presumptive Diagnosis constituted the basis of urologic practice, at his start in San Francisco in 1920 as the first trained urologist west of the Mississippi: history, general examination, abdominal and external genital exam, urinalysis including a stained smear, prostate exam, plain x-ray, phenolsulfonephthalein test (PSP), and residual urine. [Bloom DA, Hinman F Jr. Frank Hinman, Sr: a first generation urologist. Urology. 61:876-881, 2003.] Color and other sensory inspection still matter and while details have changed, urology is diminished somewhat when its practitioners no longer personally inspect urine grossly and microscopically, favoring instead automated readout from machine or lab.

 

Five.

The story of urology at the University of Michigan was last told 20 years ago just after the Urology Section in the Medical School Department of Surgery emerged as a full-fledged department alongside its sibling disciplines of Neurosurgery and Orthopaedic Surgery. Much happened in the next 20 years to justify a new rendition of the story and additionally much more has been learned about the earlier years. The new book should coincide with the Michigan Urology Centennial, beginning later this year. Urology is a microcosm of modern specialized health care, but its roots are also of particular interest as the first designated medical specialty in Hippocratic times and the stories since then of the discoverers, progression of skills, and innovations that led to 19th century genitourinary practice and 20th century urology should be retold and interpreted for each new generation.

No story is ever complete, in its recollections of the past, because only partial relevant knowledge is known to any author and myriad other details of the cultural and physical soups surrounding those facts are mostly lost to historical recollection. Lucky historians may find, reconstruct, resuscitate, or recover useful details, but all stories are largely narratives of imagination and facts, whether true facts or otherwise, in the words of the late urological scientist, Don Coffey. Stories, even as particular as one of an academic urology unit, are enriched by the context of its people, events, and circumstances. For example, it’s inconceivable to consider urology at Michigan without understanding Moses Gunn, and any appreciation of Gunn requires the context of the Civil War. In that sense, the Michigan urology story aims to be rich in context.

 

Six.

The bicentennial edition of Howard Peckham’s sesquicentennial work, The Making of the University of Michigan, by Margaret and Nicholas Steneck is indispensable to understanding this institution. The Stenecks proposed, metaphorically, that this university began with a single strand that represented the foundational aim of the university to disseminate knowledge and embracing education at all levels. This strand thickened over time and became joined by a second strand, turning around the first one, the new strand representing knowledge itself, that must be interpreted, renewed, created, and disseminated through explorations, criticism, research, and invention. The Stenecks identified yet another part of the braid.

“Now there is a third strand wound with the other two. The University touches more than just its young students and faculty. It gives services to the State that help maintain it; it aids citizens who never enroll. These services began when its hospitals received perplexing cases from all over the State. It continued with the upgrading of high schools, the testing of municipal water supplies, with experiments in reforestation, testing programs for state highways. It supplied reading lists for club programs, lecture series for enlightenment, and musical concerts for entertainment. It expanded to research contracts for Michigan industries, development of new products for manufacture in Michigan, seminars for business executives, realtors and assessors, state college presidents, and refresher demonstrations for physicians and dentists. It provided radio and TV educational programs for all. Teaching–research-and service. These are the warp and woof of the University today.” [Peckham HH. The Making of the University of Michigan. 1817-1992. Edited and updated by ML Steneck and NH Steneck. University of Michigan. Ann Arbor. 1967, 1994. p. 1-2.]

A better term for “service thread” is that of public goods, and today those public goods extend far beyond the state of Michigan to the world at large. Universities, since the Middle Ages, have been the single entity in human society to attend consistently and dutifully, albeit imperfectly, to the human and planetary future. In the past few centuries the university, or the Academy as some call it, has extended from small Ivory Towers that educate a particular narrow subset of learners, to complex Multiversities with broader aims such as the Stenecks listed.

 

Seven.

Mission homeostasis. The University of Michigan entered the 20th century with a more complex, but clearer iteration of an academic medical center than it displayed at its start when medical education was the sole basis for its existence. The Chemical Laboratory in 1856 introduced the service of chemical analysis to medical education, clinical practice, and scientific discovery. A more complete linkage of medical education to clinical practice came with Michigan’s first university hospital in 1869 and by its third iteration in 1891 the triple mission of an academic medical center was fully in place, although confusion over priorities played out in such disputes as moving the medical school closer to large urban populations and hospitals, compensation of clinical faculty, and criteria for academic promotion.

Mission balance continued to confuse faculty and perplex leadership for that next century and into the present one. History brings some clarity to the matter: the University of Michigan Medical School began with an educational mission of training the next generation of physicians, research followed quickly initially to refine biochemistry in the service of the public, and clinical care was recognized as the necessary milieu for medical education and research. Among these three parts of the conjoined mission, clinical care is the moral epicenter, trumping any other part of the mission at any moment. Furthermore clinical care, a matter of complex intellectual teams, is the financial engine that currently underpins the other missions. Any great academic medical center must be first and foremost a state-of-the-art health care system that not only delivers excellent patient-centric service, but also studies and improves its systems of care and technologies along with its many scholarly and clinical disciplines. Clinical teams are the essential center and most important deliverable of academic medical centers. [Above: scribe’s heart measured against “feather of truth.” Book of the Dead, c. 1,265 BC. National Geographic, Ancient Egyptians. May 2009.]

 

Eight.

No Property in Man. January 15, 1929, the birthday of Martin Luther King, Jr., is celebrated later this month for his role in the slow, halting, and sometimes retreating movement towards universal human rights, a struggle that remains a very incomplete paradigm shift worldwide. [Above: MLK 1964.] Extending Mahatma Gandhi’s methodology of nonviolence and civil disobedience, King fought inequality through resistance that was nonviolent on his side of the bridge to change laws, public sensibility, and hearts and minds. Martin Luther King Day is celebrated around the time of Dr. King’s birthday, January 15, but the specific day this year will be January 21 according to the Uniform Monday Holiday Act. Michigan Representative John Conyers along with US Senator Edward Brook (MA) offered the first bill in Congress to honor King, but it fell short of passage by a few votes in 1979. In 1983, President Reagan signed the final bill to establish the day of remembrance, which commenced in 1986, also establishing a federal commission to oversee observance of the holiday. In 1989 President George HW Bush made Coretta Scott King a lifetime member of the commission. Toronto, Canada, Hiroshima, Japan, and Wassenaar, Netherlands also honor Dr. King with public observances.

We don’t close clinics, operating rooms, or phone lines for that day at Michigan (that would hardly have been in the spirit of Dr. King, anyway), but the occasion offers a time for reflection, study, relevant academic talks, and renewed efforts toward the unfulfilled paradigm shift to universal human rights. A good friend and Americana scholar, Jim Beuche, recommended a book called No Property in Man, by Sean Wilentz. In the spirit of this month, this is a “must-read” for 2019. Wilentz explains the issue starting at the Federal Convention (U.S. “Constitutional Convention”) in 1787.

“Descriptions of the Constitution as proslavery have misconstrued critical debates inside the convention. They have slighted the anti-slavery impulses generated by the American Revolution, to which the delegates, for better or for worse, paid heed. They have missed the crucial subtlety, which is this: although the framers agreed to compromises over slavery that blunted antislavery hopes and augmented the slaveholders’ power, they also deliberately excluded any validation of property in man.” [Wilentz. No Property in Man. Harvard University Press, 2018.]

Many forces assembled to abolish slavery in America, but Wilentz argues that the United States Constitution, the Republican Party (“an antislavery mass organization unprecedented in world history”), Proclamation 95 (Lincoln’s Emancipation Proclamation), and the 13th Amendment, legally abolished any legitimacy of the notion of “property in man” in America. [Below: page one of the five-page Emancipation Proclamation. National Archives.]

At President Kennedy’s suggestion, King led an effort to draft a Second Emancipation Proclamation, that would have outlawed segregation and expanded equality, but Kennedy’s Executive Order 11063 fell short of the draft. Lyndon Johnson’s Civil Rights Act of 1964, fulfilled more of King’s aspiration. That year King won the Nobel Peace Prize at age 35. He was assassinated in 1968 at age 39.

 

Nine.

Harvey Ball (1921-2001) designed the Happy Face to repair a decline in morale after the bumpy merger of two insurance companies. How effective the ideogram was in that instance is not clear, but Ball earned $45 for it and never applied for trademark or copyright. He never voiced regret for giving his symbol to the public, even after it became a universal symbol. Ball was born and raised in Worcester, Massachusetts, served in the Pacific Theater of WWII with a Bronze Star for heroism at Okinawa, started his own advertising company in his home town in 1959. One day, in 1963, he drew Smiley.

 

As a matter of law, copyright goes back to 1709 and the Statute of Queen Anne of Britain, the last monarch of the House of Stuart and the same Anne portrayed in the current film, The Favourite. Another current film, Mary Queen of Scots, portrays the start of the House of Stuart two centuries earlier, with the conception and birth of James, later first Stuart and first king to preside over England and Scotland.

The U.S. Constitution in 1787 includes a Copyright Clause (Article 1, Section 8), recently updated with the Copyright Act of 1976 and the Sonny Bono Copyright Term Extension Act of 1998, also called the “Mickey Mouse Protection Act” [Above: Queen Anne’s Statute. Below: Bell’s graph of US Copyright law expansion. “©1999-2008 Tom W. Bell. All rights reserved. Fully attributed noncommercial use of this document permitted if accompanied by this paragraph.” Wikipedia.]

Three days ago (Jan 1, 2019), according to U.S. copyright laws, all works published in 1923 entered the public domain. Sonny’s name was likely linked more to his music than his love of 1923 literature. (Wikipedia.) Works published then were to have entered the public domain in 1999, but were granted postponement by 20 years when Congress extended their copyright length with the Bono Act. Willa Cather’s A Lost Lady, Agatha Christie’s The Murder of the Links, Joseph Conrad’s, The Rover, Kahlil Gibran’s The Prophet, Marcel Proust’s The Prisoner (vol. 5 of In Search of Lost Time), William Carlos Williams’s The Great American Novel, and Virginia Wolfe’s Mrs. Dalloway in Bond Street were so reprieved.

[Above: copyright applied. Below: public domain.]

 

Ten.

Matula Thoughts analytics, 2018. We have no sense of the readership of the monthly What’s New delivered by email, but the web version, MatulaThoughts.org had 3454 views last year compared 3173 views in 2017. Viewers came from 89 countries, ranging from a few viewers in 35 countries, to 54 in Germany, 70 in the U.K., 87 in Canada, and 2578 in the US. Most views are cursory, but we enjoy hearing back directly from periodic careful readers who challenge our facts and alert us to errors.

[Above: analytics 2018.]
New Year 2019 began on a Tuesday and a short work week ends today for most people, but health care is a 24/7 business and by necessity we will offer more scheduled afterhours and weekend services at Michigan Medicine Urology, even though we have been doing so formally and informally for years. It is curious that most calendars begin each week on Sunday, although for most people that day is the end of the week and weekend, with the next week beginning at sunrise on Monday.

The 1902 fantasy film, Le Voyage dans la Lune, by Georges Méliés, shows an oversize spacecraft planted in the right lunar eye. We don’t have to travel 240,000 miles to stick it to a heavenly body, because Homo sapiens is doing this well enough right here at home on Earth, but possibly 2019 will be a turning point for planetary stewardship.

[Above: Schedel’s World History or Nuremburg Chronicle, 1493. Below: Earthrise, December 24, 1968. Apollo 8 astronaut William Anders.]

 

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

November rains

Matula Thoughts Nov 2, 2018

November rains


3724 words

One.

Autumn will transition from the front windshield to the rearview mirror this month, with November showers and Thanksgiving soon to follow. Colorful drives to work on Huron Drive, shown above a few weeks ago, are already memories as another seasonal foliage falls away and biological preparations begin for next season. [Below: back yard, October.]

While November rainfall is usually around the yearly average in Ann Arbor, at 3.07 inches, it bites harder than summer or earlier autumn precipitation, edging closer to snow. Last night’s rain was a taste of things to come. In contrast, November meteor showers, truly high lights, are considerably more prominent than in any other month. These falling or shooting stars are also seasonal, extraterrestrial bits of rock, usually nickel or iron, heating up and glowing as they enter the atmosphere 45-75 miles high and 45,000 miles per hour. Most night skies in the year display 5-8 sporadic meteors hourly, but in autumn, November especially, meteor storms are intense with more than 1000 shooting stars per hour. The Greek derivation of meteor means high in the air. Classification varies, with asteroids and comets as the larger interplanetary travelers while micrometeoroids and interplanetary dust are at the other end of the scale. The Meteor Data Centre lists some 900 meteor showers, but barely a dozen are well-known.

The Andromedids meteor shower first showed up soon after the University of Michigan Medical School opened its doors in 1850, when Biela’s Comet, passing near Jupiter, disintegrated into countless pieces around 1852. Earth passes through these remnants, among other celestial bits, every autumn with peak nights this year November 9-14. The Leonid shower, peaking November 15-20, contains meteoroids up to 10 mm diameter and 0.5 grams, annually depositing 12-13 tons of its stardust on Earth. The Alpha Monocerotid and Northern Taurid showers occur later in the month. Names come from the zodiac constellation locations of the origins (radiants) of the individual meteors in the night skies. [Above: all-sky fish-eye view of Leonid shower 17 November 1998, Modra Observatory, Comenius University, Bratislava. Wikipedia.] The existential threat of a large meteor strike, of course, is always “out there.”

Thanksgiving history precedes the Andromedids with origins in 16th century England where the monarchy, initially fused with Roman Catholicism, was intolerant of dissenting religions. The Church instilled many religious holidays in daily life and the calendar, 95 Church holidays not counting Sundays until 1536, when King Henry VIII, seeking an heir and other matrimonial opportunities, initiated the English Reformation. As supreme head of the Church of England, he and the new national religion were no less tolerant of dissenting religions, and pilgrims and puritans who couldn’t tolerate English intolerance relocated to North America where they initiated Thanksgiving ceremonies in Canada (1578), Virginia (1619), and Massachusetts (1621).

[Above: Shrine at Berkley Plantation, site of proposed “First Thanksgiving” December 4, 1619, in what would become Virginia. Wikipedia.]

Reforms of King Henry VIII reduced the Church holidays to 27 in 1536, but remaining dissenters argued to eliminate them entirely, calling for Days of Fasting or Days of Thanksgiving in reaction to the overwhelming burden of state-ordained religious holidays; disasters elicited fasting days while happier events, such as defeat of the Spanish Armada or birth of royal children, bringing thanksgiving days.

Independence of the United States brought separation of religion from government, and the fortunate afterthought of the First Amendment guaranteed freedom of religion and four other specified freedoms: speech, assembly, the press, and the right to lobby the government in redress of grievances. A book, The Soul of the First Amendment, by Floyd Abrams gives some of the backstory of that cornerstone of democracy, initially taken for granted in The Constitution. [Abrams F. Yale University Press. 2017.]

 

Two.

Thanksgiving and Ohio. Thanksgiving has largely avoided encroachment by the greeting card industry, which hasn’t pursued this unusual Thursday holiday as much as it has religious holidays, birthdays, Mother’s Day, or Father’s Day, to name a few. Some ingenious friends and colleagues, however, devise their own Thanksgiving greetings such as this from Nesbit alumnus, Frank Begun (1984), now at Ohio State, a few years back.

Frank looked more like a curmudgeonly surgeon than a cheerful Thanksgiving pilgrim, although his Michigan moustache in his Ohio State workplace, warmed our hearts.
I was at Ohio State last month as the Chester Winter Visiting Professor, where Cheryl Lee (1997) is the chair of urology, following Bob Bahnson.

Dr. Winter, a trainee like me from Willard Goodwin’s urology program at UCLA, led Ohio State Urology from 1960 to 1978 when Henry Wise II took over. Chester still lives in the Columbus area, but was unable to attend the education day that I greatly enjoyed in his honor. Chester got his BA and MD from the University of Iowa in 1943 and 1946 and trained in urology at UCLA. Chester co-invented radioisotope renography in 1955 and radioisotope cystography in 1960. He educated a generation of medical students and residents in urology, and cared for thousands of patients. Chester innovated procedures for priapism and incontinence, and contributed significantly to the urological literature. He has also written widely in American history, including a book on the history of Columbus, Ohio (below).

An interview with Chester online from the University of Iowa (May 16, 2017): “If you could change one thing about the practice or business of medicine, what would it be? Equality of opportunity and adequate quality in all the benefits.” [Above: Chet & Sandy, October, 2018, photo courtesy Cheryl Lee. Below: Cheryl, Emefah Loccoh medical student, Rama Jayanthi.]

Another Buckeye link, is Milwaukee pediatric urologist Jon Ellison (OSU MD and Nesbit 2013), after a stint in Seattle. Jon’s dad, Chris Ellison, was chief of surgery and medical school dean at Ohio State. Chris, Bob Bahnson, and I served together on the American College of Surgeons. The Winter Symposium was held by the Ohio State Urology Department at Nationwide Children’s Hospital, where Rama Jayanthi leads a superb pediatric urology team. Many residents and faculty, including the non-pediatric cohort, were present for the day. I’m grateful to the three chief residents who picked me as the Winter Professor and want to compliment Cheryl on the very strong OSU program and the intellectual excitement I saw there. [Below: chief residents Kristin Ebert, Joshua Ebel, Joseph Wan.]

Ohio State, Michigan’s perpetual Big Ten rival on playing fields, is a land-grant university, like most other Big Ten schools. Michigan, however, has a different origin story that began when America, at the start of the 19th century, nearly doubled in size after Thomas Jefferson’s Louisiana Purchase in 1803, that turned the American northwest into the midwest. Michigan territory got carved out in 1805 and territorial judge, Augustus Woodward, had an educational vision for the region that included a University of Michigan.

 

Three.

Higher education in America traces back, conceptually, to 1618 when Henrico College in Virginia was chartered by the London Company and given a grant of land and donation of a library, but a native American uprising killed the local colonists in 1622 before any educational program had started and the charter was revoked in 1624. Harvard College in Boston, founded in 1636 to educate the next generation of clergymen and civic leaders, fared better. The London Company and other New World ventures gave way to 13 colonies and a United States of America in 1776. After a rapid doubling of the national geography, it was evident that builders were needed, alongside the educated clergymen and civic leaders, to create national infrastructure. Rensselaer Polytechnic Institute (RPI) in 1824, introduced the German scientific/technical college, the next type of higher education in America. Stephen van Rensselaer and Amos Eaton established RPI for the “application of science to the common purposes of life.” [Wikipedia] Coincidentally (but not simultaneously) both Cheryl Lee and I graduated from RPI.

Medical education was separate from the rest of higher education in 19th century American colleges. Medicine, with little preliminary educational requirements, was taught, by lectures, cadaver demonstrations, preceptorships, and apprenticeships. The oldest public medical school, the College of Medicine of Maryland, charted in December 1807, founded the University System of Maryland and was at the time only the fifth medical school in the United States (after the University of Pennsylvania in 1765, Harvard University 1782, Dartmouth College 1798, and Columbia College of Physicians and Surgeons earlier in 1807.) Most medical schools throughout the entire 19th century were stand-alone small-scale private enterprises until after the mid-19th century when verifiable and scientific conceptual knowledge merged with new technology to bring specialized skills to clinical practice.

Augustus Woodward in 1816 published, A System of Universal Science, and proposed an epistemological framework for education, envisioning a catholepistemiad, or university, with a medical school called Iatrica and comprised of fields of anatomia, zoönomia, therapeutria, anthropiatria, chirurgia, mæeutria, zoötomia, and zoïatria. The rudimentary University of Michigania began in Detroit in 1817, but didn’t deploy Iatrica until 1848 after relocation to Ann Arbor, then calling it the Department of Medicine and Surgery. Abram Sager, the best educated of the five founders of the new medical branch, had graduated RPI in 1831 and obtained his medical degree from Castleton Medical College in Vermont before coming to Ann Arbor.

 

Four.

Land grant agricultural schools comprised the next iteration of higher education in America. Michigan State University in 1854 was a model for the federal Morrill Land-Grant Act of 1862 that allowed states to use proceeds from sales of federal lands, specifically 30,000 acres per state, to establish land-grant schools. Justin Smith Morrill, a founder of the Republican Party and US Congressman and Senator from Vermont between 1855-1898, proposed the act in 1857. [Above: Library of Congress] It was passed by Congress in 1859, but vetoed by President Buchanan. Morrill tweaked the act to include provisions for the colleges to include engineering and military instruction, and President Lincoln signed it into law on July 2, 1862, amidst the Civil War. The act was prohibited to any state “in a condition of rebellion or insurrection.”

Iowa, the first state to implement the Morrill Act, created its State Agricultural College and Model Farm in 1862, later becoming Iowa State University of Science and Technology. After the Civil War, the Morrill Act was extended to former Confederate states as well as future states and territories. If a jurisdiction claimed insufficient federal land to fulfill the land grant, the federal government authorized the state or territory to utilize federal lands in other states. Thus, New York State used Wisconsin timberland to fund Cornell University.

Ohio State University was founded in 1870 as a land-grant university and first named The Ohio Agricultural and Mechanical College, notably Ohio’s ninth higher-educational institution at the time. Its formation had been heavily promoted by Republican President Rutherford B. Hayes, against contrary lobbying by other Ohio public universities, that preceded the land-grant opportunity, namely Ohio University (opening for students in 1809) and Miami University (opening for students in 1824). In 1878, the school name in the charter changed to The Ohio State University to distinguish it from Ohio University.  [Below: National Institute of Food and Agriculture map of land grant colleges.]

 

 

Five.

The research university paradigm was a subsequent iteration of higher education, with the Doctor of Philosophy (PhD), the highest academic degree, as the distinguishing feature of the school. German educational reforms, inspired by Wilhelm von Humboldt, were embodied at the University of Berlin in 1810 under its various names before the present one. The Humboldtian model of higher education merged research, study, and education into the PhD and by mid-19th century many of America’s brightest students would go to Germany for PhDs after completing preliminary studies in America. Yale was among the first American schools to give out PhD’s and others followed. The first PhD hired at the University of Michigan was Franz Brünnow, from Berlin, whom President Henry Tappan brought to Ann Arbor in 1854 to deploy the university’s Detroit Observatory, although it was more than 20 years before Michigan awarded its first two academic PhDs. Victor Vaughan, later dean of the medical school, was one of those two recipients, later recalling:

“I had gone to Ann Arbor in 1874 some days before the sessions was to open. I was to work in the chemical laboratory, that was certain, but I wished to enter the graduate school and, if possible, secure a higher degree… In June, 1875, I was granted the degree of Master of Science. I wrote a thesis on ‘Separation of Arsenic and Antimony.’ This was published in the American Chemical Journal… In the fall of 1875 I continued in the same graduate work for the degree of Ph.D. This was the first time that this degree was offered ‘in course’ at Michigan. Hitherto it had been given, if at all, as an honorary degree, but about this time, it appears that the leading universities in this country decided to drop it as an honorary and offer it as a working degree. In this they followed the German Universities… There were two of us, the other being William H. Smith, who had graduated at Michigan and had taught one year at Vassar. Both of us received the coveted honor and entered the Medical School in the fall of 1876.” [Vaughan VC. A Doctor’s Memories. Bobbs-Merrill Company, Indianapolis, 1926. P. 94-99.]

Vaughan obtained an MD according to Michigan’s original two-year program, which soon thereafter became a three-year and then a four-year curriculum, and in time totally under the charge of Dean Victor Vaughan.

Within a century, a fifth iteration of higher education was evident here at the University of Michigan as well as some other universities that encompass all previous four iterations plus many other public goods and performing arts, including museums, athletic competitions, theaters, musical series, hospitals, health care centers, patent ownership, technology spin-off companies, and commercial partnerships. Most major universities have medical schools and, over time, many medical schools became closely tied to academic health care centers or networks, even fully integrating them as in our case at the University of Michigan.

 

Six.

The Woodward backstory. “‘Futurity,’ epigrammatically says he, ‘is an object of curiosity to all, but in some that curiosity is mingled with hope, in others with fear.’” This quotation comes from a paper called Augustus Brevoort Woodward – a citizen of two cities, and read March 5, 1900 to the Columbia Historical Society in Washington, D.C. by Charles Moore. [Records of the Columbia Historical Society. Volume 4, 1901. p. 116.] The “he” was Woodward, a curious man of obscure origins who became friends with Thomas Jefferson, then a civilian planter and politician in Virginia around 1795. After a contested election in 1796, Jefferson became Vice President under his rival John Adams on March 4, 1797. Woodward, meanwhile, had moved to Alexandria where he invested in property, with an initial $25,000, in the new Federal City. Woodward’s keen interest in government of that city likely transcended his economic interest, as judged by his numerous writings that also included matters of education and science. [Above: Golbez/maps Wikipedia Commons. Below: Judge Woodward, U.S. Department of Transportation Federal Highway Administration #68586. Woodward Avenue Action Association © 2006.]

Woodward and Jefferson continued their friendship, and after Jefferson won the subsequent presidential election, assuming office on March 4, 1801. Only 19 days later, March 23, Woodward was among the lawyers presenting themselves for admission at the first session of the Circuit Court of the District of Columbia, in the “half-finished Capital.” In a series of papers related to government of the District, Woodward argued for local representational jurisdiction, but in 1802 Congress allowed only a mayor appointed by President Jefferson and a council elected by property owners. The council would include Woodward.

Jefferson’s Louisiana Purchase required new cities, governments, and infrastructure within the Northwest Territory. A Congressional Act on 11 January, 1805, established the Territory of Michigan and required appointment of a governor and three judges. Jefferson named William Hull of Massachusetts as governor and the judges were Woodward, Frederick Bates, and John Griffin, all from Virginia. Woodward arrived in Michigan Territory, on horseback, the weekend after Detroit’s great fire.

Seven.

Woodward and Jefferson had very different personalities, but shared deep interest and expertise in education and in natural history, categorized now as science. The two men were early adaptors of the modern term. Woodward’s interests were expressed most inclusively in his 1816 book, A System of Science, that contained the basis for the University of Michigania, as named in 1817, when Michigan was still a territory. Woodward called the medical branch of knowledge Iatrica, listing its various components in on of the two curious fold-out tables at the end of the book. The grandly-named, but meagerly implemented university opened in Detroit in a modest building, but little record remains of the curriculum and students, except that activity was suspended due to cholera epidemics in 1832 and 1834. [Below: title page of Woodward’s book and fold-out table.]

 

Michigan became a state in 1837 and the University of Michigan moved from Detroit to Ann Arbor in 1838. The medical school didn’t open until 1850, and its official title was The Department of Medicine and Surgery.

 

Eight.

Faculty retention. Astronomy had a big place in the early years of the University of Michigan and its Detroit Observatory, built in 1854, was a marvel of the time. Its first director, Franz Brünnow of Berlin, had met University of Michigan president Henry Tappan who was in Berlin to acquire instruments for the new observatory. Tappan convinced Brünnow to come to Ann Arbor, although factors other than academic opportunity may have been play in the recruitment. Brünnow served from 1854 to 1863, was the first UM faculty appointee with a Ph.D., and married the president’s daughter. University politics, the firing of Tappan by the regents, and anti-German sentiments caused Brünnow to leave for the position as Astronomer Royal of Ireland and director of the Dunsink Observatory. [Above: Detroit Observatory, autumn 2018.]

His successor, James Craig Watson also became a big name in astronomy. Born in 1838, Watson came to Ann Arbor with his family from Fingal, Ontario in 1850, obtained a BA in classical languages in 1857, and then fell under the academic influence of Brünnow, succeeding him as director of the observatory in 1863 until 1878. During those years Watson discovered 22 asteroids, wrote the textbook, Theoretical Astronomy (1868), and was a member of important astronomical expeditions including trips to Iowa to see a solar eclipse in 1869 and China to see the transit of Venus in 1874. During a solar eclipse in Wyoming in 1878 Watson thought he saw planetary bodies closer to the Sun than Mercury and was convinced that a planet, he named Vulcan, existed. He believed that an underground observatory would prove Vulcan’s existence.

Michigan wanted to retain him, but didn’t commit to the odd idea of an underground observatory and Watson left for the University of Wisconsin in 1879 as inaugural director of the Washburn Observatory, with expectations of building the underground apparatus. Watson died of peritonitis, perhaps appendicitis, on November 23, 1880, and was buried in Ann Arbor at Forest Hill Cemetery, leaving a great legacy in astronomy. Vulcan proved to exist only in Star Trek and the underground observatory, built by Watson’s successor at Wisconsin, couldn’t find even the brightest stars and was declared useless. The stories of Brünnow and Watson reveal in academic astronomy, what we know so well in academic medicine: the sky is not always the limit in faculty retention. A lunar impact crater on the far side of the moon is named for Watson and underground detectors recently discovered the neutrino. [Photo below: Watson crater on moon. Acquired by Lunar Orbiter 5, 1967. Lunar Orbital Photo Gallery, NASA.]

 

Nine.

November rain. As Ann Arbor cools down and prepares for Thanksgiving, the month sometimes douses us with sobering realism, a sense captured in the musical ballad of Axl Rose, a work in progress at least since 1986 and released by Guns N’ Roses in their 1991, Use Your Illusion, I. The original album cover by Mark Kostabi evoked a detail in Raphael’s The School of Athens, although to me, the album title and the band’s name are more reflective of several works of Rene Magritte. In the larger sense November Rain, reminds us simultaneously of seasonal meteor showers, the complex nature of humanity, and the sobering reality of global environmental deterioration. The School of Athens detail gives some hope that human intellect, best stewarded in schools and universities, can improve the human condition and lead it forward in some harmony with its resource bank and engine, Earth.

[Above: Raphael (1483-1520) Vatican Collections. Below: detail.]

[Below: Use Your Illusion, I, Guns N’Roses, Geffen Records. 1991.]

[Above: Magritte. The Human Condition, 1933. National Gallery of Art, Washington. Below: Magritte, The Survivor, 1950.]

 

Ten.

Biela’s comet was zipping around Earth for a long, long time before it was identified and named by human beings. Baron Wilhelm von Biela (1782-1856), a German-Austrian military officer who fought in the Austrian Army in military campaigns against Napoleon, provided the name. An amateur astronomer, Biela had a keen interest in comets and sunspots. His comet, 3D/Biela, was recorded as an object in the sky in 1772 by French astronomer Charles Messier, but it was Biela who, in 1826, recognized it as a comet with periodicity of 6.6 years. It was spotted next by John Herschel on September 24, 1832, and calculations indicated that it would pass through the Earth’s orbit October 29, leading to dire predictions of catastrophic collision. Only two other comets had been recognized as periodic at that time, Halley and Encke. Biela also identified the Great Comet of 1823, as did Nell de Bréauté in Dieppe, France, and Jean-Louis Pons working in Italy. Biela’s Comet didn’t crash into the Earth, but rather started to break up before its 1845 return and by 1852 it came back in two large distinct sections, both identified by Otto Wilhelm von Struve, a family name familiar to urologists. [Above: von Biela. Below: drawing of Comet 3D/Biela in February 1846 after split into 2 pieces. 1888 book by E. Weiss, Bilderatlas der Sternenwelt. Sources, Wikipedia.]

The comet pieces were not seen on expected return in 1859 or 1865, but on November 27, 1872 a brilliant meteor shower with 3,000 pieces per hour was seen radiating from the predicted comet position and these meteors became known as the Andromedids, for their position relative to the imaginary Zodiac figure, or historically more precisely as the Bielids.

An intact Biela was making its rounds around Earth when the University of Michigan formed in Detroit in 1817, even if not observed in the sky and recorded by anyone at that particular time, yet shortly after the University Medical Department opened up the comet had been replaced by the Andromedids meteor shower a nightly spectacle of hot November rain witnessed by many if not most Michigan medical graduates over the past 168 years.

 

 

October correction: an earlier edition of October Matula Thoughts mistakenly noted Daylight Savings adjustment would end that month, when in fact it ends this weekend on November 4.

 

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

October incongruities and congruities.

 

Matula Thoughts 

Oct 5, 2018

October incongruities & congruities.
3813 words

 

One.

October is an odd month, not just with its odd number of days and shortening hours of daylight, but with unpredictable weather shifts including tropical cyclones, the Atlantic hurricanes and Pacific typhoons. Autumn is already in progress and Michigan is fortunate to witness spectacular foliage displays that peak this later this month. October lacks much in the way of major national holidays. Columbus Day, October 8 this year, is observed variably, in some states, Puerto Rico, banks, school districts, the Postal Service, federal and state agencies, but not generalized nationally or celebrated at Michigan Medicine.

Columbus Day had its start when the Tammany Society in NYC and the Massachusetts Historical Society in 1792 celebrated the 300th anniversary of the Columbus landing. A century later, President Benjamin Harrison similarly highlighted the 400th anniversary. Harrison, notably, was the only president (so far) who was the grandson of a president. Columbus Day became a state-level holiday in Colorado in 1907, in 1934 Franklin Roosevelt designated October 12 a national holiday, and since 1971 it has been set on the second Monday of October. The ambiguous details of European “discovery” of America, problematic from the indigenous people perspective, makes it unlikely that Columbus Day will have a long future as a national holiday. Alternatively, Hawaii celebrates Discoverer’s Day and Vermont declared it Indigenous Peoples’ Day. Native American Day is celebrated by California and Nevada on the fourth Friday of September, while in South Dakota on October’s second Monday. Tennessee observes American Indian Day on the fourth Monday of September and other countries in the Americas have their own origin celebrations.

University homecoming events provide other respites in October, although our Urology Department held its Nesbit Alumni reunion prematurely last month, nearly colliding with our biennial Dow Health Services Research Symposium due to coordination with autumn scientific meetings, religious holidays, and the dominating effect of the home football schedule relegating the 2018 Nesbit Meeting to September’s Nebraska game.

October ends with Halloween, an ancient Celtic harvest tradition, now centered on costumed children prowling their neighborhoods for treats, ostensibly as bribes to withhold pranks. Carved pumpkins or turnips become jack-o’-lanterns signaling target-rich households. Pumpkins are more octagonal than spherical to my eye and Halloween face-carving liberates pumpkin fruit for pies and pepita snacks. [Above: Irish Halloween turnip lantern, Museum of Country Life, Turlough Village, County Mayo, Ireland. Courtesy, Wikipedia. Below: October 2, 2018, Dee Fenner and Red Maple tree, outside Dean’s wing.]

 

 

Two.

Recollections of last month include the opening of Michigan Medicine’s Brighton Specialty Center, a large organizational effort led by John Wei, yielding 300,000 square feet of new clinical space. Anne Cameron did three of the first cases in the Brighton Center for Specialty Care operating rooms. [Above: John Wei at pre-opening ceremony. Below: Anne & OR team September 24.]

Our Dow Health Services Research Symposium #4, directed by Chad Ellimoottil and Lindsey Herrel, featured TED-style talks at Power Center.

[Above: Matt Nielsen University of North Carolina with slide congratulating Lindsey and Chad. Below: Greg Auffenberg (Nesbit 2017), Brent Hollenbeck, Chris Saigal of UCLA, Jim Montie.]

The featured speakers and short abstracts and lightning presentations were first rate, including Preeti Malani and Ken Warner (below).

The flying microphone, shown below with Rod Dunn, livened up the atmosphere. Jim Dupree discussed the successful Michigan Urological Surgical Improvement Collaborative (also below).

The following week Chris Sweeney, of Harvard Medical School/Dana Farber Cancer Institute, gave the Jerry Weisbach Lecture, speaking on clinical trial insights regarding prostate cancer heterogeneity. [Below: Chris & Ganesh Palapattu.]

The Nesbit Reunion, later in the week at NCRC (above), featured Toby Chai, Professor of Urology at Yale (Nesbit 1994) as Nesbit visiting professor who gave two excellent talks.

Our own Matt Davenport was the Nesbit guest speaker. John Wei did a superb job, as Secretary-Treasurer, organizing the program and event. [Above: Toby & Matt. Below: John Wei & Sherman Silber N’73.]

Sherman Silber spoke on “Progress making sperm and eggs from skin.” We also heard Kevin Stone and Brian Stork from West Shore Urology. [Below: Dave Harrold N’1978, Surendra Kumar N’81, Dan Piazza N’79, C. Peter Fischer N’79.]

[Below: Utah Pete Fisher N’06 & son Mitch.]

The Nesbit Tailgate entertained alumni and friends from around the country and the victory over Nebraska completed the weekend. Next year, around this time, we will launch the Centennial of Urology at Michigan. [Below top: Meidee Goh, sister Lindee from Boston, husband David Fry; bottom: Yuting Fan, Sherman Silber, David Burk N’89 & brother-in-law Rupert Baily from North Carolina.]

Next year’s Nesbit Reunion, 2019, will open up the year-long Michigan Urology Centennial.

 

Three.

Octopus, octagon, octogenarian, and October come from the Proto-European h₁oḱtṓw stem for eight, an odd fact given that this is the tenth calendar month of the year. How this came to be is a curious quirk of calendar history.

Lunar phases provided the first “calendars” throughout most of human history, marking time between solar days and solar years using the moon’s regular phases. Lunar phases are still essential for fishermen and sailors to predict tides, noting big swings in tidal amplitude during full and new moons (spring tides) and lesser differences during the quarter phases (neap tides). Etruscans and Romans approximated 8-day weeks to lunar cycles to coordinate commercial markets, political affairs, and holidays, although some fudging was necessary each year to match the solar cycle. An early Roman calendar ran from March through December with lunar cycles that filled up 304 days, exclusive of 51 winter days during an “unorganized expanse” of slack time. [Wikipedia entry Nundinae.] The ten calendar months of Romulus were then: Martius, Aprilis, Maius, Iunius, Quintilis, Sextilis, September, October, November, and December.

Julius Caesar gave us the Julian calendar, bringing Roman calendar years into closer agreement with solar years. He implemented the new system on January first in a year that he had no way of knowing would be 45 BC. The Julian Calendar offered three normal years with 365 days and an intervening leap year of 366 days, to make up for the inexact match of solar days to solar years. The leap day was doubled every fourth year to maintain solar synchrony, but nevertheless the calendar gradually lost its alignment with the solar year and by the time of Pope Gregory XIII in 1582, the asynchrony had drifted to 10 full days. Lawyer and law teacher in his earlier career, Ugo Boncompagni was summoned to Rome by Pope Paul III and served Paul IV and Paul V before election to Pope himself. His term was one of church reform, largely in response to the Protestant Reformation. [Below: Pope Gregory XIII portrait by Lavinia Fontana in list of extant papal tombs. Wikipedia.]

Gregory XIII refined the Julian Calendar by advancing the calendar that year so that 4 October was followed, the next day, by 15 October and using leap year spacing to make the average year 365.2425 days long. The Gregorian Calendar, fixing the 10-day drift and shortening the average year by 0.0075 days, is widely used throughout the world today for business and government. Because of Gregory XIII, the October of 1582 lacked a 5th day and nine others in between. The credit for the math involved belongs to Aloysius Lilius, an Italian physician and astronomer, and Christopher Clavius, a German Jesuit astronomer and mathematician.

Science has proven the actual length of solar days vary, due to tides sloshing around and slowing rotation of the Earth. The solar year (tropical year) in 2000 was 365.24219 ephemeris days, ephemeris time (ET) being defined by orbital period rather than axial rotation of Earth. The Système International (SI) divides an ephemeris day into 86,200 SI seconds. For most landlubbers lunar phases have limited utility, although they still show up on modern wrist watches, that keep us on time.

 

Four.

The regular weekly focal point of our department is 7 AM Thursday, regardless of month, when residents and faculty assemble for conferences where each summer a tide of 4th year medical students begins as rotating “clinical clerks” begin to audition for residency training slots. Students spend a month with us in clinics, hospital rounds, operating rooms, and then make individual presentations at Grand Rounds, having been directed and mentored by residents, fellows, and faculty. The tide recedes when nationwide formal interviews begin in October. [Above: Thursday 7 AM conference.]

Out of around 340 students who apply, around 20 clinical clerks, and 47 who interview, we will match 4 students who will spend their next five years or more with us. The candidate pool is very strong academically and in terms of individual personalities, life experiences, drive, and talents, these students are the best of the best of medical students. The proof is seen in our residents.

It is a tough time to be a medical student and entering medicine. Most students have accumulated egregious debt in the form of student loans. This fact is a black mark on our society. There is little excuse for a large medical school tuition bill, students create enough personal debt with living expenses alone during medical school. Society, particularly that of advanced industrialized nations, can afford to teach its next generation of health care workers. As it is, young doctors spend large fractions of their income paying back their debt (with interest) to banks and other funding sources – money that they would otherwise pump back into the economy through local stores, car dealers, home purchases, and Amazon. Philanthropy too would be served because former trainees in their first years of practice would be more likely each year to give a hundred bucks or so to the institutions that taught them (and even to the Nesbit Society), thus developing “a habit of giving back” rather than trying to stay afloat in the tsunami of educational debt.

The uncertainty of health care economics adds to the difficulty for students, and massive regulatory changes coming from the federal government place academic medicine and all of health care at risk, perhaps the greatest risk in our time. Yet, all times have been tough, and many of the best and brightest people continue to choose medical careers.

 

Five.

Political campaigning heats up in October with elections next month for governor, state legislators, other regional officers, one third of the US Senate, and the US House of Representatives. Voter turnout in the US tends to be around 58% of eligible voters in national presidential election and 40% in mid-term elections. Even less turn out in odd years, primaries, or local elections, indicating that Americans take the responsibility of democracy far too lightly. This fact should disturb us at least as much as the idea of foreign governments messing with our processes (that’s what rough opponents do – so why are we surprised and apparently so defenseless?) Below is a chart from the U.S. Census Bureau.

Our predecessors worked hard and against odds to create a government of the people, by the people, and for the people. The Declaration of Independence is a beautiful and aspirational document that explains why people should be entrusted to their own destiny, The Constitution creates a working framework for government, and its Bill of Rights presents a list of individual protections from authority (with some nonsense that politics mixed into it). A greater cynic might argue, given the voter turnout data, that today’s citizens are not working hard enough to protect foundational elements of western society.

On the other hand, deception has its moments and admits many self-serving hucksters and bad actors to the corridors of power. Voters are often attracted to bright shiny celebrities, single issue extremists, or deceptive campaigns. Trickery is part of the human confection, one classic example being the Trojan Horse of Homer’s stories, although new technologies magnify the possibilities of deception and crowd manipulation. Technology aside, our society has failed to properly educate an informed citizenry capable of critical thinking. Biologic trickery takes many forms, and the octopus is one of the most versatile masters, using camouflage, mimicry, threat, shape-shifting, and environmental opacification. While octopi (scientific order Octopoda) may be the biologic champions, humans are good learners.

[Jens Petersen. Image of greater blue-ringed octopus, Hapalochlaena lunulata. Tasik Ria, North Sulawesi, Indonesia GFDL license. Wikipedia.]

 

Six.

Octoberfest. Beer and political campaigning mingle in October. Octoberfest, as a celebration, dates back to 12 October 1810, when citizens of Munich attended festivities around the royal marriage of King Ludwig I to Princess Therese. Münchners, Munich’s community-folk, gathered peacefully to drink beer, watch horse races, and enjoy a day off work, unless they were helping with the crowd, distributing the food and beer, or organizing the races. Civilization requires organizers, workers, and leaders.

Octoberfest has spread around the world as a respite from routine of work and a chance to celebrate as a community. For some people this is simply an excuse to drink beer, but others enjoy some civic sensibility. Beer and other spirits may help navigate the politics that necessarily attend all communities and the periodic stress of politicking to elect around 500,000 state and national public officials.

Leadership is an unfortunate necessity of human affairs, and over the course of documented history it is evident that most leadership has been self-serving, foolish, and extended the sum total of human misery. Nevertheless, seven billion humans need forms of leadership to organize sports, workplaces, community events, local governments, geographic regions, religions, and nations.

The U.S. Congress on 23 January, 1845 passed “An act to establish a uniform time for holding elections of President and Vice President in all the States of the Union.” The Tuesday after the first Monday of November was selected and that date continues to this time. Federal elections occur only in even-numbered years, and presidential elections take place every four years. October, the heaviest month of campaigning, is exhilarating for many people as evidence of the aspiration of “government of the people, by the people, and for the people.” Election day is a public holiday in some states and territories, but not Michigan. November 5 is our next election day.

 

Seven.

October fiction. October Country, the name of a 1943 Ray Bradbury collection of stories, conveys a sense of the oddness of October. The introductory “mini-story,” The Grim Reaper, in the modern paperback version, is a stark commentary on modern humankind in the mid-20th century. [Bradbury. The October Country. Del Rey Ballantine Books, NY. 1996.]

Bradbury used the title, The October Country, as a metaphor for that time of the year when people and places become melancholy with thoughts and preparations for winter. His dystopian novel, Fahrenheit 451, imagines the dark winter of an authoritarian society where free speech no longer exists. The 1966 Francis Truffaut film version with Julie Christie was a classic in its own right. Bradbury (1920-2012), along with Isaac Asimov, Arthur Clark, Robert Heinlein, and Stanislaw Lem carried science fiction into the literary mainstream according to a 2012 obituary [Gerald Jonas, NYT, June 6, 2012.]:

“The futuristic world envisioned by Bradbury among others is coming fast upon us, compelled by the erosion of democracy and the ascendency of technology. We not be able to curtail the latter, but we should be shamed by our pathetic efforts as a species to build and disperse democratic institutions and human rights.”

Machine-learning algorithms, even those multi-layer “neural” networks capable of “deep learning,” in my opinion can ever equate to human intelligence. Programs and systems are built by people susceptible to particular ideologies, biases, “isms,” greed, and other intoxications that plague everyone and their clever systems invariable reflect some, but not all particularities. These algorithms are already in play in our lives and will become increasingly pervasive with autonomous capabilities in many sectors of our lives, however we must be cautious of accepting artificial intelligence (AI) as a substitute for human authenticity. How can AI distinguish between fact and true facts, given the mutability of fact and truth and their continual arbitration, in “real time,” by human values, science, and consensus? A cynic might argue that AI shouldn’t be expected to distinguish between facts and true facts if most humans can’t do so.

Ian Fleming’s final James Bond book, the 14th in the series, Octopussy and the Living Daylights, was a collection of short stories published posthumously in 1966, originally with just those two stories, but later including The Property of a Lady and also 007 in New York. The first story and provided the backstory for the film Octopussy, with Roger Moore in 1983. A pet octopus, owned by the villain, give that story its name and elements of the other stories found their way into other Bond films.

 

Eight.

October tides. Back in the times of the earliest wine and beermakers, days were defined by sunrises and sunsets, tides and lunar phases framed the weeks, and sun and star positions marked out months and years. It must have taken a leap of faith for early thinkers to convince themselves that something as far away as the moon could physically move the massive oceans of earth, but the tidal relationships to moon and sun were recognized as early as the second century BC by Hellenistic astronomer Seleucus of Seleucia who linked tides to lunar position, with height of tides depending on the position of the moon relative to the sun.

Tide tables were made for tourists in China in 1056 so that they could coordinate visits to the legendary tidal bore of the Qiantang River. Due to the mismatch in size between the Hangzhou Bay and Qiantang (Tsientang) River, this daily occurrence with 30 foot tides moving at 25 mph, can double in size when the moon and coincidental typhoons align. This has been celebrated for thousands of years during the 8th month of the lunar year, known as the Mid-Autumn Festival. [David K. Lynch. Scientific American. January, 1982. Alan Taylor. The Atlantic. Sept. 20, 2016.]

Newton may have been deemed a tidal bore when wrote the essay Discourse on the Tides, in 1616 in a letter to Cardinal Orsini and later used calculations and his theory of universal gravitation in Principia in 1687 to explain the tidal influences of sun and moon. Great Lakes tides at their greatest reach 5 centimeters, although much larger standing waves called seiches, caused by wind and atmospheric pressure, are mistaken for tides.

 

Nine.

Tecumseh, Harrison, and the Battle of the Thames. The Thames River in Ontario comes to mind in relation to a famous Native American who died on this day, October 5, 1813. We have many referrals for patient care from our neighboring town, Tecumseh, and while I vaguely recognized this as a Native American name, I knew little until I looked it up and learned this day is the anniversary of a battle in 1813 when Chief Tecumseh was killed at the age of 45. An American Shawnee, he was born in Ohio Country and he grew up amidst the American Revolution and the Northwest Indian Wars. He became a great leader, compelling orator, and staunch advocate for tribal unity.

Tecumseh’s War in Indiana Territory between his American Indian confederacy and the U.S. began with a confrontation in 1810 at Grouseland, the home of William Henry Harrison, governor of the territory. Conflict continued with a defeat for the multi-tribal confederacy at the Battle of Tippecanoe in 1811, and spilled over into the War of 1812 after Tecumseh formed an alliance with Great Britain that helped capture Fort Detroit. After the fledgling U.S. Navy gained control of Lake Erie in 1813, the British and multi-tribal confederacy retreated into Canada, where American Forces engaged them at the Battle of the Thames (also known as the Battle of Moraviantown) and Tecumseh was killed.

[Above: Tecumseh, attrib. Owen Staples. Toronto Public Library. Below: Tecumseh’s War map by Kevin Myers, Wikipedia.]

[Below: Battle of Tippecanoe. Alonzo Chappel Collection, Smithsonian Institute.]

With the death of Tecumseh, the confederacy collapsed and Detroit returned to American control, where only four years later the University of Michigan would be established. Most native Americans were eventually pushed west of the Mississippi.

Harrison considered Tecumseh remarkable, once calling him a genius. With soaring popularity after the War of 1812 Harrison became U.S. House Representative in 1816 and Senator in 1825, truncated by appointment as Minister Plenipotentiary to Gran Columbia in 1828. He returned to private life in Ohio at his farm, but was prompted to make a few runs for presidency, ultimately winning and becoming ninth American President in 1841, the last president born before the Revolution.

Harrison’s term was short-lived as Harrison was sworn in on 4 March 1841 and died of pneumonia a month later. Vice President John Tyler assumed office, but a constitutional crisis concerning succession lingered for more than a century until resolution by the Twenty-fifth Amendment of 1967. Tyler was the son of Founding Father Benjamin Harrison V and the paternal grandfather of 23rd U.S. President Benjamin Harrison, who nationalized Columbus Day.

It might be argued that the choice of our ninth president was a risky one from the point of health vulnerability, at age 68 he was the oldest sworn into office until Ronald Reagan in 1981 at 69. On the other hand, far younger presidents and major political leaders have been cut short by disease or assassination, so perhaps age should be a minor consideration for long range leadership. Representative democracy seems a far better method of leadership selection than royalty, birthright, or sectarian succession, but genetics (or epigenetics) always seems to be lurking behind the scenes as the American presidency has shown through Adams, Harrison, Roosevelt, and Bush.

 

Ten.

Octopus traps and Halloween spiders. Matula Thoughts often seeks threads or themes, sometimes risking belaboring a point or putting too fine an edge on a detail, such as comparing pumpkins to octagons, or relating October to medicine. Of course, October 16, 1846 was the first demonstration of general anesthesia.

A stretch to the octo stem brings in Takotsubo cardiomyopathy, a non-ischemic heart crisis of sudden temporary weakening of the muscle also known as stress cardiomyopathy, transient apical ballooning cardiomyopathy, or the broken heart syndrome, and leading to acute heart failure, lethal ventricular arrhythmias, or ventricular rupture. Most cases (85%) are set in motion by severe physical or emotional distress that causes myofibrillar degeneration. The first studied case was by Sabo et al in Japan, reported in 1991, and the name came from the traditional octopus traps used by Japanese fishermen, setting them out when the tides were favorable. [Yoshihiro YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo cardiomyopathy. Circulation. 118:2754, 2008.] [Below: octopus traps, Wikipedia, public domain.]

Octopi aside, eight doesn’t have a heavy presence in biology, Stedman’s Dictionary expends barely a half a page to words beginning with oct. Although spiders and ticks (larger category = class, Arachnida) have eight legs, octo hasn’t tainted their names. Spiders rank seventh in species diversity among all organisms, with nearly 90,000 species compared to 300 species of octopi, and our single human species. Spiders (biologic classification order, Araneae) have enormously complex genomics and have a universal ability to make silks and venoms. [Pennisi. Science. 358:288, 2018.] Spiders scare kids and are completely congruous with Halloween, so be prepared with shock, awe, and a basket of treats when permutations of 8-legged creatures knock at your door at the end of this month. [Below: Marvel Spider-Man symbiote suit.]

 

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

Sunrises, sunsets, & summer imaginations

Matula Thoughts Aug 3, 2018

Sunrises, sunsets, summer imaginations & facts

3951 words

One.

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

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

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

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

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

 

Two.

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

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

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

 

Three.

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

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

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

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

 

Four.

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

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

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

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

 

Five.

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

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

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

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

 

Six.

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

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

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

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

 

Seven.

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

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

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

 

Eight.

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

 

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

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

[Above: Martha Bloom, George and Peggy.]

 

Nine.

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

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

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

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

 

Ten.

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

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

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

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

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

 

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

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

Birthdays, graduations, and centennials

July 6, 2018

Birthdays, graduations, and centennials
3678 words

One.


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

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

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

 

Two.

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

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

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

 

Three.

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

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

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

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

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

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

 

Four.

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

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

 

Five.

 

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

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

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

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

 

Six.

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

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

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

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

 

Seven.

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

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

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

 

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

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

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

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

 

Nine.

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

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

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

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

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

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

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

 

Ten.

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

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

Thanks for reading Matula Thoughts this July, 2018.

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

 

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

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

Rules, boundaries, and stories

DAB What’s New June 1, 2018

Rules, boundaries, & stories

3722 words

 

One.

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

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

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

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

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

 

Two.

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

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

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

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

 

Three.

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

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

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

 

Four.

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

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

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

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

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

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

 

Five.

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

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

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

 

Six.

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

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

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

 

Seven.

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

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

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

 

Eight.

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

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

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

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

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

 

Nine.

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

 

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

But now back to 2018.

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

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

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

 

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

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

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

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

 

Ten.

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

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

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

 

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

Mays and blues

DAB Matula Thoughts May 4, 2018

Mays, blues, & other thoughts
3855 words

 

One.

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

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

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

 

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

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

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

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

 

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

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

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

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

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

 

Four.

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

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

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

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

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

 

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

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

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

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

 

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

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

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

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

[Below: Jean and Mary DeKernion.]

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

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

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

 

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

[Above: Grady Festschrift group photograph.]

 

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

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

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

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

 

Eight.

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

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

 

Nine.

 

 

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

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

 

 

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

[Above: The Rock.]

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

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

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

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

 

Thanks for reading Matula Thoughts.

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

November matters

DAB What’s New Nov 3, 2017

3742 words

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

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

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

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

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

 

Two.


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

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

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

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

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

 

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

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

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

 

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

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

 

Five.

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

 

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

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

 

Seven.

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

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

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

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

 

Eight.

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

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

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

 

Nine.

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

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

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

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

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

 

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

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

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

[Autumn foliage, my neighborhood 2017]

 

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