Matula Thoughts May 6, 2016

DAB What’s New May 6, 2016

Matula Thoughts Logo2

(3948 words)

 

Carl

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

 

 

One.           May, at last.

May 2015

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

 

 

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

 

 

Three.           UMMS graduation.

Cropsey copy

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

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

UMHS

[UM Health System 2016]

 

 

Four.           Role models.

JOW & MJ

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

MR

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

Family Doc

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

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

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

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

 

 

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

Stutzman, DAB, McLeod

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

 

 

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

 

 

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

 

 

Eight.           Harvey & hearts.

Screen Shot 2016-04-26 at 4.28.40 PM

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

Screen Shot 2016-04-26 at 4.32.15 PM

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

 

 

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

Baylor fac & DAB

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

Res Conf


Boone & Bloom

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

Roth & Miles


Chester

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

Residents dinner

[Below: Michael DeBakey, museum photo]

220px-Michael_DeBakey

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

 

 

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

Bradford, Carol

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

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

Matula Thoughts December 4, 2015

DAB What’s New/Matula Thoughts

December 4, 2015

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

3140 words

 

 

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

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

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

 Feed the world 

 

 

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

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

 

 

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

WoodrowWilson

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

 

 

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

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

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

 

 

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

Wheat & Wang

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

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

 Carol Greider

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

 

 

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

World Nov 24

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

Histo Nov 24

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

Band-Aid

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

 

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

JOW Bill Kelly

Clin chairs JOW

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

 

 

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

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

220px-George_Eliot_BNF_Gallica

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

 

 

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

 

 

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

Syrian toddler

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

 

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

David A. Bloom

Matula Thoughts September 4, 2015

DAB What’s New/Matula Thoughts September 4, 2015

 

Matula Thoughts Logo1

Labor & laborers: “Individual commitment to a group effort – that is what makes a team work, a society work, a civilization work.” Vince Lombardi

[This monthly email to faculty, residents, staff, alumni, and friends of the University of Michigan Medical School Department of Urology is alternatively published as an email called What’s New]

3914 words

 1.    September returns a serious tone to the calendar and recent world market volatility adds to the sobriety. With vacations over we buckle down to the work of a new academic year in our evolving academic medical center. The fiscal year has already been in play for 2 months and the numbers look good so far.

Screen Shot 2015-08-29 at 11.51.55 AM

Our Faculty Group Practice, now known as the UMMG (UM Medical Group), is figuring out how to deliver the best care we can in nearly 150 Ambulatory Care Units attuned  to our other missions (education and research), to our inpatient functions, and to the needs of our environment. The UMMG Board meets monthly and delegates operational details to 4 key committees (Executive Committee, Budget & Finance Committee, Clinical Practice Committee, and the Bylaws Committee). [Picture above: David Spahlinger our Executive Associate Dean for Clinical Affairs and Director of the UMMG with Philippe Sammour, Senior Project Manager UMMG. Picture below: UMMG Board of Directors – August 2015]

Screen Shot 2015-08-29 at 11.34.38 AM

The UMMG is a multispecialty group practice of more than 2000 faculty with many other providers and staff in well over a hundred specialties and areas of precisely detailed expertise. The coordination of all these practices among our clinical departments and within our health system at Michigan is a work in progress – and the progress is good. As large as we are, however, we are too small to fulfill the expectations of the patient population we serve today and too small for our research and educational aspirations for tomorrow. Given a steady increase in clinical volume of 6% a year for many years, without infrastructure growth to match, we find ourselves deficient today in terms of clinic facilities, hospital beds, operating rooms (12 short by recent analysis of our daily needs), faculty (at least 250 FTEs short for today’s clinical volume), faculty offices (550 too few today), etc. We also fear that we may be too small to matter in the grand scheme of health care as it is evolving nationally in the face of the Affordable Care Act and the consolidation of networks. In spite of all these problems we are still pretty good compared to our peer institutions as things stand, although modest impending changes in our health system structure and governance will likely bring us much closer to realizing our potential as an unsurpassed integrated health care system and academic medical center – an effective team, a leader, and one of the few truly best. At the University of Michigan we often refer back to our great coach, Bo Schembechler, for his inspiring phrases, notably: “The team, the team, the team.” A fellow great coach, Vince Lombardi who died 45 years ago as of yesterday, echoed some of the ideas of Adam Smith the lead quote this month.

2.     September began last Tuesday and meteorological autumn in the Northern Hemisphere starts this month. Farmers traditionally begin the harvest, schools come into session, and the workday, as we noted, becomes a little more serious. Labor Day anticipates the seasonal transition and brings to mind Adam Smith who famously observed (with the examples of the butcher, the brewer, and the baker) that civilization requires specialization of work, although two millennia earlier Hippocrates made a similar recognition that medical practice requires specialization. In the Hippocratic world that first particular brand of work happened to be urology, manifested back then as lithotomy – the cutting for (bladder) stone. Were Hippocrates to visit us today at UMMG in a time machine, the only specialty he would recognize out of the hundred plus areas of practice would be urology – the single specialty he deferred to “specialists of that art.” The knowhow involved with cystolithotomy was rightly described as an art, just as the practice of medicine today is often still called an art. Artists go even further back in time: cave-dwelling paintings, long before Hippocrates, prove visual artists were among the earliest branches of the human labor force.

 

3.    Sept Heures

We previously have commented on the beautiful monthly panels illustrated by the Limbourg brothers in a book of prayers called The Très Riches Heures du Duc de Berry. Brothers Herman, Paul, and Johan were Dutch miniature painters from the city of Nijmegen active in early 15th century in Europe. Like Diego Rivera, closer to our time, the brothers travelled to the best sponsors who could commission their art. In 1416 the artists and the Duke of Berry died abruptly (likely from a plague pandemic) and their ambitious Très Riches Heures was completed by others. The September panel, shown above, features a harvest with 5 people picking grapes, while a man and pregnant woman seem to be supervising (the managers?). The grapes are placed in baskets, transferred to mules, then moved to oxen carts. Presumably the actual wine-making processes took place within the castle walls along with other trades and crafts. A fair degree of work specialization was evident at the Castle of Saumur there in the France’s Anjou wine region. Worker productivity was of immediate concern to the Duke or whoever was in charge of the castle, with carrot and stick as the time-honored means of motivation.

 Feb 1848

[February Revolution in Paris at l’Hôtel de Ville. HFE Philippoteaux at Carnavalet Museum]

It was over 500 years later in France before the rights of workers achieved their due attention. The head rolling of the French Revolution was evidence of the disequilibrium between workers and those in charge of them, but it was not until 1864 that French workers obtained a legislated right to strike and in 1866 the right to organize. Louis-Napoleon Bonaparte, nephew of his namesake, was the force behind these workers’ rights. His big moment had come in 1848 when the February French Revolution (an aftershock of the big one in 1789) allowed him to change places in exile in England with the deposed King Louis Philippe who had lost the trust of the citizens. Louis-Napoleon then became France’s first president by popular vote in February, 1848. When his term of office ended in 1852 and he found a second term blocked by the Constitution and Parliament, Louis-Napoleon conveniently organized a coup d’etait, re-naming himself Napoleon III and reigning as Emperor until 1870 (coincidentally wrapping up that term on this calendar day – September 4).

Napoleon III

[Napoleon III by A. Cabanet. At Musée du Second Empire. Compiègne]

 

 4.     In the heyday of industrialization some types of work were especially dangerous and abusive, although workers had little recourse to ask for safe conditions or fairness. Labor unions arose to occupy the need to balance the worker and employer disequilibrium. Labor Day, to be celebrated next Monday, is a marker for this necessary balance. Forward-looking businesses today embrace the belief that workers themselves are the best source of workplace knowledge and have the best motivation to make better products, with greater efficiency and greater satisfaction for critical stakeholders. This idea is intrinsic to lean process systems that represent the newest evolutionary step in the human labor force. Enlightened leaders have come to realize that the health and happiness of workers are linked to productivity, but more importantly are human rights as well.

Unionization of dangerous occupations makes more sense than unionization of less risky trades – think mine workers versus postal workers – yet, work is work and few can argue that any worker can be abused by any manager or any system. The recent exposé of alleged management abuse of workers at Amazon illustrates this point. Nonetheless, unionization of white collar cognitive professions takes some explanation for, by their very nature, professions have their own intrinsic protections. When professions are commoditized, however, and their members believe themselves treated poorly, unionization becomes a rational step. Unionization of professions might not be necessary in a perfect world, but this world is far from perfect. The Eastern Michigan University faculty are unionized, for example, while the University of Michigan faculty are not. While I am no authority on the EMU story, that particular unionization was likely a direct result of faculty grievances against past administrations. At the University of Michigan, though, the nurses, houses officers, many hospital employees, graduate students, and lecturers are represented by unions. The bottom line is the old story that power has a corruptive tendency and a just equilibrium must exist between labor and management.

EMU AAUP

[Ann Arbor News, August 12, 2015. The 690 EMU AAUP Professors reach a tentative agreement for annual 2.5% raises, changes in health care payments, administrative support, and research incentives]

Administrators and leaders can become self-important and smug (urology chairs are not immune). In the words of the respected Stanford business professor, Robert I. Sutton, some managers are worse than jerks, if you accept the use of his term in his book title.

Sutton RI

[Sutton RI, The No Asshole Rule. 2007 ]

 

5.     All people, governed or managed, need to believe that they are being treated fairly and that their voices are taken seriously by leadership. No employee can expect to agree with all organizational decisions, but an overall sense of fairness and responsiveness to individual opinion must pertain. Fairness is a fundamental human belief, evident too in many of our fellow primates plus some other mammals, but unique for humans among the eusocial species (bees, ants, etc.), as mentioned here last month in regard to E.O. Wilson’s work. Beliefs and language govern us with greater sophistication than the governance by pheromones and patterned behaviors of the other eusocials. We shouldn’t disparage pheromones, however, as they provide colonies the ability to react to observations of its individual members monitoring the challenges and opportunities of the environment. In this way the colony becomes a superorganism. We humans have infinitely greater communication tools to govern and regulate ourselves using facial expressions, noise, language, audible conversations, writing, music, visual art, customs, manners, beliefs, laws, and other ways of conveying information. When the public shares a general perception of fairness, civil harmony is likely to pertain, if not hell can break out. Just as corrosive to society as abusive work, perhaps even worse, is the inability to find work. A few weeks ago I heard the author Walter Mosley being interviewed on NPR by Renee Montagne about his experiences as a 12-year old boy in Watts during the riots of 1965, just 50 years ago. Mosley said, simply: “You could feel the rage”  – a statement capturing the raw emotion that exploded on the streets after a young man was arrested for drunk driving. [NPR. Morning Edition. Renee Montagne: Walter Mosley remembers the Watts Riots. August 13, 2015] Ten years after the riots I rotated from UCLA to Martin Luther King, Jr. Hospital in Watts and the effects of the riots were still present physically on the streets and emotionally among the people. My time at MLK was personally and educationally a good experience, I liked the hospital and its gritty esprit d’corps. It was quite a contrast to UCLA’s upscale Westwood campus. The full time staff at MLK felt a part of the community, where the daily struggles were still too often very raw. I didn’t fully understand the rawness then. A new book, Between the World and Me, by Ta-Nehisi Coates however, brings one closer.

 

6.     The first French Revolution of 1789-99 was not the only time in history when it people’s opinions mattered and we see evidence of the power of public opinion again and again. Wise political leaders, administrators, and managers understand that protests, strikes, riots, civil disobedience, or revolutions are unfortunate recourses when public opinion and leadership clash. Political lobbying, referendums, and orderly change of representational governance are more civilized, kinder, and less wasteful. Opinion surveys are another tool to understand stakeholders, with the first documented opinion poll occurring in 1824 when a Pennsylvania “straw poll” found Andrew Jackson leading John Quincy Adams 335 to 169 in the presidential race. Jacksonian democrats thought they had the election in the bag.

John Quincy Adams

[JQ Adams’ daguerreotype c. 1840s; Smithsonian Archives. Although Jackson had more popular votes and expected to win, Adams, a great statesman and politician, gained the support of Henry Clay to win the presidency, serving from 1825 to 1829, when Jackson finally gained the position]

A straw poll is a figure of speech referring to a thin plant stalk held up to the wind of public opinion to see which way it is blowing. George Gallup in Iowa in 1936 added science and statistics to the methodology of opinion sampling. Elmo Roper and Louis Harris entered the field of predictive polling around that time. Perhaps the darkest day for that business was the mistaken prediction of Thomas Dewey’s “defeat” of Harry S Truman in the 1948 presidential election by 5-15 percentage points. Although Gallup explained his error by noting that he concluded polling three weeks before election day, his humiliation endured, demonstrating to us once again that numbers are mere human inventions that may (or may not) approximate reality. All data must be viewed with suspicion, no numbers or numeric manipulations are sacrosanct.

 Deweytruman12

Some thoughts on surveys, but first, a disclaimer: I don’t like spending time on surveys and am quick to delete requests for them in my email. Personal bandwidth in this “age of information” is crowded and in clinical medicine the crowding is especially intense. Last winter I decided to try to list email requests for surveys consecutively over the prospective calendar year, but my effort lasted less than 3 weeks. I gave up after more than 2 dozen such well-intended requests whether from the medical school, the health system, the university, colleagues from other institutions, my professional organizations, etc. The proliferation of surveys, however, is not a bad thing, but rather a reflection of democratic society; others care what we think. Many stakeholders in our work and community want to assess their services to us and hope to discover our opinions of their contributions. The fundamental problem is not their curiosity, but rather our limited bandwidth. No one can satisfy all the requests: you must pick and choose.

 

 7.     Just about 50 years ago at this time of year, the Rolling Stones released their hit song “I can’t get no satisfaction.” Written by Mick Jagger and Keith Richards the lyrics referred to sexual frustration and commercialization.

220px-Satisfaction-us

Who would have believed that 50 years later the matter of satisfaction in health care (on the part of patients, providers, and employees) would be major matters of national attention? When I was an associate dean, Gil Omenn and Doug Strong asked me to create a faculty satisfaction survey. After a few reminders, I did this with Skip Campbell, aiming for a very brief set of less than 10 questions to assess satisfaction of the faculty regarding their work and environment. To convince faculty to fill this out we sent out a cogent personal initial request with a few reminders and provided a generous window of time. The response rate turned out quite good. Widespread dissatisfaction was discovered concerning the faculty’s ability to deliver the clinical care they deemed appropriate. This data was an important factor in shaping the transfer of ambulatory care management from the hospital administration to a “faculty group practice.” The information obtained also gave the dean an ability to assess the general “faculty temperature” and understand relative degrees of satisfaction in each department. Since then, the faculty satisfaction survey has been shaped to ascertain more granular information at specific worksites and it has grown in size and complexity. Currently at Michigan we have a number of additional  “satisfaction” surveys, but the following ones affect us most directly.

a.)     Faculty satisfaction survey. Take this one seriously – it is important to us. Variances from our past numbers or from other departmental data are  analyzed carefully by the dean, leadership, and our fellow departments.

b.)     Employee satisfaction survey. This gauges how the tens of thousands of employees in the medical school and health system view their work lives and work places. We examine the details at many levels in our administrative hierarchy. The dean also discusses this data with chairs in the yearly evaluation process.

c.)     SACUA administrators survey. This comes from the University of Michigan Faculty Senate and queries faculty about their immediate administrators (in our case, this is me) and all the others in the long line to and including the president. Medical School participation in this has generally been weak, perhaps indicating faculty sense of remoteness from the central campus.

d.)     Patient satisfaction surveys are increasingly tied to clinical re-imbursement. Initially the UM Health System used Press Ganey surveys of patient encounters. This company has a 30-year history of healthcare experience and the consistency of data was useful for year-to-year comparisons, but we are now constrained to switch to the HCAHPS (Hospital Consumers Assessment of Healthcare Providers and Systems) survey, provided by vendors on behalf of CMS. The change disconnected us from our historic data. HCAHPS queries a random sample of patients 48 hours – 6 weeks after discharge and asks 27 questions related to their hospital experiences.

e.)     Those pesky reputation and quality surveys.  The US News and World Reports surveys not only rescued a dying newsmagazine, but also galvanized attention and resources of every major health care system and medical school in the country. How do we stand in 2015 national rankings?  Our Department of Urology is number 10 nationally.

Retreat

[Above: Urology Department Spring Retreat, realigning ourselves and listening to each other]

Our Medical School stacks up as #5 for primary care and #10 for research.  Our Hospital ranked number 10 in pediatric specialties and number 11 in adult specialties (in spite of our stubborn determination over the past 16 years to avoid joining the “nurse magnet hospital” list).

Recent “quality” ratings such as ProPublica are attracting attention. These low hanging fruits of public data commercialization to date offer incomplete information and lack meaningful context. While these products may have commercial and titillational value, on the scale of meaningful data so far they set the bar at the left end (near zero) of the Likert Scale. By the way, the originator of the Likert Scale, Rensis Likert, was a UM alumnus who died 34 years ago as of yesterday (September 3, 1981) at age 78 of bladder cancer here in Ann Arbor. He is buried at Forest Hill Cemetery, just a short walk from our offices. More on him in a future What’s New/Matula Thoughts.

 

8.     It is wonderful to see a resurgence of high quality labor in Detroit and Shinola is a premier example. Shinola shoe polish originated as a brand in 1907, was trademarked in 1929, and became popular during WWII.  Anyone who was in the military then and for a generation thereafter usually had a can of shoe polish at hand because shoes were expected to have a high shine, outside of combat conditions. A spit shine was literally obtained by spit. (When I was in the Army, however, newer permanently glossy black shoes became available and all you had to do was wipe them clean.) During WWII a colorful phrase developed around Shinola, although its author will probably remain forever unknown. The phrase compared Shinola to a bodily output usually more formed than spit, although much less acceptable in public, even at baseball games or on sidewalks. The phrase established a basic measure of intelligence as the ability to discern that aforesaid product of elimination from Shinola shoe polish. The concept was captured beautifully in a scene in the classic film, The Jerk, with Steve Martin. [The Jerk, 1979, Directed by Carl Reiner] Anyway, in 2001 a venture capital firm in Dallas, Bedrock Marketing, acquired the name Shinola and began manufacturing watches, bicycles, the shoe polish, and leather products – all made in America and usually in Detroit. The company also produces a high-quality note pad that, unlike that of most competitors, has paper that doesn’t “bleed” with fountain pen ink. The pads are made here in Ann Arbor by Edwards Brothers-Malloy. Shinola headquarters in Detroit is in an Alfred A. Taubman Building. Of course that building’s name is well represented on our University of Michigan campus and especially in the medical school. Alfred passed away last year after an extraordinary life that continues to impact us so positively on our campus.

 

9.    Shinola

In this era of expensive but disposable athletic shoes, the well-shined shoe is less common than in the first Shinola era. My old chief of surgery at UCLA, Bill Longmire, would express visible distaste for sloppiness among his house officers, and sloppy shoes were quick to catch his eyes. Army experience made me an average shoe shiner and I still keep polish and a brush in the office. When I am on the road as a “travelling salesman” on behalf of our department I generally give myself time at the airport to see Rick Jackson, a shoe professional I’ve known for 30 years. Rick is at his job daily opposite gate 47 in Detrot’s McNamara Terminal and one of his chairs is my preferred place to sit and converse while at the airport. Rick also keeps track of fellow traveller urologists, such as Mani Menon. Stop by sometime and let Rick make you look more presentable. [Below: our own Gary Faerber and Dan Hayes of Hematology Oncology with Rick]

 Rick

 

10.    Historically in the University of Michigan Health System, as well as at most other large health care systems, health care workers labored in disequilibrium with administration. All well-intended specialists in the health care labor force (physicians, nurses, managers, residents, hospital employees, researchers, administrators, unionists, etc.) pushed their agendas, but too often the ultimate agendas of patient care, education, new knowledge, and worker satisfaction were side-tracked. Full and effective faculty participation in the daily management of clinical work as well as strategic planning and deployment was an idea advanced here in the 1990s by Mark Orringer, but soundly rebuffed by the dean and hospital administration back then. The concept had legs, as it might be said, for it is a sensible Darwinian evolution and certainly in tune with the modern industrial ideas of lean process systems. The Faculty Group Practice (FGP) emerged around a decade later and has proven successful in its limited application to our ambulatory (outpatient) activities. In practice, however, the division of clinical work into ambulatory and in-patient spheres is artificial and ultimately counter-productive to our real goals of clinical excellence, safety, efficiency, ideal patient experience, education, new knowledge, and ultimate job satisfaction for all employees. With our current EVPMA, Marschall Runge, we sense new alignment of our health system structure and governance. (Marschall, by the way, is the grandson of a 1918 UMMS alumnus.) The FGP, now the University of Michigan Medical Group (UMMG), hopes to be a cornerstone in the alignment of all essential facets of our academic medical center to fulfill those elusive goals of clinical excellence and mission optimization as mentioned above. We should be able to accomplish this here at Michigan as well or better than any other place on the planet. Our history has set that precedence, our people are as good as they come, and we have, I hope, the collective will and drive to come together and get it done now that September is here.  

 Runge, Johnson

[Two UM health care laborers, a cardiologist and a gynecologist/obstetrician: Marschall Runge & Tim Johnson]

 

Best wishes, thanks for reading What’s New/Matula Thoughts and happy Labor Day.

David A. Bloom

 

Matula Thoughts August 7, 2015

Fair weather, formicidae, fables, and funambulism

3415 words

 

 1.   Brehm

August in Ann Arbor with long days of sunlight, warm breezes, and summer clothing is especially sweet by contrast to our winter days. Thanks to generous rains filling our rivers and refreshing the ground water Ann Arbor’s August is immersed in green. [Above: view from the roof of the Brehm Tower of Kellogg Eye Center. Below: kayaks by the Huron]

Kayaks

Birds, cicadas, tree frogs, and lightning bugs create accidental symphonies of sound and light in my neighborhood. Summertime in the Northern Hemisphere brings a measure of balance, relaxation, and sunny public spaces. Vacation allows time to recharge and summer in Ann Arbor is pretty much as good as it gets for doing that.

Golf

[Michigan Stadium from Ann Arbor Golf Outing]

August in parts of Europe is almost entirely set aside as vacation time for many workers, whereas in North America “work-life balance” is stricter with a week or two of vacation, plus the long weekends of Memorial Day, Fourth of July, and Labor Day. These thoughts remind me of an animated cartoon that I loved as a kid called the Grasshopper and the Ants, an ancient fable of Aesop recast by a young Walt Disney in 1934 in The Silly Symphony (you can find it on YouTube – it runs 8 minutes).

220px-The_Grasshopper_and_the_Ants

The gist of the story was that a grasshopper had fun and played all summer, while the neighboring ants aligned industriously to work throughout the sunny days storing up food and preparing for winter. When winter came, the cold and hungry grasshopper realized his sorry situation and came begging to the ants for food and shelter. According to Disney’s version, after a momentary reprimand the ants kindly took in the pitiful grasshopper who then entertained them with his fiddle over the winter. In the Aesopian corpus this story is The Cicada and the Ant (classified as Perry 373). The simplistic moral to the story is a useful lesson for children, but humans, unlike ants, need vacations; motivations in the human sphere differ from those in ant land.

 

2.   Screen shot 2015-07-18 at 9.09.21 AM

[EOW by DAB 2002]  

Ants and humans, E.O. Wilson teaches us, are among the very rare eusocial species on Earth. These colonial animals live in multi-generational groups where most individuals cooperate to advance the public good and to perpetuate the species into the next generation. In effect, their colonies are superorganisms that transcend  individual biologic lives and create civilizations turned over to successive generations. The meaning of individual lives, then, is simply to be found in their contribution to their tomorrow and the tomorrows of their successors. Ants accomplish this work by communicating via pheromones, chemical signals that Wilson and his collaborators elucidated. Pheromones, added to genetic and epigenetic capabilities, vastly enhance the ability of eusocial organisms to deal with and transmit information. The human luck of spoken and written language allows us to process information (sensory, narrative, and numeric), work cooperatively, and create new information that we deploy and pass along to successive generations. The cultural and scientific ways of thinking that emerged from language have produced creativity that has changed the Earth. Whereas internal motivation and environmental pressures inspire personal creativity, it is largely personal and political freedom that allows its dissemination, thereby expanding civilization intellectually and materially.

Tai Che 2

It is a beautiful thing to see people acting in harmonious synchrony. This picture I took outside the de Young Museum in San Francisco this spring shows a display of T’ai chi (太極拳), a Chinese martial art practiced for its health effects, focusing the mind for mental calm and clarity. No pheromones or visible rewards motivate this alignment, the motivation is internal. T’ai chi is lovely to watch, the harmony and synchrony registering pleasurably in the hardwiring of our brains. This is the stuff of art, the deliberate work of other people that we admire and that sometimes astonishes us. You can find beauty in a myriad of other aligned performances. The Stanley Cup playoffs are one example of exquisite and harmonious alignment of teams. Surgical procedures may fall into this realm; it’s interesting that in Great Britain the operating room is referred to as the surgical theatre. When synchrony is harshly enforced, however, as in the dark vision of industrialism depicted by the Diego Rivera murals in Detroit or the failed experiments of communism, alignment is not so pretty. 

 

3.  Diego Rivera

The cartoonish stereotype of disheartened industrial assembly line workers in the Rivera murals has been reinforced by generations of business schools and accounting management ideology. The belief was that managers should determine work-flow methodology and set production targets as if assembly lines were machines to be sped up or slowed down as managers deemed necessary. This is the essence of accounting-based management. The Toyota Process System, now embraced world-wide by forward-looking businesses as lean process methodology, turns this paradigm around, having shown that where workers are empowered to think, innovate, and take pride in their work, better products, greater efficiency, and customer satisfaction will result. Ironically, Toyota’s innovation was initiated over 60 years ago when the company’s founder visited Ford’s massive River Rouge plant just as Japan was rebuilding its industrial base after WWII. Where the American managers saw one thing in the Ford assembly line, the Japanese leaders saw something completely different. The following quote explaining “What Toyota saw at the Rouge” comes from an excellent book called Profit Beyond Measure, by H. Thomas Johnson and Anders Bröms: “When Eiji Toyoda told Philip Caldwell that Toyota had discovered the secret to success at the Rouge, his comment implied that what Toyota had perceived about operations at the Rouge was very different than what Caldwell and his Ford colleagues or their counterparts in the other Big Three auto companies had seen. For one thing, it seems that Toyota people did not view low cost at the Rouge in terms of its scale, its throughput, or its managers’ effort to impose external targets for speed and cost on workers in the plant. Instead, they seemed to perceive a holistic pattern permeating every minute particular of the system. On one level, the pattern that caught Toyota’s attention was the overall continuous flow of work in the Rouge as a whole. But at a much deeper level, they observed that work flowed continuously through each part of the system – literally through each individual work station – at the same rate that finished units flowed off the line.” (Caldwell was President of Ford at the time.) Toyoda saw an organic self-learning system in the assembly line, where expertise at work stations is continuously harvested by motivated workers to improve work flow and product. Jeanne Kin and Jack Billi floated this book to my attention a few years ago and it continues to strongly impact my view of organizational systems.

 

4.   Just as modern industry is embracing the concepts of Toyota Lean Processes, health care systems in their frenzy to cut costs while complying with increasingly onerous regulation are oddly embracing the failed experiments of management accounting that impose cost and throughput targets on health care providers. Data (numeric information) should inform decisions whenever possible, but it cannot be the sole driver of key operational choices. All data must be viewed as suspect for, after all, the numeric information we produce for ourselves is merely an artifact of human invention: numbers and their manipulation may or may not reflect reality accurately. Intense focus on data tends to obliterate stories (narrative information). Truth is elusive and while stories can be just as false or misleading as data can be wrong or misinterpreted, when stories resonate with truth, prove to be genuine, or otherwise offer value they get repeated and stick around. While the accounting mentality examines data for consistency and at its best extracts useful stories from data, the scientific mentality examines and hypothesizes stories and then seeks data to support the story and create a better one. Accounting is a matter of numbers, but science is ultimately a matter of stories. The human brain is hard-wired to relate to meaningful stories, and those ancient ones that endure, such as The Iliad, The Odyssey, and the Bible, endure because they give artful evidence of larger truths, exemplary behavior, or experiences that we keep repeating. Some stories are extremely succinct, but have enough truth that we keep repeating them like: Pythagoras’s story that for a right-sided triangle the area of the square on the side opposite the right angle equals the sum of the areas of the squares of the other two sides. Another durable story is that the area within a circle is its radius squared times an irrational number called pi.One might argue that by its very substance this story is irrational, but it sure seems to have held up through time. A newer story tells of the ultimate connection of light, matter, and energy, that is, is e=mc2. These stories seem to be true and have found their Darwinian niche in the human narrative.

 

5.   We are indoctrinated by stories since childhood. Fables, short stories with moral lessons, typically feature animals with human qualities. Aesop, supposedly a slave in ancient Greece (620-560 BC) a generation after Pythagoras and a century prior to Hippocrates, is the fabulist best known in the Western world. It is an astonishing demonstration of Darwinian durability that his fables have been repeated to children in most languages for well over 2500 years. Ben Perry, the 20th century authority on Aesop, indexed and edited Aesop’s stories for the Loeb Classical Library in 1952. One of the half dozen fables dealing with health care is The Old Woman and the Thieving Physician. This may have been added to the Aesop corpus rather than an original of the actual fabulist. The tale involves an elderly lady with sore eyes who asks a physician to cure her from anticipated blindness, but her deal was that payment had to await cure. The doctor made repeated house calls to apply salves and with each visit stole anything he could take away from the house. Once the cure was competed the woman refused payment saying that her sight seemed to be worse than ever since she now couldn’t see or find any of her household property. This characterization of the dishonest physician was number 57 of the Perry Index.

 

6.   Ben Perry was born in 1852 in Fayette Ohio and received his B.A. in 1915 from the University of Michigan and a Ph.D from Princeton in 1919. His early academic posts took him to Urbana Ohio University, Dartmouth, Western Reserve, and then, for the bulk of his career from 1924-1960 at the University of Illinois. He returned to Michigan as visiting professor in 1967 and died back in Urbana, Illinois in 1968. Perry concentrated his work in two minor genres, the fable and the ancient novel. The Perry Index includes all fables related to, ascribed to, or connected to Aesop and goes from #1 The Eagle and the Fox to #584The River-fish and the Sea-fish.  In addition, the Extended Perry Index goes from #585 Sick Lion, Fox and Bear to #725 Fish from Frying Pan into Coals. Curiously Aesop offered tales of all sorts of creatures and many occupations, but only the occasional doctor’s story in addition to the ophthalmologic case: #7 Cat as Physician and the Hens,  #114 The Physician at the Funeral, # 170 Physician and Sick Man,  #187 The Wolf as Physician, or #289 The Frog Physician, and #317The Unskilled Physician. Some of these were matters of impersonations while others like #57 above were character studies of the profession. Perry #427 was the classic Fox and Hedgehog story, resurrected for our time by Isaiah Berlin.

 

7.   The Art Fair is a special time in Ann Arbor. I lived here for about 10 years before I ever walked around in it – summertime is busy for those who take care of children, pediatric urologists included. In 1997 we started the John Duckett Lecture in Pediatric Urology, in honor of a colleague and a friend of Michigan Urology who had passed away that year. The idea was that this would take place on the Friday morning of the Art Fair, and we would close up most of our clinical and research work for the day. Our staff would simultaneously have Staff Education Day in the morning and the afternoon free for the Art Fair or whatever, as their annual birthday present. Over the years we have expanded the intellectual part of our Art Fair week with the Chang Lecture on Art and Medicine Chang on the Thursday and usually added a Lapides Lecture to the Friday session. This year we asked one person, Pierre Mouriquand from Lyon France, to do both the Chang and Duckett Lectures. In effect this was asking Pierre to walk a tightrope between two intellectual towers, and he navigated the line beautifully.  As a great pediatric urologist and a painter of substance and daily practice, he is well qualified on both fronts. The Chang Lecture consisted of Pierre’s story Slowly down the Rhône: the River and its Artists. He produced a magnificent talk bringing together not only art and medicine, but also geography.

Screen Shot 2015-07-20 at 7.40.50 AM

His Duckett Lecture was Understanding the Growth of the Genital Tubercle: Why it is relevant for the Hypospadiologist.  Here he showed his mastery of the field with a brilliant update on embryology and challenging thoughts on surgical reconstruction of difficult dysfunctional anatomy. He fielded a series of case presentations from residents and later in the day attended our Disorders of Sex Development (DSD) team meeting and lunch, where he challenged the modern terminology and presented some videos that showed new concepts in reconstruction. In the evening at dinner our residents and the pediatric urology team got to know Pierre and his wife Jessica mixing technical talk, health systems discussions, and seeing how a couple successfully navigates the challenging world of life, family, and academic medicine. 

Pierre & Jessica

Regarding this first academic event of the new season of residency training (also called Graduate Medical Education or GME) I need to invoke a sports metaphor and say that “Pierre hit it out of the park.” Events like these fulfill the essential duty of the university: sharpening inquisitiveness, disseminating ideas, widening cosmopolitanism, and educating our successors.

 

8.   Chang Lecture on Art and Medicine 2016. Our speaker next year will be Don Nakayama, former chair of the Surgery Department at West Virginia. He wrote an interesting article in Pharos last year on the Diego Rivera murals at the Detroit Institute of Arts. [The Pharos 77: 8, 2014] Perceptively, he recognized that the so-called Surgery Panel on the South Wall was not a depiction of “brain surgery” as art historians have claimed, but rather an illustration of an orchiectomy, a procedure much more attuned to Rivera’s view of the Rouge Plant workers. It is a great testimony to the vision of Edsel Ford to have brought Rivera, arguably the world’s best muralist of the time and an ardent communist, to Detroit to produce the work in 1932. Things didn’t go so well later in New York City when Rivera tried to repeat the experiment with the Rockefellers, but that’s another story.

Orch

[Lower right mural on the South Wall: the orchiectomy]

Caleb Nelson will be doing the Duckett Lecture and Bart Grossman will be doing the Lapides Lecture next year for an all-Nesbit Line up on that Friday of the 2016 Art Fair.

 

9.   Little Red Hen  Disney’s Silly Symphonies also included The Wise Little Hen, a version of a Russian folk tale more popularly known as The Little Red Hen. The nugget of the story was that the hen finds a grain of wheat and asks the other animals on the farm to help plant, grow, and harvest it. None chose to help, but after she harvests the wheat she asks again for help threshing, milling, and baking, but none step forward. After the bread is done, she asks who should help eat it – and of course everybody volunteers. The hen, however, says sorry “if any would not work, neither should he eat.” (The Wise Little Hen  included the debut of Donald Duck.) President Ronald Reagan referred to this story in 1976, citing a politicized version  in which the farmer chastised the hen for being unfair. After the hen was forced to share her bread, she lost the incentive to work and the entire barnyard suffered. This twist on the story made it a cautionary tale slamming the welfare state. While the story teaches children the importance of doing their part in terms of the daily work of the community it lacks the complexity of reality. Modern society is far more complicated than a barnyard and the line between personal responsibility and public beneficence (i.e. government) is tricky to arbitrate. Furthermore, many in society experience tragic bad luck beyond their control or are unable to assume personal responsibility. Reagan’s farmer had the un-antlike characteristic of compassion, a human quality that must have long-preceded even our biblical days. A society has to nurture personal freedom, creativity, and individual responsibility if it is to be successful, but without kindness and compassion a civilization is not a human one. After all, when Disney anthropomorphized his ants he gave them not just language, but also compassion.

Where do we draw the lines regarding personal freedom and such things as immunization mandates, smoking, drug use, obesity, and dangerous behavior? Should motorcyclists have to wear helmets? How do we provide health care to the indigent and incapable? How do we create health care equality and affordability? These questions ultimately get arbitrated in the political arenas regionally and nationally, generation after generation. Our nation walks on a tightrope between the cartoonish ideologies of the welfare state and what some might call individualism, capturing the beliefs of libertarianism, laissez-faire capitalism, and ethical egoism. Obviously neither the welfare state nor any “ism” has it right – the best path for a just, creative, and cosmopolitan civilization is a path in between the cartoons. The bad news of today (and maybe this is the bad news for every human era) is that cartoonish people find their ways to leadership and compel the rest of us along irrational paths that threaten  the future we want to turn over to our next generation. All citizens need to step up their understanding of the issues of public policy and health care as well as involving themselves in its regional and national discussions. We can no longer let politicians, accountants, and pundits alone shape the critical decisions.

 

10.  Funambulism. On this day, August 7, in 1974 a 24-year old Frenchman named Philippe Petit walked across a high wire he had rigged between the Twin Towers of the World Trade Center. He actually crossed the wire 8 times, performing for 45 minutes to the amazement of on-lookers in the towers. He must have looked like an  ant to those on the ground, and vice versa. Petit’s funambulism represents a perfection of self-alignment in terms of balance that few can achieve, yet it is also an astonishing display of self-confidence, clandestine preparation, and admirable civil-disobedience. Curiously funambulism defines tightrope walking and a show of mental agility interchangeably. Few can deny that serious tightrope walking is as much a matter of mental as physical agility and you have to admire the internal drive that motivated Petit to accomplish this heroic feat. That was art.

Pettit

Postscript: With the start of August we saw the retirement of Jack Cichon, our departmental administrator, and Malissa Eversole is now steadily in place on the job. Jack managed the business and operational affairs of Michigan Urology for 20 years with great loyalty, integrity, and (at some challenging times) extraordinary courage under pressure. He becomes an honorary member of the Nesbit Society and we hope to continue to see him in the course of our departmental events, noting his broadened smile of relief from the administrative pressures of the University of Michigan Medical School and Health System that he served so admirably.   

Cichon 2015

Thanks for spending time with What’s New and Matula Thoughts.

David A. Bloom, MD

Department of Urology, University of Michigan Medical School

Ann Arbor

 

Matula Thoughts July 3, 2015

 

Matula Thoughts July 3, 2015

Independence, PGY1s, peonies, & art.

3673 words

 

©Photo. R.M.N. / R.-G. OjŽda

©Photo. R.M.N. / R.-G. OjŽda

Wash Monument

1.     It’s July and peasants farm and shear sheep outside the protective walls of a castle in the beautiful panel of the renowned 15th century illustrated manuscript, Très Riches Heures du Duc de Berry. Life was safer within the castle walls than outside them. The authority in charge of the castle and grounds was a nobleman governing locally on behalf of a distant ruler and the governance was absolute. Many Julys have come and gone since the Duke of Berry (600 Julys since 1415) and government has become more representative throughout much of today’s world for villagers, city folk, and the rest of us who perform the daily work of civilization. The relationship between the authority we call government and “the people” has evolved based on principles extending back to the Magna Carta 800 years ago (June 15, 1215) and even before.

Magna Carta

[Magna Carta Brit. Lib. 4000 or so words in Latin on sheepskin]

The principles of authority for the United States of America are seated in the Declaration of Independence, adopted by the Continental Congress on July 4, 1776. If you’ve not read the book published last year by Danielle Allen, Our Declaration, you should do so this summer. It is an amazing study and quite readable. As discussed previously on these pages of What’s New and Matula Thoughts, Our Declaration will give you, among many other things, a more sophisticated sense of the idea of equality than you likely now have.

declaration-of-independence

[1337 well-crafted words]

When the three Limbourg brothers of Nijmegen produced the “very richly decorated book of hours” for the Duke of Berry, the Duke probably felt little sense of equality with his workers. In some parts of today’s world things remain little different than in the days of the Très Riches Heures when dukes and kings had total unchecked authority over their subjects. Such nations are rarely successful in terms of aggregate innovation, intellectual contribution, education, environmental stewardship, industrial production, or social justice. Conversely, most modern nations today enjoy a shared belief that all people are equal before the law. In these places where the ideas of representative government, equality, personal liberty, and cosmopolitanism take hold, the potential of the human factor is unleashed and creativity emerges on a large scale. History shows that, when people have freedom to achieve their potentials, individual happiness and general human progress are served far better than when the state or crown decides what’s best for its people. Tomorrow we celebrate that particular success of government by the people, for the people, and of the people in our nation. Yet, these aspirational ideals remain under challenge not only by human imperfections in their implementation, but also by today’s iterations of tribalism, despotism, human subjugation, sectarianism, extremism, and war. The divergent symbolism of a castle and protective walls on one hand, and our iconic monument of an open society is striking.

 

2.     With July comes a new class of interns (PGY1s, residents) and fellows. I’ve enjoyed being a part of this cycle for many years. Our careers flip by in the blink of an eye and I myself was at that early stage of medical education not so long ago. Although relatively clueless back then, I had the ambition of becoming a credible children’s surgeon of one sort or another. With influences like Judah Folkman, Rick Fonkalsrud, Bill Longmire, Don Skinner, Will Goodwin, Joe Kaufman, and Rick Ehrlich, I was inspired to push ahead toward that ambition, but felt a long way from my goal and quite distant from a place in the “establishment” of pediatric surgery and urology. A year in London following the footsteps of David Innes Williams gained me a slight bit of early credibility in addition to lifelong friends in urology – Robert and Anita Morgan, John Fitzpatrick, and Christopher Woodhouse. A couple in the Royal Shakespeare Company, Mike Williams and his wife Judi, further broadened my perspective on the world, and I often think back to Mike’s description of their work as that of “travelling players.” This metaphor applies to us in academic medicine – we are travelling salesmen indeed, going here and there to sell our ideas, observations, clinical experiences, and research findings at national meetings and during visiting professorships. On my return from London I experienced an incomparable month with Hardy Hendren in Boston, filling a notebook equivalent to the size as that from 11 months in London. During that stay I further was schooled in gracious hospitality by Mike and Connie Mitchell and John and Fiona Heaney. Wonderful reminiscences and the start of deep friendships. Our residents and fellows are now assembling their own stories of educational experiences, no doubt as rich and meaningful to them.

 

3.     Most people at certain times of their lives entertain the nagging question of the meaning of life. The question comes up in good times or bad, in the midst of crises, or even randomly. It is too big a question to answer in a general sense and certainly beyond the reach of these small essays. Maybe it’s a silly question, a human conceit, for in the grand scheme of things it could be argued that the meaning of geology, for example, is of no less significance as a question. In the specific personal sense many people find life’s greatest meaning lies in the ways they individually make their lives useful to others. In this sense, then, the meaning of life is simply its public relevance. This might well be Darwin’s ultimate revelation: a life’s meaning is found in its specific relevance today and in its more general relevance to the tomorrow of future generations. The desire to do things for other people is deeply established in our genes and has been reinforced by millennia of human culture. Not only do we seek to have meaning individually to others and to our society, but we are compelled to construct a world where our generation’s children can create their own meaningful lives. It probably seemed easier for the kings, queens, and noblemen in the days of the Duke de Berry. They were born into a world where their meaning (in terms of the faulty surrogate of their self-importance) was pre-ordained, but that world didn’t offer much of a chance for anyone else, hardly a sustainable Darwinian scenario. Self-importance is a biologic necessity, but its socially-acceptable expressions occur across a spectrum with Mother Teresas on one end and Donald Trumps at the other.   Off that spectrum, deranged and delusional self-importance leads to shootings, bombings, and beheadings – public slaughterings designed to induce terror and 15 minutes of “fame” that in fact become horrendous perpetual shame for the perp. Random tragedy still stalks us and may never disappear, but our responses as a society are sometimes great and inspiring, as we witnessed in Charleston SC one week ago today.

AME Church

[Emanuel AME Church, Calhoun St. Charleston SC. June 30, 2015. DAB]

In spite of the personal good fortune of many of us today, our gift of freedom has not been making the world a better place uniformly. One bit of evidence that it’s not: the UN released figures last month showing that 60 million people, half of them children, are fleeing chaotic lands looking for safety, food, and asylum. This is a staggering and unprecedented number. It is mentally incomprehensible. Another bit of evidence: Pope Francis’s recent encyclical Laudato Si, warns that our failure of planetary stewardship has left even larger numbers of mankind living in piles of filth and at risk from effects of deleterious climate change. An article about this 192-page document said: “Pope Francis unmasks himself not only as a very green pontiff, but also as a total policy wonk.” [Faiola, Boorstein, Mooney. National Post (Toronto) June 19, 2015. A11]

 

4.     Last season’s interns are now seasoned house officers (PGY2s). They have performed admirably and are well on their way to becoming excellent urologists. Just as we will make them better, they will make us better. We look forward to their full-bore immersion in urology starting now.

PGY1s 2014 copy

[PGY2s:Ted Lee, Ella Doerge, Parth Shah, Zach Koloff]

Our new interns (PGY1s), mentioned here last month, have just come on board. When I started in that same position at UCLA on July 1, 1971, I stepped right into the game of hospital medicine, taking orders from the higher level residents, watching them and the attendings at work, and anxiously taking call, hopeful that a disaster wouldn’t blow up around me. The world has changed and now we give the new medical school graduates days of preparation for the complex systems of healthcare, the explicit and implicit expectations of their daily work, the hierarchy of graduate medical education, and the local idiosyncrasies of the University of Michigan (e.g. when we put on gowns and gloves in the OR the left hand is always gloved first). Only after a deliberate program of “in-boarding” do our new interns step into the real-time practice of clinical medicine. We hope the new members of our urology family will embrace our sense of mission and values. We hope they will pick up the professionalism of our faculty, staff, and their senior residents and fellows. We hope they will learn the histories of our department and institution and become inspired by those stories. We hope they will learn their craft and become superior in providing our essential deliverable: kind and excellent patient centered care, thoroughly integrated with innovation and education at all levels. The fact is, looking at our finishing chief residents and fellows this year, Michigan urology trainees are superior and we expect them to get even better throughout their careers.

 

5.     While governments, in many nations, have become more representative and recognize that they exist for the people they represent, one unintended, but inevitable consequence is that they become self-righteous. Authority corrupts itself. This happens today no less than it did for any of the Dukes of Berry and their counterparts over the past millennia. We should be wary that self-righteousness of large organizations is a feature of all self-organizing systems. This propensity is seen in the reordering of our haphazard health care system, for example in the ill-conceived HITECH Act that forced the jettisoning of perfectly good electronic medical record systems in favor of a few clunky propriety systems that satisfied arcane details of the law including the mandated “meaningful use.” We also see this in the overwrought “Time-Outs” in the operating rooms that default individual responsibility to a team check-list. (As a pilot in training, when I was a resident, the checklist was the responsibility of the pilot and co-pilot, not a formulaic team exercise of everyone on the airfield.) I thoroughly believe that health care, surgery most especially, is a team activity and that rigid hierarchy is not conducive to a highly performing team. However, rote adherence to a formulaic “Time-Out” for all operative procedures is equally counterproductive. We hope that the next generation of physicians, especially the urologists we educate, will not be taken in by regulatory self-righteousness of third party payers, national professional boards, state boards, and hospital systems so as to believe that the practice of medicine is a checklist, patients are clients, that a patient’s story is a dot phrase or series of templates, and that time-outs do not obviate Murphy’s rule. No check-list or algorithm can substitute for individual sensibility (and anxiety) of the operating surgeon. The formulaic and monitored checklist ritual, in fact, defuses the sensibility. Finally we pray that the ancient Hippocratic idea of listening to and looking at the patient (and the patient’s family) is where medical practice must begin and end – not with the computer and electronic health care record.

 

6.     Visiting professors challenge us with new ideas and perspectives. They offer our residents and fellows a more cosmopolitan view of the world of urology, and visitors take away strong impressions of the Michigan Urology Family. The same happens when we visit other institutions and see how their residents learn. I was recently at the University of Toronto as Bob Jeffs visiting professor at the time for their fellowship graduation and was duly inspired by the faculty, residents, fellows, nurses, and systems that Marty Koyle and his team have developed at Sick Kids’ Hospital. They have some great innovations that might fit us well. The children’s hospital is vibrant, welcoming, and user friendly.

Sick Kids fellows

[At Toronto Sick Kids: Kakan Odeh, Keith Lawson, Frank Penna, Paul Bowlin, DAB, Marty Koyle, Joanna Dos Santos]

Sick Kids

[Toronto Sick Kids Atrium & lobby from urology & surgery floor]

In Ann Arbor we recently hosted visiting professor Tim O’Brien from Guy’s Hospital in London and he gave a wonderful talk on his work ranging from bladder cancer to retroperitoneal fibrosis. He explained that he has given up doing clinical trials due to the overbearing regulatory paperwork and processes involved in setting them up and implementing them in Great Britain. Tim used a phrase that “the many were controlling the few” in the quagmire of clinical trial regulation. This is the opposite of the Duke de Berry’s situation where the few controlled the many and it begs the question: What is sovereign in a society and what is the source of its laws? It seems right that the people in a society should ultimately be sovereign and that the source of its laws should derive from cosmopolitan human reason and experience. Rules, however, should not be so oppressive as to impede the function and flourishing of the workers. A sheep cannot be sheared well and efficiently by a committee, nor can a bus be driven by a team representing all the diverse interests of the stakeholders of the passengers, neighborhoods of passage, and owners of the bus. Society has to trust its workers to a great extent, knowing that some mistakes will be made and accidents will happen, although minimized by means of education, training, sensible rules, and systems. It seems that clinical trials, and perhaps much of modern medicine driven by HITECH mandates, ICD-10, and other regulatory burdens is not flourishing. Anyway, Tim gave us a terrific visit and showed that we share many regulatory impediments with the U.K.

Tim O'Brien

[David Miller, Tim O’Brien, Kurshid Ghani at Grand Rounds in Sheldon Auditorium]

 

 

7.     Chiefs dinner Chief residents’ dinner. Our residents go from newly minted graduates of medical school to skilled genitourinary surgeons and excellent clinicians in a matter of 5 or so years. In that time we, as faculty, work with them initially as teachers, but increasingly as colleagues during the progression of their training. It is said that it takes around 10,000 hours of practice to become proficient at chess, golf, piloting, piano, or other specific tasks. The evolution of graduate medical education in urology to a 5-year program points to a gestational period of around 20,000 hours to achieve competency as a genitourinary surgeon. Our expectation at Michigan, however, goes beyond mere competency. We have a strong track record of producing not just urologists but the leaders and the best in urology, and this year I believe we did it again. Our yearly graduation dinner (pictured above) for the completing residents and fellows is a signature event in our calendar. We held it at the University of Michigan Art Museum for the first time this year. As intently as we work with our residents throughout the years of their training, the narratives of their lives, as told so excellently this year by their fourth year colleagues, Amy Li, Miriam Hadj-Moussa, and Rebekah Beach offered entirely new perspectives on our chiefs – Noah Canvasser, Casey Dauw, and Joanne Lundgren. We heard “the rest of the story” for these three who have come a long way from novice PGY1s. They have withstood the intense pressures of high-stakes clinical work in the ORs and at the bedsides. They have studied hard to compete in a rarified intellectual environment of high stakes exams. And they have solved problems for patients and eased their anxieties in the high stakes of urological disease and disability. Still, their learning and practice must continue, and the stakes only get greater as our graduates advance in their careers, but they have given us confidence that they will become the leaders and the best of urologists and physicians. Our graduating fellows, a notch higher on the learning ladder, have been equally superb and have now become truly independent: Lindsey Cox, Sara Lenherr, and Paul Womble.  The art gallery was an appropriate place to celebrate this milestone with them and their families. The Shirley Chang Gallery in the Art Museum is an especially lovely space to stroll and reflect.

 

8.     The four “Rs.” The world provides as many opportunities to stroll and reflect as individual imaginations allow. A few years ago our friend Bill and Kathleen Turner (Bill was chair at the Medical University of South Carolina as well as Secretary-Treasurer and then President of the American Urological Association) a few years back took us to Mepkin Abbey in South Carolina where a dozen or so Cistercian monks have developed a community with open gates for visitors to come stroll and reflect.

Mepkin

The unofficial motto of the abbey is: read, reflect, respond, and rest. Reading intends the sense of thoughtful examination of the world around us visually, literally, auditorily, and emotionally. You don’t have to go to exotic abbeys and other places to perform the four “Rs.” Here at home you can reflect in places like the Shirley Change Gallery and in May and June, you can wander in the University of Michigan Peony Gardens. These were designed and established in 1922 with many of the original plants donated by William Upjohn, an 1875 graduate of our medical school. The collection consists mainly of one species, Paeonia lactiflora, blooming in pinks, whites, and red. The peony is named after Paeon, a pupil of the Greek god of medicine Asclepius. When the teacher became dangerously jealous as his student began to outshine him, Zeus intervened to save Paeon by turning him into the flower. Thus you might argue that the peony symbolizes education’s ultimate aim – the success of producing students who outshine their teachers. The root of the peony is a common ingredient of traditional Chinese, Japanese, and Korean medicine. Indiana has made this its state flower.

Peonies Yun_Shouping Freer

[Peonies by Chinese artist Yun Shouping, 17th century. Freer Gallery]

Peony gardens

[UM Peony Garden, June 7, 2015]

 

9.     Hippocrates allegedly said: Life is short, and Art long; the crisis fleeting; experience perilous, and decision difficult. According to the way I read this enduring aphorism and the way it is punctuated, the fleetingness of life and durability of art are linked as one thought. Life creates art, but art transcends life, and being passed across generations epigenetically, art changes life by enhancing it, inspiring it, or altering its perceptions. My late aunt Evelyn Brodzinski, a painter throughout her life and a student of visual arts, once said in reply to my question as to what, actually, constitutes art “Art is anything that is choice.” In the process of creation, selection, and omission of material and information people produce content that, presumably, had some meaning to the artist. Craving meaning in our lives, we find value in inspecting the visual, literary, or musical content that had meaning for their creators. When we started the Chang Lecture on Art & Medicine in 2007, in honor of the Chang family of artists & urologists, we hoped to offer a yearly lecture that would link the 2 essential human interests of art and medicine in some way. The choices thus made by our lecturers over the years have been amazing, and last year’s lecture by James Ravin, ophthalmologist and author of the book, The Artist’s Eye, was superb. I eagerly anticipate this year’s talk by Pierre Mouriquand who is both a pediatric urologist and an accomplished artist.

 

The Chang Lecture, targeted to a general audience, has attracted growing number of friends and members of our community. “Public goods” of our university such as the Chang Lecture and the Peony Gardens are part of the social compact between the University of Michigan and its community.

Chang 2013

 

Chang 2014

[Top: Chang Lecture 2013; bottom: Hamilton Chang, James Ravin, Dr. Cheng-Yang Chang]

 

Tom & Sharon 2013 copy

[Tom & Sharon Shumaker, loyal Chang Lecture attendees. Tom passed away in January this year.]

 

10.    Universities are the single institutions of civilization that exist for tomorrow. At the individual level they provide a framework for individuals to find their specific relevance as well as to understand the cosmopolitan nature of the world and their responsibility in it. In the larger perspective they create new knowledge through inquiry and research to provide the ideas and technology of the future. It is no accident that the largest piece of most great universities has become the health care enterprise. This is totally appropriate since health care is a dominant part of the GDP, it ultimately affects everyone, and economically it employs 1 in every 6 citizens. The bedrock of the best medical school departments consists of its faculty and the glue to secure the best of the best is the endowed professorship. Last month we held a lovely ceremony in which we turned over three existing endowed professorships to three faculty members who will carry the names of the professorships along with their titles: Khaled Hafez the George Valassis Professor, Ganesh Palapattu the George and Sandra Valassis Professor, and Julian Wan the Reed Nesbit Professor. They are superb surgeons, noteworthy thinkers, and astute clinicians. The endowed professorships allow them a little independence from the daily pressures of clinical effort and funded research.  These three are smart and kind people of the highest order and I’m lucky to call them colleagues and friends. They epitomize the cosmopolitan nature of our department, medical school, and university. Cosmopolitanism is a term I’ve come to appreciate through the work of Kwame Appiah (another author for your reading list!) and it consists of the belief that all of us human beings belong to a single global community with shared values and principles. Julian, Khaled, and Ganesh will be teaching our next generation of physicians and producing useful new knowledge in the milieu of our essential deliverable: kind and excellent clinical care. Someday, their successors – the future Valassis and Nesbit chairs – will be doing the same in the world of tomorrow that we may hardly be able to predict, but that we have thus prepared for amply.

Triple prof

[Julian Wan, Khaled Hafez, Ganesh Palapattu]

 

Best wishes, and thanks for spending time on “Matula Thoughts.”

David A. Bloom

 

 

Matula Thoughts June 5, 2015

 Matula Thoughts June 5, 2015

(2686 words)

Summertime, wolverines, universities & other disparate thoughts from a clinical department of medicine at the University of Michigan

 

1.     Huron River  June at last. Even though clinical medicine is a 24/7 business, in contrast to the seasonality of the university calendar, we can’t help but notice that summer has arrived. Ann Arbor is a glorious place to be this time of year when you can walk along, fish, kayak, or canoe the Huron River (shown above with the Gandy Dancer in the distant background). Our applicants for residency training from the west coast or south see none of this lovely environment when we interview them in late November, a real recruiting disadvantage. Nevertheless, we have again recruited a superb resident and fellow cohort to start training with us next month. Spring and summer also bring the pleasure of seeing and hearing the birds in our neighborhoods. Surviving another rough winter and hatching their 2015 chicks, they bring to mind John James Audubon, who, born 230 years ago (April 26, 1785) in Haiti, documented and detailed all sorts of American wildlife, birds especially. His Birds of America is thought to have been the first book acquired by the University of Michigan after it moved to Ann Arbor in 1837. I learned this in an article by Kevin Graffagnino in The Quarto, the quarterly publication of our Clements Library [Fall-Winter 2014]. Kevin is the Director of the Clements, one of the crown jewels of the UM. The library’s magnificent reading room with its periodic displays is an ennobling place to spend a little time, although you will have to wait until the current renovations are completed.

 Audubon

[White House copy of 1826 painting of Audubon Portrait by John Syme]

 

2.     Gulo gulo. While Audubon is best known for his birds, his work also extended to mammals and included the Viviparous Quadrupeds of North America, produced in 1845-48. The Quarto, mentioned above, included an image of a wolverine from the Quadrupeds (shown below). A miniscule number of wolverines still exist in the lower 48 states, but their Darwinian niche is contracting and it is unlikely that you or I will ever see one in the wild. Of note, a wolverine was spotted in Utah at a nocturnal baited camera station last summer. Kevin’s article says: “By one account, Ohioans were responsible for pinning the name ‘wolverine’ on Michiganians, claiming that they shared the animal’s ill temper and greedy nature.” Buckeyes can be relied upon for charming perspectives of their northern neighbors. 

OLYMPUS DIGITAL CAMERA

Audubon’s wolverine

 The wolverine (Gulo gulo) is the largest land-dwelling species of the weasel family (Mustelidae). They have weights generally of 20-55 pounds but males have been found as large as 71 pounds. Their fur is thick and oily, making it very hydrophobic and resistant to frost. Like other mustelids their anal scent glands are very pungent. Aggressive hunters and voracious eaters, wolverines are extremely rare in Michigan outside of the Big House. The skull and teeth are the most robust of carnivores their size, allowing them to eat frozen meat and crush large bones. Gulo comes from the Latin term for glutton.

Wolverine

[National Park Service photo in Wikipedia. Taken in 1968]

Wolverine brown

[Wikipedia Commons, author Zefram, 2006]

 Wolverine ranges

[Wolverine ranges – Wikipedia]

 

3.     Linnaeus, nomenclature and humanity’s obesity. The identification of the wolverine as Gulo gulo is a convention of biologists that traces back to Carl Linnaeus in the 18th century (1707-1778). This Swedish physician got his professional start with a medical practice that rested heavily on its urological aspects and provided him the opportunity to initiate an academic career in Uppsala at the university where he developed his enduring nomenclature system. His university remains one of great institutions of worldwide academia.

Linnaeus

Returning briefly to Gulo gulo, Linnaeaus never anticipated modern molecular biology, but ironically GULO also turns out to be L-gulonolactone oxidase, an enzyme that makes the precursor to Vitamin C in most living creatures although not Homo sapiens. GULO is nonfunctional in Haplorhini (namely us dry-nosed primates) as well as some bats, some birds, and guinea pigs. Loss of GULO activity in primates occurred around 63 million years ago when they (we) split into wet-nosed and dry-nosed suborders (Strepsirrhini and Haplorhini). It has been speculated that the critical mutation leading to loss of GULO production benefited survival of early primates by increasing their uric acid levels and enhancing fructose effects leading to fat accumulation and weight gain. (Johnson et al. Trans. Am Clin Climatol Assoc. 121:295, 2010) The human susceptibility to scurvy thus is a likely side effect of one of the critical evolutionary steps in the making of modern man. This amazing thought leads back to the University of Michigan and our beloved colleague Jim Neel, the founding chair, in 1956, of our Department of Human Genetics, that I believe was the first in North America, if not the world. Towards the end of his life, Jim often showed up for lunch in our medical center’s cafeteria, always toting his old well-traveled knapsack, and we had a number of provocative conversations on such matters as the biology of morality. Johnson refers specifically to Jim’s landmark “thrifty gene” paper of 1962 [Am J Hum Genetics. 1962;14:353-62] wherein Neel suggested that genetic adaptation of our primate ancestors to famine may have left modern day humans with an increased risk for obesity and diabetes when foods became plentiful. Johnson notes that while the thrifty gene hypothesis was initially well received “the inability to identify the specific genes potentially driving this response has reduced enthusiasm for the hypothesis.” Johnson’s 2010 paper revisits Neel’s hypothesis and argues that at least 2 critical mutations led to our genetic adaptation to famine: the silencing of genes necessary for Vitamin C synthesis and for uric acid degradation. These two “knock-outs” enhance the effect of fructose in increasing fat stores.   

 

 4.     Universities. The durability of Linnaeus’s university is no fluke. Darwinian forces have kept universities in play since their origin in the Middle Ages, and since then even grown their relative effect in society. When you think about it, it seems that universities are the only truly durable organizations that are legitimately here “for tomorrow.” A modern academic, David Damrosch, demonstrated this durability by quoting a study from the Carnegie Council, so permit me to repeat his observation. “A report by the Carnegie Council in 1980 began by asking how many Western institutions have shown real staying power across time. Beginning with 1530, the date of the founding of the Lutheran Church, the authors asked how many institutions that existed then can still be found now. The authors identified sixty-six in all: the Catholic Church, the Lutheran Church, the parliaments of Iceland and of the Isle of Man – and sixty-two universities.” [Damrosch D. We Scholars. Changing the Culture of the University. Harvard University Press. 1996. p. 18] This is a powerful observation. For all their annoying features (medieval hierarchy, guild mentality, ecclesiastical titles, indentured work force, elitism, resistance to change, decentralization) universities function primarily to educate the next generation and advance knowledge.

 

5.     Named lectures. William J. Mayo, a graduate of the University of Michigan Medical School in 1883, left us $2000 as “a perpetual endowment for a yearly Mayo Lecture on some subject connected with surgery.” So that the fund could grow, he gave the first two lectures himself (1924 and 1925) and had his younger brother Charlie (a graduate of Northwestern University’s medical school in 1887) give the third lecture. Except for 1929, 1930, and 1945 the tradition has been continued. Reed Nesbit was the speaker in 1968. This year our colleague and friend Skip Campbell gave a superb talk called “From volume to value: charting a course for surgery.” He discussed our incipient brave new era wherein payments to health systems and individual physicians for services will disconnect from clinical volume alone (which is easily measured and indisputable) to parameters of quality and value (which are not so indisputably measured).

 Skip - Mayo Lecture

[Skip Campbell]

 

6.     Dick and Norma Sarns, friends and neighbors, have impacted our world and local community beyond easy measure. The impact of their company in Ann Arbor, Sarns Inc., innovator and producer of heart lung machine technology, has been incredible. The Sarns device was the one used by Dr. Christian Barnard in 1967 for the first human heart transplant. Other Sarns devices followed and the company was acquired in time by 3M and is now owned by Terumo Corporation. Cardiac rehabilitation became the next focus of Dick and Norma with their next company, NuStep, Inc. As benefactors to our community through the Ann Arbor Area Community Foundation, the University of Michigan, and numerous other nonprofits, the Sarns family has been uncommonly generous with astute focus on building a better tomorrow. The Sarns story is now permanently embedded in the  larger University of Michigan narrative in the Sarns Professorship in Cardiac Surgery. The choice of Rich Prager as the inaugural Sarns Professor is fitting. You may recall that Rich gave a magnificent Chang Lecture on Art and Medicine for us in 2013. You can revisit the  talk in his subsequent JAMA article on the murals of Henry Bethune (JAMA: PN Malani, RL Prager, “Journey in Thick Wood: The Childhood of Henry Norman Bethune”, JAMA, October 8, 2014, Volume 312.) Endowments such as the Sarns Professorship will allow the University of Michigan Medical School and Health System to recruit and retain the best of the best in academic medicine to teach the next generation, to discover new knowledge and technology for tomorrow, and to do these in the milieu of our essential deliverable – kind and excellent patient care.

Sarns  Rich Prager

[Top: Dick & Norma Sarns. Bottom: Richard Prager]

 Prager:Sarns

[Standing ovation for Rich Prager]

 

7.     Next week we will recirculate 3 three existing urology professorships in a ceremony that is long overdue (June 10 at 4 PM in the BSRB Auditorium). The Valassis endowment, originally given to Jim Montie by George Valassis, has grown enough to be split into two independent professorships. Ganesh Palapattu will be installed as the George and Sandra Valassis Professor, previously held by David Wood. Khaled Hafez will receive the George Valassis Professorship, previously held by Jim Montie. Julian Wan has taken over the Nesbit Professorship, occupied up till recently by Ed McGuire. These professorships will continue in perpetuity. These conjoined celebrations of the past and investments in the future will exist as long as the University of Michigan stands. We will need more endowed professorships here in Ann Arbor if we are to remain at the top of the game as a leader and one of the best in academic medicine as federal and clinical funding of medical education and research continue to slip.

 

 8.     The American Urological Association met in New Orleans this mid-May, having last convened in the Crescent City in 1997. University of Michigan faculty and residents had well over 100 abstracts, posters, podium sessions, and panels in addition to dozens of committee meetings. While it is impossible to even mention but a fraction of these, the MUSIC collaborative initiated by Jim Montie, deployed so excellently by David Miller and now assisted so well by Khurshid Ghani, was a highlight. This collaborative has brought many urologic practices and other urology centers outside the UM to podiums at the AUA in the interest of improving urologic care and practice. The quality, value, and safety of health care cannot effectively be managed centrally by government, industry, or national organizations such as the American Board of Medical Specialties. These attributes of excellence must be played out at the bedsides, clinics, operating tables, hospitals and in the offices of committed practitioners. Lean process believers would say that improvements in complex systems are most efficiently and effectively recognized and tested in the workplace, at the “Gemba” (lean process engineering terminology for workplace). Just as central management of a nation’s economy failed in the Soviet Union, central regulation of quality, safety, and “value” is a doomed experiment. Collaboratives such as MUSIC, built on trust and a desire to improve patient care, work best at the local and regional levels. An educational and social reception at the AUA showcased MUSIC and David Miller challenged the group to extend its work beyond prostate cancer to other urologic conditions. Walking through the main hallway of the giant convention center at the AUA meeting I kept seeing Toby Chai and Ganesh Palapattu on the video screen in the Rising Stars display. Michigan had a heavy presence at the AUA again this year.

 

9.     Our Nesbit Reception hosted more than 130 alumni, friends, faculty, and residents. For me the Nesbit Society events are high points of the year. We held this event at the 100 year-old Le Pavilion Hotel. Although hit hard by Katrina in 2005, Le Pavilion took in many of its employees with their families and pets in the wake of the devastation, yet was back up and running as a hotel by December of that year. The social part of a profession, especially a profession as social as medicine, is an essential part of its substance and pleasure and the Nesbit Society serves this function well. We had a large contingent from Denmark and the University of Copenhagen including Jens Sönksen and his daughter Louise who was a little girl when they lived in Ann Arbor. Barry Kogan, Bart & Amy Grossman, Marty & Anne Sanda, Kathleen Kieran, and our contributions to the Northwestern urology program (JO DeLancey, Diana Bowen, & Drew Flum) were on hand. So too were Sarah Fraumann and Jackie Milose who will both be doing reconstructive urology for the University of Chicago but at polar ends of the city. Stephanie Kielb of course is in the middle of the city on the Northwestern faculty. Jill Macoska was back from Boston and Bunmi (E. Oluwabunmi Olapade-Olaopa) was the most distant traveler, hailing from Ibadan, Nigeria. Many other former students and friends joined our faculty and residents for a lovely evening that Mike Kozminski and Julian Wan put together with Sandy Heskett and April Malis. Our next Nesbit event will be in the autumn (October 15-17), deep in the midst of football season and we have great expectations for our pigskin wolverines. With a new coaching staff on the scene we can well understand the need to have put aside our annual prostate cancer fund raiser, the Michigan Men’s Football Experience. It must be “first things first” for Coach Harbaugh’s team this inaugural year. While fund raisers come and go, our work in the Medical School and Health System remains nonstop without seasonality. Urologic research at Michigan continues to progress, with a number of exciting findings and technologies in play that will be discussed in upcoming departmental What’s New communications.

 Danes Jens & daughter

[Above-Danish contingent: L-> R Stefan Howart from Coloplast, Peter Oestergren, Lasse Fahrenkrug, Eric Halvarsen, André Germaine, Jens Sönksen. Bottom: Jens & Louise]

 Barry & Bart Marty & Cheryl

[Top-Barry Kogan Chair at Albany, Bart Grossman from MD Anderson; Bottom-Lindsey Herrel, Cheryl Lee, & Marty Sanda Chair at Emory]

 Osawa NPR ladies

[Top–Takahiro Osawa, Noburo Shinohara, Takahiro Mitsui; Bottom-Lindsey Cox, Yahir Santiago-Lastra, Anne Cameron]

 Alon, PAs, Jacuqi

[Alon Weizer, Jackie Milose, Mary Nowlin, Liz Marsh]

 Bonmie

[Bunmi Olapade-Olaopa, Peter Knapp, Quentin Clemens]

 

10.    It is worth reflecting upon telltale signals that we either pick up or miss. On this particular day in 1981 the Morbidity and Mortality Weekly Report of the Centers for Disease Control and Prevention reported that five people in Los Angeles, California, had a rare form of pneumonia seen only in patients with weakened immune systems. At the time this observation was a matter of only faint curiosity to most physicians, and of even less interest to the public at large until it turned out, in retrospect, to have been the first recognized cases of AIDS. In the crowded bandwidth of everyday clinical life, narrow subspecialty focus, and the administrative hassles of the practice of medicine it is important to keep a deliberate open mental channel tuned to the greater environment of healthcare and science. Many telltale signs that presage tomorrow surround us and one wonders what telltale signals we are missing amidst today’s noise and summertime moments.

May flowers [Lilacs in front of old Mott]

Upcoming events: Residents graduation dinner. Triple professorship installation. Chang Lecture on Art and Medicine Thursday July 16 – Dr. Pierre Mouriquand Professor Claude-Bernard University, Lyon, France: “Slowly down the Rhône: the river and its artists.”

 

Thanks for spending time on “Matula Thoughts” this month.

David A. Bloom